Medical image segmentation has made remarkable progress with advances in deep learning technology, depending on the quality and quantity of labeled data. Although various deep learning model structures and training methods have been proposed and high performance has been published, limitations such as inter-class accuracy bias exist in actual clinical applications, especially due to the significant lack of small object performance in multi-organ segmentation tasks. In this paper, we propose an uncertainty-based contrastive learning technique, namely UncerNCE, with an optimal hybrid architecture for high classification and segmentation performance of small organs. Our backbone architecture adopts a hybrid network that employs both convolutional and transformer layers, which have demonstrated remarkable performance in recent years. The key proposal of this study addresses the multi-class accuracy bias and resolves a common tradeoff in existing studies between segmenting regions of small objects and reducing overall noise (i.e., false positives). Uncertainty based contrastive learning based on the proposed hybrid network performs spotlight learning on selected regions based on uncertainty and achieved accurate segmentation for all classes while suppressing noise. Comparison with state-of-the-art techniques demonstrates the superiority of our results on BTCV and 1K data.

OBJECTIVE: In recent years, the use of deep learning for medical image segmentation has become a popular trend, but its development also faces some challenges. Firstly, due to the specialized nature of medical data, precise annotation is time-consuming and labor-intensive. Training neural networks effectively with limited labeled data is a significant challenge in medical image analysis. Secondly, convolutional neural networks commonly used for medical image segmentation research often focus on local features in images. However, the recognition of complex anatomical structures or irregular lesions often requires the assistance of both local and global information, which has led to a bottleneck in its development. Addressing these two issues, in this paper, we propose a novel network architecture.
METHODS: We integrate a shift window mechanism to learn more comprehensive semantic information and employ a semi-supervised learning strategy by incorporating a flexible amount of unlabeled data. Specifically, a typical U-shaped encoder-decoder structure is applied to obtain rich feature maps. Each encoder is designed as a dual-branch structure, containing Swin modules equipped with windows of different size to capture features of multiple scales. To effectively utilize unlabeled data, a level set function is introduced to establish consistency between the function regression and pixel classification.
RESULTS: We conducted experiments on the COVID-19 CT dataset and DRIVE dataset and compared our approach with various semi-supervised and fully supervised learning models. On the COVID-19 CT dataset, we achieved a segmentation accuracy of up to 74.56%. Our segmentation accuracy on the DRIVE dataset was 79.79%.
CONCLUSIONS: The results demonstrate the outstanding performance of our method on several commonly used evaluation metrics. The high segmentation accuracy of our model demonstrates that utilizing Swin modules with different window sizes can enhance the feature extraction capability of the model, and the level set function can enable semi-supervised models to more effectively utilize unlabeled data. This provides meaningful insights for the application of deep learning in medical image segmentation. Our code will be released once the manuscript is accepted for publication.

OBJECTIVE: The proximal isovelocity surface area (PISA) method is a well-established approach for mitral regurgitation (MR) quantification. However, it exhibits high inter-observer variability and inaccuracies in cases of non-hemispherical flow convergence and non-holosystolic MR. To address this, we present EasyPISA, a framework for automated integrated PISA measurements taken directly from 2-D color-Doppler sequences.
METHODS: We trained convolutional neural networks (UNet/Attention UNet) on 1171 images from 196 recordings (54 patients) to detect and segment flow convergence zones in 2-D color-Doppler images. Different preprocessing schemes and model architectures were compared. Flow convergence surface areas were estimated, accounting for non-hemispherical convergence, and regurgitant volume (RVol) was computed by integrating the flow rate over time. EasyPISA was retrospectively applied to 26 MR patient examinations, comparing results with reference PISA RVol measurements, severity grades, and cMRI RVol measurements for 13 patients.
RESULTS: The UNet trained on duplex images achieved the best results (precision: 0.63, recall: 0.95, dice: 0.58, flow rate error: 10.4 ml/s). Mitigation of false-positive segmentation on the atrial side of the mitral valve was achieved through integration with a mitral valve segmentation network. The intraclass correlation coefficient was 0.83 between EasyPISA and PISA, and 0.66 between EasyPISA and cMRI. Relative standard deviations were 46% and 53%, respectively. Receiver operator characteristics demonstrated a mean area under the curve between 0.90 and 0.97 for EasyPISA RVol estimates and reference severity grades.
CONCLUSIONS: EasyPISA demonstrates promising results for fully automated integrated PISA measurements in MR, offering potential benefits in workload reduction and mitigating inter-observer variability in MR assessment.

