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Ashraf Ganjouei A, Romero-Hernandez F, Wang JJ, Hamed A, Alaa A, Bartlett D, Alseidi A, Choudry MH, Adam M. A machine learning approach for predicting textbook outcome after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. World J Surg 2024; 48:1404-1413. [PMID: 38651936 DOI: 10.1002/wjs.12184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 04/04/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Peritoneal carcinomatosis is considered a late-stage manifestation of neoplastic diseases. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) can be an effective treatment for these patients. However, the procedure is associated with significant morbidity. Our aim was to develop a machine learning model to predict the probability of achieving textbook outcome (TO) after CRS-HIPEC using only preoperatively known variables. METHODS Adult patients with peritoneal carcinomatosis and who underwent CRS-HIPEC were included from a large, single-center, prospectively maintained dataset (2001-2020). TO was defined as a hospital length of stay ≤14 days and no postoperative adverse events including any complications, reoperation, readmission, and mortality within 90 days. Four models (logistic regression, neural network, random forest, and XGBoost) were trained, validated, and a user-friendly risk calculator was then developed. RESULTS A total of 1954 CRS-HIPEC procedures for peritoneal carcinomatosis were included. Overall, 13% (n = 258) achieved TO following CRS-HIPEC procedure. XGBoost and logistic regression had the highest area under the curve (AUC) (0.76) after model optimization, followed by random forest (AUC 0.75) and neural network (AUC 0.74). The top preoperative variables associated with achieving a TO were lower peritoneal cancer index scores, not undergoing proctectomy, splenectomy, or partial colectomy and being asymptomatic from peritoneal metastases prior to surgery. CONCLUSION This is a data-driven study to predict the probability of achieving TO after CRS-HIPEC. The proposed pipeline has the potential to not only identify patients for whom surgery is not associated with prohibitive risk, but also aid surgeons in communicating this risk to patients.
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Affiliation(s)
| | | | - Jaeyun Jane Wang
- Department of Surgery, University of California, San Francisco, California, USA
| | - Ahmed Hamed
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Ahmed Alaa
- University of California, Berkeley, California, USA
- University of California, San Francisco, California, USA
| | - David Bartlett
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Adnan Alseidi
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, California, USA
| | - Mohammad Haroon Choudry
- Division of Surgical Oncology, Department of Surgery, UPMC Cancer Pavilion, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mohamed Adam
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, California, USA
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Wang J, Tozzi F, Ashraf Ganjouei A, Romero-Hernandez F, Feng J, Calthorpe L, Castro M, Davis G, Withers J, Zhou C, Chaudhary Z, Adam M, Berrevoet F, Alseidi A, Rashidian N. Machine learning improves prediction of postoperative outcomes after gastrointestinal surgery: a systematic review and meta-analysis. J Gastrointest Surg 2024; 28:956-965. [PMID: 38556418 DOI: 10.1016/j.gassur.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 03/04/2024] [Accepted: 03/08/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Machine learning (ML) approaches have become increasingly popular in predicting surgical outcomes. However, it is unknown whether they are superior to traditional statistical methods such as logistic regression (LR). This study aimed to perform a systematic review and meta-analysis to compare the performance of ML vs LR models in predicting postoperative outcomes for patients undergoing gastrointestinal (GI) surgery. METHODS A systematic search of Embase, MEDLINE, Cochrane, Web of Science, and Google Scholar was performed through December 2022. The primary outcome was the discriminatory performance of ML vs LR models as measured by the area under the receiver operating characteristic curve (AUC). A meta-analysis was then performed using a random effects model. RESULTS A total of 62 LR models and 143 ML models were included across 38 studies. On average, the best-performing ML models had a significantly higher AUC than the LR models (ΔAUC, 0.07; 95% CI, 0.04-0.09; P < .001). Similarly, on average, the best-performing ML models had a significantly higher logit (AUC) than the LR models (Δlogit [AUC], 0.41; 95% CI, 0.23-0.58; P < .001). Approximately half of studies (44%) were found to have a low risk of bias. Upon a subset analysis of only low-risk studies, the difference in logit (AUC) remained significant (ML vs LR, Δlogit [AUC], 0.40; 95% CI, 0.14-0.66; P = .009). CONCLUSION We found a significant improvement in discriminatory ability when using ML over LR algorithms in predicting postoperative outcomes for patients undergoing GI surgery. Subsequent efforts should establish standardized protocols for both developing and reporting studies using ML models and explore the practical implementation of these models.
