Interaction between clinicians and artificial intelligence to detect fetal atrioventricular septal defects on ultrasound: how can we optimize collaborative performance?

OBJECTIVES: Artificial intelligence (AI) has shown promise in improving the performance of fetal ultrasound screening in detecting congenital heart disease (CHD). The effect of giving AI advice to human operators has not been studied in this context. Giving additional information about AI model workings, such as confidence scores for AI predictions, may be a way of further improving performance. Our aims were to investigate whether AI advice improved overall diagnostic accuracy (using a single CHD lesion as an exemplar), and to determine what, if any, additional information given to clinicians optimized the overall performance of the clinician-AI team. METHODS: An AI model was trained to classify a single fetal CHD lesion (atrioventricular septal defect (AVSD)), using a retrospective cohort of 121 130 cardiac four-chamber images extracted from 173 ultrasound scan videos (98 with normal hearts, 75 with AVSD); a ResNet50 model architecture was used. Temperature scaling of model prediction probability was performed on a validation set, and gradient-weighted class activation maps (grad-CAMs) produced. Ten clinicians (two consultant fetal cardiologists, three trainees in pediatric cardiology and five fetal cardiac sonographers) were recruited from a center of fetal cardiology to participate. Each participant was shown 2000 fetal four-chamber images in a random order (1000 normal and 1000 AVSD). The dataset comprised 500 images, each shown in four conditions: (1) image alone without AI output; (2) image with binary AI classification; (3) image with AI model confidence; and (4) image with grad-CAM image overlays. The clinicians were asked to classify each image as normal or AVSD. RESULTS: A total of 20 000 image classifications were recorded from 10 clinicians. The AI model alone achieved an accuracy of 0.798 (95% CI, 0.760-0.832), a sensitivity of 0.868 (95% CI, 0.834-0.902) and a specificity of 0.728 (95% CI, 0.702-0.754), and the clinicians without AI achieved an accuracy of 0.844 (95% CI, 0.834-0.854), a sensitivity of 0.827 (95% CI, 0.795-0.858) and a specificity of 0.861 (95% CI, 0.828-0.895). Showing a binary (normal or AVSD) AI model output resulted in significant improvement in accuracy to 0.865 (P < 0.001). This effect was seen in both experienced and less-experienced participants. Giving incorrect AI advice resulted in a significant deterioration in overall accuracy, from 0.761 to 0.693 (P < 0.001), which was driven by an increase in both Type-I and Type-II errors by the clinicians. This effect was worsened by showing model confidence (accuracy, 0.649; P < 0.001) or grad-CAM (accuracy, 0.644; P < 0.001). CONCLUSIONS: AI has the potential to improve performance when used in collaboration with clinicians, even if the model performance does not reach expert level. Giving additional information about model workings such as model confidence and class activation map image overlays did not improve overall performance, and actually worsened performance for images for which the AI model was incorrect. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Search for Lorentz invariance and CPT violation with the MINOS far detector.

We searched for a sidereal modulation in the MINOS far detector neutrino rate. Such a signal would be a consequence of Lorentz and CPT violation as described by the standard-model extension framework. It also would be the first detection of a perturbative effect to conventional neutrino mass oscillations. We found no evidence for this sidereal signature, and the upper limits placed on the magnitudes of the Lorentz and CPT violating coefficients describing the theory are an improvement by factors of 20-510 over the current best limits found by using the MINOS near detector.

Mitochondria and neuronal glutamate excitotoxicity.

The role of mitochondria in the control of glutamate excitotoxicity is investigated. The response of cultured cerebellar granule cells to continuous glutamate exposure is characterised by a transient elevation in cytoplasmic free calcium concentration followed by decay to a plateau as NMDA receptors partially inactivate. After a variable latent period, a secondary, irreversible increase in calcium occurs (delayed calcium deregulation, DCD) which precedes and predicts subsequent cell death. DCD is not controlled by mitochondrial ATP synthesis since it is unchanged in the presence of the ATP synthase inhibitor oligomycin in cells with active glycolysis. However, mitochondrial depolarisation (and hence inhibition of mitochondrial calcium accumulation) without parallel ATP depletion (oligomycin plus either rotenone or antimycin A) strongly protects the cells against DCD. Glutamate exposure is associated with an increase in the generation of superoxide anion by the cells, but superoxide generation in the absence of mitochondrial calcium accumulation is not neurotoxic. While it is concluded that mitochondrial calcium accumulation plays a critical role in the induction of DCD we can find no evidence for the involvement of the mitochondrial permeability transition.

Mechanisms of neuronal damage in brain hypoxia/ischemia: focus on the role of mitochondrial calcium accumulation.

