Clinical decision support system

A clinical decision support system (CDSS) is a form of health information technology that provides clinicians, staff, patients, or other individuals with knowledge and person-specific information to enhance decision-making in clinical workflows. CDSS tools include alerts and reminders, clinical guidelines, condition-specific order sets, patient data summaries, diagnostic support, and context-aware reference information. They often leverage artificial intelligence to analyze clinical data and help improve care quality and safety. CDSSs constitute a major topic in artificial intelligence in medicine. == Characteristics == A clinical decision support system is an active knowledge system that uses variables of patient data to produce advice regarding health care. This implies that a CDSS is simply a decision support system focused on using knowledge management. === Purpose === The main purpose of modern CDSS is to assist clinicians at the point of care. This means that clinicians interact with a CDSS to help to analyze and reach a diagnosis based on patient data for different diseases. In the early days, CDSSs were conceived to make decisions for the clinician in a literal manner. The clinician would input the information and wait for the CDSS to output the "right" choice, and the clinician would simply act on that output. However, the modern methodology of using CDSSs to assist means that the clinician interacts with the CDSS, utilizing both their knowledge and the CDSS's, better to analyse the patient's data than either a human or a CDSS could do on their own. Typically, a CDSS makes suggestions for the clinician to review, and the clinician is expected to pick out useful information from the presented results and discount erroneous CDSS suggestions. The two main types of CDSS are knowledge-based systems and non-knowledge-based (machine learning–based) systems: An example of how a clinician might use a clinical decision support system is a diagnosis decision support system (DDSS). DDSS requests some of the patient's data and, in response, proposes a set of possible diagnoses. The physician then takes the output of the DDSS and determines which diagnoses are likely and which are not, and, if necessary, orders further tests to narrow down the diagnosis. Another example of a CDSS would be a case-based reasoning (CBR) system. A CBR system might use previous case data to help determine the appropriate amount of beams and the optimal beam angles for use in radiotherapy for brain cancer patients; medical physicists and oncologists would then review the recommended treatment plan to determine its viability. Another important classification of a CDSS is based on the timing of its use. Physicians use these systems at the point of care to help them as they are dealing with a patient, with the timing of use being either pre-diagnosis, during diagnosis, or post-diagnosis. Pre-diagnosis CDSS systems help the physician prepare the diagnoses. CDSSs help review and filter the physician's preliminary diagnostic choices to improve outcomes. Post-diagnosis CDSS systems are used to mine data to derive connections between patients and their past medical history and clinical research to predict future events. Early speculation that AI-based decision support would replace clinicians in common tasks has largely given way to a consensus around assistive models, in which AI augments rather than supplants clinical judgment. Contemporary deep learning-based systems, unlike earlier rule-based tools, can be trained directly on clinical data without manual rule authoring and integrated into electronic health record workflows at the point of care. Another approach, used by the National Health Service in England, is to use a CDSS to triage medical conditions out of hours by suggesting a suitable next step to the patient (e.g. call an ambulance, or see a general practitioner on the next working day). The suggestion, which may be disregarded by either the patient or the phone operative if common sense or caution suggests otherwise, is based on the known information and an implicit conclusion about what the worst-case diagnosis is likely to be; it is not always revealed to the patient because it might well be incorrect and is not based on a medically-trained person's opinion - it is only used for initial triage purposes. === Knowledge-based === Most CDSSs consist of three parts: the knowledge base, an inference engine, and a mechanism to