Closed-loop effects in cardiovascular clinical decision support

We have recently seen impressive methodological developments in quantitative cardiovascular physiology and pathophysiology, with novel mathematical models for the mechanical and electrophysiological processes of the heart, and fluid dynamical models to describe the pressure and flow distribution in the blood vessel network. This allows us to gain deeper insight into the state of a variety of serious cardiovascular diseases. The majority of recent research studies have focused on the forward problem: developing flexible mathematical models and robust numerical simulation procedures to match characteristics of physiological target data, and the inverse problem: inferring model parameters from cardiac physiological data with reliable uncertainty quantification. However, when connecting mathematical model predictions and statistical inference to the clinical decision process, new challenges arise. This paper briefly discusses the complications that potentially result from closed-loop effects, and the model extensions that are required to reduce the ensuing bias

Closed-loop effects in coupling cardiac physiological models to clinical interventions

There have been impressive methodological advancements in the mathematical modelling of cardio-physiological processes. The majority of recent articles have focused on the forward problem: developing flexible mathematical models and robust numerical simulation procedures to match characteristics of physiological target data, and the inverse problem: inferring model parameters from cardiac physiological data with reliable uncertainty quantification. However, when connecting mathematical model predictions to the clinical decision process, new challenges arise. This paper briefly discusses the complications that poten- tially result from closed-loop effects, and the model extensions that are required to reduce the ensuing bias

Parameter Inference in the Pulmonary Circulation of Mice

This study focuses on parameter inference in a pulmonary blood cir- culation model for mice. It utilises a fluid dynamics network model that takes selected parameter values and aims to mimic features of the pulmonary haemody- namics under normal physiological and pathological conditions. This is of medical relevance as it allows monitoring of the progression of pulmonary hypertension. Constraint nonlinear optimization is successfully used to learn the parameter values

MCMC with Delayed Acceptance using a Surrogate Model with an Application to Cardiovascular Fluid Dynamics

Parameter estimation and uncertainty quantification in physiological modelling is a vital step towards personalised medicine. Current state-of-the-art in this research area performs parameter optimisation, with very limited uncertainty quantification. This paper demonstrates the advantage of novel sampling methods, applied on a complex biological PDE system of the pulmonary circulation. The aim is to find an efficient and accurate method for the inference and uncertainty quantification of unknown parameters, relevant for disease diagnosis (pulmonary hypertension) from limited and noisy blood pressure data. The data likelihood is expensive to evaluate as it requires solving numerically a system of PDEs. Therefore, having a model that best trades off accuracy and computational efficiency is of uppermost importance. In this study, we employ fast Bayesian methods, namely MCMC algorithms coupled with emulation using Gaussian Processes, to achieve a computational speed-up. We compare the Delayed Rejection Adaptive Metropolis algorithm in a History Matching framework to the delayed acceptance Adaptive Metropolis algorithm. The first algorithm draws samples from the approximate posterior distribution, while the latter is guaranteed to generate samples from the exact posterior distribution asymptotically. In this paper we propose and derive the n-steps ahead delayed acceptance Metropolis-Hastings algorithm, which is a generalisation of the classical 1-step ahead delayed acceptance Metropolis-Hastings. We show the superiority of the n-steps ahead algorithm over the 1-step ahead method

Influence of image segmentation on one-dimensional fluid dynamics predictions in the mouse pulmonary arteries

Computational fluid dynamics (CFD) models are emerging as tools for assisting in diagnostic assessment of cardiovascular disease. Recent advances in image segmentation has made subject-specific modelling of the cardiovascular system a feasible task, which is particularly important in the case of pulmonary hypertension (PH), which requires a combination of invasive and non-invasive procedures for diagnosis. Uncertainty in image segmentation can easily propagate to CFD model predictions, making uncertainty quantification crucial for subject-specific models. This study quantifies the variability of one-dimensional (1D) CFD predictions by propagating the uncertainty of network geometry and connectivity to blood pressure and flow predictions. We analyse multiple segmentations of an image of an excised mouse lung using different pre-segmentation parameters. A custom algorithm extracts vessel length, vessel radii, and network connectivity for each segmented pulmonary network. We quantify uncertainty in geometric features by constructing probability densities for vessel radius and length, and then sample from these distributions and propagate uncertainties of haemodynamic predictions using a 1D CFD model. Results show that variation in network connectivity is a larger contributor to haemodynamic uncertainty than vessel radius and length