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Affiliation(s)
- Jane Wang
- Department of Surgery, University of California, San Francisco, San Francisco, California, United States
| | - Francesca Tozzi
- Department of General, HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Amir Ashraf Ganjouei
- Department of Surgery, University of California, San Francisco, San Francisco, California, United States
| | - Fernanda Romero-Hernandez
- Department of Surgery, University of California, San Francisco, San Francisco, California, United States
| | - Jean Feng
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States
| | - Lucia Calthorpe
- Department of Surgery, University of California, San Francisco, San Francisco, California, United States
| | - Maria Castro
- Department of Surgery, University of California, San Francisco, San Francisco, California, United States
| | - Greta Davis
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, California, United States
| | - Jacquelyn Withers
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, California, United States
| | - Connie Zhou
- Department of Surgery, University of California, San Francisco, San Francisco, California, United States
| | - Zaim Chaudhary
- University of California, Berkeley, Berkeley, California, United States
| | - Mohamed Adam
- Department of Surgery, University of California, San Francisco, San Francisco, California, United States
| | - Frederik Berrevoet
- Department of General, HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Adnan Alseidi
- Department of Surgery, University of California, San Francisco, San Francisco, California, United States
| | - Nikdokht Rashidian
- Department of General, HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium.
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Chaudhary R, Nourelahi M, Thoma FW, Gellad WF, Lo-Ciganic WH, Bliden KP, Gurbel PA, Neal MD, Jain SK, Bhonsale A, Mulukutla SR, Wang Y, Harinstein ME, Saba S, Visweswaran S. Machine Learning - Based Bleeding Risk Predictions in Atrial Fibrillation Patients on Direct Oral Anticoagulants. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.27.24307985. [PMID: 38854094 PMCID: PMC11160827 DOI: 10.1101/2024.05.27.24307985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Importance Accurately predicting major bleeding events in non-valvular atrial fibrillation (AF) patients on direct oral anticoagulants (DOACs) is crucial for personalized treatment and improving patient outcomes, especially with emerging alternatives like left atrial appendage closure devices. The left atrial appendage closure devices reduce stroke risk comparably but with significantly fewer non-procedural bleeding events. Objective To evaluate the performance of machine learning (ML) risk models in predicting clinically significant bleeding events requiring hospitalization and hemorrhagic stroke in non-valvular AF patients on DOACs compared to conventional bleeding risk scores (HAS-BLED, ORBIT, and ATRIA) at the index visit to a cardiologist for AF management. Design Prognostic modeling with retrospective cohort study design using electronic health record (EHR) data, with clinical follow-up at one-, two-, and five-years. Setting University of Pittsburgh Medical Center (UPMC) system. Participants 24,468 non-valvular AF patients aged ≥18 years treated with DOACs, excluding those with prior history of significant bleeding, other indications for DOACs, on warfarin or contraindicated to DOACs. Exposures DOAC therapy for non-valvular AF. Main Outcomes and Measures The primary endpoint was clinically significant bleeding requiring hospitalization within one year of index visit. The models incorporated demographic, clinical, and laboratory variables available in the EHR at the index visit. Results Among 24,468 patients, 553 (2.3%) had bleeding events within one year, 829 (3.5%) within two years, and 1,292 (5.8%) within five years of index visit. We evaluated multivariate logistic regression and ML models including random forest, classification trees, k-nearest neighbor, naive Bayes, and extreme gradient boosting (XGBoost) which modestly outperformed HAS-BLED, ATRIA, and ORBIT scores in predicting clinically significant bleeding at 1-year follow-up. The best performing model (random forest) showed area under the curve (AUC-ROC) 0.76 (0.70-0.81), G-Mean score of 0.67, net reclassification index 0.14 compared to 0.57 (0.50-0.63), G-Mean score of 0.57 for HASBLED score, p-value for difference <0.001. The ML models had improved performance compared to conventional risk across time-points of 2-year and 5-years and within the subgroup of hemorrhagic stroke. SHAP analysis identified novel risk factors including measures from body mass index, cholesterol profile, and insurance type beyond those used in conventional risk scores. Conclusions and Relevance Our findings demonstrate the superior performance of ML models compared to conventional bleeding risk scores and identify novel risk factors highlighting the potential for personalized bleeding risk assessment in AF patients on DOACs.
