Deep Risk Prediction and Embedding of Patient Data: Application to Acute Gastrointestinal Bleeding

Acute gastrointestinal bleeding is a common and costly condition, accounting for over 2.2 million hospital days and 19.2 billion dollars of medical charges annually. Risk stratification is a critical part of initial assessment of patients with acute gastrointestinal bleeding. Although all national and international guidelines recommend the use of risk-assessment scoring systems, they are not commonly used in practice, have sub-optimal performance, may be applied incorrectly, and are not easily updated. With the advent of widespread electronic health record adoption, longitudinal clinical data captured during the clinical encounter is now available. However, this data is often noisy, sparse, and heterogeneous. Unsupervised machine learning algorithms may be able to identify structure within electronic health record data while accounting for key issues with the data generation process: measurements missing-not-at-random and information captured in unstructured clinical note text. Deep learning tools can create electronic health record-based models that perform better than clinical risk scores for gastrointestinal bleeding and are well-suited for learning from new data. Furthermore, these models can be used to predict risk trajectories over time, leveraging the longitudinal nature of the electronic health record. The foundation of creating relevant tools is the definition of a relevant outcome measure; in acute gastrointestinal bleeding, a composite outcome of red blood cell transfusion, hemostatic intervention, and all-cause 30-day mortality is a relevant, actionable outcome that reflects the need for hospital-based intervention. However, epidemiological trends may affect the relevance and effectiveness of the outcome measure when applied across multiple settings and patient populations. Understanding the trends in practice, potential areas of disparities, and value proposition for using risk stratification in patients presenting to the Emergency Department with acute gastrointestinal bleeding is important in understanding how to best implement a robust, generalizable risk stratification tool. Key findings include a decrease in the rate of red blood cell transfusion since 2014 and disparities in access to upper endoscopy for patients with upper gastrointestinal bleeding by race/ethnicity across urban and rural hospitals. Projected accumulated savings of consistent implementation of risk stratification tools for upper gastrointestinal bleeding total approximately $1 billion 5 years after implementation. Most current risk scores were designed for use based on the location of the bleeding source: upper or lower gastrointestinal tract. However, the location of the bleeding source is not always clear at presentation. I develop and validate electronic health record based deep learning and machine learning tools for patients presenting with symptoms of acute gastrointestinal bleeding (e.g., hematemesis, melena, hematochezia), which is more relevant and useful in clinical practice. I show that they outperform leading clinical risk scores for upper and lower gastrointestinal bleeding, the Glasgow Blatchford Score and the Oakland score. While the best performing gradient boosted decision tree model has equivalent overall performance to the fully connected feedforward neural network model, at the very low risk threshold of 99% sensitivity the deep learning model identifies more very low risk patients. Using another deep learning model that can model longitudinal risk, the long-short-term memory recurrent neural network, need for transfusion of red blood cells can be predicted at every 4-hour interval in the first 24 hours of intensive care unit stay for high risk patients with acute gastrointestinal bleeding. Finally, for implementation it is important to find patients with symptoms of acute gastrointestinal bleeding in real time and characterize patients by risk using available data in the electronic health record. A decision rule-based electronic health record phenotype has equivalent performance as measured by positive predictive value compared to deep learning and natural language processing-based models, and after live implementation appears to have increased the use of the Acute Gastrointestinal Bleeding Clinical Care pathway. Patients with acute gastrointestinal bleeding but with other groups of disease concepts can be differentiated by directly mapping unstructured clinical text to a common ontology and treating the vector of concepts as signals on a knowledge graph; these patients can be differentiated using unbalanced diffusion earth mover’s distances on the graph. For electronic health record data with data missing not at random, MURAL, an unsupervised random forest-based method, handles data with missing values and generates visualizations that characterize patients with gastrointestinal bleeding. This thesis forms a basis for understanding the potential for machine learning and deep learning tools to characterize risk for patients with acute gastrointestinal bleeding. In the future, these tools may be critical in implementing integrated risk assessment to keep low risk patients out of the hospital and guide resuscitation and timely endoscopic procedures for patients at higher risk for clinical decompensation