Currently, deep learning is developing rapidly in the field of image segmentation, and medical image segmentation is one of the key applications in this field. Conventional CNN has achieved great success in general medical image segmentation tasks, but it has feature loss in the feature extraction part and lacks the ability to explicitly model remote dependencies, which makes it difficult to adapt to the task of human organ segmentation. Although methods containing attention mechanisms have made good progress in the field of semantic segmentation, most of the current attention mechanisms are limited to a single sample, while the number of samples of human organ images is large, ignoring the correlation between the samples is not conducive to image segmentation. In order to solve these problems, an internal and external dual-attention segmentation network (IEA-Net) is proposed in this paper, and the ICSwR (interleaved convolutional system with residual) module and the IEAM module are designed in this network. The ICSwR contains interleaved convolution and hopping connection, which are used for the initial extraction of the features in the encoder part. The IEAM module (internal and external dual-attention module) consists of the LGGW-SA (local-global Gaussian-weighted self-attention) module and the EA module, which are in a tandem structure. The LGGW-SA module focuses on learning local-global feature correlations within individual samples for efficient feature extraction. Meanwhile, the EA module is designed to capture inter-sample connections, addressing multi-sample complexities. Additionally, skip connections will be incorporated into each IEAM module within both the encoder and decoder to reduce feature loss. We tested our method on the Synapse multi-organ segmentation dataset and the ACDC cardiac segmentation dataset, and the experimental results show that the proposed method achieves better performance than other state-of-the-art methods.

Medical image segmentation is crucial for healthcare, yet convolution-based methods like U-Net face limitations in modeling long-range dependencies. To address this, Transformers designed for sequence-to-sequence predictions have been integrated into medical image segmentation. However, a comprehensive understanding of Transformers\' self-attention in U-Net components is lacking. TransUNet, first introduced in 2021, is widely recognized as one of the first models to integrate Transformer into medical image analysis. In this study, we present the versatile framework of TransUNet that encapsulates Transformers\' self-attention into two key modules: (1) a Transformer encoder tokenizing image patches from a convolution neural network (CNN) feature map, facilitating global context extraction, and (2) a Transformer decoder refining candidate regions through cross-attention between proposals and U-Net features. These modules can be flexibly inserted into the U-Net backbone, resulting in three configurations: Encoder-only, Decoder-only, and Encoder+Decoder. TransUNet provides a library encompassing both 2D and 3D implementations, enabling users to easily tailor the chosen architecture. Our findings highlight the encoder\'s efficacy in modeling interactions among multiple abdominal organs and the decoder\'s strength in handling small targets like tumors. It excels in diverse medical applications, such as multi-organ segmentation, pancreatic tumor segmentation, and hepatic vessel segmentation. Notably, our TransUNet achieves a significant average Dice improvement of 1.06% and 4.30% for multi-organ segmentation and pancreatic tumor segmentation, respectively, when compared to the highly competitive nn-UNet, and surpasses the top-1 solution in the BrasTS2021 challenge. 2D/3D Code and models are available at https://github.com/Beckschen/TransUNet and https://github.com/Beckschen/TransUNet-3D, respectively.

Medical image segmentation demands precise accuracy and the capability to assess segmentation uncertainty for informed clinical decision-making. Denoising Diffusion Probability Models (DDPMs), with their advancements in image generation, can treat segmentation as a conditional generation task, providing accurate segmentation and uncertainty estimation. However, current DDPMs used in medical image segmentation suffer from low inference efficiency and prediction errors caused by excessive noise at the end of the forward process. To address this issue, we propose an accelerated denoising diffusion probabilistic model via truncated inverse processes (ADDPM) that is specifically designed for medical image segmentation. The inverse process of ADDPM starts from a non-Gaussian distribution and terminates early once a prediction with relatively low noise is obtained after multiple iterations of denoising. We employ a separate powerful segmentation network to obtain pre-segmentation and construct the non-Gaussian distribution of the segmentation based on the forward diffusion rule. By further adopting a separate denoising network, the final segmentation can be obtained with just one denoising step from the predictions with low noise. ADDPM greatly reduces the number of denoising steps to approximately one-tenth of that in vanilla DDPMs. Our experiments on four segmentation tasks demonstrate that ADDPM outperforms both vanilla DDPMs and existing representative accelerating DDPMs methods. Moreover, ADDPM can be easily integrated with existing advanced segmentation models to improve segmentation performance and provide uncertainty estimation. Implementation code: https://github.com/Guoxt/ADDPM.