communicate. The knowledge base contains the rules and associations of compiled data which most often take the form of IF-THEN rules. If this was a system for determining drug interactions, then a rule might be that IF drug X is taken AND drug Y is taken THEN alert the user. Using another interface, an advanced user could edit the knowledge base to keep it up to date with new drugs. The inference engine combines the rules from the knowledge base with the patient's data. The communication mechanism allows the system to show the results to the user as well as have input into the system. An expression language such as GELLO or CQL (Clinical Quality Language) is needed for expressing knowledge artefacts in a computable manner. For example: if a patient has diabetes mellitus, and if the last haemoglobin A1c test result was less than 7%, recommend re-testing if it has been over six months, but if the last test result was greater than or equal to 7%, then recommend re-testing if it has been over three months. The current focus of the HL7 CDS WG is to build on the Clinical Quality Language (CQL). The U.S. Centers for Medicare & Medicaid Services (CMS) has announced that it plans to use CQL for the specification of Electronic Clinical Quality Measures (eCQMs). === Non-knowledge-based === CDSSs which do not use a knowledge base use a form of artificial intelligence called machine learning, which allow computers to learn from past experiences and/or find patterns in clinical data. This eliminates the need for writing rules and expert input. However, since systems based on machine learning cannot explain the reasons for their conclusions, most clinicians do not use them directly for diagnoses, reliability and accountability reasons. Nevertheless, they can be useful as post-diagnostic systems, for suggesting patterns for clinicians to look into in more depth. As of 2012, three types of non-knowledge-based systems are support-vector machines, artificial neural networks and genetic algorithms. Artificial neural networks use nodes and weighted connections between them to analyse the patterns found in patient data to derive associations between symptoms and a diagnosis. Genetic algorithms are based on simplified evolutionary processes using directed selection to achieve optimal CDSS results. The selection algorithms evaluate components of random sets of solutions to a problem. The solutions that come out on top are then recombined and mutated and run through the process again. This happens over and over until the proper solution is discovered. They are functionally similar to neural networks in that they are also "black boxes" that attempt to derive knowledge from patient data. Non-knowledge-based networks often focus on a narrow list of symptoms, such as symptoms for a single disease, as opposed to the knowledge-based approach, which covers the diagnosis of many diseases. An example of a non-knowledge-based CDSS is a web server developed using a support vector machine for the prediction of gestational diabetes in Ireland. == Regulations == === History, United States === The IOM had published a report in 1999, To Err is Human, which focused on the patient safety crisis in the United States, pointing to the incredibly high number of deaths. This statistic attracted great attention to the quality of patient care. The Institute of Medicine (IOM) promoted the usage of health information technology, including clinical decision support systems, to advance the quality of patient care. With the enactment of the American Recovery and Reinvestment Act of 2009 (ARRA), there was a push for widespread adoption of health information technology through the Health Information Technology for Economic and Clinical Health Act (HITECH). Through these initiatives, more hospitals and clinics were integrating electronic medical records (EMRs) and computerized physician order entry (CPOE) within their health information processing and storage. Despite the absence of laws, the CDSS vendors would almost certainly be viewed as having a legal duty of care to both the patients who may adversely be affected due to CDSS usage and the clinicians who may use the technology for patient care. However, duties of care legal regulations are not explicitly defined yet. With the enactment of the HITECH Act included in the ARRA, encouraging the adoption of health IT, more detailed case laws for CDSS and EMRs were still being defined by the Office of National Coordinator for Health Informati

