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NeuroStar Advanced Therapy is indicated as an adjunct for the treatment of Major Depressive Disorder (MDD) in adolescent patients (age 15-21).

The NeuroStar Advanced Therapy System is a transcranial magnetic stimulation device. Specifically, it is a computerized, electromechanical medical device that produces and delivers non-invasive magnetic fields to induce electrical currents targeting specific regions of the cerebral cortex. Transcranial magnetic stimulation (TMS) is a non-invasive technique used to apply brief magnetic pulses to the brain. The pulses are administered by passing high currents through an electromagnetic coil placed adjacent to a patient's scalp. The pulses induce an electric field in the underlying brain tissue. When the induced field is above a certain threshold and is directed in an appropriate orientation relative the brain's neuronal pathway, localized axonal depolarizations are produced, thus activating neurons in the targeted brain region.

The NeuroStar System consists of a combination of hardware, disposable, and consumable supplies, which are required for the operation of the system. The basic configuration includes the following components:

• Mobile Console
• System Software
• Treatment Chair
• Head Support System
• MT Cap
• . D-Tect MT Accessory
• TrakStar Data Management

The NeuroStar Advanced Therapy System is indicated as an adjunct for the treatment of Major Depressive Disorder (MDD) in adolescent patients (age 15-21).

1. Table of Acceptance Criteria and Reported Device Performance

2. Sample Size Used for the Test Set and Data Provenance

• Sample Size (Test Set): 1,169 per protocol adolescent patients (age 12-21) were included in the real-world data analysis.
• Data Provenance: The data was retrospective real-world data (RWD) derived from the TrakStar registry, collected from patients across 347 TMS centers in the US over a span of 15 years, beginning in 2008.

3. Number of Experts Used to Establish Ground Truth and Qualifications

The document does not explicitly state the number of experts used to establish ground truth or their qualifications for the test set derived from the TrakStar registry. The clinical data was based on real-world data (RWD) which would imply physician diagnoses and assessments during routine clinical care, not necessarily a separate expert panel for ground truth within the study itself.

4. Adjudication Method for the Test Set

The document does not specify an adjudication method like 2+1 or 3+1 for the test set. The data was collected from clinical practice (TrakStar registry) and analyzed retrospectively.

5. Multi-Reader Multi-Case (MRMC) Comparative Effectiveness Study

No multi-reader multi-case (MRMC) comparative effectiveness study was mentioned where human readers improved with AI vs. without AI assistance. The study focuses on the effectiveness of the NeuroStar Advanced Therapy System itself, not on an AI-assisted diagnostic tool for human readers.

6. Standalone (Algorithm Only) Performance Study

The NeuroStar Advanced Therapy System is a medical device that delivers transcranial magnetic stimulation, not a standalone algorithm. Therefore, a standalone (algorithm only) performance study as typically understood for AI/ML devices, was not performed. The performance data relates to the device's clinical efficacy in treating MDD.

7. Type of Ground Truth Used

The ground truth for the real-world data analysis was based on clinical diagnosis of Major Depressive Disorder (MDD) according to DSM-4/ICD-9 or DSM-5/ICD-19 criteria, and Patient Health Questionnaire-9 (PHQ-9) scores for depression severity and remission, collected as part of routine clinical care and stored in the TrakStar registry.

8. Sample Size for the Training Set

The document does not explicitly mention a "training set" in the context of an AI/ML algorithm that requires training. The device itself is a non-AI medical device; however, the submission uses real-world clinical data and literature reviews to support its expanded indication. If "training set" refers to the data used to initially establish the device's efficacy, the previous FDA clearances (K083538, K130233, etc.) would have involved their own clinical studies. For this specific expanded indication, the submission relies on the large-scale retrospective analysis of 1,169 adolescent patients (treated with the NeuroStar device in real-world settings) and a literature review of 14 studies involving a total of 1,812 adolescents.

9. How the Ground Truth for the Training Set Was Established

As noted in point 8, this is not an AI/ML algorithm requiring a "training set" in the typical sense. The "ground truth" for the real-world data analysis and literature review, which serve as evidence for device efficacy, was established through:

• Clinical Diagnoses: Primary diagnosis of MDD according to DSM-4/ICD-9 or DSM-5/ICD-19 criteria.
• Validated Clinical Scales: Assessment using standardized and validated depression scales such as PHQ-9, HAMD-24, HAM-D, CDRS-R, QIDS-A17-SR, CGI-S, HDRS-17, BDI-II, MADRS, BPRS-C, and CGAS. These scores represent objective measures of symptom severity and improvement, as reported in clinical practice and research studies.
• Physician Assessment: The inclusion criteria for the RWD study specified "Primary diagnosis of Major Depressive Disorder (MDD), according to DSM-4/ICD-9 or DSM-5/ICD-19 criteria applicable on the date treatment with NeuroStar Advanced Therapy begins," indicating physician-based diagnosis.

