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Reyes Gil M, Pantanowitz J, Rashidi HH. Venous thromboembolism in the era of machine learning and artificial intelligence in medicine. Thromb Res 2024; 242:109121. [PMID: 39213896 DOI: 10.1016/j.thromres.2024.109121] [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: 05/06/2024] [Revised: 07/19/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024]
Abstract
In this review, we embark on a comprehensive exploration of venous thromboembolism (VTE) in the context of medical history and its current practice within medicine. We delve into the landscape of artificial intelligence (AI), exploring its present utility and envisioning its transformative roles within VTE management, from prevention to screening and beyond. Central to our discourse is a forward-looking perspective on the integration of AI within VTE in medicine, advocating for rigorous study design, robust validation processes, and meticulous statistical analysis to gauge the efficacy of AI applications. We further illuminate the potential of large language models and generative AI in revolutionizing VTE care, while acknowledging their inherent limitations and proposing innovative solutions to overcome challenges related to data availability and integrity, including the strategic use of synthetic data. The critical importance of navigating ethical, legal, and privacy concerns associated with AI is underscored, alongside the imperative for comprehensive governance and policy frameworks to regulate its deployment in VTE treatment. We conclude on a note of cautious optimism, where we highlight the significance of proactively addressing the myriad challenges that accompany the advent of AI in healthcare. Through diligent design, stringent validation, extensive education, and prudent regulation, we can harness AI's potential to significantly enhance our understanding and management of VTE. As we stand on the cusp of a new era, our commitment to these principles will be instrumental in ensuring that the promise of AI is fully realized within the realm of VTE care.
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Affiliation(s)
- Morayma Reyes Gil
- Thrombosis and Hemostasis Labs, Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, United States of America.
| | - Joshua Pantanowitz
- Computational Pathology and AI Center of Excellence, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Hooman H Rashidi
- Computational Pathology and AI Center of Excellence, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America.
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Development of a system to support warfarin dose decisions using deep neural networks. Sci Rep 2021; 11:14745. [PMID: 34285309 PMCID: PMC8292496 DOI: 10.1038/s41598-021-94305-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/09/2021] [Indexed: 11/09/2022] Open
Abstract
The first aim of this study was to develop a prothrombin time international normalized ratio (PT INR) prediction model. The second aim was to develop a warfarin maintenance dose decision support system as a precise warfarin dosing platform. Data of 19,719 inpatients from three institutions was analyzed. The PT INR prediction algorithm included dense and recurrent neural networks, and was designed to predict the 5th-day PT INR from data of days 1-4. Data from patients in one hospital (n = 22,314) was used to train the algorithm which was tested with the datasets from the other two hospitals (n = 12,673). The performance of 5th-day PT INR prediction was compared with 2000 predictions made by 10 expert physicians. A generator of individualized warfarin dose-PT INR tables which simulated the repeated administration of varying doses of warfarin was developed based on the prediction model. The algorithm outperformed humans with accuracy terms of within ± 0.3 of the actual value (machine learning algorithm: 10,650/12,673 cases (84.0%), expert physicians: 1647/2000 cases (81.9%), P = 0.014). In the individualized warfarin dose-PT INR tables generated by the algorithm, the 8th-day PT INR predictions were within 0.3 of actual value in 450/842 cases (53.4%). An artificial intelligence-based warfarin dosing algorithm using a recurrent neural network outperformed expert physicians in predicting future PT INRs. An individualized warfarin dose-PT INR table generator which was constructed based on this algorithm was acceptable.