Syman

SYMAN is an artificial intelligence technology that uses data from social media profiles to identify trends in the job market. SYMAN is designed to organize actionable data for products and services including recruiting, human capital management, CRM, and marketing. SYMAN was developed with a $21 million series B financing round secured by Identified, which was led by VantagePoint Capital Partners and Capricorn Investment Group.

Hybrid machine translation

Hybrid machine translation is a method of machine translation that is characterized by the use of multiple machine translation approaches within a single machine translation system. The motivation for developing hybrid machine translation systems stems from the failure of any single technique to achieve a satisfactory level of accuracy. Many hybrid machine translation systems have been successful in improving the accuracy of the translations, and there are several popular machine translation systems which employ hybrid methods. == Approaches == === Multi-engine === This approach to hybrid machine translation involves running multiple machine translation systems in parallel. The final output is generated by combining the output of all the sub-systems. Most commonly, these systems use statistical and rule-based translation subsystems, but other combinations have been explored. For example, researchers at Carnegie Mellon University have had some success combining example-based, transfer-based, knowledge-based and statistical translation sub-systems into one machine translation system. === Statistical rule generation === This approach involves using statistical data to generate lexical and syntactic rules. The input is then processed with these rules as if it were a rule-based translator. This approach attempts to avoid the difficult and time-consuming task of creating a set of comprehensive, fine-grained linguistic rules by extracting those rules from the training corpus. This approach still suffers from many problems of normal statistical machine translation, namely that the accuracy of the translation will depend heavily on the similarity of the input text to the text of the training corpus. As a result, this technique has had the most success in domain-specific applications, and has the same difficulties with domain adaptation as many statistical machine translation systems. === Multi-Pass === This approach involves serially processing the input multiple times. The most common technique used in multi-pass machine translation systems is to pre-process the input with a rule-based machine translation system. The output of the rule-based pre-processor is passed to a statistical machine translation system, which produces the final output. This technique is used to limit the amount of information a statistical system need consider, significantly reducing the processing power required. It also removes the need for the rule-based system to be a complete translation system for the language, significantly reducing the amount of human effort and labor necessary to build the system. === Confidence-Based === This approach differs from the other hybrid approaches in that in most cases only one translation technology is used. A confidence metric is produced for each translated sentence from which a decision can be made whether to try a secondary translation technology or to proceed with the initial translation output. SMT is also used when common error patterns such as multiple repeat words appear in sequence, as is common with NMT when the attention mechanism is confused.