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Hernandez MC, Chen C, Nguyen A, Choong K, Carlin C, Nelson RA, Rossi LA, Seth N, McNeese K, Yuh B, Eftekhari Z, Lai LL. Explainable Machine Learning Model to Preoperatively Predict Postoperative Complications in Inpatients With Cancer Undergoing Major Operations. JCO Clin Cancer Inform 2024; 8:e2300247. [PMID: 38648576 PMCID: PMC11161247 DOI: 10.1200/cci.23.00247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/24/2024] [Accepted: 03/06/2024] [Indexed: 04/25/2024] Open
Abstract
PURPOSE Preoperative prediction of postoperative complications (PCs) in inpatients with cancer is challenging. We developed an explainable machine learning (ML) model to predict PCs in a heterogenous population of inpatients with cancer undergoing same-hospitalization major operations. METHODS Consecutive inpatients who underwent same-hospitalization operations from December 2017 to June 2021 at a single institution were retrospectively reviewed. The ML model was developed and tested using electronic health record (EHR) data to predict 30-day PCs for patients with Clavien-Dindo grade 3 or higher (CD 3+) per the CD classification system. Model performance was assessed using area under the receiver operating characteristic curve (AUROC), area under the precision recall curve (AUPRC), and calibration plots. Model explanation was performed using the Shapley additive explanations (SHAP) method at cohort and individual operation levels. RESULTS A total of 988 operations in 827 inpatients were included. The ML model was trained using 788 operations and tested using a holdout set of 200 operations. The CD 3+ complication rates were 28.6% and 27.5% in the training and holdout test sets, respectively. Training and holdout test sets' model performance in predicting CD 3+ complications yielded an AUROC of 0.77 and 0.73 and an AUPRC of 0.56 and 0.52, respectively. Calibration plots demonstrated good reliability. The SHAP method identified features and the contributions of the features to the risk of PCs. CONCLUSION We trained and tested an explainable ML model to predict the risk of developing PCs in patients with cancer. Using patient-specific EHR data, the ML model accurately discriminated the risk of developing CD 3+ complications and displayed top features at the individual operation and cohort level.
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Affiliation(s)
| | - Chen Chen
- Department of Applied AI and Data Science, City of Hope National Medical Center, Duarte, CA
| | - Andrew Nguyen
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Kevin Choong
- Department of Surgery, Division of Oncology, Primas Health, University of South Carolina Medical School, Greeneville, SC
| | - Cameron Carlin
- Department of Applied AI and Data Science, City of Hope National Medical Center, Duarte, CA
| | - Rebecca A. Nelson
- Department of Computational and Quantitative Medicine, Division of Biostatistics, City of Hope National Medical Center, Duarte, CA
| | - Lorenzo A. Rossi
- Department of Applied AI and Data Science, City of Hope National Medical Center, Duarte, CA
| | - Naini Seth
- Department of Clinical Informatics, City of Hope National Medical Center, Duarte, CA
| | - Kathy McNeese
- Department of Surgery, University of New Mexico, Albuquerque, NM
| | - Bertram Yuh
- Department of Surgery, University of New Mexico, Albuquerque, NM
| | - Zahra Eftekhari
- Department of Applied AI and Data Science, City of Hope National Medical Center, Duarte, CA
| | - Lily L. Lai
- Department of Surgery, University of New Mexico, Albuquerque, NM
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Hu C, Gao C, Li T, Liu C, Peng Z. Explainable artificial intelligence model for mortality risk prediction in the intensive care unit: a derivation and validation study. Postgrad Med J 2024; 100:219-227. [PMID: 38244550 DOI: 10.1093/postmj/qgad144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND The lack of transparency is a prevalent issue among the current machine-learning (ML) algorithms utilized for predicting mortality risk. Herein, we aimed to improve transparency by utilizing the latest ML explicable technology, SHapley Additive exPlanation (SHAP), to develop a predictive model for critically ill patients. METHODS We extracted data from the Medical Information Mart for Intensive Care IV database, encompassing all intensive care unit admissions. We employed nine different methods to develop the models. The most accurate model, with the highest area under the receiver operating characteristic curve, was selected as the optimal model. Additionally, we used SHAP to explain the workings of the ML model. RESULTS The study included 21 395 critically ill patients, with a median age of 68 years (interquartile range, 56-79 years), and most patients were male (56.9%). The cohort was randomly split into a training set (N = 16 046) and a validation set (N = 5349). Among the nine models developed, the Random Forest model had the highest accuracy (87.62%) and the best area under the receiver operating characteristic curve value (0.89). The SHAP summary analysis showed that Glasgow Coma Scale, urine output, and blood urea nitrogen were the top three risk factors for outcome prediction. Furthermore, SHAP dependency analysis and SHAP force analysis were used to interpret the Random Forest model at the factor level and individual level, respectively. CONCLUSION A transparent ML model for predicting outcomes in critically ill patients using SHAP methodology is feasible and effective. SHAP values significantly improve the explainability of ML models.
