ࡱ> q`%bjbjqPqP;4:: R'R'R'R'R'R'R'f')))8)$*f'&*&*&*&*&*&*$J*^* ,......$hPRR',&*&*,,RR'R'&*&*g---,R'&*R'&*,-,,--^rhR'R'*&** b/\),ڠh }0BE!-jE**ER'0Oj*L*6-*,+j*j*j*RR-^j*j*j*,,,,f'f'f'D)f'f'f')f'f'f'R'R'R'R'R'R' Resumo: Objetivando-se a reduo dos erros nos diagnsticos, Sistemas de Suporte Deciso Clnica (CDSS) tm sido utilizados para auxiliar os profissionais da sade na avaliao e diagnstico de pacientes. Tais sistemas sugerem, com base nos registros de sade de certo paciente, um diagnstico mais provvel, o qual pode ser levado em considerao pelo mdico ao decidir quanto ao diagnstico do paciente. Para a sugesto do diagnstico mais provvel, os registros de sade do paciente so casados com os atributos de um modelo previamente construdo utilizando aprendizado de mquina, daqui para frente referenciado como modelo de deciso. Um problema atual que a maioria dos CDSS est baseada em modelos de deciso estticos. Nos modelos de deciso estticos, o aprendizado do modelo realizado uma nica vez, antes do sistema de apoio ao diagnstico ser posto em operao. Tais modelos estticos no so refinados ou reconstrudos durante o uso do sistema e, portanto, no permitem que o mdico especialista reporte o diagnstico final para a melhoria do modelo. Na literatura, existem alguns trabalhos baseados em modelos de deciso dinmicos, mas estes no so adequados utilizao simultnea por centros de sade distintos que utilizam diferentes conjuntos de exames para diagnosticar a mesma doena, ou seja, utilizam prticas diagnsticas distintas. Nesta tese, prope-se um modelo de deciso dinmico e flexvel, o qual alimentado pelos diagnsticos finais reportados por mdicos especialistas, sendo adequado a centros de sade empregando prticas diagnsticas distintas, uma vez que permite que novos exames sejam definidos pelos mdicos e o modelo de deciso automaticamente os inclui como atributos, caso sejam potencialmente relevantes para diagnosticar. O modelo de deciso dinmico proposto baseia-se em um processo de aprendizado de mquina supervisionado que retreina o modelo atravs da seleo dos atributos considerados potencialmente relevantes, avaliao de vrios cenrios de pr-processamento e classificadores e seleo da combinao de cenrio e classificador que alcana melhor desempenho na classificao considerando um conjunto de medidas. Na aplicao do modelo dinmico proposto ao diagnstico do comprometimento cognitivo, um CDSS foi projetado e desenvolvido para auxiliar mdicos menos experientes ou especializados a decidirem sobre o diagnstico de Demncia, Doena de Alzheimer (DA) e Comprometimento Cognitivo Leve (CCL). Para cada paciente, o CDSS sugere o diagnstico mais provvel, os registros de sade mais relevantes que levaram ao diagnstico sugerido e, no caso de um fator de certeza baixo, o CDSS recomenda testes neuropsicolgicos a serem realizados para confirmar ou refutar a sugesto diagnstica inicial. O CDSS proposto adequado para centros de sade que utilizam diferentes conjuntos de testes neuropsicolgicos para diagnosticar Demncia, DA e CCL. Dados de pacientes do Centro de Doena de Alzheimer e outras Desordens Mentais na Velhice (CDA) do Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (UFRJ) e do Centro de Referncia em Ateno Sade dos Idosos (CRASI) do Hospital Universitrio Antonio Pedro da Universidade Federal Fluminense (UFF) foram usados para a realizao de testes experimentais. CDA e CRASI aplicam conjuntos distintos no disjuntos de testes neuropsicolgicos aos pacientes. Quando os dados do CRASI foram adicionados aos dados do CDA, o classificador final obtido para diagnstico de CCL melhorou sua generalizao com a incluso de exames exclusivos do CRASI. Alm disso, os testes experimentais mostraram que os classificadores obtidos para Demncia, DA e CCL alcanaram desempenho competitivo na comparao com outros trabalhos da literatura baseados em modelos dinmicos. Palavras-chave: Modelo de Deciso Dinmico; Sistemas de Suporte Deciso Clnica; Diagnstico Auxiliado por Computador; Modelos Preditivos; Demncia; Doena de Alzheimer; Comprometimento Cognitivo Leve. Abstract: Aiming at reducing diagnostic errors, Clinical Decision Support Systems (CDSS) have been used to assist health professionals to evaluate and diagnose patients. Such systems suggest, based on a patient's health records, the most probable diagnosis, which can be taken into consideration by the physician to decide about the patient's diagnosis. To suggest the most probable diagnosis, the patient's health records are matched to the features of a model previously constructed using machine learning, hereafter referenced as decision model. A current problem is that most CDSS are based on static decision models. In static decision models, model learning is performed only once, before the diagnostic support system is put into operation. Such static models are not refined or reconstructed during the use of the system and, therefore, do not allow the expert physician to report the final diagnosis to improve the model. In the literature, there are some works based on dynamic decision models, but these are not suitable for simultaneous use by different health centers that use different sets of tests to diagnose the same disease, that is, use different diagnostic practices. In this thesis, a dynamic and flexible decision model is proposed, which is fed by the final diagnoses reported by expert physicians, being appropriate to health centers that use different diagnostic practices, since it allows new exams to be defined by physicians and the decision model automatically includes them as attributes if they are potentially relevant for diagnosis. The proposed dynamic decision model is based on a supervised machine learning process that retrains the model by selection of attributes considered potentially relevant, assessment of several pre-processing scenarios and classifiers, and selection of the combination of scenario and classifier that achieves better classification performance considering a set of measures. In the application of the proposed dynamic model to diagnose cognitive impairment, a CDSS was designed and implemented to assist less experienced or specialized physicians to decide about diagnosis of Dementia, Alzheimer's Disease (AD) and Mild Cognitive Impairment (MCI). For each patient, the CDSS suggests the most likely diagnosis, the most relevant health records that led to the suggested diagnosis, and in case of a low certainty factor, the CDSS recommends neuropsychological tests to be performed to confirm or refute the initial diagnostic suggestion. The proposed CDSS is suitable for health centers that use different sets of neuropsychological tests to diagnose Dementia, AD and MCI. Patient data from Center for Alzheimers Disease (CAD) at Institute of Psychiatry of Federal University of Rio de Janeiro (UFRJ) and from Center of Reference in Attention to Health of the Elderly (CRASI) at Antonio Pedro University Hospital of Fluminense Federal University (UFF) were used to perform experimental tests. CAD and CRASI apply distinct non-disjoint sets of neuropsychological tests to patients. When CRASI data were added to CAD data, the final classifier obtained for MCI diagnosis improved its generalization with the inclusion of neuropsychological tests that are present only in CRASI data. Besides, the experimental tests showed that the classifiers obtained for Dementia, AD and MCI achieved a competitive performance in comparison to other works of literature based on dynamic models. Keywords: Dynamic Decision Model; Clinical Decision Support Systems; Computer-aided Diagnosis; Predictive Models; Dementia; Alzheimers Disease; Mild Cognitive Impairment.     Ei  ! & ' E Z o L W _ k fz'0[_|ceٽٽٽٽٽٽٳ٬٬٬٬٥٥٥٥ٽٽٞ hu0_hPR hWhPR h,i8hPRhL XhPR6] hhPR hQhPR hK"hPR h)hPRhPR h0%hPRh5;CJ\aJh0%hPR5;CJ\aJ>%%%%%%%%%%%%dgd="q d`gd$d`a$gd $da$gd d`gdd7$8$H$`gd$dh`a$gd%%JRTUlopy)\`fgqz{|ž}u}u}u}hPRmH sH hRhPRmH sH hhPRmH sH h5;CJ\aJmH sH %hhPR5;CJ\aJmH sH hmH sH  h*4hPRh*4hPR5\ h5\ hPR5\h:OKhPR5\ h:OKhPR hGhPR hu0_hPRhPR. !y}*Dls! ' 0 1 < ? B!a!!!+#,#-#.######I$$$%%%%%4%U%V%o%p%%%%%%%%%%%%%%Ծh9wjh9wUhe hPRmH sH h5\mH sH he hPR5\mH sH hY^hPRmH sH hRhPRmH sH hPRmH sH F%%%%he hPRmH sH h9wjh9wU%% d`gd9 01hP:p.[. 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