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The NeuroStar Advanced Therapy System is indicated for the treatment of depressive episodes and for decreasing anxiety symptoms for those who may exhibit comorbid anxiety symptoms in adult patients suffering from Major Depressive Disorder (MDD) and who failed to achieve satisfactory improvement from previous antidepressant medication treatment in the current episode.

The NeuroStar Advanced Therapy System is a transcranial magnetic stimulation device. Specifically, it is a computerized, electromechanical medical device that produces and delivers non-invasive maqnetic fields to induce electrical currents targeting specific regions of the cerebral cortex. Transcranial magnetic stimulation (TMS) is a non-invasive technique used to apply brief magnetic pulses to the brain. The pulses are administered by passing high currents through an electromagnetic coil placed adjacent to a patient's scalp. The pulses induce an electric field in the underlying brain tissue. When the induced field is above a certain threshold and is directed in an appropriate orientation relative the brain's neuronal pathway, localized axonal depolarizations are produced, thus activating neurons in the targeted brain region.

The NeuroStar Advanced Therapy System is an integrated system consisting of a combination of the following components:

• Mobile Console .
• System Software .
• . Treatment Chair
• Ferromagnetic Treatment Coil
• . Head Support System
• SenStar® Connect Treatment Link & SenStar® Treatment Link ●
• . MT Cap
• TrakStar™ Patient Data Management System ●
• D-Tect™ MT Accessory ●

The proposed change to the NeuroStar Advanced Therapy System that is the subject of this 510(k) is the addition of the NeuroStar D-Tect™ MT Accessory, which is a non-sterile, multi-use device that provides an optional method to aid in the Motor Threshold (MT) hunt process. This device is used to provide indication and amplitude of hand movement during this process. The D-Tect™ MT Accessory includes a user display interface and a human hand interface with builtin sensors for measuring thumb and finger movements. The device is a standalone accessory that does not communicate or interact with the NeuroStar Advanced Therapy System, except for receiving pulse signals in order to sync data collection. Use of the device is optional, and provides an alternative, quantitative method to determine the MT compared to the standard of care, which includes a qualitative, visual assessment. The D-Tect™ MT Accessory is only used during the Motor Threshold (MT) determination process, which is only performed the first time a patient is seen by the doctor and is performed prior to the first treatment session.

This document describes a 510(k) premarket notification for the NeuroStar D-Tect™ MT Accessory, an addition to the NeuroStar Advanced Therapy System. The accessory is designed to aid in the Motor Threshold (MT) hunt process by providing an optional, quantitative method to determine the MT, as an alternative to the standard qualitative, visual assessment.

Acceptance Criteria and Device Performance:

The document does not specify quantified acceptance criteria or reported device performance metrics in the format of a table for the D-Tect™ MT Accessory itself. Instead, it relies on demonstrating that the D-Tect™ MT Accessory does not introduce new questions of safety or effectiveness and that the overall NeuroStar Advanced Therapy System, with the addition of this accessory, continues to conform to established performance standards.

The closest information related to performance is the statement that the device provides an "indication and amplitude of hand movement" during the MT hunt process.

Study Information:

The document explicitly states: "There is no clinical testing required to support this submission."
Therefore, the following points associated with clinical studies are not applicable or provided:

2. Sample size used for the test set and the data provenance: Not applicable as no clinical testing was performed for this submission.
3. Number of experts used to establish the ground truth for the test set and the qualifications of those experts: Not applicable as no clinical testing was performed for this submission.
4. Adjudication method (e.g., 2+1, 3+1, none) for the test set: Not applicable as no clinical testing was performed for this submission.
5. If a multi-reader multi-case (MRMC) comparative effectiveness study was done, If so, what was the effect size of how much human readers improve with AI vs without AI assistance: Not applicable. The device is not an AI-assisted diagnostic tool that would involve human readers or MRMC studies.
6. If a standalone (i.e., algorithm only without human-in-the-loop performance) was done: Not applicable as no clinical testing was performed for this submission. The D-Tect™ MT Accessory is a physical device that provides quantitative data to aid a human operator, not a standalone algorithm.
7. The type of ground truth used (expert consensus, pathology, outcomes data, etc.): Not applicable as no clinical testing was performed for this submission.
8. The sample size for the training set: Not applicable as no clinical testing was performed for this submission.
9. How the ground truth for the training set was established: Not applicable as no clinical testing was performed for this submission.

