Best Practices for Large Language Models in Radiology

At the heart of radiological practice is the challenge of integrating complex imaging data with clinical information to produce actionable insights. Nuanced application of language is key for various activities, including managing requests, describing and interpreting imaging findings in the context of clinical data, and concisely documenting and communicating the outcomes. The emergence of large language models (LLMs) offers an opportunity to improve the management and interpretation of the vast data in radiology. Despite being primarily general-purpose, these advanced computational models demonstrate impressive capabilities in specialized language-related tasks, even without specific training. Unlocking the potential of LLMs for radiology requires basic understanding of their foundations and a strategic approach to navigate their idiosyncrasies. This review, drawing from practical radiology and machine learning expertise and recent literature, provides readers insight into the potential of LLMs in radiology. It examines best practices that have so far stood the test of time in the rapidly evolving landscape of LLMs. This includes practical advice for optimizing LLM characteristics for radiology practices along with limitations, effective prompting, and fine-tuning strategies.

Foundation Models in Radiology: What, How, When, Why and Why Not

Recent advances in artificial intelligence have witnessed the emergence of large-scale deep learning models capable of interpreting and generating both textual and imaging data. Such models, typically referred to as foundation models, are trained on extensive corpora of unlabeled data and demonstrate high performance across various tasks. Foundation models have recently received extensive attention from academic, industry, and regulatory bodies. Given the potentially transformative impact that foundation models can have on the field of radiology, this review aims to establish a standardized terminology concerning foundation models, with a specific focus on the requirements of training data, model training paradigms, model capabilities, and evaluation strategies. We further outline potential pathways to facilitate the training of radiology-specific foundation models, with a critical emphasis on elucidating both the benefits and challenges associated with such models. Overall, we envision that this review can unify technical advances and clinical needs in the training of foundation models for radiology in a safe and responsible manner, for ultimately benefiting patients, providers, and radiologists.

Evaluating and Improving the Effectiveness of Synthetic Chest X-Rays for Medical Image Analysis

Purpose: To explore best-practice approaches for generating synthetic chest X-ray images and augmenting medical imaging datasets to optimize the performance of deep learning models in downstream tasks like classification and segmentation. Materials and Methods: We utilized a latent diffusion model to condition the generation of synthetic chest X-rays on text prompts and/or segmentation masks. We explored methods like using a proxy model and using radiologist feedback to improve the quality of synthetic data. These synthetic images were then generated from relevant disease information or geometrically transformed segmentation masks and added to ground truth training set images from the CheXpert, CANDID-PTX, SIIM, and RSNA Pneumonia datasets to measure improvements in classification and segmentation model performance on the test sets. F1 and Dice scores were used to evaluate classification and segmentation respectively. One-tailed t-tests with Bonferroni correction assessed the statistical significance of performance improvements with synthetic data. Results: Across all experiments, the synthetic data we generated resulted in a maximum mean classification F1 score improvement of 0.150453 (CI: 0.099108-0.201798; P=0.0031) compared to using only real data. For segmentation, the maximum Dice score improvement was 0.14575 (CI: 0.108267-0.183233; P=0.0064). Conclusion: Best practices for generating synthetic chest X-ray images for downstream tasks include conditioning on single-disease labels or geometrically transformed segmentation masks, as well as potentially using proxy modeling for fine-tuning such generations.

RaVL: Discovering and Mitigating Spurious Correlations in Fine-Tuned Vision-Language Models

Fine-tuned vision-language models (VLMs) often capture spurious correlations between image features and textual attributes, resulting in degraded zero-shot performance at test time. Existing approaches for addressing spurious correlations (i) primarily operate at the global image-level rather than intervening directly on fine-grained image features and (ii) are predominantly designed for unimodal settings. In this work, we present RaVL, which takes a fine-grained perspective on VLM robustness by discovering and mitigating spurious correlations using local image features rather than operating at the global image level. Given a fine-tuned VLM, RaVL first discovers spurious correlations by leveraging a region-level clustering approach to identify precise image features contributing to zero-shot classification errors. Then, RaVL mitigates the identified spurious correlation with a novel region-aware loss function that enables the VLM to focus on relevant regions and ignore spurious relationships during fine-tuning. We evaluate RaVL on 654 VLMs with various model architectures, data domains, and learned spurious correlations. Our results show that RaVL accurately discovers (191% improvement over the closest baseline) and mitigates (8.2% improvement on worst-group image classification accuracy) spurious correlations. Qualitative evaluations on general-domain and medical-domain VLMs confirm our findings.

SOE: SO(3)-Equivariant 3D MRI Encoding

Representation learning has become increasingly important, especially as powerful models have shifted towards learning latent representations before fine-tuning for downstream tasks. This approach is particularly valuable in leveraging the structural information within brain anatomy. However, a common limitation of recent models developed for MRIs is their tendency to ignore or remove geometric information, such as translation and rotation, thereby creating invariance with respect to geometric operations. We contend that incorporating knowledge about these geometric transformations into the model can significantly enhance its ability to learn more detailed anatomical information within brain structures. As a result, we propose a novel method for encoding 3D MRIs that enforces equivariance with respect to all rotations in 3D space, in other words, SO(3)-equivariance (SOE). By explicitly modeling this geometric equivariance in the representation space, we ensure that any rotational operation applied to the input image space is also reflected in the embedding representation space. This approach requires moving beyond traditional representation learning methods, as we need a representation vector space that allows for the application of the same SO(3) operation in that space. To facilitate this, we leverage the concept of vector neurons. The representation space formed by our method captures the brain's structural and anatomical information more effectively. We evaluate SOE pretrained on the structural MRIs of two public data sets with respect to the downstream task of predicting age and diagnosing Alzheimer's Disease from T1-weighted brain scans of the ADNI data set. We demonstrate that our approach not only outperforms other methods but is also robust against various degrees of rotation along different axes. The code is available at https://github.com/shizhehe/SOE-representation-learning.