Inference in Cardiovascular Modelling Subject to Medical Interventions

Pulmonary hypertension (PH), i.e., high blood pressure in the lungs, is a serious medical condition that can damage the right ventricle of the heart and ultimately lead to heart failure. Standard diagnostic procedures are based on right-heart catheterization, which is an invasive technique that can potentially have serious side effects. Recent methodological advancements in fluid dynamics modelling of the pulmonary blood circulation system promise to mathematically predict the blood pressure based on non-invasive measurements of the blood flow. Thus, subsequent to PH diagnostication, further investigations would no longer require catheterization. However, in order for these alternative techniques to be applicable in the clinic, accurate model calibration and parameter estimation are paramount. Medical interventions taken to combat high blood pressure (as predicted from the mathematical model) alter the underlying cardiovascular physiology, thus interfering with the parameter estimation procedure. In the present study, we have carried out a series of cardiovascular simulations to assess the reliability of cardiovascular physiological parameter estimation in the presence of medical interventions. Our principal result is that if the closed-loop effect of medical interventions is accounted for, the model calibration provides accurate parameter estimates. This finding has important implications for the applicability of cardio-physiological modelling in the clinical practice

Assessing model mismatch and model selection in a Bayesian uncertainty quantification analysis of a fluid-dynamics model of pulmonary blood circulation

This study uses Bayesian inference to quantify the uncertainty of model parameters and haemodynamic predictions in a one-dimensional pulmonary circulation model based on an integration of mouse haemodynamic and micro-computed tomography imaging data. We emphasize an often neglected, though important source of uncertainty: in the mathematical model form due to the discrepancy between the model and the reality, and in the measurements due to the wrong noise model (jointly called ‘model mismatch’). We demonstrate that minimizing the mean squared error between the measured and the predicted data (the conventional method) in the presence of model mismatch leads to biased and overly confident parameter estimates and haemodynamic predictions. We show that our proposed method allowing for model mismatch, which we represent with Gaussian processes, corrects the bias. Additionally, we compare a linear and a nonlinear wall model, as well as models with different vessel stiffness relations. We use formal model selection analysis based on the Watanabe Akaike information criterion to select the model that best predicts the pulmonary haemodynamics. Results show that the nonlinear pressure–area relationship with stiffness dependent on the unstressed radius predicts best the data measured in a control mouse

Markov chain Monte Carlo with Gaussian processes for fast parameter estimation and uncertainty quantification in a 1D fluid‐dynamics model of the pulmonary circulation

The past few decades have witnessed an explosive synergy between physics and the life sciences. In particular, physical modelling in medicine and physiology is a topical research area. The present work focuses on parameter inference and uncertainty quantification in a 1D fluid‐dynamics model for quantitative physiology: the pulmonary blood circulation. The practical challenge is the estimation of the patient‐specific biophysical model parameters, which cannot be measured directly. In principle this can be achieved based on a comparison between measured and predicted data. However, predicting data requires solving a system of partial differential equations (PDEs), which usually have no closed‐form solution, and repeated numerical integrations as part of an adaptive estimation procedure are computationally expensive. In the present article, we demonstrate how fast parameter estimation combined with sound uncertainty quantification can be achieved by a combination of statistical emulation and Markov chain Monte Carlo (MCMC) sampling. We compare a range of state‐of‐the‐art MCMC algorithms and emulation strategies, and assess their performance in terms of their accuracy and computational efficiency. The long‐term goal is to develop a method for reliable disease prognostication in real time, and our work is an important step towards an automatic clinical decision support system

The global burden of cancer attributable to risk factors, 2010-19 : a systematic analysis for the Global Burden of Disease Study 2019

