Although digoxin is important in heart rate control, the utilization of digoxin is declining due to its narrow therapeutic window. Misdiagnosis or delayed diagnosis of digoxin toxicity is common due to the lack of awareness and the time-consuming laboratory work that is involved. Electrocardiography (ECG) may be able to detect potential digoxin toxicity based on characteristic presentations. Our study attempted to develop a deep learning model to detect digoxin toxicity based on ECG manifestations. This study included 61 ECGs from patients with digoxin toxicity and 177,066 ECGs from patients in the emergency room from November 2011 to February 2019. The deep learning algorithm was trained using approximately 80% of ECGs. The other 20% of ECGs were used to validate the performance of the Artificial Intelligence (AI) system and to conduct a human-machine competition. Area under the receiver operating characteristic curve (AUC), sensitivity, and specificity were used to evaluate the performance of ECG interpretation between humans and our deep learning system. The AUCs of our deep learning system for identifying digoxin toxicity were 0.912 and 0.929 in the validation cohort and the human-machine competition, respectively, which reached 84.6% of sensitivity and 94.6% of specificity. Interestingly, the deep learning system using only lead I (AUC = 0.960) was not worse than using complete 12 leads (0.912). Stratified analysis showed that our deep learning system was more applicable to patients with heart failure (HF) and without atrial fibrillation (AF) than those without HF and with AF. Our ECG-based deep learning system provides a high-accuracy, economical, rapid, and accessible way to detect digoxin toxicity, which can be applied as a promising decision supportive system for diagnosing digoxin toxicity in clinical practice.

Intracranial germ cell tumors (GCTs) are uncommon and may cause obstructive hydrocephalus, making adequate drainage necessary in symptomatic patients. Here, we present the case of a 36-year-old male patient with intracranial germinoma metastasis to the peritoneal cavity. He had a medical history of pineal germinoma status post ventriculoperitoneal (VP) shunt implantation and definitive radiotherapy. Two years later, the patient presented with epigastric pain, and intra-abdominal metastasis through the VP shunt with malignant transformation to a nongerminomatous GCT was noted. Chemotherapy followed by surgical resection was arranged, and he got disease free after treatment. The present report alerts clinicians to the progression of this uncommon disease and suggests that a thorough physical examination is imperative in patients with a history of intracranial GCTs who have undergone VP shunt implantation, and an alternative therapeutic plan should be considered to treat intracranial GCT-related obstructive hydrocephalus.