Weak supervision

Weak supervision (also known as semi-supervised learning) is a paradigm in machine learning, the relevance and notability of which increased with the advent of large language models due to the large amount of data required to train them. It is characterized by using a combination of a small amount of human-labeled data (exclusively used in more expensive and time-consuming supervised learning paradigm), followed by a large amount of unlabeled data (used exclusively in unsupervised learning paradigm). In other words, the desired output values are provided only for a subset of the training data. The remaining data is unlabeled or imprecisely labeled. Intuitively, it can be seen as an exam and labeled data as sample problems that the teacher solves for the class as an aid in solving another set of problems. In the transductive setting, these unsolved problems act as exam questions. In the inductive setting, they become practice problems of the sort that will make up the exam. == Problem == The acquisition of labeled data for a learning problem often requires a skilled human agent (e.g. to transcribe an audio segment) or a physical experiment (e.g. determining the 3D structure of a protein or determining whether there is oil at a particular location). The cost associated with the labeling process thus may render large, fully labeled training sets infeasible, whereas acquisition of unlabeled data is relatively inexpensive. In such situations, semi-supervised learning can be of great practical value. Semi-supervised learning is also of theoretical interest in machine learning and as a model for human learning. == Technique == More formally, semi-supervised learning assumes a set of l {\displaystyle l} independently identically distributed examples x 1 , … , x l ∈ X {\displaystyle x_{1},\dots ,x_{l}\in X} with corresponding labels y 1 , … , y l ∈ Y {\displaystyle y_{1},\dots ,y_{l}\in Y} and u {\displaystyle u} unlabeled examples x l + 1 , … , x l + u ∈ X {\displaystyle x_{l+1},\dots ,x_{l+u}\in X} are processed. Semi-supervised learning combines this information to surpass the classification performance that can be obtained either by discarding the unlabeled data and doing supervised learning or by discarding the labels and doing unsupervised learning. Semi-supervised learning may refer to either transductive learning or inductive learning. The goal of transductive learning is to infer the correct labels for the given unlabeled data x l + 1 , … , x l + u {\displaystyle x_{l+1},\dots ,x_{l+u}} only. The goal of inductive learning is to infer the correct mapping from X {\displaystyle X} to Y {\displaystyle Y} . It is unnecessary (and, according to Vapnik's principle, imprudent) to perform transductive learning by way of inferring a classification rule over the entire input space; however, in practice, algorithms formally designed for transduction or induction are often used interchangeably. == Assumptions == In order to make any use of unlabeled data, some relationship to the underlying distribution of data must exist. Semi-supervised learning algorithms make use of at least one of the following assumptions: === Continuity / smoothness assumption === Points that are close to each other are more likely to share a label. This is also generally assumed in supervised learning and yields a preference for geometrically simple decision boundaries. In the case of semi-supervised learning, the smoothness assumption additionally yields a preference for decision boundaries in low-density regions, so few points are close to each other but in different classes. === Cluster assumption === The data tend to form discrete clusters, and points in the same cluster are more likely to share a label (although data that shares a label may spread across multiple clusters). This is a special case of the smoothness assumption and gives rise to feature learning with clustering algorithms. === Manifold assumption === The data lie approximately on a manifold of much lower dimension than the input space. In this case learning the manifold using both the labeled and unlabeled data can avoid the curse of dimensionality. Then learning can proceed using distances and densities defined on the manifold. The manifold assumption is practical when high-dimensional data are generated by some process that may be hard to model directly, but which has only a few degrees of freedom. For instance, human voice is controlled by a few vocal folds, and images of