the unified medical language system what is it and how to use it?
TRANSCRIPT
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The Unified Medical Language SystemWhat is it and how to use it?
Olivier BodenreiderOlivier Bodenreider, MD, PhD, MD, PhD
Lister Hill National CenterLister Hill National Centerfor Biomedical Communicationsfor Biomedical CommunicationsBethesda, Maryland Bethesda, Maryland -- USAUSA
Korea Advanced Instituteof Science and Technology
December 4, 2007
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OutlineOutline
Part I: Part I: WhatWhat isis the UMLS?the UMLS?IntroductionIntroductionOverviewOverview throughthrough an an exampleexampleThe The threethree UMLS UMLS KnowledgeKnowledge SourcesSources
UMLS MetathesaurusUMLS MetathesaurusUMLS UMLS SemanticSemantic NetworkNetworkSPECIALIST SPECIALIST LexiconLexicon and lexical and lexical toolstools
Part II: Part II: How to use the UMLS?How to use the UMLS?A UMLSA UMLS--basedbased algorithmalgorithm
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Part IWhat is the UMLS?
(1) Introduction
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What does UMLS stand for?What does UMLS stand for?
UUnifiednifiedMMedicaledicalLLanguageanguageSSystemystem
UMLS®
Unified Medical Language System®
UMLS Metathesaurus®
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MotivationMotivation
Started in 1986Started in 1986National Library of MedicineNational Library of Medicine““LongLong--term R&D projectterm R&D project””Complementary to IAIMSComplementary to IAIMS
«[…] the UMLS project is an effort to overcome two significant barriers to effective retrieval of machine-readable information.
• The first is the variety of ways the same concepts are expressedin different machine-readable sources and by different people.
• The second is the distribution of useful information among many disparate databases and systems.»
(Integrated Academic(Integrated AcademicInformation Management Systems)Information Management Systems)
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The UMLS in practiceThe UMLS in practice
DatabaseDatabaseSeries of relational filesSeries of relational files
InterfacesInterfacesWeb interface: Knowledge Source Server (UMLSKS)Web interface: Knowledge Source Server (UMLSKS)Application programming interfacesApplication programming interfaces(Java and XML(Java and XML--based)based)
ApplicationsApplicationslvglvg (lexical programs)(lexical programs)MetamorphoSysMetamorphoSys (installation and customization)(installation and customization)RRF browser (browsing subsets)RRF browser (browsing subsets)
The UMLS is not an end-user application
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Part IWhat is the UMLS?
(2) Overview through an example
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AddisonAddison’’s diseases disease
Addison's disease is a rare Addison's disease is a rare endocrine disorderendocrine disorderAddison's disease occurs Addison's disease occurs when the when the adrenal glandsadrenal glandsdo not produce enough of do not produce enough of the hormone the hormone cortisolcortisolFor this reason, the For this reason, the disease is sometimes disease is sometimes called called chronic adrenal chronic adrenal insufficiencyinsufficiency, or , or hypocortisolismhypocortisolism
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Adrenal insufficiency Adrenal insufficiency Clinical variantsClinical variants
Primary / SecondaryPrimary / SecondaryPrimary: lesion of the Primary: lesion of the adrenal glands themselvesadrenal glands themselvesSecondary: inadequate Secondary: inadequate secretion of ACTH by the secretion of ACTH by the pituitary glandpituitary gland
Acute / ChronicAcute / ChronicIsolated / Isolated / PolyendocrinePolyendocrinedeficiency syndromedeficiency syndrome
ACTH
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AddisonAddison’’s disease: s disease: SymptomsSymptoms
FatigueFatigueWeaknessWeaknessLow blood pressureLow blood pressurePigmentation of the skin (exposed and nonPigmentation of the skin (exposed and non--exposed parts of the body)exposed parts of the body)……
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AD in medical vocabulariesAD in medical vocabularies