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Zhang Y, Xie C, Xue L, Tao Y, Yue G, Jiang B. A post-hoc interpretable ensemble model to feature effect analysis in warfarin dose prediction for Chinese patients. IEEE J Biomed Health Inform 2021; 26:840-851. [PMID: 34166206 DOI: 10.1109/jbhi.2021.3092170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
To interprete the importance of clinical features and genotypes for warfarin daily dose prediction, we developed a post-hoc interpretable framework based on an ensemble predictive model. This framework includes permutation importance for global interpretation and local interpretable model-agnostic explanation (LIME) and shapley additive explanations (SHAP) for local explanation. The permutation importance globally ranks the importance of features on the whole data set. This can guide us to build a predictive model with less variables and the complexity of final predictive model can be reduced. LIME and SHAP together explain how the predictive model give the predicted dosage for specific samples. This help clinicians prescribe accurate doses to patients using more effective clinical variables. Results showed that both the permutation importance and SHAP demonstrated that VKORC1, age, serum creatinine (SCr), left atrium (LA) size, CYP2C9 and weight were the most important features on the whole data set. In specific samples, both SHAP and LIME discovered that in Chinese patients, wild-type VKORC1-AA, mutant-type CYP2C9*3, age over 60, abnormal LA size, SCr within the normal range, and using amiodarone definitely required dosage reduction, whereas mutant-type VKORC1-AG/GG, small age, SCr out of normal range, normal LA size, diabetes and heavy weight required dosage enhancement.
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Liu Y, Chen J, You Y, Xu A, Li P, Wang Y, Sun J, Yu Z, Gao F, Zhang J. An ensemble learning based framework to estimate warfarin maintenance dose with cross-over variables exploration on incomplete data set. Comput Biol Med 2021; 131:104242. [PMID: 33578070 DOI: 10.1016/j.compbiomed.2021.104242] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 11/16/2022]
Abstract
MOTIVATION Warfarin is a widely used oral anticoagulant, but it is challenging to select the optimal maintenance dose due to its narrow therapeutic window and complex individual factor relationships. In recent years, machine learning techniques have been widely applied for warfarin dose prediction. However, the model performance always meets the upper limit due to the ignoration of exploring the variable interactions sufficiently. More importantly, there is no efficient way to resolve missing values when predicting the optimal warfarin maintenance dose. METHODS Using an observational cohort from the Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine, we propose a novel method for warfarin maintenance dose prediction, which is capable of assessing variable interactions and dealing with missing values naturally. Specifically, we examine single variables by univariate analysis initially, and only statistically significant variables are included. We then propose a novel feature engineering method on them to generate the cross-over variables automatically. Their impacts are evaluated by stepwise regression, and only the significant ones are selected. Lastly, we implement an ensemble learning based approach, LightGBM, to learn from incomplete data directly on the selected single and cross-over variables for dosing prediction. RESULTS 377 unique patients with eligible and time-independent 1173 warfarin order events are included in this study. Through the comprehensive experimental results in 5-fold cross-validation, our proposed method demonstrates the efficiency of exploring the variable interactions and modeling on incomplete data. The R2 can achieve 75.0% on average. Moreover, the subgroup analysis results reveal that our method performs much better than other baseline methods, especially in the medium-dose and high-dose subgroups. Lastly, the IWPC dosing prediction model is used for further comparison, and our approach outperforms it by a significant margin. CONCLUSION In summary, our proposed method is capable of exploring the variable interactions and learning from incomplete data directly for warfarin maintenance dose prediction, which has a great premise and is worthy of further research.
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Affiliation(s)
- Yan Liu
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Jihui Chen
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Yin You
- Department of Neurology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China
| | - Ajing Xu
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Ping Li
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Yu Wang
- Beijing Medicinovo Technology Co. Ltd, Beijing, 100071, China
| | - Jiaxing Sun
- Beijing Medicinovo Technology Co. Ltd, Beijing, 100071, China
| | - Ze Yu
- Beijing Medicinovo Technology Co. Ltd, Beijing, 100071, China
| | - Fei Gao
- Beijing Medicinovo Technology Co. Ltd, Beijing, 100071, China.
| | - Jian Zhang
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China.