Non-clinical Testing:

The device's acceptance is primarily based on non-clinical performance and usability testing. These tests conform to the following recognized consensus standards:

• ISO 10993-1
• ANSI AAMI ES60601-1
• IEC 60601-1-2
• IEC 60601-1-6

Additionally, usability testing was completed in accordance with IEC 60601-1-6 Edition 3.1 2013-10 and the FDA Guidance Document: "Applying Human Factors and Usability Engineering to Medical Devices."

The overarching conclusion is that the addition of the D-Tect™ MT Accessory, while providing an optional quantitative method for MT determination, does not alter the fundamental safety or effectiveness of the NeuroStar Advanced Therapy System, which has existing regulatory clearances (predicate devices listed: K083538, K130233, K133408, K160703, K161519, K201158, K213543, and K220127). The accessory's function is to aid in a process, not to independently make diagnostic or treatment decisions.

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NeuroStar Advanced Therapy is indicated for the treatment of Major Depressive Disorder in adult patients who have failed to receive satisfactory improvement from prior antidepressant medication in the current episode.

The NeuroStar Advanced Therapy System is a computerized, electromechanical medical device that produces and delivers non-invasive, magnetic stimulation using brief duration rapidly alternating, or pulsed, magnetic fields to induce electrical currents directed at spatially discrete regions of the cerebral cortex. This method of cortical stimulation by application of brief magnetic pulses to the head is known as Transcranial Magnetic Stimulation (TMS).

NeuroStar Advanced Therapy is a non-invasive tool for the stimulation of cortical neurons for the treatment of adult patients with Major Depressive Disorder (MDD) who have failed to receive satisfactory improvement from prior antidepressant medication in the current episode. NeuroStar Advanced Therapy is used for patient treatment by prescription only under the supervision of a licensed physician and can be used in both inpatient and outpatient settings including physician's offices, clinics, and hospitals.

The proposed changes to the NeuroStar Advanced Therapy System described in this Traditional 510(k) Premarket Notification include the introduction of a new feature that allows the NeuroStar Advanced Therapy system to perform the TMS therapy known as intermittent theta burst stimulation (iTBS). NeuroBurst is the proprietary name for the iTBS treatment conducted by the NeuroStar Advanced Therapy System. The NeuroBurst treatment protocol consists of a burst of three (3) pulses at 50Hz with a 160ms interval between bursts. The protocol uses a train that consists of five (5) bursts per second for two (2) seconds with an eight (8) second interval between trains. A treatment session lasts for 20 trains or 3.3 minutes.

The NeuroStar Advanced Therapy System is an integrated system consisting of a combination of the following components:

• Mobile Console for housing the electronics and includes a software controlled graphical user interface, display monitor, display arm, and gantry that supports the treatment coil.
• Ferromagnetic Coil for delivering treatment.
• Head Support System for positioning the treatment coil and includes a laser-guided alignment system.
• Multi-use consumable SenStar Treatment Link for contact sensing of the treatment coil with the patient's head and magnetic field quality control.
• TrakStar Patient Data Management System for recording patient data and includes a stand-alone computer and data management software.

The provided text is a 510(k) summary for the NeuroStar Advanced Therapy System, primarily focusing on demonstrating substantial equivalence to a predicate device and introducing a new feature (iTBS treatment, or NeuroBurst). It lacks the specific details required to answer your questions about acceptance criteria and a study proving a device meets these criteria in the context of an AI/ML medical device.

The document describes a medical device (Transcranial Magnetic Stimulation System) for treating Major Depressive Disorder, not an AI/ML algorithm that predicts or diagnoses based on data. Therefore, the concepts of "test sets," "ground truth," "expert consensus," "MRMC studies," or "standalone algorithm performance" as typically applied to AI/ML device validation are not discussed.

The "performance data" mentioned here refers to:

• Physical performance of the device: magnetic field characteristics, output waveform, linear output level, electromagnetic compatibility (EMC), and electrical safety.
• Comparison to predicate/reference devices: demonstrating that the NeuroStar system's technological characteristics, indications for use, and principles of operation are substantially equivalent. The clinical effectiveness of iTBS itself is supported by the reference device's prior FDA clearance, not a new clinical study presented in this 510(k) summary for the NeuroStar device's NeuroBurst feature.

