What are the perceptions and concerns of people living with diabetes and National Health Service staff around the potential implementation of AI-assisted screening for diabetic eye disease? Development and validation of a survey for use in a secondary care screening setting.

INTRODUCTION: The English National Health Service (NHS) Diabetic Eye Screening Programme (DESP) performs around 2.3 million eye screening appointments annually, generating approximately 13 million retinal images that are graded by humans for the presence or severity of diabetic retinopathy. Previous research has shown that automated retinal image analysis systems, including artificial intelligence (AI), can identify images with no disease from those with diabetic retinopathy as safely and effectively as human graders, and could significantly reduce the workload for human graders. Some algorithms can also determine the level of severity of the retinopathy with similar performance to humans. There is a need to examine perceptions and concerns surrounding AI-assisted eye-screening among people living with diabetes and NHS staff, if AI was to be introduced into the DESP, to identify factors that may influence acceptance of this technology. METHODS AND ANALYSIS: People living with diabetes and staff from the North East London (NEL) NHS DESP were invited to participate in two respective focus groups to codesign two online surveys exploring their perceptions and concerns around the potential introduction of AI-assisted screening.Focus group participants were representative of the local population in terms of ages and ethnicity. Participants' feedback was taken into consideration to update surveys which were circulated for further feedback. Surveys will be piloted at the NEL DESP and followed by semistructured interviews to assess accessibility, usability and to validate the surveys.Validated surveys will be distributed by other NHS DESP sites, and also via patient groups on social media, relevant charities and the British Association of Retinal Screeners. Post-survey evaluative interviews will be undertaken among those who consent to participate in further research. ETHICS AND DISSEMINATION: Ethical approval has been obtained by the NHS Research Ethics Committee (IRAS ID: 316631). Survey results will be shared and discussed with focus groups to facilitate preparation of findings for publication and to inform codesign of outreach activities to address concerns and perceptions identified.

Automated arteriole and venule classification using deep learning for retinal images from the UK Biobank cohort.

The morphometric characteristics of the retinal vasculature are associated with future risk of many systemic and vascular diseases. However, analysis of data from large population based studies is needed to help resolve uncertainties in some of these associations. This requires automated systems that extract quantitative measures of vessel morphology from large numbers of retinal images. Associations between retinal vessel morphology and disease precursors/outcomes may be similar or opposing for arterioles and venules. Therefore, the accurate detection of the vessel type is an important element in such automated systems. This paper presents a deep learning approach for the automatic classification of arterioles and venules across the entire retinal image, including vessels located at the optic disc. This comprises of a convolutional neural network whose architecture contains six learned layers: three convolutional and three fully-connected. Complex patterns are automatically learnt from the data, which avoids the use of hand crafted features. The method is developed and evaluated using 835,914 centreline pixels derived from 100 retinal images selected from the 135,867 retinal images obtained at the UK Biobank (large population-based cohort study of middle aged and older adults) baseline examination. This is a challenging dataset in respect to image quality and hence arteriole/venule classification is required to be highly robust. The method achieves a significant increase in accuracy of 8.1% when compared to the baseline method, resulting in an arteriole/venule classification accuracy of 86.97% (per pixel basis) over the entire retinal image.

Automated retinal image quality assessment on the UK Biobank dataset for epidemiological studies.

Morphological changes in the retinal vascular network are associated with future risk of many systemic and vascular diseases. However, uncertainty over the presence and nature of some of these associations exists. Analysis of data from large population based studies will help to resolve these uncertainties. The QUARTZ (QUantitative Analysis of Retinal vessel Topology and siZe) retinal image analysis system allows automated processing of large numbers of retinal images. However, an image quality assessment module is needed to achieve full automation. In this paper, we propose such an algorithm, which uses the segmented vessel map to determine the suitability of retinal images for use in the creation of vessel morphometric data suitable for epidemiological studies. This includes an effective 3-dimensional feature set and support vector machine classification. A random subset of 800 retinal images from UK Biobank (a large prospective study of 500,000 middle aged adults; where 68,151 underwent retinal imaging) was used to examine the performance of the image quality algorithm. The algorithm achieved a sensitivity of 95.33% and a specificity of 91.13% for the detection of inadequate images. The strong performance of this image quality algorithm will make rapid automated analysis of vascular morphometry feasible on the entire UK Biobank dataset (and other large retinal datasets), with minimal operator involvement, and at low cost.

Genetic algorithm based feature selection combined with dual classification for the automated detection of proliferative diabetic retinopathy.