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Asiimwe IG, Zhang EJ, Osanlou R, Jorgensen AL, Pirmohamed M. Warfarin dosing algorithms: A systematic review. Br J Clin Pharmacol 2020; 87:1717-1729. [PMID: 33080066 PMCID: PMC8056736 DOI: 10.1111/bcp.14608] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/04/2020] [Accepted: 10/05/2020] [Indexed: 12/11/2022] Open
Abstract
Aims Numerous algorithms have been developed to guide warfarin dosing and improve clinical outcomes. We reviewed the algorithms available for various populations and the covariates, performances and risk of bias of these algorithms. Methods We systematically searched MEDLINE up to 20 May 2020 and selected studies describing the development, external validation or clinical utility of a multivariable warfarin dosing algorithm. Two investigators conducted data extraction and quality assessment. Results Of 10 035 screened records, 266 articles were included in the review, describing the development of 433 dosing algorithms, 481 external validations and 52 clinical utility assessments. Most developed algorithms were for dose initiation (86%), developed by multiple linear regression (65%) and mostly applicable to Asians (49%) or Whites (43%). The most common demographic/clinical/environmental covariates were age (included in 401 algorithms), concomitant medications (270 algorithms) and weight (229 algorithms) while CYP2C9 (329 algorithms), VKORC1 (319 algorithms) and CYP4F2 (92 algorithms) variants were the most common genetic covariates. Only 26% and 7% algorithms were externally validated and evaluated for clinical utility, respectively, with <2% of algorithm developments and external validations being rated as having a low risk of bias. Conclusion Most warfarin dosing algorithms have been developed in Asians and Whites and may not be applicable to under‐served populations. Few algorithms have been externally validated, assessed for clinical utility, and/or have a low risk of bias which makes them unreliable for clinical use. Algorithm development and assessment should follow current methodological recommendations to improve reliability and applicability, and under‐represented populations should be prioritized.
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Affiliation(s)
- Innocent G Asiimwe
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, United Kingdom
| | - Eunice J Zhang
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, United Kingdom
| | - Rostam Osanlou
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, United Kingdom
| | - Andrea L Jorgensen
- Department of Biostatistics, Institute of Population Health Sciences, University of Liverpool, United Kingdom
| | - Munir Pirmohamed
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, United Kingdom
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Shoji M, Suzuki S, Otsuka T, Arita T, Yagi N, Semba H, Kano H, Matsuno S, Kato Y, Uejima T, Oikawa Y, Matsuhama M, Yajima J, Yamashita T. A Simple Formula for Predicting the Maintenance Dose of Warfarin with Reference to the Initial Response to Low Dosing at an Outpatient Clinic. Intern Med 2020; 59:29-35. [PMID: 31511484 PMCID: PMC6995699 DOI: 10.2169/internalmedicine.3415-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective The pharmacodynamic effect of warfarin varies among individuals, and its maintenance dose is widely distributed. Although many formulae for predicting the maintenance dose of warfarin have been developed, most of them are complex and not in practical use. Methods and Materials Among 12,738 new patients visiting the Cardiovascular Institute between 2004 and 2009, we identified 127 patients (66.6±8.8 years, 89 men) with atrial fibrillation for whom warfarin was newly started with an initial dose of 2 mg/day and the international normalized ratio (INR) at 1 year after warfarin was started was within the therapeutic range. The prediction models for the maintenance dose were developed by an exponential equation and a first-order equation. Results The initial response of the INR to the dose of 2 mg/day (initial INR) ranged from 1.00-3.24 (mean 1.43), while the maintenance dose of warfarin ranged from 0.5-14 mg (mean 3.8 mg). The maintenance dose showed an exponential correlation to the initial INR: (predicted maintenance dose) =5.522× (initial INR) -1.556 (R2=0.795, p<0.001). Excluding the patients with a poor response to the initial dose (initial INR <1.1, n=32) permitted a simple correlation with a first-order approximation: (predicted maintenance dose) =-2.009× (initial INR) +6.172 (R2=0.706, p<0.001). Conclusion We developed a simple formula for predicting the maintenance dose of warfarin using the initial response of the INR to low-dose warfarin.
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Affiliation(s)
- Masaaki Shoji
- Department of Cardiovascular Medicine, National Cancer Center Hospital, Japan
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Takayuki Otsuka
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Takuto Arita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Naoharu Yagi
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Hiroaki Semba
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Hiroto Kano
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Shunsuke Matsuno
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Yuko Kato
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Tokuhisa Uejima
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Yuji Oikawa
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Minoru Matsuhama
- Department of Cardiovascular Surgery, The Cardiovascular Institute, Japan
| | - Junji Yajima
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
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