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Islam NU, Zhou Z, Gehlot S, Gotway MB, Liang J. Seeking an optimal approach for Computer-aided Diagnosis of Pulmonary Embolism. Med Image Anal 2024; 91:102988. [PMID: 37924750 PMCID: PMC11039560 DOI: 10.1016/j.media.2023.102988] [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: 05/26/2022] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 11/06/2023]
Abstract
Pulmonary Embolism (PE) represents a thrombus ("blood clot"), usually originating from a lower extremity vein, that travels to the blood vessels in the lung, causing vascular obstruction and in some patients death. This disorder is commonly diagnosed using Computed Tomography Pulmonary Angiography (CTPA). Deep learning holds great promise for the Computer-aided Diagnosis (CAD) of PE. However, numerous deep learning methods, such as Convolutional Neural Networks (CNN) and Transformer-based models, exist for a given task, causing great confusion regarding the development of CAD systems for PE. To address this confusion, we present a comprehensive analysis of competing deep learning methods applicable to PE diagnosis based on four datasets. First, we use the RSNA PE dataset, which includes (weak) slice-level and exam-level labels, for PE classification and diagnosis, respectively. At the slice level, we compare CNNs with the Vision Transformer (ViT) and the Swin Transformer. We also investigate the impact of self-supervised versus (fully) supervised ImageNet pre-training, and transfer learning over training models from scratch. Additionally, at the exam level, we compare sequence model learning with our proposed transformer-based architecture, Embedding-based ViT (E-ViT). For the second and third datasets, we utilize the CAD-PE Challenge Dataset and Ferdowsi University of Mashad's PE Dataset, where we convert (strong) clot-level masks into slice-level annotations to evaluate the optimal CNN model for slice-level PE classification. Finally, we use our in-house PE-CAD dataset, which contains (strong) clot-level masks. Here, we investigate the impact of our vessel-oriented image representations and self-supervised pre-training on PE false positive reduction at the clot level across image dimensions (2D, 2.5D, and 3D). Our experiments show that (1) transfer learning boosts performance despite differences between photographic images and CTPA scans; (2) self-supervised pre-training can surpass (fully) supervised pre-training; (3) transformer-based models demonstrate comparable performance but slower convergence compared with CNNs for slice-level PE classification; (4) model trained on the RSNA PE dataset demonstrates promising performance when tested on unseen datasets for slice-level PE classification; (5) our E-ViT framework excels in handling variable numbers of slices and outperforms sequence model learning for exam-level diagnosis; and (6) vessel-oriented image representation and self-supervised pre-training both enhance performance for PE false positive reduction across image dimensions. Our optimal approach surpasses state-of-the-art results on the RSNA PE dataset, enhancing AUC by 0.62% (slice-level) and 2.22% (exam-level). On our in-house PE-CAD dataset, 3D vessel-oriented images improve performance from 80.07% to 91.35%, a remarkable 11% gain. Codes are available at GitHub.com/JLiangLab/CAD_PE.
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Affiliation(s)
- Nahid Ul Islam
- School of Computing and Augmented Intelligence, Arizona State University, Tempe, AZ 85281, USA
| | - Zongwei Zhou
- Department of Computer Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Shiv Gehlot
- Biomedical Informants Program, Arizona State University, Phoenix, AZ 85054, USA
| | | | - Jianming Liang
- Biomedical Informants Program, Arizona State University, Phoenix, AZ 85054, USA.