Background Understanding the magnitude of cancer burden attributable to potentially modifiable risk factors is crucial for development of effective prevention and mitigation strategies. We analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to inform cancer control planning efforts globally. Methods The GBD 2019 comparative risk assessment framework was used to estimate cancer burden attributable to behavioural, environmental and occupational, and metabolic risk factors. A total of 82 risk-outcome pairs were included on the basis of the World Cancer Research Fund criteria. Estimated cancer deaths and disability-adjusted life-years (DALYs) in 2019 and change in these measures between 2010 and 2019 are presented. Findings Globally, in 2019, the risk factors included in this analysis accounted for 4.45 million (95% uncertainty interval 4.01-4.94) deaths and 105 million (95.0-116) DALYs for both sexes combined, representing 44.4% (41.3-48.4) of all cancer deaths and 42.0% (39.1-45.6) of all DALYs. There were 2.88 million (2.60-3.18) risk-attributable cancer deaths in males (50.6% [47.8-54.1] of all male cancer deaths) and 1.58 million (1.36-1.84) risk-attributable cancer deaths in females (36.3% [32.5-41.3] of all female cancer deaths). The leading risk factors at the most detailed level globally for risk-attributable cancer deaths and DALYs in 2019 for both sexes combined were smoking, followed by alcohol use and high BMI. Risk-attributable cancer burden varied by world region and Socio-demographic Index (SDI), with smoking, unsafe sex, and alcohol use being the three leading risk factors for risk-attributable cancer DALYs in low SDI locations in 2019, whereas DALYs in high SDI locations mirrored the top three global risk factor rankings. From 2010 to 2019, global risk-attributable cancer deaths increased by 20.4% (12.6-28.4) and DALYs by 16.8% (8.8-25.0), with the greatest percentage increase in metabolic risks (34.7% [27.9-42.8] and 33.3% [25.8-42.0]). Interpretation The leading risk factors contributing to global cancer burden in 2019 were behavioural, whereas metabolic risk factors saw the largest increases between 2010 and 2019. Reducing exposure to these modifiable risk factors would decrease cancer mortality and DALY rates worldwide, and policies should be tailored appropriately to local cancer risk factor burden. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.Peer reviewe

Global investments in pandemic preparedness and COVID-19: development assistance and domestic spending on health between 1990 and 2026

Background The COVID-19 pandemic highlighted gaps in health surveillance systems, disease prevention, and treatment globally. Among the many factors that might have led to these gaps is the issue of the financing of national health systems, especially in low-income and middle-income countries (LMICs), as well as a robust global system for pandemic preparedness. We aimed to provide a comparative assessment of global health spending at the onset of the pandemic; characterise the amount of development assistance for pandemic preparedness and response disbursed in the first 2 years of the COVID-19 pandemic; and examine expectations for future health spending and put into context the expected need for investment in pandemic preparedness. Methods In this analysis of global health spending between 1990 and 2021, and prediction from 2021 to 2026, we estimated four sources of health spending: development assistance for health (DAH), government spending, out-of-pocket spending, and prepaid private spending across 204 countries and territories. We used the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System (CRS) and the WHO Global Health Expenditure Database (GHED) to estimate spending. We estimated development assistance for general health, COVID-19 response, and pandemic preparedness and response using a keyword search. Health spending estimates were combined with estimates of resources needed for pandemic prevention and preparedness to analyse future health spending patterns, relative to need. Findings In 2019, at the onset of the COVID-19 pandemic, US$9·2 trillion (95$7·3 trillion (95% UI 7·2–7·4) in 2019; 293·7 times the $24·8 billion (95$43·1 billion in development assistance was provided to maintain or improve health. The pandemic led to an unprecedented increase in development assistance targeted towards health; in 2020 and 2021, $1·8 billion in DAH contributions was provided towards pandemic preparedness in LMICs, and$37·8 billion was provided for the health-related COVID-19 response. Although the support for pandemic preparedness is 12·2% of the recommended target by the High-Level Independent Panel (HLIP), the support provided for the health-related COVID-19 response is 252·2% of the recommended target. Additionally, projected spending estimates suggest that between 2022 and 2026, governments in 17 (95% UI 11–21) of the 137 LMICs will observe an increase in national government health spending equivalent to an addition of 1% of GDP, as recommended by the HLIP. Interpretation There was an unprecedented scale-up in DAH in 2020 and 2021. We have a unique opportunity at this time to sustain funding for crucial global health functions, including pandemic preparedness. However, historical patterns of underfunding of pandemic preparedness suggest that deliberate effort must be made to ensure funding is maintained