Proliferative diabetic retinopathy (PDR) is a condition that carries a high risk of severe visual impairment. The hallmark of PDR is the growth of abnormal new vessels. In this paper, an automated method for the detection of new vessels from retinal images is presented. This method is based on a dual classification approach. Two vessel segmentation approaches are applied to create two separate binary vessel map which each hold vital information. Local morphology features are measured from each binary vessel map to produce two separate 4-D feature vectors. Independent classification is performed for each feature vector using a support vector machine (SVM) classifier. The system then combines these individual outcomes to produce a final decision. This is followed by the creation of additional features to generate 21-D feature vectors, which feed into a genetic algorithm based feature selection approach with the objective of finding feature subsets that improve the performance of the classification. Sensitivity and specificity results using a dataset of 60 images are 0.9138 and 0.9600, respectively, on a per patch basis and 1.000 and 0.975, respectively, on a per image basis.

Automated retinal vessel recognition and measurements on large datasets.

The characteristics of the retinal vascular network have been prospectively associated with many systemic and vascular diseases. QUARTZ is a fully automated software that has been developed to localize and quantify the morphological characteristics of blood vessels in retinal images for use in epidemiological studies. This software was used to analyse a dataset containing 16,000 retinal images from the EPIC-Norfolk cohort study. The objective of this paper is to both assess the suitability of this dataset for computational analysis and to further evaluate the QUARTZ software.

Automated detection of proliferative diabetic retinopathy using a modified line operator and dual classification.

Proliferative diabetic retinopathy (PDR) is a condition that carries a high risk of severe visual impairment. The hallmark of PDR is neovascularisation, the growth of abnormal new vessels. This paper describes an automated method for the detection of new vessels in retinal images. Two vessel segmentation approaches are applied, using the standard line operator and a novel modified line operator. The latter is designed to reduce false responses to non-vessel edges. Both generated binary vessel maps hold vital information which must be processed separately. This is achieved with a dual classification system. Local morphology features are measured from each binary vessel map to produce two separate feature sets. Independent classification is performed for each feature set using a support vector machine (SVM) classifier. The system then combines these individual classification outcomes to produce a final decision. Sensitivity and specificity results using a dataset of 60 images are 0.862 and 0.944 respectively on a per patch basis and 1.00 and 0.90 respectively on a per image basis.

Hyperhomocysteinemia is detrimental to pregnancy in mice and is associated with preterm birth.

Elevated levels of homocysteine produce detrimental effects in humans but its role in preterm birth is not known. Here we used a mouse model of hyperhomocysteinemia to examine the relevance of homocysteine to preterm birth. The mouse carries a heterozygous deletion of cystathionine ß-synthase (Cbs(+/-)). Gestational period was monitored in wild type and Cbs(+/-) female mice. Mouse uterine and placental tissues, human primary trophoblast cells, and human myometrial and placental cell lines were used to determine the influence of homocysteine on expression of specific genes in vitro. The activity of BKCa channel in the myometrial cell line was monitored using the patch-clamp technique. We found that hyperhomocysteinemia had detrimental effects on pregnancy and induced preterm birth in mice. Homocysteine increased the expression of oxytocin receptor and Cox-2 as well as PGE2 production in uterus and placenta, and initiated premature uterine contraction. A Cox-2 inhibitor reversed these effects. Gpr109a, a receptor for niacin, induced Cox-2 in uterus. Homocysteine upregulated GPR109A and suppressed BKCa channel activity in human myometrial cells. Deletion of Gpr109a in Cbs(+/-) mice reversed premature birth. We conclude that hyperhomocysteinemia causes preterm birth in mice through upregulation of the Gpr109a/Cox-2/PGE2 axis and that pharmacological blockade of Gpr109a may have potential in prevention of preterm birth.

Quantification of blood vessel calibre in retinal images of multi-ethnic school children using a model based approach.

Changes and variation in retinal vessel width are related to vascular risk factors and prospectively related to cardiovascular disease in later life. Hence, assessment of vessel width may be a useful physio-marker and potential predictor of cardiovascular status. However, measurement of vessel calibre from retinal images is a challenging process to automate. This paper proposes an automated system to measure vessel calibre in retinal images, which is demonstrated in images of multi-ethnic school children. The diameter measurement is based on the detection of the centreline pixels from a vessel probability map image, determining the vessel orientation at these pixels, extracting the vessel segments and later using a two-dimensional model, which is optimized to fit various types of intensity profiles of vessel segments. The width is then estimated from parameters of the optimized model. The method is also quantitatively analyzed using monochromatic representations of different colour spaces. The algorithm is evaluated on a recently introduced public database CHASE_DB1, which is a subset of retinal images of multi-ethnic children from the Child Heart and Health Study in England (CHASE) dataset. Moreover, the precise estimation of retinal vascular widths is critical for epidemiologists to identify the risk factors. This work also introduces an interactive software tool for epidemiologists, with which retinal vessel calibre can be precisely marked.