Therefore, I cannot extract the requested information as it is not present in the provided text.

To illustrate what kind of information would be needed to answer your questions, here's a hypothetical example relevant to an AI/ML device, assuming the NeuroStar was an AI/ML device (which it is not, based on this document):

Hypothetical Example (If NeuroStar were an AI/ML device):

Let's imagine the NeuroStar Advanced Therapy System had an AI component designed to predict patient response to TMS therapy based on patient characteristics and brain imaging data.

1. A table of acceptance criteria and the reported device performance

2. Sample size used for the test set and the data provenance

• Test Set Sample Size: 500 patients
• Data Provenance:
  • Country of Origin: Multi-center study including data from the United States (40%), United Kingdom (30%), and Canada (30%).
  • Retrospective/Prospective: Data collected prospectively from an observational cohort study specifically designed for AI model validation.

3. Number of experts used to establish the ground truth for the test set and the qualifications of those experts

• Number of Experts: 3 independent expert psychiatrists.
• Qualifications of Experts: Each psychiatrist had at least 15 years of clinical experience in treating Major Depressive Disorder and specialized in TMS therapy. They were board-certified in psychiatry in their respective countries.

4. Adjudication method (e.g. 2+1, 3+1, none) for the test set

• Adjudication Method: 3-reader consensus. If all three experts agreed on the patient's responder status (responder or non-responder), that was taken as the ground truth. In cases of disagreement (e.g., 2 agree, 1 disagrees), a fourth, senior adjudicating psychiatrist (not involved in initial readings) reviewed the case and made the final determination.

5. If a multi reader multi case (MRMC) comparative effectiveness study was done, If so, what was the effect size of how much human readers improve with AI vs without AI assistance

• MRMC Study: Yes, an MRMC study was conducted.
• Effect Size:
  • Without AI Assistance: Average AUC for human readers was 0.70 (95% CI: 0.68-0.72).
  • With AI Assistance: Average AUC for human readers improved to 0.80 (95% CI: 0.78-0.82).
  • Improvement (Effect Size): The AI assistance led to an average increase of 0.10 in AUC for human readers (p < 0.001), indicating a statistically significant improvement in their ability to predict treatment response.

6. If a standalone (i.e. algorithm only without human-in-the-loop performance) was done

• Standalone Performance: Yes, standalone performance was evaluated. The AI algorithm achieved an AUC of 0.88, Sensitivity of 82%, and Specificity of 75%.

7. The type of ground truth used (expert consensus, pathology, outcomes data, etc)

• Type of Ground Truth: Clinical outcomes data (validated depression symptom scales, e.g., MADRS or HAM-D, post-treatment scores indicating significant reduction in symptoms) independently assessed by the 3 expert psychiatrists via patient records and follow-up data abstraction. This was augmented by their consensus-based clinical determination of "responder" status.

8. The sample size for the training set

• Training Set Sample Size: 5,000 patients.

9. How the ground truth for the training set was established

• Ground Truth Establishment for Training Set: Ground truth for the training set was established through retrospective review of patient electronic medical records from multiple institutions. "Responder" status was defined by a pre-specified threshold reduction in a standardized depression symptom scale (e.g., ≥50% reduction in HAM-D scores) at the end of the TMS treatment course, as documented by treating physicians. Data was then cross-referenced and anonymized by research coordinators. While not as rigorously adjudicated as the test set, standard clinical documentation was considered sufficient for training purposes given the large volume of data.

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The NeuroStar TMS Therapy System is indicated for the treatment of Major Depressive Disorder in adult patients who have failed to receive satisfactory improvement from prior antidepressant medication in the current episode.

The NeuroStar TMS Therapy System is a computerized, electromechanical medical device that produces and delivers non-invasive, magnetic stimulation using brief duration (185 usec nominal) rapidly alternating, or pulsed, magnetic fields to induce electrical currents directed at spatially discrete regions of the cerebral cortex. This method of cortical stimulation by application of brief magnetic pulses to the head is known as Transcranial Magnetic Stimulation or TMS. NeuroStar TMS Therapy is a non-invasive tool for the stimulation of cortical neurons for the treatment of adult patients with Major Depressive Disorder (MDD) who have failed to receive satisfactory improvement from prior antidepressant medication as described under Intended Use. The NeuroStar System is used for patient treatment by prescription only under the supervision of a licensed physician. It can be used in both inpatient and outpatient settings including physician's offices and clinics, and hospitals.

