Deep Multi-instance Networks with Sparse Label Assignment for Whole Mammogram Classification

Mammogram classification is directly related to computer-aided diagnosis of breast cancer. Traditional methods rely on regions of interest (ROIs) which require great efforts to annotate. Inspired by the success of using deep convolutional features for natural image analysis and multi-instance learning (MIL) for labeling a set of instances/patches, we propose end-to-end trained deep multi-instance networks for mass classification based on whole mammogram without the aforementioned ROIs. We explore three different schemes to construct deep multi-instance networks for whole mammogram classification. Experimental results on the INbreast dataset demonstrate the robustness of proposed networks compared to previous work using segmentation and detection annotations.Comment: MICCAI 2017 Camera Read

Crowd disagreement about medical images is informative

Classifiers for medical image analysis are often trained with a single consensus label, based on combining labels given by experts or crowds. However, disagreement between annotators may be informative, and thus removing it may not be the best strategy. As a proof of concept, we predict whether a skin lesion from the ISIC 2017 dataset is a melanoma or not, based on crowd annotations of visual characteristics of that lesion. We compare using the mean annotations, illustrating consensus, to standard deviations and other distribution moments, illustrating disagreement. We show that the mean annotations perform best, but that the disagreement measures are still informative. We also make the crowd annotations used in this paper available at \url{https://figshare.com/s/5cbbce14647b66286544}.Comment: Accepted for publication at MICCAI LABELS 201

Signed Laplacian Deep Learning with Adversarial Augmentation for Improved Mammography Diagnosis

Computer-aided breast cancer diagnosis in mammography is limited by inadequate data and the similarity between benign and cancerous masses. To address this, we propose a signed graph regularized deep neural network with adversarial augmentation, named \textsc{DiagNet}. Firstly, we use adversarial learning to generate positive and negative mass-contained mammograms for each mass class. After that, a signed similarity graph is built upon the expanded data to further highlight the discrimination. Finally, a deep convolutional neural network is trained by jointly optimizing the signed graph regularization and classification loss. Experiments show that the \textsc{DiagNet} framework outperforms the state-of-the-art in breast mass diagnosis in mammography.Comment: To appear in MICCAI October 201

Double burden of malnutrition in Nepal: A trend analysis of protein-energy malnutrition and High Body Mass Index using the data from Global Burden of Disease 2010–2019

Background The co-existence of undernutrition and overnutrition is a global public health threat. We aim to report the burden of both nutritional deficiency (Protein-Energy Malnutrition) and overweight (high Body Mass Index) in Nepal over a decade (2010–2019) and observe the changes through trend charts. Methods We did a secondary data analysis using the Institute for Health Metrics and Evaluation (IHME)’s Global Burden of Disease (GBD) database to download age-standardized data on Protein Energy Malnutrition (PEM) and high Body Mass Index (BMI). We presented the trend of death, Disability Adjusted Life Years (DALYs), Years of Life Lost (YLL), and Years Lost due to Disability (YLD) of PEM and high BMI in Nepal from 2010 to 2019 and also compared data for 2019 among South Asian countries. Results Between 2010 and 2019, in Nepal, the Disability Adjusted Life Years (DALYs) due to PEM were declining while high BMI was in increasing trend. Sex-specific trends revealed that females had higher DALYs for PEM than males. In contrast, males had higher DALYs for high BMI than females. In 2019, Nepal had the highest death rate for PEM (5.22 per 100,000 populations) than any other South Asian country. The burden of PEM in terms of DALY was higher in under-five children (912 per 100,000 populations) and elderly above 80 years old (808.9 per 100,000 populations), while the population aged 65–69 years had the highest burden of high BMI (5893 per 100,000 populations). In the last decade, the DALYs for risk factors contributing to PEM such as child growth failure (stunting and wasting), unsafe water, sanitation and handwashing, and sub-optimal breastfeeding have declined in Nepal. On the contrary, the DALYs for risk factors contributing to high BMI, such as a diet high in sugar-sweetened beverages, a diet high in trans fatty acid, and low physical activity, have increased. This could be a possible explanation for the increasing trend of high BMI and decreasing trend of PEM. Conclusion Rapidly growing prevalence of high BMI and the persistent existence of undernutrition indicate the double burden of malnutrition in Nepal. Public health initiatives should be planned to address this problem

Self-medication and non-doctor prescription practices in Pokhara valley, Western Nepal: a questionnaire-based study

BACKGROUND: Self-medication and non-doctor prescribing of drugs is common in developing countries. Complementary and alternative medications, especially herbs, are also commonly used. There are few studies on the use of these medications in Pokhara Valley, Western Nepal. METHODS: Previously briefed seventh semester medical students, using a semi-structured questionnaire, carried out the study on 142 respondents. Demographic information and information on drugs used for self-medication or prescribed by a non-allopathic doctor were collected. RESULTS: Seventy-six respondents (54%) were aged between 20 to 39 years. The majority of the respondents (72 %) stayed within 30 minutes walking distance of a health post/medical store. 59% of these respondents had taken some form of self-medication in the 6-month period preceding the study. The common reasons given for self-medication were mild illness, previous experience of treating a similar illness, and non-availability of health personnel. 70% of respondents were prescribed allopathic drugs by a non-allopathic doctor. The compounder and health assistant were common sources of medicines. Paracetamol and antimicrobials were the drugs most commonly prescribed. A significantly higher proportion of young (<40 years) male respondents had used self-medication than other groups. CONCLUSIONS: Self-medication and non-doctor prescribing are common in the Pokhara valley. In addition to allopathic drugs, herbal remedies were also commonly used for self-medication. Drugs, especially antimicrobials, were not taken for the proper duration. Education to help patients decide on the appropriateness of self-medication is required