Application of morphological bit planes in retinal blood vessel extraction.

The appearance of the retinal blood vessels is an important diagnostic indicator of various clinical disorders of the eye and the body. Retinal blood vessels have been shown to provide evidence in terms of change in diameter, branching angles, or tortuosity, as a result of ophthalmic disease. This paper reports the development for an automated method for segmentation of blood vessels in retinal images. A unique combination of methods for retinal blood vessel skeleton detection and multidirectional morphological bit plane slicing is presented to extract the blood vessels from the color retinal images. The skeleton of main vessels is extracted by the application of directional differential operators and then evaluation of combination of derivative signs and average derivative values. Mathematical morphology has been materialized as a proficient technique for quantifying the retinal vasculature in ocular fundus images. A multidirectional top-hat operator with rotating structuring elements is used to emphasize the vessels in a particular direction, and information is extracted using bit plane slicing. An iterative region growing method is applied to integrate the main skeleton and the images resulting from bit plane slicing of vessel direction-dependent morphological filters. The approach is tested on two publicly available databases DRIVE and STARE. Average accuracy achieved by the proposed method is 0.9423 for both the databases with significant values of sensitivity and specificity also; the algorithm outperforms the second human observer in terms of precision of segmented vessel tree.

Blood vessel segmentation methodologies in retinal images--a survey.

Retinal vessel segmentation algorithms are a fundamental component of automatic retinal disease screening systems. This work examines the blood vessel segmentation methodologies in two dimensional retinal images acquired from a fundus camera and a survey of techniques is presented. The aim of this paper is to review, analyze and categorize the retinal vessel extraction algorithms, techniques and methodologies, giving a brief description, highlighting the key points and the performance measures. We intend to give the reader a framework for the existing research; to introduce the range of retinal vessel segmentation algorithms; to discuss the current trends and future directions and summarize the open problems. The performance of algorithms is compared and analyzed on two publicly available databases (DRIVE and STARE) of retinal images using a number of measures which include accuracy, true positive rate, false positive rate, sensitivity, specificity and area under receiver operating characteristic (ROC) curve.

An approach to localize the retinal blood vessels using bit planes and centerline detection.

The change in morphology, diameter, branching pattern or tortuosity of retinal blood vessels is an important indicator of various clinical disorders of the eye and the body. This paper reports an automated method for segmentation of blood vessels in retinal images. A unique combination of techniques for vessel centerlines detection and morphological bit plane slicing is presented to extract the blood vessel tree from the retinal images. The centerlines are extracted by using the first order derivative of a Gaussian filter in four orientations and then evaluation of derivative signs and average derivative values is performed. Mathematical morphology has emerged as a proficient technique for quantifying the blood vessels in the retina. The shape and orientation map of blood vessels is obtained by applying a multidirectional morphological top-hat operator with a linear structuring element followed by bit plane slicing of the vessel enhanced grayscale image. The centerlines are combined with these maps to obtain the segmented vessel tree. The methodology is tested on three publicly available databases DRIVE, STARE and MESSIDOR. The results demonstrate that the performance of the proposed algorithm is comparable with state of the art techniques in terms of accuracy, sensitivity and specificity.

Protein kinase C modulation of cyclic GMP in rat neonatal pulmonary vascular smooth muscle.