Synonyms: Synonyms: different termsdifferent termsAddisonianAddisonian syndromesyndromeBronzed diseaseBronzed diseaseMelasma addisoniiAsthenia Asthenia pigmentosapigmentosaPrimary adrenal deficiencyPrimary adrenal deficiencyPrimary adrenal insufficiencyPrimary adrenal insufficiencyPrimary adrenocortical insufficiencyPrimary adrenocortical insufficiencyChronic adrenocortical insufficiencyChronic adrenocortical insufficiency
Contexts: Contexts: different hierarchiesdifferent hierarchies
symptoms
clinicalvariants
eponym
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Organize termsOrganize terms
Synonymous terms clustered into a conceptSynonymous terms clustered into a conceptPreferred termPreferred termUnique identifier (CUI)Unique identifier (CUI)
Addison's disease
Addison Disease MeSH D000224Primary hypoadrenalism MedDRA 10036696Primary adrenocortical insufficiency ICD-10 E27.1Addison's disease (disorder) SNOMED CT 363732003
C0001403
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Endocrine system diseasesEndocrine system diseases
Adrenal gland diseasesAdrenal gland diseases
Adrenal InsufficiencyAdrenal Insufficiency
Addison DiseaseAddison Disease
DiseaseDiseaseMeSHMeSH
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Endocrine disordersEndocrine disorders
Adrenal gland disordersAdrenal gland disorders
Adrenal cortical Adrenal cortical hypofunctionshypofunctions
AddisonAddison’’s Diseases Disease
MedDRAMedDRA
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Diseases of the endocrine systemDiseases of the endocrine system
Diseases of the adrenal glandsDiseases of the adrenal glands
AddisonAddison’’s Diseases Disease
Disease/DiagnosesDisease/DiagnosesSNOMED International
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Disorder of endocrine systemDisorder of endocrine system
Disorder of adrenal gland Disorder of adrenal gland
Disorder ofDisorder ofadrenal cortex adrenal cortex Adrenal Adrenal hypofunctionhypofunction
Adrenal cortical Adrenal cortical hypofunctionhypofunction
AddisonAddison’’s Diseases Disease
SNOMED CT (native)SNOMED CT (native)
HypoadrenalismHypoadrenalism
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Disorder of endocrine systemDisorder of endocrine system
Disorder of adrenal gland Disorder of adrenal gland
Disorder ofDisorder ofadrenal cortex adrenal cortex
Adrenal glandAdrenal glandhypofunctionhypofunction
Adrenal cortical Adrenal cortical hypofunctionhypofunction
AddisonAddison’’s Diseases Disease
SNOMED CT (UMLS view)SNOMED CT (UMLS view)
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NonNon--neoplasticneoplasticendocrine disorderendocrine disorder
NonNon--neoplasticneoplasticadrenal gland disorderadrenal gland disorder
Endocrine DisorderEndocrine Disorder
Adrenal gland disorderAdrenal gland disorder
Adrenal glandAdrenal glandinsufficiencyinsufficiency
Adrenal cortical insufficiencyAdrenal cortical insufficiency
AddisonAddison’’s Diseases Disease
NCI ThesaurusNCI Thesaurus
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Other disorders ofOther disorders ofadrenal glandadrenal gland
Disorders of otherDisorders of otherendocrine glandsendocrine glands
Primary Primary adrenocorticaladrenocortical insufficiencyinsufficiency
Endocrine, nutritionalEndocrine, nutritionaland metabolic diseases and metabolic diseases
ICDICD--1010
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Organize conceptsOrganize concepts
InterInter--concept concept relationships: hierarchies relationships: hierarchies from the source from the source vocabulariesvocabulariesRedundancy: multiple Redundancy: multiple pathspathsOne One graphgraph instead of instead of multiple multiple treestrees(multiple inheritance)(multiple inheritance)
A
B D E H D E
B
G H
E F H
C
B C
A
E FD
G H
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organize concepts
SNOMED CTSNOMED IntlMeSHMedDRA
Endocrine system diseasesEndocrine system diseases
Adrenal gland diseasesAdrenal gland diseases
Adrenal cortexAdrenal cortexdiseasesdiseases
Adrenal glandAdrenal glandhypofunctionhypofunction
Adrenal cortical Adrenal cortical hypofunctionhypofunction
AddisonAddison’’s Diseases Disease
DiseaseDisease