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Affiliation(s)
- Chang Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
| | - Chao Gao
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
| | - Tianlong Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
| | - Chang Liu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
| | - Zhiyong Peng
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
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SenthilKumar G, Merrill J, Maduekwe UN, Cloyd JM, Fournier K, Abbott DE, Zafar N, Patel S, Johnston F, Dineen S, Baumgartner J, Grotz TE, Maithel SK, Raoof M, Lambert L, Hendrix R, Kothari AN. Prediction of Early Recurrence Following CRS/HIPEC in Patients With Disseminated Appendiceal Cancer. J Surg Res 2023; 292:275-288. [PMID: 37666090 DOI: 10.1016/j.jss.2023.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/01/2023] [Accepted: 06/25/2023] [Indexed: 09/06/2023]
Abstract
INTRODUCTION In patients with disseminated appendiceal cancer (dAC) who underwent cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC), characterizing and predicting those who will develop early recurrence could provide a framework for personalizing follow-up. This study aims to: (1) characterize patients with dAC that are at risk for recurrence within 2 y following of CRS ± HIPEC (early recurrence; ER), (2) utilize automated machine learning (AutoML) to predict at-risk patients, and (3) identifying factors that are influential for prediction. METHODS A 12-institution cohort of patients with dAC treated with CRS ± HIPEC between 2000 and 2017 was used to train predictive models using H2O.ai's AutoML. Patients with early recurrence (ER) were compared to those who did not have recurrence or presented with recurrence after 2 y (control; C). However, 75% of the data was used for training and 25% for validation, and models were 5-fold cross-validated. RESULTS A total of 949 patients were included, with 337 ER patients (35.5%). Patients with ER had higher markers of inflammation, worse disease burden with poor response, and received greater intraoperative fluids/blood products. The highest performing AutoML model was a Stacked Ensemble (area under the curve = 0.78, area under the curve precision recall = 0.66, positive predictive value = 85%, and negative predictive value = 63%). Prediction was influenced by blood markers, operative course, and factors associated with worse disease burden. CONCLUSIONS In this multi-institutional cohort of dAC patients that underwent CRS ± HIPEC, AutoML performed well in predicting patients with ER. Variables suggestive of poor tumor biology were the most influential for prediction. Our work provides a framework for identifying patients with ER that might benefit from shorter interval surveillance early after surgery.
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Affiliation(s)
- Gopika SenthilKumar
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer Merrill
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ugwuji N Maduekwe
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel E Abbott
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Nabeel Zafar
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Sameer Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Fabian Johnston
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Sean Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Morsani College of Medicine, Tampa, Florida; Department of Oncologic Sciences, Morsani College of Medicine, Tampa, Florida
| | - Joel Baumgartner
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, California
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mustafa Raoof
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Laura Lambert
- Department of Surgery, University of Utah Huntsman Cancer Institute, Salt Lake City, Utah
| | - Ryan Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, North Worcester, Massachusetts
| | - Anai N Kothari
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Nagendran M, Festor P, Komorowski M, Gordon AC, Faisal AA. Quantifying the impact of AI recommendations with explanations on prescription decision making. NPJ Digit Med 2023; 6:206. [PMID: 37935953 PMCID: PMC10630476 DOI: 10.1038/s41746-023-00955-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 10/27/2023] [Indexed: 11/09/2023] Open
Abstract
The influence of AI recommendations on physician behaviour remains poorly characterised. We assess how clinicians' decisions may be influenced by additional information more broadly, and how this influence can be modified by either the source of the information (human peers or AI) and the presence or absence of an AI explanation (XAI, here using simple feature importance). We used a modified between-subjects design where intensive care doctors (N = 86) were presented on a computer for each of 16 trials with a patient case and prompted to prescribe continuous values for two drugs. We used a multi-factorial experimental design with four arms, where each clinician experienced all four arms on different subsets of our 24 patients. The four arms were (i) baseline (control), (ii) peer human clinician scenario showing what doses had been prescribed by other doctors, (iii) AI suggestion and (iv) XAI suggestion. We found that additional information (peer, AI or XAI) had a strong influence on prescriptions (significantly for AI, not so for peers) but simple XAI did not have higher influence than AI alone. There was no correlation between attitudes to AI or clinical experience on the AI-supported decisions and nor was there correlation between what doctors self-reported about how useful they found the XAI and whether the XAI actually influenced their prescriptions. Our findings suggest that the marginal impact of simple XAI was low in this setting and we also cast doubt on the utility of self-reports as a valid metric for assessing XAI in clinical experts.