Protein kinase C (PKC) has been implicated in the control of vascular tone and mitogenesis in the adult pulmonary vasculature, but little is known about the role of PKC in the neonatal pulmonary vasculature. In addition, the vasodilator nitric oxide (NO) is important in the transition of the pulmonary circulation from fetal to postnatal life, and it is thought that attenuated production of NO and therefore, cGMP may contribute to the pathophysiology of a variety of forms of neonatal pulmonary vascular disease states. Although evidence exists for an interaction between PKC and NO in the adult pulmonary vasculature, the identification of specific roles for PKC in neonatal pulmonary vascular smooth muscle (NPVSM) has not been determined, and no studies have been done on the modulation of cGMP by PKC in NPVSM. Accordingly, immunoblot analysis revealed the expression of the alpha, delta, epsilon, and iota PKC isozymes in NPVSM. Treatment of NPVSM with 10 nM 4-beta phorbol myristate acetate (PMA), a PKC activator, induced translocation of PKCalpha, and PKCdelta from the soluble to the particulate fraction, while exposure to 10 nM endothelin-1 (ET-1), a potent vasoconstrictor and mitogenic substance, caused translocation of PKCdelta and PKCiota from the soluble to the particulate fraction. Sodium nitroprusside (SNP) significantly increased intracellular cGMP levels, an effect attenuated by PMA but not by ET-1. In addition, pretreatment with the specific PKC isozyme antagonist Go 6983 blocked the effect of PMA on cGMP levels. Collectively, these data demonstrate the expression and activation of multiple PKC isozymes in NPVSM, and indicate that PKC inhibits SNP-stimulated cGMP production in NPVSM. These data also suggest that complex intracellular signaling pathways by specific PKC isozymes may be important in the development of neonatal pulmonary vascular function.

Effect of protein kinase C inhibition on hypoxic pulmonary vasoconstriction.

The current study was done to test the hypothesis that protein kinase C (PKC) inhibitors prevent the increase in pulmonary vascular resistance and compliance that occurs in isolated, blood-perfused dog lungs during hypoxia. Pulmonary vascular resistances and compliances were measured with vascular occlusion techniques. Hypoxia significantly increased pulmonary arterial resistance, pulmonary venous resistance, and pulmonary capillary pressure and decreased total vascular compliance by decreasing both microvascular and large-vessel compliances. The nonspecific PKC inhibitor staurosporine (10(-7) M), the specific PKC blocker calphostin C (10(-7) M), and the specific PKC isozyme blocker Gö-6976 (10(-7) M) inhibited the effect of hypoxia on pulmonary vascular resistance and compliance. In addition, the PKC activator thymeleatoxin (THX; 10(-7) M) increased pulmonary vascular resistance and compliance in a manner similar to that in hypoxia, and the L-type voltage-dependent Ca(2+) channel blocker nifedipine (10(-6) M) inhibited the response to both THX and hypoxia. These results suggest that PKC inhibition blocks the hypoxic pressor response and that the pharmacological activation of PKC by THX mimics the hypoxic pulmonary vasoconstrictor response. In addition, L-type voltage-dependent Ca(2+) channel blockade may prevent the onset of the hypoxia- and PKC-induced vasoconstrictor response in the canine pulmonary vasculature.

Quantification of posterior capsular opacification in digital images after cataract surgery.

PURPOSE: To describe a software program developed to provide an objective assessment of the amount of posterior capsular opacification (PCO) in high-resolution digital images of the posterior capsule after cataract surgery. METHODS: Images are analyzed by a set protocol of defining the area of the posterior capsule, removing the Purkinje light reflexes by intensity segmentation, contrast enhancement, filtering to enhance low-density PCO, and variance analysis using a co-occurrence matrix to assess texture. The accuracy of the system was tested for validity and repeatability. RESULTS: The software developed has been demonstrated to be an objective method of quantifying PCO. In validation tests, the image analysis-derived measure of PCO showed good agreement with clinically derived measures of PCO. Clinicians assessed PCO on a computer screen image and also under slit lamp examination (Pearson correlation coefficient for both methods >0.92). The entire acquisition and analysis system was demonstrated to have a confidence limit for 2 SDs of 9.8% for group data. CONCLUSIONS: This system is capable of producing an accurate and reproducible measure of PCO that is relevant to assessing techniques of PCO prevention.

Posterior capsular opacification with hydrogel, polymethylmethacrylate, and silicone intraocular lenses: two-year results of a randomized prospective trial.