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UMLS view
Endocrine system diseasesEndocrine system diseases
Adrenal gland diseasesAdrenal gland diseases
Adrenal cortexAdrenal cortexdiseasesdiseases
Adrenal glandAdrenal glandhypofunctionhypofunction
Adrenal cortical Adrenal cortical hypofunctionhypofunction
AddisonAddison’’s Diseases Disease
DiseaseDisease
Other disorders ofOther disorders ofadrenal glandadrenal gland
Disorders of otherDisorders of otherendocrine glandsendocrine glands
Endocrine / nutritional /Endocrine / nutritional /metabolic disordermetabolic disorder
NonNon--neoplasticneoplasticendocrine disorderendocrine disorder
NonNon--neoplasticneoplasticadrenal gland disorderadrenal gland disorder
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Immune system diseasesImmune system diseases
Autoimmune diseases Autoimmune diseases Other disorders ofOther disorders ofadrenal glandadrenal gland
Disorders of otherDisorders of otherendocrine glandsendocrine glands
Endocrine system diseasesEndocrine system diseases
Adrenal gland diseasesAdrenal gland diseases
Adrenal cortexAdrenal cortexdiseasesdiseases
Adrenal glandAdrenal glandhypofunctionhypofunction
Adrenal cortical Adrenal cortical hypofunctionhypofunction
AddisonAddison’’s Diseases Disease
DiseaseDiseaseEndocrine / nutritional /Endocrine / nutritional /
metabolic disordermetabolic disorder
AddisonAddison’’s diseases diseasedue to autoimmunitydue to autoimmunity
TuberculousTuberculousAddison's diseaseAddison's disease
NonNon--neoplasticneoplasticendocrine disorderendocrine disorder
NonNon--neoplasticneoplasticadrenal gland disorderadrenal gland disorder
UMLS view
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Relate to other conceptsRelate to other concepts
Additional hierarchical relationshipsAdditional hierarchical relationshipslink to other treeslink to other treesmake relationships explicitmake relationships explicit
NonNon--hierarchical relationshipshierarchical relationshipsCoCo--occurring conceptsoccurring conceptsMapping relationshipsMapping relationships
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Categorize conceptsCategorize concepts
HighHigh--level categories level categories (semantic types)(semantic types)Assigned by the Assigned by the Metathesaurus editorsMetathesaurus editorsIndependently of the Independently of the hierarchies in which these hierarchies in which these concepts are locatedconcepts are located
Disease or Syndrome
Endocrine Diseases
Adrenal Gland Diseases
Addison’s Disease
Diseases
Adrenal Gland Hypofunction
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How do they do that?How do they do that?
Lexical knowledgeLexical knowledge
Semantic preSemantic pre--processingprocessing
UMLS editorsUMLS editors
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Lexical knowledgeLexical knowledge
Adrenal gland diseasesAdrenal disorderDisorder of adrenal glandDiseases of the adrenal glandsC0001621
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Semantic preSemantic pre--processingprocessing
Metadata in the source vocabulariesMetadata in the source vocabularies
Tentative categorizationTentative categorizationPositive (or negative) evidence for tentative Positive (or negative) evidence for tentative synonymy relations based on lexical featuressynonymy relations based on lexical features
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Additional knowledge: UMLS editorsAdditional knowledge: UMLS editors
Other disorders ofOther disorders ofadrenal glandadrenal gland
Adrenal gland diseasesAdrenal gland diseases
Adrenal cortexAdrenal cortexdiseasesdiseases
Adrenal glandAdrenal glandhypofunctionhypofunction
Adrenal cortical Adrenal cortical hypofunctionhypofunction
AddisonAddison’’s Diseases Disease
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UMLS UMLS SummarySummary
Synonymous terms clustered into conceptsSynonymous terms clustered into conceptsUnique identifierUnique identifier
Finer granularityFiner granularityBroader scopeBroader scopeAdditional hierarchical relationshipsAdditional hierarchical relationshipsSemantic categorizationSemantic categorization
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Part IWhat is the UMLS?