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Jarman AF, Mumma BE, White R, Dooley E, Yang NT, Taylor SL, Newgard C, Morris C, Cloutier J, Maughan BC. Sex differences in guideline-consistent diagnostic testing for acute pulmonary embolism among adult emergency department patients aged 18-49. Acad Emerg Med 2023; 30:896-905. [PMID: 36911917 PMCID: PMC10497718 DOI: 10.1111/acem.14722] [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: 12/20/2022] [Revised: 03/02/2023] [Accepted: 03/05/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is a frequent diagnostic consideration in emergency department (ED) patients, yet diagnosis is challenging because symptoms of PE are nonspecific. Guidelines recommend the use of clinical decision tools to increase efficiency and avoid harms from overtesting, including D-dimer screening in patients not at high risk for PE. Women undergo testing for PE more often than men yet have a lower yield from testing. Our study objective was to determine whether patient sex influenced the odds of received guideline-consistent care. METHODS We performed a retrospective cohort study at two large U.S. academic EDs from January 1, 2016, to December 31, 2018. Nonpregnant patients aged 18-49 years were included if they presented with chest pain, shortness of breath, hemoptysis, or syncope and underwent testing for PE with D-dimer or imaging. Demographic and clinical data were exported from the electronic medical record (EMR). Pretest risk scores were calculated using manually abstracted EMR data. Diagnostic testing was then compared with recommended testing based on pretest risk. The primary outcome was receipt of guideline-consistent care, which required an elevated screening D-dimer prior to imaging in all non-high-risk patients. RESULTS We studied 1991 discrete patient encounters; 37% (735) of patients were male and 63% (1256) were female. Baseline characteristics, including revised Geneva scores, were similar between sexes. Female patients were more likely to receive guideline-consistent care (70% [874/1256] female vs. 63% [463/735] male, p < 0.01) and less likely to be diagnosed with PE (3.1% [39/1256] female vs. 5.3% [39/735] male, p < 0.05). The most common guideline deviation in both sexes was obtaining imaging without a screening D-dimer in a non-high-risk patient (75% [287/382] female vs. 75% [205/272] male). CONCLUSIONS In this cohort, females were more likely than males to receive care consistent with current guidelines and less likely to be diagnosed with PE.
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Affiliation(s)
- Angela F Jarman
- Department of Emergency Medicine, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Richard White
- Department of Internal Medicine, Division of Rheumatology, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Emily Dooley
- University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Nuen Tsang Yang
- Department of Public Health Sciences, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Sandra L. Taylor
- Department of Public Health Sciences, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Craig Newgard
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Cynthia Morris
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA
| | - Jared Cloutier
- School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Brandon C Maughan
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
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Islam NU, Gehlot S, Zhou Z, Gotway MB, Liang J. Seeking an Optimal Approach for Computer-Aided Pulmonary Embolism Detection. MACHINE LEARNING IN MEDICAL IMAGING. MLMI (WORKSHOP) 2021; 12966:692-702. [PMID: 35695860 PMCID: PMC9184235 DOI: 10.1007/978-3-030-87589-3_71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pulmonary embolism (PE) represents a thrombus ("blood clot"), usually originating from a lower extremity vein, that travels to the blood vessels in the lung, causing vascular obstruction and in some patients, death. This disorder is commonly diagnosed using CT pulmonary angiography (CTPA). Deep learning holds great promise for the computer-aided CTPA diagnosis (CAD) of PE. However, numerous competing methods for a given task in the deep learning literature exist, causing great confusion regarding the development of a CAD PE system. To address this confusion, we present a comprehensive analysis of competing deep learning methods applicable to PE diagnosis using CTPA at the both image and exam levels. At the image level, we compare convolutional neural networks (CNNs) with vision transformers, and contrast self-supervised learning (SSL) with supervised learning, followed by an evaluation of transfer learning compared with training from scratch. At the exam level, we focus on comparing conventional classification (CC) with multiple instance learning (MIL). Our extensive experiments consistently show: (1) transfer learning consistently boosts performance despite differences between natural images and CT scans, (2) transfer learning with SSL surpasses its supervised counterparts; (3) CNNs outperform vision transformers, which otherwise show satisfactory performance; and (4) CC is, surprisingly, superior to MIL. Compared with the state of the art, our optimal approach provides an AUC gain of 0.2% and 1.05% for image-level and exam-level, respectively.
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Affiliation(s)
| | - Shiv Gehlot
- Arizona State University, Tempe, AZ 85281, USA
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Fernández‐Capitán C, Rodriguez Cobo A, Jiménez D, Madridano O, Ciammaichella M, Usandizaga E, Otero R, Di Micco P, Moustafa F, Monreal M. Symptomatic subsegmental versus more central pulmonary embolism: Clinical outcomes during anticoagulation. Res Pract Thromb Haemost 2021; 5:168-178. [PMID: 33537541 PMCID: PMC7845079 DOI: 10.1002/rth2.12446] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/01/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The optimal therapy of patients with acute subsegmental pulmonary embolism (PE) is controversial. METHODS We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) database to compare the rate of symptomatic PE recurrences during anticoagulation in patients with subsegmental, segmental, or more central PEs. RESULTS Among 15 963 patients with a first episode of symptomatic PE, 834 (5.2%) had subsegmental PE, 3797 (24%) segmental, and 11 332 (71%) more central PE. Most patients in all subgroups received initial therapy with low-molecular-weight heparin, and then most switched to vitamin K antagonists. Median duration of therapy was 179, 185, and 204 days, respectively. During anticoagulation, 183 patients developed PE recurrences, 131 developed deep vein thrombosis (DVT), 543 bled, and 1718 died (fatal PE, 135). The rate of PE recurrences was twofold higher in patients with subsegmental PE than in those with segmental (hazard ratio [HR], 2.13; 95% confidence interval [CI], 1.16-3.85) or more central PE (HR, 1.89; 95% CI, 1.12-3.13). On multivariable analysis, patients with subsegmental PE had a higher risk for PE recurrences than those with central PE (adjusted HR, 1.75; 95% CI, 1.02-3.03). After stratifying patients with subsegmental PE according to ultrasound imaging in the lower limbs, the rate of PE recurrences was similar in patients with DVT, in patients without DVT, and in those with no ultrasound imaging. CONCLUSIONS Our study reveals that the risk for PE recurrences in patients with segmental PE is not lower than in those with more central PE, thus suggesting that the risk of PE recurrences is not influenced by the anatomic location of PE.