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Affiliation(s)
- Myura Nagendran
- UKRI Centre for Doctoral Training in AI for Healthcare, Imperial College London, London, UK
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Imperial College London, London, UK
- Brain and Behaviour Lab, Imperial College London, London, UK
| | - Paul Festor
- UKRI Centre for Doctoral Training in AI for Healthcare, Imperial College London, London, UK
- Brain and Behaviour Lab, Imperial College London, London, UK
- Department of Computing, Imperial College London, London, UK
| | - Matthieu Komorowski
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Imperial College London, London, UK
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Imperial College London, London, UK
| | - Aldo A Faisal
- UKRI Centre for Doctoral Training in AI for Healthcare, Imperial College London, London, UK.
- Brain and Behaviour Lab, Imperial College London, London, UK.
- Department of Computing, Imperial College London, London, UK.
- Institute of Artificial & Human Intelligence, University of Bayreuth, Bayreuth, Germany.
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He Z, Liu J, Gou F, Wu J. An Innovative Solution Based on TSCA-ViT for Osteosarcoma Diagnosis in Resource-Limited Settings. Biomedicines 2023; 11:2740. [PMID: 37893113 PMCID: PMC10604772 DOI: 10.3390/biomedicines11102740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/24/2023] [Accepted: 10/08/2023] [Indexed: 10/29/2023] Open
Abstract
Identifying and managing osteosarcoma pose significant challenges, especially in resource-constrained developing nations. Advanced diagnostic methods involve isolating the nucleus from cancer cells for comprehensive analysis. However, two main challenges persist: mitigating image noise during the capture and transmission of cellular sections, and providing an efficient, accurate, and cost-effective solution for cell nucleus segmentation. To tackle these issues, we introduce the Twin-Self and Cross-Attention Vision Transformer (TSCA-ViT). This pioneering AI-based system employs a directed filtering algorithm for noise reduction and features an innovative transformer architecture with a twin attention mechanism for effective segmentation. The model also incorporates cross-attention-enabled skip connections to augment spatial information. We evaluated our method on a dataset of 1000 osteosarcoma pathology slide images from the Second People's Hospital of Huaihua, achieving a remarkable average precision of 97.7%. This performance surpasses traditional methodologies. Furthermore, TSCA-ViT offers enhanced computational efficiency owing to its fewer parameters, which results in reduced time and equipment costs. These findings underscore the superior efficacy and efficiency of TSCA-ViT, offering a promising approach for addressing the ongoing challenges in osteosarcoma diagnosis and treatment, particularly in settings with limited resources.
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Affiliation(s)
- Zengxiao He
- School of Computer Science and Engineering, Central South University, Changsha 410083, China;
| | - Jun Liu
- The Second People’s Hospital of Huaihua, Huaihua 418000, China
| | - Fangfang Gou
- State Key Laboratory of Public Big Data, College of Computer Science and Technology, Guizhou University, Guiyang 550025, China;
| | - Jia Wu
- School of Computer Science and Engineering, Central South University, Changsha 410083, China;
- State Key Laboratory of Public Big Data, College of Computer Science and Technology, Guizhou University, Guiyang 550025, China;
- Research Center for Artificial Intelligence, Monash University, Melbourne, Clayton, VIC 3800, Australia
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Ding Z, Chen G, Zhang L, Baheti B, Wu R, Liao W, Liu X, Hou J, Mao Z, Guo Y, Wang C. Residential greenness and cardiac conduction abnormalities: epidemiological evidence and an explainable machine learning modeling study. CHEMOSPHERE 2023; 339:139671. [PMID: 37517666 DOI: 10.1016/j.chemosphere.2023.139671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Previous studies indicated the beneficial influence of residential greenness on cardiovascular disease (CVD), however, the association of residential greenness with cardiac conduction performance remains unclear. This study aims to examine the epidemiological associations between residential greenness and cardiac conduction abnormalities in rural residents, simultaneously exploring the role of residential greenness for cardiac health in an explainable machine learning modeling study. METHODS A total of 27,294 participants were derived from the Henan Rural Cohort. Two satellite-based indices, the normalized difference vegetation index (NDVI) and the enhanced vegetation index (EVI), were used to estimate residential greenness. Independent and combined associations of residential greenness indices and physical activities with electrocardiogram (ECG) parameter abnormalities were evaluated using the logistic regression model and generalized linear model. The Gradient Boosting Machine (GBM) and the SHapely Additive exPlanations (SHAP) were employed in the modeling study. RESULTS The odds ratios (OR) and 95% confidence interval (CI) for QRS interval, heart rate (HR), QTc interval, and PR interval abnormalities with per interquartile range in NDVI were 0.896 (0.873-0.920), 0.955 (0.926-0.986), 1.015 (0.984-1.047), and 0.986 (0.929-1.045), respectively. Furthermore, the participants with higher physical activities plus residential greenness (assessed by EVI) were related to a 1.049-fold (1.017-1.081) and 1.298-fold (1.245-1.354) decreased risk for abnormal QRS interval and HR. Similar results were also observed in the sensitivity analysis. The NDVI ranked fifth (SHAP mean value 0.116) in the analysis for QRS interval abnormality risk in the modeling study. CONCLUSION A higher level of residential greenness was significantly associated with cardiac conduction abnormalities. This effect might be strengthened in residents with more physical activities. This study indicated the cruciality of environmental greenness to cardiac functions and also contributed to refining preventive medicine and greenness design strategies.
