Interpretable Machine Learning Predicts Postpartum Hemorrhage with Severe Maternal Morbidity in a Lower Risk Laboring Obstetric Population.

BACKGROUND: Early identification of patients at increased risk for postpartum hemorrhage (PPH) associated with severe maternal morbidity (SMM) is critical for preparation and preventative intervention. However, prediction is challenging in patients without obvious risk factors for postpartum hemorrhage with severe maternal morbidity. Current tools for hemorrhage risk assessment use lists of risk factors rather than predictive models. OBJECTIVE: To develop, validate (internally and externally), and compare a machine learning model for predicting PPH associated with SMM against a standard hemorrhage risk assessment tool in a lower-risk laboring obstetric population. STUDY DESIGN: This retrospective cross-sectional study included clinical data from singleton, term births (>=37 weeks' gestation) at 19 US hospitals (2016-2021) using data from 44,509 births at 11 hospitals to train a generalized additive model (GAM) and 21,183 births at 8 held-out hospitals to externally validate the model. The outcome of interest was PPH with severe maternal morbidity (blood transfusion, hysterectomy, vascular embolization, intrauterine balloon tamponade, uterine artery ligation suture, uterine compression suture, or admission to intensive care). Cesarean birth without a trial of vaginal birth and patients with a history of cesarean were excluded. We compared the model performance to that of the California Maternal Quality Care Collaborative (CMQCC) Obstetric Hemorrhage Risk Factor Assessment Screen. RESULTS: The GAM predicted PPH with an area under the receiver-operating characteristic curve (AUROC) of 0.67 (95% CI 0.64-0.68) on external validation, significantly outperforming the CMQCC risk screen AUROC of 0.52 (95% CI 0.50-0.53). Additionally, the GAM had better sensitivity of 36.9% (95% CI 33.01, 41.02) than the CMQCC screen sensitivity of 20.30% (95% CI 17.40, 22.52) at the CMQCC screen positive rate of 16.8%. The GAM identified in-vitro fertilization as a risk factor (adjusted OR 1.5; 95% CI 1.2-1.8) and nulliparous births as the highest PPH risk factor (adjusted OR 1.5; 95% CI; 1.4-1.6). CONCLUSION: Our model identified almost twice as many cases of PPH as the CMQCC rules-based approach for the same screen positive rate and identified in-vitro fertilization and first-time births as risk factors for PPH. Adopting predictive models over traditional screens can enhance PPH prediction.

Interpretable Predictive Models to Understand Risk Factors for Maternal and Fetal Outcomes.

Although most pregnancies result in a good outcome, complications are not uncommon and can be associated with serious implications for mothers and babies. Predictive modeling has the potential to improve outcomes through a better understanding of risk factors, heightened surveillance for high-risk patients, and more timely and appropriate interventions, thereby helping obstetricians deliver better care. We identify and study the most important risk factors for four types of pregnancy complications: (i) severe maternal morbidity, (ii) shoulder dystocia, (iii) preterm preeclampsia, and (iv) antepartum stillbirth. We use an Explainable Boosting Machine (EBM), a high-accuracy glass-box learning method, for the prediction and identification of important risk factors. We undertake external validation and perform an extensive robustness analysis of the EBM models. EBMs match the accuracy of other black-box ML methods, such as deep neural networks and random forests, and outperform logistic regression, while being more interpretable. EBMs prove to be robust. The interpretability of the EBM models reveal surprising insights into the features contributing to risk (e.g., maternal height is the second most important feature for shoulder dystocia) and may have potential for clinical application in the prediction and prevention of serious complications in pregnancy.

Automated interpretable discovery of heterogeneous treatment effectiveness: A COVID-19 case study.

Testing multiple treatments for heterogeneous (varying) effectiveness with respect to many underlying risk factors requires many pairwise tests; we would like to instead automatically discover and visualize patient archetypes and predictors of treatment effectiveness using multitask machine learning. In this paper, we present a method to estimate these heterogeneous treatment effects with an interpretable hierarchical framework that uses additive models to visualize expected treatment benefits as a function of patient factors (identifying personalized treatment benefits) and concurrent treatments (identifying combinatorial treatment benefits). This method achieves state-of-the-art predictive power for COVID-19 in-hospital mortality and interpretable identification of heterogeneous treatment benefits. We first validate this method on the large public MIMIC-IV dataset of ICU patients to test recovery of heterogeneous treatment effects. Next we apply this method to a proprietary dataset of over 3000 patients hospitalized for COVID-19, and find evidence of heterogeneous treatment effectiveness predicted largely by indicators of inflammation and thrombosis risk: patients with few indicators of thrombosis risk benefit most from treatments against inflammation, while patients with few indicators of inflammation risk benefit most from treatments against thrombosis. This approach provides an automated methodology to discover heterogeneous and individualized effectiveness of treatments.

Time-Varying Mortality Risk Suggests Increased Impact of Thrombosis in Hospitalized Covid-19 Patients.

Treatment protocols, treatment availability, disease understanding, and viral characteristics have changed over the course of the Covid-19 pandemic; as a result, the risks associated with patient comorbidities and biomarkers have also changed. We add to the ongoing conversation regarding inflammation, hemostasis and vascular function in Covid-19 by performing a time-varying observational analysis of over 4000 patients hospitalized for Covid-19 in a New York City hospital system from March 2020 to August 2021 to elucidate the changing impact of thrombosis, inflammation, and other risk factors on in-hospital mortality. We find that the predictive power of biomarkers of thrombosis risk have increased over time, suggesting an opportunity for improved care by identifying and targeting therapies for patients with elevated thrombophilic propensity.