The NeuroStar TMS Therapy System is an integrated system consisting of a combination of hardware, software, accessories and consumable supplies. It includes a Mobile Console which houses the electronics, includes a software controlled graphical user interface, and gantry that supports the Treatment Coil. The ferromagnetic Treatment Coil delivers NeuroStar TMS Therapy®. The Head Support System provides accurate positioning of the Treatment Coil using a laser-guided alignment system. The SenStar Connect is a non-sterile, multi-use consumable which is applied to the Treatment Coil, provides contact sensing to monitor contact of the treatment coil with the patient's head throughout a treatment session, quality control by monitoring the magnetic field level prior to patient treatment and provides surface field cancellation to reduce stimulation of the scalp. The TMS TrakStar™ practice data management system consists of a standalone computer and data management software that facilitates recording and retrieval of patient and treatment information and communication of data among multiple NeuroStar TMS Systems.

The provided text is a 510(k) summary for the NeuroStar® TMS Therapy System. It describes the device, its indications for use, and its substantial equivalence to a predicate device. However, it does not contain information about acceptance criteria or a study proving that the device meets those criteria, specifically in the context of clinical performance or diagnostic accuracy relevant to AI/algorithm performance.

The document primarily focuses on engineering and performance specifications related to the physical function of the TMS device and its safety (electrical safety, EMC). It highlights that the 3.0 version of the device has "enhanced thermal performance," "improved ergonomics and reliability," and "improved user work flow" compared to the predicate device.

Therefore, I cannot fulfill the request as it asks for information (acceptance criteria, study details, sample sizes, ground truth, expert qualifications, adjudication methods, MRMC studies, standalone performance, training set details) that is not present in the provided text. The text does not describe an AI/algorithmic medical device in the way implied by the questions regarding acceptance criteria for clinical performance, ground truth, expert consensus, or comparative effectiveness studies with human readers.

The available information is limited to:

• Device Performance Specifications Table: This table compares physical and operational characteristics of the device (like treatment level range, pulses per second, coil type, etc.) between the predicate and the new device. These are engineering specifications, not clinical performance metrics related to diagnostic accuracy.
• Bench Performance Testing: This section lists tests performed to demonstrate the substantial equivalence of the new device to the predicate in terms of physical characteristics (magnetic field mapping, coil positioning accuracy) and safety (electrical safety, EMC). It explicitly states that "Verification and validation testing demonstrated that the changes to NeuroStar 3.0 do not substantially modify the performance of the device," implying the performance remains similar to the predicate.

To answer your specific questions, I would need a different type of document, such as a clinical study report or a 510(k) summary that details the clinical performance and validation of an AI-driven medical device.

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The NeuroStar TMS Therapy System is indicated for the treatment of Major Depressive Disorder in adult patients who have failed to receive satisfactory improvement from prior antidepressant medication in the current episode.

The NeuroStar TMS Therapy System is a computerized, electromechanical medical device that produces and delivers non-invasive, magnetic stimulation using brief duration (185 usec nominal) rapidly alternating, or pulsed, magnetic fields to induce electrical currents directed at spatially discrete regions of the cerebral cortex. This method of cortical stimulation by application of brief magnetic pulses to the head is known as Transcranial Magnetic Stimulation or TMS. NeuroStar TMS Therapy is a non-invasive tool for the stimulation of cortical neurons for the treatment of adult patients with Major Depressive Disorder (MDD) who have failed to receive satisfactory improvement from prior antidepressant medication as described under Intended Use. The NeuroStar System is used for patient treatment by prescription only under the supervision of a licensed physician. It can be used in both inpatient and outpatient settings including physician's offices and clinics, and hospitals.

The NeuroStar TMS Therapy System is an integrated system consisting of a combination of hardware, software, accessories and consumable supplies. It includes a Mobile Console which houses the electronics, includes a software controlled graphical user interface, and gantry that supports the Treatment Coil. The ferromagnetic Treatment Coil delivers NeuroStar TMS Therapy®. The Head Support System provides accurate positioning of the Treatment Coil using a laser-guided alignment system. The SenStar® Connect is a non-sterile, multi-use consumable which is applied to the Treatment Coil, provides contact sensing to monitor contact of the treatment coil with the patient's head throughout a treatment session, quality control by monitoring the magnetic field level prior to patient treatment and provides surface field cancellation to reduce stimulation of the scalp. The TMS TrakStar™ practice data management system consists of a stand-alone computer and data management software that facilitates recording and retrieval of patient and treatment information and communication of data among multiple NeuroStar TMS Systems.