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Affiliation(s)
| | - Ana Rodriguez Cobo
- Department of Internal MedicineHospital de Madrid Norte SanchinarroMadridSpain
| | - David Jiménez
- Respiratory DepartmentRamón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCISMadridSpain
| | - Olga Madridano
- Department of Internal MedicineHospital Infanta SofíaMadridSpain
| | | | - Esther Usandizaga
- Department of Internal MedicineHospital de Sant Joan Despí Moises BroggiBarcelonaSpain
| | - Remedios Otero
- Department of PneumonologyHospital Universitario Virgen del RocíoSevillaSpain
| | - Pierpaolo Di Micco
- Department of Internal Medicine and Emergency RoomOspedale Buon Consiglio FatebenefratelliNaplesItaly
| | - Farès Moustafa
- Department of EmergencyClermont‐Ferrand University HospitalClermont‐FerrandFrance
| | - Manuel Monreal
- Department of Internal MedicineHospital de Badalona Germans Trias i PujolUniversidad Católica de MurciaMurciaSpain
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Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016; 149:315-352. [PMID: 26867832 DOI: 10.1016/j.chest.2015.11.026] [Citation(s) in RCA: 3251] [Impact Index Per Article: 406.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 11/24/2015] [Accepted: 11/25/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND We update recommendations on 12 topics that were in the 9th edition of these guidelines, and address 3 new topics. METHODS We generate strong (Grade 1) and weak (Grade 2) recommendations based on high- (Grade A), moderate- (Grade B), and low- (Grade C) quality evidence. RESULTS For VTE and no cancer, as long-term anticoagulant therapy, we suggest dabigatran (Grade 2B), rivaroxaban (Grade 2B), apixaban (Grade 2B), or edoxaban (Grade 2B) over vitamin K antagonist (VKA) therapy, and suggest VKA therapy over low-molecular-weight heparin (LMWH; Grade 2C). For VTE and cancer, we suggest LMWH over VKA (Grade 2B), dabigatran (Grade 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C), or edoxaban (Grade 2C). We have not changed recommendations for who should stop anticoagulation at 3 months or receive extended therapy. For VTE treated with anticoagulants, we recommend against an inferior vena cava filter (Grade 1B). For DVT, we suggest not using compression stockings routinely to prevent PTS (Grade 2B). For subsegmental pulmonary embolism and no proximal DVT, we suggest clinical surveillance over anticoagulation with a low risk of recurrent VTE (Grade 2C), and anticoagulation over clinical surveillance with a high risk (Grade 2C). We suggest thrombolytic therapy for pulmonary embolism with hypotension (Grade 2B), and systemic therapy over catheter-directed thrombolysis (Grade 2C). For recurrent VTE on a non-LMWH anticoagulant, we suggest LMWH (Grade 2C); for recurrent VTE on LMWH, we suggest increasing the LMWH dose (Grade 2C). CONCLUSIONS Of 54 recommendations included in the 30 statements, 20 were strong and none was based on high-quality evidence, highlighting the need for further research.
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Leopold SS. Editor's Spotlight/Take 5: CT pulmonary angiography after total joint arthroplasty: overdiagnosis and iatrogenic harm? Interview by Seth S. Leopold. Clin Orthop Relat Res 2013; 471:2733-6. [PMID: 23775572 PMCID: PMC3734396 DOI: 10.1007/s11999-013-3108-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 06/07/2013] [Indexed: 01/31/2023]
Affiliation(s)
- Seth S. Leopold
- Clinical Orthopaedics and Related Research, 1600 Spruce Street, Philadelphia, PA 19013 USA
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