Precision Lasso: accounting for correlations and linear dependencies in high-dimensional genomic data.

MOTIVATION: Association studies to discover links between genetic markers and phenotypes are central to bioinformatics. Methods of regularized regression, such as variants of the Lasso, are popular for this task. Despite the good predictive performance of these methods in the average case, they suffer from unstable selections of correlated variables and inconsistent selections of linearly dependent variables. Unfortunately, as we demonstrate empirically, such problematic situations of correlated and linearly dependent variables often exist in genomic datasets and lead to under-performance of classical methods of variable selection. RESULTS: To address these challenges, we propose the Precision Lasso. Precision Lasso is a Lasso variant that promotes sparse variable selection by regularization governed by the covariance and inverse covariance matrices of explanatory variables. We illustrate its capacity for stable and consistent variable selection in simulated data with highly correlated and linearly dependent variables. We then demonstrate the effectiveness of the Precision Lasso to select meaningful variables from transcriptomic profiles of breast cancer patients. Our results indicate that in settings with correlated and linearly dependent variables, the Precision Lasso outperforms popular methods of variable selection such as the Lasso, the Elastic Net and Minimax Concave Penalty (MCP) regression. AVAILABILITY AND IMPLEMENTATION: Software is available at https://github.com/HaohanWang/thePrecisionLasso. SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

Personalized regression enables sample-specific pan-cancer analysis.

Motivation: In many applications, inter-sample heterogeneity is crucial to understanding the complex biological processes under study. For example, in genomic analysis of cancers, each patient in a cohort may have a different driver mutation, making it difficult or impossible to identify causal mutations from an averaged view of the entire cohort. Unfortunately, many traditional methods for genomic analysis seek to estimate a single model which is shared by all samples in a population, ignoring this inter-sample heterogeneity entirely. In order to better understand patient heterogeneity, it is necessary to develop practical, personalized statistical models. Results: To uncover this inter-sample heterogeneity, we propose a novel regularizer for achieving patient-specific personalized estimation. This regularizer operates by learning two latent distance metrics-one between personalized parameters and one between clinical covariates-and attempting to match the induced distances as closely as possible. Crucially, we do not assume these distance metrics are already known. Instead, we allow the data to dictate the structure of these latent distance metrics. Finally, we apply our method to learn patient-specific, interpretable models for a pan-cancer gene expression dataset containing samples from more than 30 distinct cancer types and find strong evidence of personalization effects between cancer types as well as between individuals. Our analysis uncovers sample-specific aberrations that are overlooked by population-level methods, suggesting a promising new path for precision analysis of complex diseases such as cancer. Availability and implementation: Software for personalized linear and personalized logistic regression, along with code to reproduce experimental results, is freely available at github.com/blengerich/personalized_regression.

Opportunities and obstacles for deep learning in biology and medicine.

Deep learning describes a class of machine learning algorithms that are capable of combining raw inputs into layers of intermediate features. These algorithms have recently shown impressive results across a variety of domains. Biology and medicine are data-rich disciplines, but the data are complex and often ill-understood. Hence, deep learning techniques may be particularly well suited to solve problems of these fields. We examine applications of deep learning to a variety of biomedical problems-patient classification, fundamental biological processes and treatment of patients-and discuss whether deep learning will be able to transform these tasks or if the biomedical sphere poses unique challenges. Following from an extensive literature review, we find that deep learning has yet to revolutionize biomedicine or definitively resolve any of the most pressing challenges in the field, but promising advances have been made on the prior state of the art. Even though improvements over previous baselines have been modest in general, the recent progress indicates that deep learning methods will provide valuable means for speeding up or aiding human investigation. Though progress has been made linking a specific neural network's prediction to input features, understanding how users should interpret these models to make testable hypotheses about the system under study remains an open challenge. Furthermore, the limited amount of labelled data for training presents problems in some domains, as do legal and privacy constraints on work with sensitive health records. Nonetheless, we foresee deep learning enabling changes at both bench and bedside with the potential to transform several areas of biology and medicine.

Experimental and computational mutagenesis to investigate the positioning of a general base within an enzyme active site.

The positioning of catalytic groups within proteins plays an important role in enzyme catalysis, and here we investigate the positioning of the general base in the enzyme ketosteroid isomerase (KSI). The oxygen atoms of Asp38, the general base in KSI, were previously shown to be involved in anion-aromatic interactions with two neighboring Phe residues. Here we ask whether those interactions are sufficient, within the overall protein architecture, to position Asp38 for catalysis or whether the side chains that pack against Asp38 and/or the residues of the structured loop that is capped by Asp38 are necessary to achieve optimal positioning for catalysis. To test positioning, we mutated each of the aforementioned residues, alone and in combinations, in a background with the native Asp general base and in a D38E mutant background, as Glu at position 38 was previously shown to be mispositioned for general base catalysis. These double-mutant cycles reveal positioning effects as large as 10(3)-fold, indicating that structural features in addition to the overall protein architecture and the Phe residues neighboring the carboxylate oxygen atoms play roles in positioning. X-ray crystallography and molecular dynamics simulations suggest that the functional effects arise from both restricting dynamic fluctuations and disfavoring potential mispositioned states. Whereas it may have been anticipated that multiple interactions would be necessary for optimal general base positioning, the energetic contributions from positioning and the nonadditive nature of these interactions are not revealed by structural inspection and require functional dissection. Recognizing the extent, type, and energetic interconnectivity of interactions that contribute to positioning catalytic groups has implications for enzyme evolution and may help reveal the nature and extent of interactions required to design enzymes that rival those found in biology.