CHOP Chemotherapy for Aggressive Non-Hodgkin Lymphoma with and without HIV in the Antiretroviral Therapy Era in Malawi

There are no prospective studies of aggressive non-Hodgkin lymphoma (NHL) treated with CHOP in sub-Saharan Africa. We enrolled adults with aggressive NHL in Malawi between June 2013 and May 2015. Chemotherapy and supportive care were standardized, and HIV+ patients received antiretroviral therapy (ART). Thirty-seven of 58 patients (64%) were HIV+. Median age was 47 years (IQR 39–56), and 35 (60%) were male. Thirty-five patients (60%) had stage III/IV, 43 (74%) B symptoms, and 28 (48%) performance status ≥2. B-cell NHL predominated among HIV+ patients, and all T-cell NHL occurred among HIV- individuals. Thirty-one HIV+ patients (84%) were on ART for a median 9.9 months (IQR 1.1–31.7) before NHL diagnosis, median CD4 was 121 cells/μL (IQR 61–244), and 43% had suppressed HIV RNA. HIV+ patients received a similar number of CHOP cycles compared to HIV- patients, but more frequently developed grade 3/4 neutropenia (84% vs 31%, p = 0.001), resulting in modestly lower cyclophosphamide and doxorubicin doses with longer intervals between cycles. Twelve-month overall survival (OS) was 45% (95% CI 31–57%). T-cell NHL (HR 3.90, p = 0.017), hemoglobin (HR 0.82 per g/dL, p = 0.017), albumin (HR 0.57 per g/dL, p = 0.019), and IPI (HR 2.02 per unit, p<0.001) were associated with mortality. HIV was not associated with mortality, and findings were similar among patients with diffuse large B-cell lymphoma. Twenty-three deaths were from NHL (12 HIV+, 11 HIV-), and 12 from CHOP (9 HIV+, 3 HIV-). CHOP can be safe, effective, and feasible for aggressive NHL in Malawi with and without HIV

Outcomes for paediatric Burkitt lymphoma treated with anthracycline-based therapy in Malawi

Burkitt lymphoma (BL) is the most common paediatric cancer in sub-Saharan Africa (SSA). Anthracyline-based treatment is standard in resource-rich settings, but has not been described in SSA. Children ≤ 18 years of age with newly diagnosed BL were prospectively enrolled from June 2013 to May 2015 in Malawi. Staging and supportive care were standardized, as was treatment with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) for six cycles. Among 73 children with BL, median age was 9.2 years (interquartile range 7.7–11.8), 48 (66%) were male and two were positive for human immunodeficiency virus. Twelve (16%) had stage I/II disease, 36 (49%) stage III and 25 (34%) stage IV. Grade 3/4 neutropenia occurred in 17 (25%), and grade 3/4 anaemia in 29 (42%) of 69 evaluable children. Eighteen-month overall survival was 29% (95% confidence interval [CI] 18–41%) overall. Mortality was associated with age >9 years [hazard ratio [HR] 2.13, 95% CI 1.15–3.94], female gender (HR 2.12, 95% CI 1.12–4.03), stage (HR 1.52 per unit, 95% CI 1.07–2.17), lactate dehydrogenase (HR 1.03 per 100 iu/l, 95% CI 1.01–1.05), albumin (HR 0. 96 per g/l, 95% CI 0.93–0.99) and performance status (HR 0.78 per 10-point increase, 95% CI 0.69–0.89). CHOP did not improve outcomes in paediatric BL compared to less intensive regimens in Malawi

Care for perinatal illness in rural Nepal: a descriptive study with cross-sectional and qualitative components

BACKGROUND: Maternal, perinatal and neonatal mortality rates remain high in rural areas of developing countries. Most deliveries take place at home and care-seeking behaviour is often delayed. We report on a combined quantitative and qualitative study of care seeking obstacles and practices relating to perinatal illness in rural Makwanpur district, Nepal, with particular emphasis on consultation strategies. METHODS: The analysis included a survey of 8798 women who reported a birth in the previous two years [of whom 3557 reported illness in their pregnancy], on 30 case studies of perinatal morbidity and mortality, and on 43 focus group discussions with mothers, other family members and health workers. RESULTS: Early pregnancy was often concealed, preparation for birth was minimal and trained attendance at birth was uncommon. Family members were favoured attendants, particularly mothers-in-law. The most common recalled maternal complications were prolonged labour, postpartum haemorrhage and retained placenta. Neonatal death, though less definable, was often associated with cessation of suckling and shortness of breath. Many home-based care practices for maternal and neonatal illness were described. Self-medication was common. There were delays in recognising and acting on danger signs, and in seeking care beyond the household, in which the cultural requirement for maternal seclusion, and the perceived expense of care, played a part. Of the 760 women who sought care at a government facility, 70% took more than 12 hours from the decision to seek help to actual consultation. Consultation was primarily with traditional healers, who were key actors in the ascription of causation. Use of the government primary health care system was limited: the most common source of allopathic care was the district hospital. CONCLUSIONS: Major obstacles to seeking care were: a limited capacity to recognise danger signs; the need to watch and wait; and an overwhelming preference to treat illness within the community. Safer motherhood and newborn care programmes in rural communities, must address both community and health facility care to have an impact on morbidity and mortality. The roles of community actors such as mothers-in-law, husbands, local healers and pharmacies, and increased access to properly trained birth attendants need to be addressed if delays in reaching health facilities are to be shortened