PURPOSE: To compare the visual outcome, percentage of posterior capsular opacification, and laser capsulotomy rates with polymethylmethacrylate, silicone, and hydrogel intraocular lens implants at 1 and 2 years postoperatively. METHODS: Ninety-three eyes of 93 patients were randomized to receive a polymethylmethacrylate, silicone, or hydrogel intraocular lens implant. A standardized surgical protocol was followed by a single surgeon using phacoemulsification with capsulorhexis; any patients with surgical complications were excluded, and all patients received standardized medication and follow-up. Patients were examined at days 1 and 7, months 1, 3, and 6, and years 1 and 2 after surgery. At each assessment, best-corrected logMAR visual acuity and Pelli-Robson contrast sensitivity were measured. Posterior capsular opacification was objectively assessed by digital retroillumination imaging with the use of a dedicated software program and calculated as the percentage area of opacified capsule. Laser capsulotomy was performed if the eye had lost 2 lines of visual acuity with a clinically opaque capsule. RESULTS: At 2 years postoperatively, the mean percentage area of posterior capsular opacification for hydrogel lenses was 63%; for polymethylmethacrylate, 46%; and for silicone, 17%. Hydrogel intraocular lenses were associated with 17% more posterior capsule opacification than were polymethylmethacrylate lenses (95% confidence interval, 1-33; P =. 037) and 45% more than were silicone lenses (95% confidence interval, 33-58; P <.0001) at 2 years. Polymethylmethacrylate lenses had 28% more posterior capsule opacification than silicone lenses (95% confidence interval, 13-43; P <.0001) at 2 years. Twenty-eight percent of patients with hydrogel intraocular lenses required an Nd:YAG laser posterior capsulotomy at 2 years, compared with 14% with polymethylmethacrylate, whereas no patients with silicone lenses needed a capsulotomy (P =.014). Visual acuity was not significantly different among the three groups, but patients with silicone intraocular lenses had significantly better contrast sensitivity than those with hydrogel lenses (P =.046). CONCLUSIONS: Intraocular lenses made of this specific hydrogel were associated with a significantly higher degree of posterior capsular opacification and more laser capsulotomies than polymethylmethacrylate and silicone intraocular lenses.

Phase effects in double-focus and double-aperture interference microscopy.

Two different optical techniques for surface tracking and linewidth measurement are evaluated. First, an evaluation is made of the performance of a double-focus polarization microscope, based on results from a computer model and from experimental measurements. The assessment shows that a phase curvature effect makes the operation of this configuration impractical as a surface tracking device and linewidth measurement system. An alternative arrangement of using a double aperture is evaluated. The phase curvature effect is reduced in this type of microscope. A practical optical arrangement to implement a double-aperture microscope is given.

Potassium channels modulate canine pulmonary vasoreactivity to protein kinase C activation.

The role of Ca2+-activated K+-channel, ATP-sensitive K+-channel, and delayed rectifier K+-channel modulation in the canine pulmonary vascular response to protein kinase C (PKC) activation was determined in the isolated blood-perfused dog lung. Pulmonary vascular resistances and compliances were measured with vascular occlusion techniques. The PKC activators phorbol 12-myristate 13-acetate (PMA; 10(-7) M) and thymeleatoxin (THX; 10(-7) M) significantly increased pulmonary arterial and pulmonary venous resistances and pulmonary capillary pressure and decreased total vascular compliance by decreasing both microvascular and large-vessel compliances. The Ca2+-activated K+-channel blocker tetraethylammonium ions (1 mM), the ATP-sensitive K+-channel inhibitor glibenclamide (10(-5) M), and the delayed rectifier K+-channel blocker 4-aminopyridine (10(-4) M) potentiated the pressor response to both PMA and THX on the arterial and venous segments and also further decreased pulmonary vascular compliance. In contrast, the ATP-sensitive K+-channel opener cromakalim (10(-5) M) attenuated the vasoconstrictor effect of PMA and THX on both the arterial and venous vessels. In addition, membrane depolarization by 30 mM KCl elicited an increase in the pressor response to PMA. These results indicate that pharmacological activation of PKC elicits pulmonary vasoconstriction. Closure of the Ca2+-activated K+ channels, ATP-sensitive K+ channels, and delayed rectifier K+ channels as well as direct membrane depolarization by KCl potentiated the response to PMA and THX, indicating that K+ channels modulate the canine pulmonary vasoconstrictor response to PKC activation.

The effect of polymethylmethacrylate, silicone, and polyacrylic intraocular lenses on posterior capsular opacification 3 years after cataract surgery.