Spectral Graph Sample Weighting for Interpretable Sub-cohort Analysis in Predictive Models for Neuroimaging

Recent advancements in medicine have confirmed that brain disorders often comprise multiple subtypes of mechanisms, developmental trajectories, or severity levels. Such heterogeneity is often associated with demographic aspects (e.g., sex) or disease-related contributors (e.g., genetics). Thus, the predictive power of machine learning models used for symptom prediction varies across subjects based on such factors. To model this heterogeneity, one can assign each training sample a factor-dependent weight, which modulates the subject's contribution to the overall objective loss function. To this end, we propose to model the subject weights as a linear combination of the eigenbases of a spectral population graph that captures the similarity of factors across subjects. In doing so, the learned weights smoothly vary across the graph, highlighting sub-cohorts with high and low predictability. Our proposed sample weighting scheme is evaluated on two tasks. First, we predict initiation of heavy alcohol drinking in young adulthood from imaging and neuropsychological measures from the National Consortium on Alcohol and NeuroDevelopment in Adolescence (NCANDA). Next, we detect Dementia vs. Mild Cognitive Impairment (MCI) using imaging and demographic measurements in subjects from the Alzheimer's Disease Neuroimaging Initiative (ADNI). Compared to existing sample weighting schemes, our sample weights improve interpretability and highlight sub-cohorts with distinct characteristics and varying model accuracy.

LieRE: Generalizing Rotary Position Encodings

While Rotary Position Embeddings (RoPE) for natural language performs well and has become widely adopted, its adoption for other modalities has been slower. Here, we introduce Lie group Relative position Encodings (LieRE) that goes beyond RoPE in supporting higher dimensional inputs. We evaluate the performance of LieRE on 2D and 3D image classification tasks and observe that LieRE leads to marked improvements in performance (up to 6%), training efficiency (3.5x reduction), data efficiency (30%) compared to the baselines of RoFormer, DeiT III, RoPE-Mixed and Vision-Llama

OpenCapBench: A Benchmark to Bridge Pose Estimation and Biomechanics

Pose estimation has promised to impact healthcare by enabling more practical methods to quantify nuances of human movement and biomechanics. However, despite the inherent connection between pose estimation and biomechanics, these disciplines have largely remained disparate. For example, most current pose estimation benchmarks use metrics such as Mean Per Joint Position Error, Percentage of Correct Keypoints, or mean Average Precision to assess performance, without quantifying kinematic and physiological correctness - key aspects for biomechanics. To alleviate this challenge, we develop OpenCapBench to offer an easy-to-use unified benchmark to assess common tasks in human pose estimation, evaluated under physiological constraints. OpenCapBench computes consistent kinematic metrics through joints angles provided by an open-source musculoskeletal modeling software (OpenSim). Through OpenCapBench, we demonstrate that current pose estimation models use keypoints that are too sparse for accurate biomechanics analysis. To mitigate this challenge, we introduce SynthPose, a new approach that enables finetuning of pre-trained 2D human pose models to predict an arbitrarily denser set of keypoints for accurate kinematic analysis through the use of synthetic data. Incorporating such finetuning on synthetic data of prior models leads to twofold reduced joint angle errors. Moreover, OpenCapBench allows users to benchmark their own developed models on our clinically relevant cohort. Overall, OpenCapBench bridges the computer vision and biomechanics communities, aiming to drive simultaneous advances in both areas.

MediSyn: Text-Guided Diffusion Models for Broad Medical 2D and 3D Image Synthesis

Diffusion models have recently gained significant traction due to their ability to generate high-fidelity and diverse images and videos conditioned on text prompts. In medicine, this application promises to address the critical challenge of data scarcity, a consequence of barriers in data sharing, stringent patient privacy regulations, and disparities in patient population and demographics. By generating realistic and varying medical 2D and 3D images, these models offer a rich, privacy-respecting resource for algorithmic training and research. To this end, we introduce MediSyn, a pair of instruction-tuned text-guided latent diffusion models with the ability to generate high-fidelity and diverse medical 2D and 3D images across specialties and modalities. Through established metrics, we show significant improvement in broad medical image and video synthesis guided by text prompts.

Almanac Copilot: Towards Autonomous Electronic Health Record Navigation

Clinicians spend large amounts of time on clinical documentation, and inefficiencies impact quality of care and increase clinician burnout. Despite the promise of electronic medical records (EMR), the transition from paper-based records has been negatively associated with clinician wellness, in part due to poor user experience, increased burden of documentation, and alert fatigue. In this study, we present Almanac Copilot, an autonomous agent capable of assisting clinicians with EMR-specific tasks such as information retrieval and order placement. On EHR-QA, a synthetic evaluation dataset of 300 common EHR queries based on real patient data, Almanac Copilot obtains a successful task completion rate of 74% (n = 221 tasks) with a mean score of 2.45 over 3 (95% CI:2.34-2.56). By automating routine tasks and streamlining the documentation process, our findings highlight the significant potential of autonomous agents to mitigate the cognitive load imposed on clinicians by current EMR systems.