BACKGROUND: A single learning algorithm can produce deep learning-based image segmentation models that vary in performance purely due to random effects during training. This study assessed the effect of these random performance fluctuations on the reliability of standard methods of comparing segmentation models.
METHODS: The influence of random effects during training was assessed by running a single learning algorithm (nnU-Net) with 50 different random seeds for three multiclass 3D medical image segmentation problems, including brain tumour, hippocampus, and cardiac segmentation. Recent literature was sampled to find the most common methods for estimating and comparing the performance of deep learning segmentation models. Based on this, segmentation performance was assessed using both hold-out validation and 5-fold cross-validation and the statistical significance of performance differences was measured using the Paired t-test and the Wilcoxon signed rank test on Dice scores.
RESULTS: For the different segmentation problems, the seed producing the highest mean Dice score statistically significantly outperformed between 0 % and 76 % of the remaining seeds when estimating performance using hold-out validation, and between 10 % and 38 % when estimating performance using 5-fold cross-validation.
CONCLUSIONS: Random effects during training can cause high rates of statistically-significant performance differences between segmentation models from the same learning algorithm. Whilst statistical testing is widely used in contemporary literature, our results indicate that a statistically-significant difference in segmentation performance is a weak and unreliable indicator of a true performance difference between two learning algorithms.

Recently, ViT and CNNs based on encoder-decoder architecture have become the dominant model in the field of medical image segmentation. However, there are some deficiencies for each of them: (1) It is difficult for CNNs to capture the interaction between two locations with consideration of the longer distance. (2) ViT cannot acquire the interaction of local context information and carries high computational complexity. To optimize the above deficiencies, we propose a new network for medical image segmentation, which is called FCSU-Net. FCSU-Net uses the proposed collaborative fusion of multi-scale feature block that enables the network to obtain more abundant and more accurate features. In addition, FCSU-Net fuses full-scale feature information through the FFF (Full-scale Feature Fusion) structure instead of simple skip connections, and establishes long-range dependencies on multiple dimensions through the CS (Cross-dimension Self-attention) mechanism. Meantime, every dimension is complementary to each other. Also, CS mechanism has the advantage of convolutions capturing local contextual weights. Finally, FCSU-Net is validated on several datasets, and the results show that FCSU-Net not only has a relatively small number of parameters, but also has a leading segmentation performance.

Swin Transformer is an important work among all the attempts to reduce the computational complexity of Transformers while maintaining its excellent performance in computer vision. Window-based patch self-attention can use the local connectivity of the image features, and the shifted window-based patch self-attention enables the communication of information between different patches in the entire image scope. Through in-depth research on the effects of different sizes of shifted windows on the patch information communication efficiency, this article proposes a Dual-Scale Transformer with double-sized shifted window attention method. The proposed method surpasses CNN-based methods such as U-Net, AttenU-Net, ResU-Net, CE-Net by a considerable margin (Approximately 3% ∼ 6% increase), and outperforms the Transformer based models single-scale Swin Transformer(SwinT)(Approximately 1% increase), on the datasets of the Kvasir-SEG, ISIC2017, MICCAI EndoVisSub-Instrument and CadVesSet. The experimental results verify that the proposed dual scale shifted window attention benefits the communication of patch information and can enhance the segmentation results to state of the art. We also implement an ablation study on the effect of the shifted window size on the information flow efficiency and verify that the dual-scale shifted window attention is the optimized network design. Our study highlights the significant impact of network structure design on visual performance, providing valuable insights for the design of networks based on Transformer architectures.

We propose a shape prior representation-constrained multi-scale features fusion segmentation network for medical image segmentation, including training and testing stages. The novelty of our training framework lies in two modules comprised of the shape prior constraint and the multi-scale features fusion. The shape prior learning model is embedded into a segmentation neural network to solve the problems of low contrast and neighboring organs with intensities similar to the target organ. The latter can provide both local and global contexts to address the issues of large variations in patient postures as well as organ\'s shape. In the testing stage, we propose a circular collaboration framework strategy which combines a shape generator auto-encoder network model with a segmentation network model, allowing the two models to collaborate with each other, resulting in a cooperative effect that leads to accurate segmentations. Our proposed method is evaluated and demonstrated on the ACDC MICCAI\'17 Challenge Dataset, CT scans datasets, namely, in COVID-19 CT lung, and LiTS2017 liver from three different datasets, and its results are compared with the recent state of the art in these areas. Our method ranked 1st on the ACDC Dataset in terms of Dice score and achieved very competitive performance on COVID-19 CT lung and LiTS2017 liver segmentation.