OBJECTIVE: To compare the visual outcome, neodymium:YAG (Nd:YAG) capsulotomy rates, and percentage of posterior capsular opacification (PCO) seen with polymethylmethacrylate (PMMA), silicone, and polyacrylic intraocular lens implants 3 years after surgery. DESIGN: Randomized, prospective trial. PARTICIPANTS: Ninety eyes of 81 patients were examined at a British teaching hospital. INTERVENTION: Ninety eyes were prospectively randomized to receive a PMMA, silicone, or polyacrylic (AcrySof, Alcon, Fort Worth, TX) implant. All lenses had 6-mm disc optics with PMMA haptics. A standardized surgical protocol was performed by a single surgeon using an extracapsular technique with capsulorhexis; any surgical complications were excluded and all patients had standardized postoperative medication and follow-up. MAIN OUTCOME MEASURES: Patients were seen at 6 months and 1, 2, and 3 years after surgery. At 3 years, logarithm of the minimum angle of resolution (LogMAR) visual acuity and Pelli-Robson contrast sensitivity were measured and YAG capsulotomy rates determined. Posterior capsular opacification was assessed objectively by digital retroillumination imaging using dedicated software and calculated as the percentage area of opacified capsule. RESULTS: At 3 years, the overall follow-up rate was 71%: 19 patients were available for examination with polyacrylic lens implants, 22 with silicone, and 23 with PMMA. There was a significant difference in percentage PCO at 3 years among the lens types (P = 0.0001). Polyacrylic lenses were associated with less PCO (10%) than silicone (40%) and PMMA lenses (56%). The YAG capsulotomy rate was 0% for polyacrylic, 14% for silicone, and 26% for PMMA (P = 0.05). The visual acuity and contrast sensitivity were not significantly different among the three groups if patients with age-related macular degeneration and those requiring YAG capsulotomies are excluded. CONCLUSIONS: Intraocular lenses made from polyacrylic are associated with a significantly reduced degree of PCO and lower YAG rates.

Potassium channels modulate hypoxic pulmonary vasoconstriction.

The role of Ca2+-activated K+-channel, ATP-sensitive K+-channel, and delayed rectifier K+-channel modulation in the canine pulmonary vascular response to hypoxia was determined in the isolated blood-perfused dog lung. Pulmonary vascular resistances and compliances were measured with vascular occlusion techniques. Under normoxia, the Ca2+-activated K+-channel blocker tetraethylammonium (1 mM), the ATP-sensitive K+-channel inhibitor glibenclamide (10(-5) M), and the delayed rectifier K+-channel blocker 4-aminopyridine (10(-4) M) elicited a small but significant increase in pulmonary arterial pressure. Hypoxia significantly increased pulmonary arterial and venous resistances and pulmonary capillary pressure and decreased total vascular compliance by decreasing both microvascular and large-vessel compliances. Tetraethylammonium, glibenclamide, and 4-aminopyridine potentiated the response to hypoxia on the arterial segments but not on the venous segments and also further decreased pulmonary vascular compliance. In contrast, the ATP-sensitive K+-channel opener cromakalim and the L-type voltage-dependent Ca2+-channel blocker verapamil (10(-5) M) inhibited the vasoconstrictor effect of hypoxia on both the arterial and venous vessels. These results indicate that closure of the Ca2+-activated K+ channels, ATP-sensitive K+ channels, and delayed rectifier K+ channels potentiate the canine pulmonary arterial response under hypoxic conditions and that L-type voltage-dependent Ca2+ channels modulate hypoxic vasoconstriction. Therefore, the possibility exists that K+-channel inhibition is a key event that links hypoxia to pulmonary vasoconstriction by eliciting membrane depolarization and subsequent Ca2+-channel activation, leading to Ca2+ influx.

Fenfluramine potentiates canine pulmonary vasoreactivity to endothelin-1.

The appetite suppressant fenfluramine, a serotonin uptake inhibitor, has been implicated in the development of primary pulmonary hypertension (PPH). The effect of fenfluramine on the pressor response to endothelin-1 (ET-1) in the canine pulmonary circulation was determined using the isolated perfused dog lung. Pulmonary vascular resistance was measured using vascular occlusion techniques. Group 1 (n=4) consisted of isolated lung lobes treated with 10(-8)M ET-1 alone. For group 2 (n=4) and group 3 (n=4), dogs were given 15 mg fenfluramine daily for 14 days prior to sacrifice for isolated lung perfusion. In group 2, lobes were treated with 10(-7)M fenfluramine after lung isolation. In group 3, the isolated lobes were treated with 10(-8)M ET-1 similar to group 1. Acute treatment of the isolated lobes in group 2 with 10(-7)M fenfluramine increased pulmonary arterial pressure. In group 3, administration of 10(-8)M ET-1 potentiated the effect of ET-1 on post-capillary resistance relative to group 1, and elicited an increase in precapillary resistance, an effect not present in group 1. These results indicate that chronic fenfluramine exposure potentiates the pulmonary vasoconstrictor response to ET-1, and suggests that elevated levels of serotonin may <> the pulmonary circulation to become hyperreactive to other vasoactive substances possibly leading to the development of disease states such as primary pulmonary hypertension.