Following a hypoxic-ischemic insult, the collapse of ion gradients results in the inappropriate release of excitatory neurotransmitters. Although excitatory amino acids such as glutamate are the likely extracellular mediators of the ensuing neuronal cell death, the intracellular events occurring downstream of glutamate receptor activation are much less clear. The present review attempts to summarize how Ca2+ overload of neurons following a hypoxic-ischemic insult is neurotoxic. In particular, the interlocked relation between mitochondrial Ca2+ accumulation and subsequent neuronal cell death is examined.

Mitochondria in the life and death of neurons.

A prolonged decrease in ATP levels underlies a number of neurodegenerative disorders. Defects in oxidative phosphorylation are associated with a number of neurodegenerative disorders. Mitochondria also play an important role in mediating the initiation of apoptosis.

Mitochondrial membrane potential and hydroethidine-monitored superoxide generation in cultured cerebellar granule cells.

Mitochondrial depolarisation has been reported to enhance the generation of superoxide anion (O2.-) in a number of cell preparations while an inhibition has been observed with isolated mitochondria. Cerebellar granule cells equilibrated with > 1 microM hydroethidine (dihydroethidium) which is oxidised to the fluorescent ethidium cation by O2.- showed a large increase in fluorescence on protonophore addition. However, controls showed the fluorescent enhancement to be a consequence of release of unbound preformed ethidium from the mitochondrial matrix within the cell with resultant fluorescent enhancement. This ambiguity was removed by the use of low (1 microM) concentrations of dye in which case generated ethidium remained bound within the mitochondria. Under these conditions antimycin A, but not protonophore addition, produced an increase in fluorescence. It is concluded that excess ethidium acts as an indicator of mitochondrial membrane potential obscuring the monitoring of O2.- and that certain experiments employing this indicator in cells may require re-evaluation.

Excitotoxicity and mitochondria.

Excitotoxicity is the process whereby a massive glutamate release in the central nervous system in response to ischaemia or related trauma leads to the delayed, predominantly necrotic death of neurons. Excitotoxicity is also implicated in a variety of slow neurodegenerative disorders. Mitochondria accumulate much of the post-ischaemic calcium entering the neurons via the chronically activated N-methyl-D-aspartate receptor. This calcium accumulation plays a key role in the subsequent death of the neuron. Cultured cerebellar granule cells demonstrate delayed calcium de-regulation (DCD) followed by necrosis upon exposure to glutamate. DCD is unaffected by the ATP synthase inhibitor oligomycin but is inhibited by the further addition of a respiratory chain inhibitor to depolarize the mitochondria and inhibit mitochondrial calcium accumulation without depleting ATP [Budd and Nicholls (1996) J. Neurochem. 67, 2282-2291]. Mitochondrial depolarization paradoxically decreases the cytoplasmic calcium elevation following glutamate addition, probably due to an enhanced calcium efflux from the cell. Cells undergo immediate calcium de-regulation in the presence of glutamate if the respiratory chain is inhibited; this is due to ATP depletion following ATP synthase reversal and can be reversed by oligomycin. In contrast, DCD is irreversible. Elevated cytoplasmic calcium is not excitotoxic as long as mitochondria are depolarized; alternative substrates do not rescue cells about to undergo DCD, suggesting that glycolytic failure is not involved. Mitochondria in situ remain sufficiently polarized during granule cell glutamate exposure to continue to generate ATP and show a classic mitochondrial state 3-state 4 hyperpolarization on inhibiting ATP synthesis; mitochondrial depolarization follows, and may be a consequence of rather than a cause of DCD. In addition, our studies show no evidence of the mitochondrial permeability transition prior to DCD. The mitochondrial generation of superoxide anions is enhanced during glutamate exposure and a working hypothesis is that DCD may be caused by oxidative damage to calcium extrusion pathways at the plasma membrane.

Quantitative perfusion imaging assessing acquired discrete peripheral pulmonary artery stenosis.

We present the case an 8-yr-old boy evaluated for anastomotic stenosis of the right pulmonary artery after surgical repair of hemitruncus at 6 wk of age. Pulmonary angiography revealed only mild narrowing and a 10-mm pressure gradient across the anastomosis, but quantitative perfusion imaging demonstrated that the right lung only received 16% of pulmonary blood flow. Subsequently, balloon angioplasty of the anastomotic site was performed, resulting in complete resolution of the stenosis and gradient. Early postangioplasty perfusion imaging demonstrated increased perfusion of the right lung to 35% of total pulmonary blood flow. It is theorized that initially a chronically hyperperfused lung may develop more capacious vessels and recruit new capillaries during the years of hyperperfusion such that a "perfect" angioplasty may result in less than symmetric perfusion. The inexpensive, noninvasive quantitative perfusion study is more sensitive and accurate in evaluating acquired (postsurgical) pulmonary artery stenoses.