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Affiliation(s)
- Zhongao Ding
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Gongbo Chen
- Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Liying Zhang
- Department of Software Engineering, School of Computer and Artificial Intelligence, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Bota Baheti
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Ruiyu Wu
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Wei Liao
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Xiaotian Liu
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Jian Hou
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Zhenxing Mao
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Yuming Guo
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China; Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Chongjian Wang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China; NHC Key Laboratory of Prevention and Treatment of Cerebrovascular Diseases, Zhengzhou, Henan, PR China.
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10
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McDonnell KJ. Leveraging the Academic Artificial Intelligence Silecosystem to Advance the Community Oncology Enterprise. J Clin Med 2023; 12:4830. [PMID: 37510945 PMCID: PMC10381436 DOI: 10.3390/jcm12144830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/05/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
Over the last 75 years, artificial intelligence has evolved from a theoretical concept and novel paradigm describing the role that computers might play in our society to a tool with which we daily engage. In this review, we describe AI in terms of its constituent elements, the synthesis of which we refer to as the AI Silecosystem. Herein, we provide an historical perspective of the evolution of the AI Silecosystem, conceptualized and summarized as a Kuhnian paradigm. This manuscript focuses on the role that the AI Silecosystem plays in oncology and its emerging importance in the care of the community oncology patient. We observe that this important role arises out of a unique alliance between the academic oncology enterprise and community oncology practices. We provide evidence of this alliance by illustrating the practical establishment of the AI Silecosystem at the City of Hope Comprehensive Cancer Center and its team utilization by community oncology providers.
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Affiliation(s)
- Kevin J McDonnell
- Center for Precision Medicine, Department of Medical Oncology & Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA
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11
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Zhuo X, Lv J, Chen B, Liu J, Luo Y, Liu J, Xie X, Lu J, Zhao N. Combining conventional ultrasound and ultrasound elastography to predict HER2 status in patients with breast cancer. Front Physiol 2023; 14:1188502. [PMID: 37501928 PMCID: PMC10369848 DOI: 10.3389/fphys.2023.1188502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/30/2023] [Indexed: 07/29/2023] Open
Abstract
Introduction: Identifying the HER2 status of breast cancer patients is important for treatment options. Previous studies have shown that ultrasound features are closely related to the subtype of breast cancer. Methods: In this study, we used features of conventional ultrasound and ultrasound elastography to predict HER2 status. Results and Discussion: The performance of model (AUROC) with features of conventional ultrasound and ultrasound elastography is higher than that of the model with features of conventional ultrasound (0.82 vs. 0.53). The SHAP method was used to explore the interpretability of the models. Compared with HER2- tumors, HER2+ tumors usually have greater elastic modulus parameters and microcalcifications. Therefore, we concluded that the features of conventional ultrasound combined with ultrasound elastography could improve the accuracy for predicting HER2 status.