(3) UMLS Metathesaurus
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Unified Medical Language SystemUnified Medical Language System
SPECIALIST LexiconSPECIALIST Lexicon360,000 lexical items360,000 lexical itemsPart of speech and variant informationPart of speech and variant information
MetathesaurusMetathesaurus6M names from over 100 terminologies6M names from over 100 terminologies1.5M concepts1.5M concepts8M relations8M relations
Semantic NetworkSemantic Network135 high135 high--level categorieslevel categories7000 relations among them7000 relations among them
Lexicalresources
Ontologicalresources
Terminologicalresources
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Metathesaurus Metathesaurus Basic organizationBasic organization
ConceptsConceptsSynonymous terms are clustered into a conceptSynonymous terms are clustered into a conceptProperties are attached to concepts, e.g.,Properties are attached to concepts, e.g.,
Unique identifierUnique identifierDefinitionDefinition
RelationsRelationsConcepts are related to other conceptsConcepts are related to other conceptsProperties are attached to relations, e.g.,Properties are attached to relations, e.g.,
Type of relationshipType of relationshipSourceSource
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Source VocabulariesSource Vocabularies
141 source vocabularies141 source vocabularies17 languages17 languages
Broad coverage of biomedicineBroad coverage of biomedicine6.1M names6.1M names1.5M concepts1.5M concepts8M relations8M relations
Common presentationCommon presentation
(2007AC)
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Biomedical terminologiesBiomedical terminologies
General vocabulariesGeneral vocabulariesanatomy (UWDA, anatomy (UWDA, NeuronamesNeuronames))drugs (drugs (RxNormRxNorm, First , First DataBankDataBank, Micromedex), Micromedex)medical devices (UMD, SPN)medical devices (UMD, SPN)
Several perspectivesSeveral perspectivesclinical terms (SNOMED CT)clinical terms (SNOMED CT)information sciences (MeSH, CRISP)information sciences (MeSH, CRISP)administrative terminologies (ICDadministrative terminologies (ICD--99--CM, CPTCM, CPT--4)4)data exchange terminologies (HL7, LOINC)data exchange terminologies (HL7, LOINC)
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Biomedical terminologies Biomedical terminologies (cont(cont’’d)d)
Specialized vocabulariesSpecialized vocabulariesnursing (NIC, NOC, NANDA, Omaha, PCDS)nursing (NIC, NOC, NANDA, Omaha, PCDS)dentistry (CDT)dentistry (CDT)oncology (PDQ)oncology (PDQ)psychiatry (DSM, APA)psychiatry (DSM, APA)adverse reactions (COSTART, WHO ART)adverse reactions (COSTART, WHO ART)primary care (ICPC)primary care (ICPC)
Terminology of knowledge bases (Terminology of knowledge bases (AI/Rheum, AI/Rheum, DXplainDXplain, QMR, QMR))
The UMLS serves as a vehicle for the regulatory standards(HIPAA, CHI)
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Integrating subdomainsIntegrating subdomains
Biomedicalliterature
Biomedicalliterature
MeSH
Genomeannotations
Genomeannotations
GOModelorganisms
Modelorganisms
NCBITaxonomy
Geneticknowledge bases
Geneticknowledge bases
OMIM
Clinicalrepositories
Clinicalrepositories
SNOMED CTOthersubdomains
Othersubdomains
…
AnatomyAnatomy
FMA
UMLS
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Integrating subdomainsIntegrating subdomains
Biomedicalliterature
Biomedicalliterature
Genomeannotations
Genomeannotations
Modelorganisms
Modelorganisms
Geneticknowledge bases
Geneticknowledge bases
Clinicalrepositories
Clinicalrepositories
Othersubdomains
Othersubdomains
AnatomyAnatomy
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TransTrans--namespace integrationnamespace integration
Genomeannotations
Genomeannotations
GOModelorganisms
Modelorganisms
NCBITaxonomy
Geneticknowledge bases
Geneticknowledge bases
OMIMOther
subdomainsOther
subdomains
…
AnatomyAnatomy
FMA
UMLSAddison Disease (D000224)
Addison's disease (363732003)
Biomedicalliterature
Biomedicalliterature
MeSH
Clinicalrepositories
Clinicalrepositories
SNOMED CT
UMLSC0001403
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AddisonAddison’’s Disease: s Disease: ConceptConcept
Addison’s Disease
C0001403
ADRENAL INSUFFICIENCY (ADDISON'S DISEASE) ADRENOCORTICAL INSUFFICIENCY, PRIMARY FAILURE Hypoadrenalisms, PrimaryMelasma addisoniiPrimary adrenal deficiency Asthenia pigmentosaBronzed disease Insufficiency, adrenal primary Primary adrenocortical insufficiency Addison's, disease
Maladie d'Addison - FrenchAddison-Krankheit - GermanMorbo di Addison - ItalianDoença de Addison - PortugueseАДДИСОНОВА БОЛЕЗНЬ - Russianアジソン病 - Japanese
An adrenal disease characterized by the progressive destruction of the adrenal cortex, resulting in insufficient production of aldosterone and hydrocortisone. Clinical symptoms include anorexia; nausea; weight loss; muscle ewakness; and hyperpigmentation of the skin due to increase in circulating levels of ACTH precursor hormone which stimulates melanocytes.