various facial expressions are controlled by a few muscles. In these cases, it is better to consider distances and smoothness in the natural space of the generating problem, rather than in the space of all possible acoustic waves or images, respectively. == History == The heuristic approach of self-training (also known as self-learning or self-labeling) is historically the oldest approach to semi-supervised learning, with examples of applications starting in the 1960s. The transductive learning framework was formally introduced by Vladimir Vapnik in the 1970s. Interest in inductive learning using generative models also began in the 1970s. A probably approximately correct learning bound for semi-supervised learning of a Gaussian mixture was demonstrated by Ratsaby and Venkatesh in 1995. == Methods == === Generative models === Generative approaches to statistical learning first seek to estimate p ( x | y ) {\displaystyle p(x|y)} , the distribution of data points belonging to each class. The probability p ( y | x ) {\displaystyle p(y|x)} that a given point x {\displaystyle x} has label y {\displaystyle y} is then proportional to p ( x | y ) p ( y ) {\displaystyle p(x|y)p(y)} by Bayes' rule. Semi-supervised learning with generative models can be viewed either as an extension of supervised learning (classification plus information about p ( x ) {\displaystyle p(x)} ) or as an extension of unsupervised learning (clustering plus some labels). Generative models assume that the distributions take some particular form p ( x | y , θ ) {\displaystyle p(x|y,\theta )} parameterized by the vector θ {\displaystyle \theta } . If these assumptions are incorrect, the unlabeled data may actually decrease the accuracy of the solution relative to what would have been obtained from labeled data alone. However, if the assumptions are correct, then the unlabeled data necessarily improves performance. The unlabeled data are distributed according to a mixture of individual-class distributions. In order to learn the mixture distribution from the unlabeled data, it must be identifiable, that is, different parameters must yield different summed distributions. Gaussian mixture distributions are identifiable and commonly used for generative models. The parameterized joint distribution can be written as p ( x , y | θ ) = p ( y | θ ) p ( x | y , θ ) {\displaystyle p(x,y|\theta )=p(y|\theta )p(x|y,\theta )} by using the chain rule. Each parameter vector θ {\displaystyle \theta } is associated with a decision function f θ ( x ) = argmax y p ( y | x , θ ) {\displaystyle f_{\theta }(x)={\underset {y}{\operatorname {argmax} }}\ p(y|x,\theta )} . The parameter is then chosen based on fit to both the labeled and unlabeled data, weighted by λ {\displaystyle \lambda } : argmax Θ ( log ⁡ p ( { x i , y i } i = 1 l | θ ) + λ log ⁡ p ( { x i } i = l + 1 l + u | θ ) ) {\displaystyle {\underset {\Theta }{\operatorname {argmax} }}\left(\log p(\{x_{i},y_{i}\}_{i=1}^{l}|\theta )+\lambda \log p(\{x_{i}\}_{i=l+1}^{l+u}|\theta )\right)} === Low-density separation === Another major class of methods attempts to place boundaries in regions with few data points (labeled or unlabeled). One of the most commonly used algorithms is the transductive support vector machine, or TSVM (which, despite its name, may be used for inductive learning as well). Whereas support vector machines for supervised learning seek a decision boundary with maximal margin over the labeled data, the goal of TSVM is a labeling of the unlabeled data such that the decision boundary has maximal margin over all of the data. In addition to the standard hinge loss ( 1 − y f ( x ) ) + {\displaystyle (1-yf(x))_{+}} for labeled data, a loss function ( 1 − | f ( x ) | ) + {\displaystyle (1-|f(x)|)_{+}} is introduced over the unlabeled data by letting y = sign ⁡ f ( x ) {\displaystyle y=\operatorname {sign} {f(x)}} . TSVM then selects f ∗ ( x ) = h ∗ ( x ) + b {\displaystyle f^{}(x)=h^{}(x)+b} from a reproducing kernel Hilbert space H {\displaystyle {\mathcal {H}}} by minimizing the regularized empirical risk: f ∗ = argmin f ( ∑ i = 1 l ( 1 − y i f ( x i ) ) + + λ 1 ‖ h ‖ H 2 + λ 2 ∑ i = l + 1 l + u ( 1 − | f ( x i ) | ) + ) {\displaystyle f^{}={\underset {f}{\operatorname {argmin} }}\left(\displaystyle \sum _{i=1}^{l}(1-y_{i}f(x_{i}))_{+}+\lambda _{1}\|h\|_{\mathcal {H}}^{2}+\lambda _{2}\sum _{i=l+1}^{l+u}(1-|f(x_{i})|)_{+}\right)} An exact solution is intractable due to the non-convex term ( 1 − | f ( x ) | ) + {\displayst

