Ensuring consistent performance across diverse populations and incorporating fairness into machine learning models are crucial for advancing medical image diagnostics and promoting equitable healthcare. However, many databases do not provide protected attributes or contain unbalanced representations of demographic groups, complicating the evaluation of model performance across different demographics and the application of bias mitigation techniques that rely on these attributes. This study aims to investigate the effectiveness of using the backbone of Foundation Models as an embedding extractor for creating groups that represent protected attributes, such as gender and age. We propose utilizing these groups in different stages of bias mitigation, including pre-processing, in-processing, and evaluation. Using databases in and out-of-distribution scenarios, it is possible to identify that the method can create groups that represent gender in both databases and reduce in 4.44% the difference between the gender attribute in-distribution and 6.16% in out-of-distribution. However, the model lacks robustness in handling age attributes, underscoring the need for more fundamentally fair and robust Foundation models. These findings suggest a role in promoting fairness assessment in scenarios where we lack knowledge of attributes, contributing to the development of more equitable medical diagnostics.

Chest X-ray is a commonly used tool during triage, diagnosis and management of respiratory diseases. In resource-constricted settings, optimizing this resource can lead to valuable cost savings for the health care system and the patients as well as to and improvement in consult time. We used prospectively-collected data from 137 patients referred for chest X-ray at the Christian Medical Center and Hospital (CMCH) in Purnia, Bihar, India. Each patient provided at least five coughs while awaiting radiography. Collected cough sounds were analyzed using acoustic AI methods. Cross-validation was done on temporal and spectral features on the cough sounds of each patient. Features were summarized using standard statistical approaches. Three models were developed, tested and compared in their capacity to predict an abnormal result in the chest X-ray. All three methods yielded models that could discriminate to some extent between normal and abnormal with the logistic regression performing best with an area under the receiver operating characteristic curves ranging from 0.7 to 0.78. Despite limitations and its relatively small sample size, this study shows that AI-enabled algorithms can use cough sounds to predict which individuals presenting for chest radiographic examination will have a normal or abnormal results. These results call for expanding this research given the potential optimization of limited health care resources in low- and middle-income countries.

Purpose: To analyze a recently published chest radiography foundation model for the presence of biases that could lead to subgroup performance disparities across biological sex and race. Materials and Methods: This retrospective study used 127,118 chest radiographs from 42,884 patients (mean age, 63 [SD] 17 years; 23,623 male, 19,261 female) from the CheXpert dataset collected between October 2002 and July 2017. To determine the presence of bias in features generated by a chest radiography foundation model and baseline deep learning model, dimensionality reduction methods together with two-sample Kolmogorov-Smirnov tests were used to detect distribution shifts across sex and race. A comprehensive disease detection performance analysis was then performed to associate any biases in the features to specific disparities in classification performance across patient subgroups. Results: Ten out of twelve pairwise comparisons across biological sex and race showed statistically significant differences in the studied foundation model, compared with four significant tests in the baseline model. Significant differences were found between male and female (P < .001) and Asian and Black patients (P < .001) in the feature projections that primarily capture disease. Compared with average model performance across all subgroups, classification performance on the 'no finding' label dropped between 6.8% and 7.8% for female patients, and performance in detecting 'pleural effusion' dropped between 10.7% and 11.6% for Black patients. Conclusion: The studied chest radiography foundation model demonstrated racial and sex-related bias leading to disparate performance across patient subgroups and may be unsafe for clinical applications.

ABSTRACTPurpose Over the last two years, the artificial intelligence (AI) … chest radiography and deep learning – success story or dataset bias?

Lung X-ray images, if processed using statistical and computational methods, can distinguish pneumonia from COVID-19. The present work shows that it is possible to extract lung X-ray characteristics to improve the methods of examining and diagnosing patients with suspected COVID-19, distinguishing them from malaria, dengue, H1N1, tuberculosis, and Streptococcus pneumonia. More precisely, an intelligent computational model was developed to process lung X-ray images and classify whether the image is of a patient with COVID-19. The images were processed and extracted their characteristics. These characteristics were the input data for an unsupervised statistical learning method, PCA, and clustering, which identified specific attributes of X-ray images with Covid-19. The introduction of statistical models allowed a fast algorithm, which used the X-means clustering method associated with the Bayesian Information Criterion (CIB). The developed algorithm efficiently distinguished each pulmonary pathology from X-ray images. The method exhibited excellent sensitivity. The average recognition accuracy of COVID-19 was 0.93 and 0.051.

Lung nodules are commonly missed in chest radiographs. We propose and evaluate P-AnoGAN, an unsupervised anomaly detection approach for lung nodules in radiographs. P-AnoGAN modifies the fast anomaly detection generative adversarial network (f-AnoGAN) by utilizing a progressive GAN and a convolutional encoder-decoder-encoder pipeline. Model training uses only unlabelled healthy lung patches extracted from the Indiana University Chest X-Ray Collection. External validation and testing are performed using healthy and unhealthy patches extracted from the ChestX-ray14 and Japanese Society for Radiological Technology datasets, respectively. Our model robustly identifies patches containing lung nodules in external validation and test data with ROC-AUC of 91.17% and 87.89%, respectively. These results show unsupervised methods may be useful in challenging tasks such as lung nodule detection in radiographs.

See article by Horng et al in this issue. William F. Auffermann, MD, PhD, is an associate professor of radiology and imaging sciences at the University of Utah School of Medicine. Dr Auffermann is a cardiothoracic radiologist and is ABPM board certified in clinical informatics. His research interests include imaging informatics, clinical informatics, applications of AI in radiology, medical image perception, and perceptual training. Recent research projects include image annotation for AI using eye tracking, human factors engineering, and developing simulation-based perceptual training methods to facilitate radiology education.