Disease or Syndrome
SNOMED CTSNOMED IntlMeSHMedDRA…
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Heart
Concepts
Metathesaurus
38
237
49
5
16
13 22
Esophagus
Left PhrenicNerve
HeartValves
FetalHeart
Medias-tinum
SaccularViscus
AnginaPectoris
CardiotonicAgents
TissueDonors
AnatomicalStructure
Fully FormedAnatomical
StructureEmbryonicStructure
Body Part, Organ orOrgan Component Pharmacologic
Substance
Disease orSyndrome
PopulationGroup
Semantic Types
SemanticNetwork
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Part IIHow to use the UMLS?
A UMLS-based algorithm
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Indexing InitiativeIndexing Initiative
For noun phrases extracted from medical texts, For noun phrases extracted from medical texts, map to UMLS conceptsmap to UMLS conceptsThen, select from the MeSH vocabulary the Then, select from the MeSH vocabulary the concepts that are the most closely related to the concepts that are the most closely related to the original conceptsoriginal concepts
Medical text
Noun phrase
UMLS
MeSH descriptor
[Aronson & al., AMIA, 2000]
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Restrict to MeSHRestrict to MeSH
Based on the principle of Based on the principle of semantic localitysemantic localityUse different components of the UMLSUse different components of the UMLS4 techniques of increasing aggressiveness4 techniques of increasing aggressiveness
Use SynonymyUse Synonymy MRCONSOMRCONSO
Use Associated expressions (Use Associated expressions (ATXsATXs)) MRATX + MRRELMRATX + MRREL
Explore the AncestorsExplore the Ancestors MRREL + SNMRREL + SN
Explore the Other related conceptsExplore the Other related concepts MRREL + SNMRREL + SN
[Bodenreider & al., AMIA, 1998]
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Restrict to MeSH Restrict to MeSH SynonymySynonymy
Term mapped to Source conceptTerm mapped to Source conceptFor this concept, is there a synonym term For this concept, is there a synonym term that comes from MeSH? that comes from MeSH? (MRCONSO)(MRCONSO)
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Restrict to MeSH Restrict to MeSH Assoc. expressionsAssoc. expressions
If not,If not,Is there an associated expression (ATX) that Is there an associated expression (ATX) that describes this concept using a combination of describes this concept using a combination of MeSH descriptors? MeSH descriptors? (MRATX/MRMAP + MRREL)(MRATX/MRMAP + MRREL)
Endoscopic removal of intraluminal foreign body from oesophagus without incision
AND
Foreign Bodies
MH/SH
Esophagus surgery
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Restrict to MeSH Restrict to MeSH AncestorsAncestors
If not, let us build the graph of the ancestors of If not, let us build the graph of the ancestors of this conceptthis concept
using parents and broader concepts using parents and broader concepts (MRREL)(MRREL)
all the way to the topall the way to the topexcluding ancestors whose semantic types are not excluding ancestors whose semantic types are not compatible with those of the source concept compatible with those of the source concept (MRSTY)(MRSTY)
From the graph, select the concepts that come From the graph, select the concepts that come from MeSH from MeSH (MRCONSO)(MRCONSO)
Remove those that are ancestors of another Remove those that are ancestors of another concept coming from MeSHconcept coming from MeSH
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Restrict to MeSH Restrict to MeSH Other related conceptsOther related concepts
If not, explore the other related concepts If not, explore the other related concepts (MRREL) (MRREL) whose semantic types are compatible with those of whose semantic types are compatible with those of the source concept the source concept (MRSTY)(MRSTY)
From those, select the concepts that come from From those, select the concepts that come from MeSH MeSH (MRCONSO)(MRCONSO)
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Restrict to MeSH Restrict to MeSH ExampleExample
Vein of neck, NOS
There is a MeSH term in the synonyms of SC
SC is described by a combination of MeSH terms (ATX)
The ancestors of SC contain MeSH terms
MeSH terms from non-hierarchically related concepts
Neck+Vein