Effect of diltiazem and low-dose aspirin on platelet aggregation and ATP release induced by paired agonists.

The authors studied the effects of diltiazem, administered alone and together with low-dose aspirin, on the platelet response to paired agonists. After a baseline period, 25 healthy volunteers were given oral diltiazem for 1 week (120, 240, or 360 mg/day), and then crossed over randomly between 1 week on diltiazem plus aspirin (81 mg/day), and 1 week on aspirin (81 mg/day) alone. Platelet function was tested on 2 consecutive days in each period. Synergistic platelet aggregation and ATP release were obtained at baseline using a subthreshold concentration of arachidonic acid combined with platelet activating factor, ADP, or epinephrine. Diltiazem resulted in significant decrease from baseline in platelet aggregation and ATP release using the arachidonic acid-epinephrine combination (35% and 40% decrease, respectively, p < 0.01) and a significant decrease in aggregation using the arachidonic acid-ADP combination (22% decrease, p < 0.01). The effects were neither dose-related, nor accompanied by any significant change in serum thromboxane B2 levels or bleeding times. There was no significant difference between the effects of aspirin alone and aspirin plus diltiazem on the synergistic platelet aggregation and ATP release induced by the paired agonists, or on thromboxane B2 levels or bleeding times. Diltiazem administered in vivo partially inhibits the synergistic platelet aggregation and ATP release induced by paired agonists; however, in contrast to a previous in vitro study it does not potentiate the platelet-inhibitory effect of aspirin.

Glutamate excitotoxicity and neuronal energy metabolism.

The bioenergetic properties of the in situ mitochondria play a central role in controlling the susceptibility of neurons to acute or chronic neurodegenerative stress. The mitochondrial membrane potential, delta psi m is the parameter that controls three interrelated mitochondrial functions of great relevance to neuronal survival: namely, ATP synthesis, Ca2+ accumulation, and superoxide generation. The in vitro model we study is the rat cerebellar granule cell in primary culture and its susceptibility to NMDA receptor-mediated necrosis, which is preceded by a delayed failure of cytoplasmic Ca2+ homeostasis ("delayed Ca2+ deregulation," DCD). DCD is not caused by a failure of mitochondrial ATP synthesis since it also occurs in cells maintained purely by glycolysis. The in situ mitochondria maintain a delta psi m sufficient for ATP synthesis throughout the exposure of the cells to glutamate until DCD occurs. Even at that stage it appears that mitochondrial depolarization may be an effect of DCD rather than a primary cause. This somewhat unorthodox view resolves a number of apparent paradoxes, such as observations of enhanced superoxide generation by in situ mitochondria during excitotoxic exposure, since isolated mitochondria generate superoxide only under conditions of high delta psi m. Mitochondrial depolarization by selective inhibitors that do not deplete cellular ATP is acutely neuroprotective.

Treatment with propylthiouracil before radioactive iodine therapy is associated with a higher treatment failure rate than therapy with radioactive iodine alone in Graves' disease.

Older reports have suggested that the use of antithyroid drugs with radioactive iodine-131 (RAI) results in higher rates of persistent hyperthyroidism than treatment with RAI alone. Our objective was to determine if propylthiouracil (PTU) given prior to RAI would be associated with a higher single dose RAI failure rate than treatment with RAI alone. Patients were considered treatment failures if a second dose of RAI was required to produce euthyroidism or hypothyroidism. All study patients stopped PTU at least 4 days before RAI therapy and did not receive PTU after RAI. The overall failure rate of one course of treatment in the 86 study patients was 17% (15/86). Persistent hyperthyroidism was seen in 4% of patients (2/48) treated with only RAI and in 34% of patients (13/38) receiving RAI after pretreatment with PTU (p = 0.003). Patients were treated with PTU for a mean of 151 +/- 32 days. There were no significant differences in race, gender, thyroid size, RAI dose, or days of follow-up between patients receiving RAI alone and those receiving PTU before RAI therapy. These data suggest that pretreatment with PTU leads to a higher failure rate even if PTU is discontinued at least 4 days before RAI therapy and not restarted after RAI dosing. Consideration should be given to increasing the dose of RAI in patients pretreated with PTU to ensure adequate treatment of Graves' disease.

The Poole Diabetes Study: how many cases of Type 2 diabetes are diagnosed each year during normal health care in a defined community?