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Affiliation(s)
- Xiaoying Zhuo
- Ultrasound Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
- Medical Imaging College of Xuzhou Medical University, Xuzhou, China
| | - Ji Lv
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
- College of Computer Science and Technology, Jilin University, Changchun, China
| | - Binjie Chen
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jia Liu
- Pathology Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yujie Luo
- Ultrasound Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jie Liu
- Ultrasound Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xiaowei Xie
- Ultrasound Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jiao Lu
- Ultrasound Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Ningjun Zhao
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
- Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, China
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12
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Loftus TJ, Altieri MS, Balch JA, Abbott KL, Choi J, Marwaha JS, Hashimoto DA, Brat GA, Raftopoulos Y, Evans HL, Jackson GP, Walsh DS, Tignanelli CJ. Artificial Intelligence-enabled Decision Support in Surgery: State-of-the-art and Future Directions. Ann Surg 2023; 278:51-58. [PMID: 36942574 DOI: 10.1097/sla.0000000000005853] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVE To summarize state-of-the-art artificial intelligence-enabled decision support in surgery and to quantify deficiencies in scientific rigor and reporting. BACKGROUND To positively affect surgical care, decision-support models must exceed current reporting guideline requirements by performing external and real-time validation, enrolling adequate sample sizes, reporting model precision, assessing performance across vulnerable populations, and achieving clinical implementation; the degree to which published models meet these criteria is unknown. METHODS Embase, PubMed, and MEDLINE databases were searched from their inception to September 21, 2022 for articles describing artificial intelligence-enabled decision support in surgery that uses preoperative or intraoperative data elements to predict complications within 90 days of surgery. Scientific rigor and reporting criteria were assessed and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. RESULTS Sample size ranged from 163-2,882,526, with 8/36 articles (22.2%) featuring sample sizes of less than 2000; 7 of these 8 articles (87.5%) had below-average (<0.83) area under the receiver operating characteristic or accuracy. Overall, 29 articles (80.6%) performed internal validation only, 5 (13.8%) performed external validation, and 2 (5.6%) performed real-time validation. Twenty-three articles (63.9%) reported precision. No articles reported performance across sociodemographic categories. Thirteen articles (36.1%) presented a framework that could be used for clinical implementation; none assessed clinical implementation efficacy. CONCLUSIONS Artificial intelligence-enabled decision support in surgery is limited by reliance on internal validation, small sample sizes that risk overfitting and sacrifice predictive performance, and failure to report confidence intervals, precision, equity analyses, and clinical implementation. Researchers should strive to improve scientific quality.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
| | - Maria S Altieri
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Jeremy A Balch
- Department of Surgery, University of Florida Health, Gainesville, FL
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
| | - Kenneth L Abbott
- Department of Surgery, University of Florida Health, Gainesville, FL
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
| | - Jeff Choi
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, Stanford University, Stanford, CA
| | - Jayson S Marwaha
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, Beth Israel Deaconess Medical Center
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA
| | - Daniel A Hashimoto
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, University of Pennsylvania Perelman School of Medicine
- General Robotics, Automation, Sensing, and Perception Laboratory, University of Pennsylvania School of Engineering and Applied Science, Philadelphia, PA
| | - Gabriel A Brat
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, Beth Israel Deaconess Medical Center
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA
| | - Yannis Raftopoulos
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Weight Management Program, Holyoke Medical Center, Holyoke, MA
| | - Heather L Evans
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Gretchen P Jackson
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Digital, Intuitive Surgical, Sunnyvale, CA; Departments of Pediatric Surgery, Pediatrics, and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Danielle S Walsh
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, University of Kentucky, Lexington, KY
| | - Christopher J Tignanelli
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery
- Institute for Health Informatics
- Program for Clinical Artificial Intelligence, Center for Learning Health Systems Science, University of Minnesota, Minneapolis, MN
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Chen Y, Shou L, Xia Y, Deng Y, Li Q, Huang Z, Li Y, Li Y, Cai W, Wang Y, Cheng Y, Chen H, Wan L. Artificial intelligence annotated clinical-pathologic risk model to predict outcomes of advanced gastric cancer. Front Oncol 2023; 13:1099360. [PMID: 37056330 PMCID: PMC10086433 DOI: 10.3389/fonc.2023.1099360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