The provided text describes a 510(k) premarket notification for the NeuroStar TMS Therapy System, focusing on a labeling modification to allow for a shorter treatment time by varying inter-train intervals. This is not a typical device performance study with acceptance criteria for diagnostic accuracy, but rather an assessment of safety and effectiveness equivalence with a predicate device under modified usage parameters.

Therefore, a table of acceptance criteria and reported device performance in the conventional sense (e.g., sensitivity, specificity) is not directly applicable. Instead, the study aims to demonstrate that a change in inter-train interval does not negatively impact the safety and efficacy of the device, which was already established for the predicate.

Here's an analysis based on the provided information:

1. Table of Acceptance Criteria and Reported Device Performance

As this is a 510(k) for a labeling change based on equivalence, there aren't explicit numeric acceptance criteria like those for diagnostic devices (e.g., minimum sensitivity of 90%). The acceptance criteria essentially revolve around demonstrating non-inferiority in safety and efficacy with the modified inter-train interval compared to the established performance of the predicate device.

2. Sample Size Used for the Test Set and Data Provenance

The "test set" here refers to the data used for the clinical performance assessment.

• Sample Size:

  • Effectiveness (Efficacy) Analysis: 44 studies (total of 50 active treatment arms) with complete information identified the TMS treatment parameter set and clinical outcome for the primary efficacy measure.
  • Safety Analysis: 61 studies (comprising 67 active treatment arms) among 2836 subjects provided adverse event data.
  • Within these, 11 clinical studies utilized the NeuroStar TMS Therapy System or progenitor iron-core devices, encompassing 1069 subjects, of whom 770 subjects received active TMS. The remaining studies used reference TMS devices.
  • The overall database search identified 79 studies and research outcomes on 3359 subjects, among whom 2162 subjects were exposed to active TMS treatment.

• Data Provenance: The studies were identified via a "database search" to identify "human studies evaluating TMS and variations in inter-train interval." This indicates the data is likely retrospective, drawing from published clinical trials and literature. The country of origin of the data is not specified but would presumably be diverse given the nature of a database search for TMS studies.

3. Number of Experts Used to Establish the Ground Truth for the Test Set and Qualifications of Those Experts

This type of information is not provided in the document. The study relies on clinical outcomes and reported adverse events from historical clinical trials, rather than forming a new "test set" with a panel of experts. The "ground truth" for efficacy would be the reported clinical outcomes (e.g., reduction in depression symptoms) in the included studies, and for safety, the reported adverse events. This ground truth was established by the original researchers and clinicians involved in those 79 studies.

4. Adjudication Method for the Test Set

This information is not provided in the document. Given that the study is a retrospective review of existing literature and clinical trial data, it's unlikely that a new, external adjudication method was applied to the outcomes of those historical studies. The outcomes were presumably adjudicated by the methods employed within each individual study.

5. If a Multi-Reader Multi-Case (MRMC) Comparative Effectiveness Study was done, If so, what was the effect size of how much human readers improve with AI vs without AI assistance

No, a Multi-Reader Multi-Case (MRMC) comparative effectiveness study was not done. This device is a treatment system (Transcranial Magnetic Stimulator) and not an AI-powered diagnostic device that involves human "readers" interpreting medical cases. Therefore, the concept of human readers improving with or without AI assistance is not applicable here.

6. If a Standalone (i.e. algorithm only without human-in-the-loop performance) was done

No, a standalone (algorithm only) performance study was not done. The NeuroStar TMS Therapy System is a physical medical device for treatment, not an algorithm, and it operates with human supervision ("under the supervision of a licensed physician").

7. The Type of Ground Truth Used

The ground truth used in this study (a literature review) is based on:

• Clinical Outcomes/Efficacy Data: Reported improvement in Major Depressive Disorder (MDD) symptoms from the primary efficacy measures in the analyzed clinical trials.
• Adverse Event Data: Verbatim adverse event terms reported in the reference studies, including the incidence of seizure.

This is essentially outcomes data and reported clinical findings from a large body of pre-existing scientific literature.

8. The Sample Size for the Training Set

This information is not applicable. The study described is a review of existing clinical data to support a labeling change for an already cleared device, not an AI or algorithm development study that would involve a distinct "training set" in the context of machine learning. The device itself was developed and cleared based on its own clinical trials in the past.

9. How the Ground Truth for the Training Set Was Established

This information is not applicable for the reasons stated in point 8.

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