UNLABELLED: We have investigated the incidence of newly diagnosed Type 2 diabetes in the Poole area and extrapolated it to the rest of the UK. METHODS: this prospective observational study used a surveillance programme in primary and secondary care. We identified all cases of newly diagnosed Type 2 diabetes mellitus occurring from 1st May 1996 to 30th June 1998 through the normal health care process without any active screening in 186889 people registered with 24 primary care practices in the Poole area. RESULTS: the 1996 prevalence of diagnosed Type 2 diabetes in this population was 1.59 (95% CI 1.53-1.65%)%. During the first 24 months of the study, 706 new cases of Type 2 diabetes mellitus, 382 men and 324 women, were identified. The crude annual incidence of newly diagnosed Type 2 diabetes, thus was 1.93/1000 (95% CI 1.73-2.13%) and age/sex adjusted incidence was 1.67/1000 (95% CI 1.49-1.84%). The age-adjusted incidence was higher in men, 1.86/1000 (95% CI 1.60-2.13), than in women, 1.48/1000 (95% CI 1.25-1.71%), relative risk 1.26 (95% CI 0.997-1.527%), but this difference did not reach statistical significance. Mean HbA1c at diagnosis was 10.8 (S.D. 2.9%)%. Men were younger at diagnosis than women (mean age, 62.9 vs. 65.9%, P<0.01). CONCLUSION: in UK, prior to the change in the WHO diagnostic criteria for diabetes, we estimate that over 98000 new cases of Type 2 diabetes were diagnosed each year.

Non-epileptic attack disorder: a clinical audit.

The results of an audit of all patients with non-epileptic attack disorder admitted over a 1-year period to a neuropsychiatry tertiary referral centre are presented. The high incidence of: sexual abuse, previous psychiatric history and previous brain injury is noted. Reference is made to the reaction of patients and relatives to disclosure of the diagnosis and the management difficulties which this group of patients pose. The different underlying psychopathological processes are discussed and it is suggested that the diagnosis of NEAD, purely by the exclusion of epilepsy, might carry the risk of treating these patients as a homogenous group. An eclectic approach by an experienced, multi-disciplinary team is probably the most appropriate way of successfully managing the condition.

Neuronal excitotoxicity: the role of mitochondria.

Chronic activation of NMDA receptors by glutamate is toxic to cultured neurons. The extensive Ca2+ entry accompanying receptor activation is largely accumulated by the intracellular mitochondria, with resultant effects on mitochondrial membrane potential, ATP synthesis, glycolysis, reactive oxygen species generation and ultimately failure of cytoplasmic Ca2+ homeostasis and cell death. Each of these parameters is inter-related and in this review we describe attempts to separate out each factor to establish the sequence of events following NMDA-receptor activation. The conclusion is that mitochondrial Ca2+ accumulation is a key event in glutamate excitotoxicity, and that cells maintained by glycolysis in the absence of a mitochondrial membrane potential are highly resistant to glutamate excitotoxicity.

UK: the current state of regulation of complementary and alternative medicine.

There is no legislation that restricts the practice of CAM in the UK apart from the practice of chiropractic and osteopathy and limits on advertising the treatments of certain conditions such as cancer and tuberculosis. The UK government has increasingly recognised the need for comprehensive regulation of CAM, though it abandoned its original plan for a single overarching regulatory body. Initiatives to examine and hasten the process of regulation have included setting up a central, well-recognised charitable body to facilitate progress for individual professions, and an authoritative survey of the existing professional organisations. One pathway open to individual professions is statutory self-regulation, which requires a single governing body, a systematic corpus of knowledge, recognised training courses and demonstrated efficacy. The other pathway is voluntary self-regulation. Chiropractic and osteopathy have adopted statutory self-regulation, though this has proved expensive for individual members of these professions. A recent House of Lords report on CAM has recommended that the herbal medicine and acupuncture professions should also develop a system of statutory regulation. Other professions, such as aromatherapy, are in the process of establishing single professional bodies as a first step towards self-regulation. Among the issues that remain to be resolved is the relationship between the CAM professions and statutory registered practitioners who also practise CAM.

Effect of dilantin on myocardial uptake of Tl-201 thallous chloride. A case report.

Dilantin has been reported to decrease myocardial uptake of Tl-201 thallous chloride by as much as 38.8% in rats. To date, no studies have been done in humans to document the effect of dilantin on the myocardial uptake of thallium or its effect clinically on the interpretation of images obtained while on dilantin. The authors report a case in which simultaneous exercise echocardiogram and Tl-201 myocardial scintigraphy and serial Tl-201 myocardial scintigraphy were performed but revealed no adverse effect on image quality or interpretation.