A multi-stage machine learning model on diagnosis of esophageal manometry

High-resolution manometry (HRM) is the primary procedure used to diagnose esophageal motility disorders. Its interpretation and classification includes an initial evaluation of swallow-level outcomes and then derivation of a study-level diagnosis based on Chicago Classification (CC), using a tree-like algorithm. This diagnostic approach on motility disordered using HRM was mirrored using a multi-stage modeling framework developed using a combination of various machine learning approaches. Specifically, the framework includes deep-learning models at the swallow-level stage and feature-based machine learning models at the study-level stage. In the swallow-level stage, three models based on convolutional neural networks (CNNs) were developed to predict swallow type, swallow pressurization, and integrated relaxation pressure (IRP). At the study-level stage, model selection from families of the expert-knowledge-based rule models, xgboost models and artificial neural network(ANN) models were conducted, with the latter two model designed and augmented with motivation from the export knowledge. A simple model-agnostic strategy of model balancing motivated by Bayesian principles was utilized, which gave rise to model averaging weighted by precision scores. The averaged (blended) models and individual models were compared and evaluated, of which the best performance on test dataset is 0.81 in top-1 prediction, 0.92 in top-2 predictions. This is the first artificial-intelligence-style model to automatically predict CC diagnosis of HRM study from raw multi-swallow data. Moreover, the proposed modeling framework could be easily extended to multi-modal tasks, such as diagnosis of esophageal patients based on clinical data from both HRM and functional luminal imaging probe panometry (FLIP)

Bayesian networks for disease diagnosis: What are they, who has used them and how?

A Bayesian network (BN) is a probabilistic graph based on Bayes' theorem, used to show dependencies or cause-and-effect relationships between variables. They are widely applied in diagnostic processes since they allow the incorporation of medical knowledge to the model while expressing uncertainty in terms of probability. This systematic review presents the state of the art in the applications of BNs in medicine in general and in the diagnosis and prognosis of diseases in particular. Indexed articles from the last 40 years were included. The studies generally used the typical measures of diagnostic and prognostic accuracy: sensitivity, specificity, accuracy, precision, and the area under the ROC curve. Overall, we found that disease diagnosis and prognosis based on BNs can be successfully used to model complex medical problems that require reasoning under conditions of uncertainty.Comment: 22 pages, 5 figures, 1 table, Student PhD first pape

Charting the single-cell landscape of colorectal cancer stem cell polarisation

Colonic epithelia is regulated by cell-intrinsic and cell-extrinsic cues, both in homeostatic tissues and colorectal cancer (CRC), where the tumour microenvironment closely interacts with mutated epithelia. Our understanding on how these cues polarise colonic stem cell (CSC) states remains incomplete. Indeed, charting the interaction between intrinsic and stromal cues requires a systematic study yet to be found in the literature. In this work I present my efforts towards computationally studying colonic stem cell polarisation at single-cell resolution. Leveraging the scalability of organoid models, my colleagues and I dissected the heterocellular CRC organoid system presented in Qin & Cardoso Rodriguez et al. using single-cell omic analyses, resolving complex interaction and polarisation processes. First, I identified bottlenecks in common mass cytometry (MC) analysis workflows benefiting from either increased accessibility or automation; designing the CyGNAL pipeline and developing a cell-state classifier to tackle these points respectively. I then used single-cell RNA sequencing (scRNA-seq) data to reveal a shared landscape of CSC polarisation; wherein stromal cues polarise the epithelia towards slow-cycling revival CSC (revCSC) and oncogenic mutations trap cells in a hyper-proliferative CSC (proCSC) state. I then developed a method to visualise single-cell differentation using a novel valley-ridge (VR) score, which can generate data-driven Waddington-like landscapes that recapitulate differentiation dynamics of the colonic epithelia. Finally, I explored an approach for holistic inter- and intra-cellular communication analysis by incorporating literature information as a directed knowledge graph (KG), showing that low-dimensional representations of the graph retain biological information and that projected cellular profiles recapitulate their transcriptomes. These results reveal a polarisation landscape where CRC epithelia is trapped in a proCSC state refractory to stromal cues, and broadly show the importance of joint collaborative wet- and dry-lab work; central towards targeting gaps in the method space and generating a comprehensive analysis of heterocellular signalling in cancer