BackgroundGastric cancer with synchronous distant metastases indicates a dismal prognosis. The success in survival improvement mainly relies on our ability to predict the potential benefit of a therapy. Our objective is to develop an artificial intelligence annotated clinical-pathologic risk model to predict its outcomes.MethodsIn participants (n=47553) with gastric cancer of the surveillance, epidemiology, and end results program, we selected patients with distant metastases at first diagnosis, complete clinical-pathologic data and follow-up information. Patients were randomly divided into the training and test cohort at 7:3 ratio. 93 patients with advanced gastric cancer from six other cancer centers were collected as the external validation cohort. Multivariable analysis was used to identify the prognosis-related clinical-pathologic features. Then a survival prediction model was established and validated. Importantly, we provided explanations to the prediction with artificial intelligence SHAP (Shapley additive explanations) method. We also provide novel insights into treatment options.ResultsData from a total 2549 patients were included in model development and internal test (median age, 61 years [range, 53-69 years]; 1725 [67.7%] male). Data from an additional 93 patients were collected as the external validation cohort (median age, 59 years [range, 48-66 years]; 51 [54.8%] male). The clinical-pathologic model achieved a consistently high accuracy for predicting prognosis in the training (C-index: 0.705 [range, 0.690-0.720]), test (C-index: 0.737 [range, 0.717-0.757]), and external validation (C-index: 0.694 [range, 0.562-0.826]) cohorts. Shapley values indicated that undergoing surgery, chemotherapy, young, absence of lung metastases and well differentiated were the top 5 contributors to the high likelihood of survival. A combination of surgery and chemotherapy had the greatest benefit. However, aggressive treatment did not equate to a survival benefit. SHAP dependence plots demonstrated insightful nonlinear interactive associations among predictors in survival benefit prediction. For example, patients who were elderly, or poor differentiated, or presence of lung or bone metastases had a worse prognosis if they undergo surgery or chemotherapy, while patients with metastases to liver alone seemed to gain benefit from surgery and chemotherapy.ConclusionIn this large multicenter cohort study, we developed an artificial intelligence annotated clinical-pathologic risk model to predict outcomes of advanced gastric cancer. It could be used to discuss treatment options.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Li Wan
- *Correspondence: Li Wan, ; Hongzhuan Chen,
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Lv J, Zhang M, Fu Y, Chen M, Chen B, Xu Z, Yan X, Hu S, Zhao N. An interpretable machine learning approach for predicting 30-day readmission after stroke. Int J Med Inform 2023; 174:105050. [PMID: 36965404 DOI: 10.1016/j.ijmedinf.2023.105050] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/13/2023] [Accepted: 03/17/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Stroke is the second leading cause of death worldwide and has a significantly high recurrence rate. We aimed to identify risk factors for stroke recurrence and develop an interpretable machine learning model to predict 30-day readmissions after stroke. METHODS Stroke patients deposited in electronic health records (EHRs) in Xuzhou Medical University Hospital between February 1, 2021, and November 30, 2021, were included in the study, and deceased patients were excluded. We extracted 74 features from EHRs, and the top 20 features (chi-2 value) were used to build machine learning models. 80% of the patients were used for pre-training. Subsequently, a 20% holdout dataset was used for verification. The Shapley Additive exPlanations (SHAP) method was used to explore the interpretability of the model. RESULTS The cohort included 6,558 patients, of whom the mean (SD) age was 65 (11) years, 3,926 were males (59.86 %), and 132 (2.01 %) were readmitted within 30 days. The area under the receiver operating characteristic curve (AUROC) for the optimized model was 0.80 (95 % CI 0.68-0.80). We used the SHAP method to identify the top 10 risk factors (i.e., severe carotid artery stenosis, weak, homocysteine, glycosylated hemoglobin, sex, lymphocyte percentage, neutrophilic granulocyte percentage, urine glucose, fresh cerebral infarction, and red blood cell count). The AUROC of a model with the 10 features was 0.80 (95 % CI 0.69-0.80) and was not significantly different from that of the model with 20 risk factors. CONCLUSIONS Our methods not only showed good performance in predicting 30-day readmissions after stroke but also revealed risk factors that provided valuable insights for treatments.
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Affiliation(s)
- Ji Lv
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; College of Computer Science and Technology, Jilin University, Changchun, Jilin Province 130000, China
| | - Mengmeng Zhang
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China
| | - Yujie Fu
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China
| | - Mengshuang Chen
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China
| | - Binjie Chen
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China
| | - Zhiyuan Xu
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China
| | - Xianliang Yan
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China.
| | - Shuqun Hu
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China.
| | - Ningjun Zhao
- Emergency Medicine Department of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China; Laboratory of Emergency Medicine, Second Clinical Medical College of Xuzhou Medical University, Xuzhou, Jiangsu Province 221002, China.
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Error in Text. JAMA Netw Open 2022; 5:e2221574. [PMID: 35731521 PMCID: PMC9218847 DOI: 10.1001/jamanetworkopen.2022.21574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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