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Restrict to MeSH Restrict to MeSH ExampleExample
Vein of neck, NOS
Vein of head and neck, NOS
Neck
Blood Vessels Vascular structure
Veins
Systemic veins
Head
Head and neck, NOS Body part, NOS
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23%
11%
54%
12%
Synonymy
Built-inmappings
Other related concepts
Graph ofancestors
Restrict to MeSH Restrict to MeSH Quantitative resultsQuantitative results
86% of UMLS concepts mapped to MeSH (2007)86% of UMLS concepts mapped to MeSH (2007)
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Restrict to MeSH Restrict to MeSH Qualitative resultsQualitative results
Qualitative evaluationQualitative evaluation1,036 concepts extracted from 200 MEDLINE citations1,036 concepts extracted from 200 MEDLINE citationsmanual review of every mapping or failuremanual review of every mapping or failure
61% Relevant61% RelevantSubtotal Subtotal GastrectomyGastrectomy GastrectomyGastrectomyEncephalopathy, NOS Encephalopathy, NOS Brain DiseasesBrain Diseases
28% More or less relevant28% More or less relevantVitamin A measurement Vitamin A measurement Laboratory ProcedureLaboratory ProcedureSwelling, NOS Swelling, NOS SymptomsSymptoms
11% Non relevant11% Non relevant
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MedicalOntologyResearch
Olivier BodenreiderOlivier Bodenreider
Lister Hill National CenterLister Hill National Centerfor Biomedical Communicationsfor Biomedical CommunicationsBethesda, Maryland Bethesda, Maryland -- USAUSA
Contact:Contact:Web:Web:
[email protected]@nlm.nih.govmor.nlm.nih.govmor.nlm.nih.gov
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Bibliography
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References: UMLS home pageReferences: UMLS home page
UMLS home pageUMLS home pagehttp:// www.nlm.nih.gov/research/umls/
UMLS documentationUMLS documentationFormerly know as the Formerly know as the ““Green BookGreen Book””Now online documentationNow online documentationhttp://http://www.nlm.nih.gov/research/umls/UMLSDOC.HTMLwww.nlm.nih.gov/research/umls/UMLSDOC.HTML
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ReferencesReferences
Short presentationShort presentationBodenreider, O. (2004) Bodenreider, O. (2004) The Unified Medical Language The Unified Medical Language System (UMLS): integrating biomedical terminologySystem (UMLS): integrating biomedical terminology..Nucleic Acids ResNucleic Acids Res, 32(Database issue), D267, 32(Database issue), D267--70.70.
UMLS as a research projectUMLS as a research projectLindberg, D. A., Humphreys, B. L., & McCray, A. T. Lindberg, D. A., Humphreys, B. L., & McCray, A. T. (1993). (1993). The Unified Medical Language SystemThe Unified Medical Language System. . Methods Methods InfInf Med, 32Med, 32(4), 281(4), 281--91.91.Humphreys, B. L., Lindberg, D. A., Schoolman, H. M., Humphreys, B. L., Lindberg, D. A., Schoolman, H. M., & Barnett, G. O. (1998). & Barnett, G. O. (1998). The Unified Medical The Unified Medical Language System: an informatics research Language System: an informatics research collaborationcollaboration. . J Am Med Inform Assoc, 5J Am Med Inform Assoc, 5(1), 1(1), 1--11.11.
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ReferencesReferences
Technical papersTechnical papersMcCray, A. T., & Nelson, S. J. (1995). McCray, A. T., & Nelson, S. J. (1995). The The representation of meaning in the UMLSrepresentation of meaning in the UMLS. . Methods Methods InfInfMed, 34Med, 34(1(1--2), 1932), 193--201.201.
Comprehensive bibliography 1986Comprehensive bibliography 1986--9696http://www.nlm.nih.gov/pubs/cbm/umlscbm.html
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Documentation and Support
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UMLS documentation and supportUMLS documentation and support
UMLS homepageUMLS homepagelinks to various UMLS resourceslinks to various UMLS resourceshttp://http://www.nlm.nih.gov/research/umlswww.nlm.nih.gov/research/umls//
UMLSKS homepageUMLSKS homepagelinks to the Userlinks to the User’’s and Developers and Developer’’s guidess guideshttp://http://umlsks.nlm.nih.govumlsks.nlm.nih.gov//
UMLS mailing listUMLS mailing [email protected]@LIST.NIH.GOV
Email address for supportEmail address for [email protected]@nlm.nih.gov