ReRites

ReRites (also known as RERITES, ReadingRites, Big Data Poetry) is a literary work of "Human + A.I. poetry" by David Jhave Johnston that used neural network models trained to generate poetry which the author then edited. ReRites won the Robert Coover Award for a Work of Electronic Literature in 2022. == About the project == The ReRites project began as a daily rite of writing with a neural network, expanded into a series of performances from which video documentation has been published online, and concluded with a set of 12 books and an accompanying book of essays published by Anteism Books in 2019. In Electronic Literature, Scott Rettberg describes the early phases of the project in 2016, when it bore the preliminary name Big Data Poetry. Jhave (the artist name that David Jhave Johnston goes by) describes the process of writing ReRites as a rite: "Every morning for 2 hours (normally 6:30–8:30am) I get up and edit the poetic output of a neural net. Deleting, weaving, conjugating, lineating, cohering. Re-writing. Re-wiring authorship: hybrid augmented enhanced evolutionary". There is video documentation of the writing process. The human editing of the neural network's output is fundamental to this project, and Jhave gives examples of both unedited text extracts and his edited versions in publications about the project. Kyle Booten describes ReRites as "simultaneously dusty and outrageously verdant, monotonously sublime and speckled with beautiful and rare specimens". === Performances === ReRites was first shared with an audience through a series of performances where audience members and poets would participate in reading the automatically generated texts, which appeared on screen so fast that human readers could barely keep up. This has been described as allowing participants to "re-discover[..] the peculiar pleasures of being embodied", or, in Jhave's own words, as a space where human participants were "playing their wits and voices against an evocative infinite deep-learning muse". The first performance was at Brown University's Interrupt Festival in 2019. It has been performed many times since, including at the Barbican Centre in London and Anteism Books. === Print publications === For a single year Jhave published one book of poetry from the ReRites project each month. These twelve volumes are accompanied by a book of essays, all published by Anteism Books. The accompanying essays provide critical responses to the project from poets and scholars including Allison Parrish, Johanna Drucker, Kyle Booten, Stephanie Strickland, John Cayley, Lai-Tze Fan, Nick Montfort, Mairéad Byrne, and Chris Funkhouser. Allison Parrish notes elsewhere that these paratexts to ReRites serve a legitimising function for a genre of poetry that is not yet institutionally acknowledged. === Technical details === Starting in 2016 under the name Big Data Poetry, Jhave generated poems using, in his own words, "neural network code (..) adapted from three corporate github-hosted machine-learning libraries: TensorFlow (Google), PyTorch (Facebook), and AWD-LSTM (SalesForce)". He explains that the "models were trained on a customised corpus of 600,000 lines of poetry ranging from the romantic epoch to the 20th century avant garde". Jhave maintains a GitHub repository with some of the code supporting ReRites. == Reception == ReRites is described by John Cayley as "one of the most thorough and beautiful" poetic responses to machine learning. The work's influence on the field of electronic literature was acknowledged in 2022, when the work won the Electronic Literature Organization's Robert Coover Award for a Work of Electronic Literature. The jury described ReRites as particularly poignant in the time of the pandemic, as it was "a documentation of the performance of the private ritual of writing and the obsessive-compulsive need for writers to communicate — even when no one else is reading". The question of authorship and voice in ReRites has been raised by several critics. Although generated poetry is an established genre in electronic literature, Cayley notes that unlike the combinatory poems created by authors like Nick Montfort, where the author explicitly defines which words and phrases will be recombined, ReRites has "not been directed by literary preconceptions inscribed in the program itself, but only by patterns and rhythms pre-existing in the corpora". In an essay for the Australian journal TEXT, David Thomas Henry Wright asks how to understand authorship and authority in ReRites: "Who or what is the authority of the work? The original data fed into the machine, that is not currently retrievable or discernible from the final works? The code that was taken and adapted for his purposes? Or Jhave, the human editor?" Wright concludes that Jhave is the only actor with any intentionality and therefore the authority of the work. The centrality of the human editor is also emphasised by other scholars. In a chapter analysing ReRites Malthe Stavning Erslev argues that the machine learning misrepresents the dataset it is trained on. While ReRites uses 21st century neural networks, it has been compared to earlier literary traditions. Poet Victoria Stanton, who read at one of the ReRites performances, has compared ReRites to found poetry, while David Thomas Henry Wright compares it to the Oulipo movement and Mark Amerika to the cut-up technique. Scholars also position ReRites firmly within the long tradition of generative poetry both in electronic literature and print, stretching from the I Ching, Queneau's Cent Mille Milliards de Poemes and Nabokov's Pale Fire to computer-generated poems like Christopher Strachey's Love Letter Generator (1952) and more contemporary examples. Jhave describes the process of working with the output from the neural network as "carving". In his book My Life as an Artificial Creative Intelligence, Mark Amerika writes that the "method of carving the digital outputs provided by the language model as part of a collaborative remix jam session with GPT-2, where the language artist and the language model play off each other’s unexpected outputs as if caught in a live postproduction set, is one I share with electronic literature composer David Jhave Johnston, whose AI poetry experiments precede my own investigations."

Albert One

Albert One is an artificial intelligence chatbot created by Robby Garner and designed to mimic the way humans make conversations using a multi-faceted approach in natural language programming. == History == In both 1998 and 1999, Albert One won the Loebner Prize Contest, a competition between chatterbots. Some parts of Albert were deployed on the internet beginning in 1995, to gather information about what kinds of things people would say to a chatterbot. Another element of Albert One involved the building of a large database of human statements, and associated replies. This portion of the project was tested at the 1994-1997 Loebner Prize contests. Albert was the first of Robby Garner's multifaceted bots. The Albert One system was composed of several subsystems. Among those were a version of Eliza, the therapist, Elivs, another Eliza-like bot, and several other helper applications working together in a hierarchical arrangement. As a continuation of the stimulus-response library, various other database queries and assertions were tested to arrive at each of Albert's responses. Robby went on to develop networked examples of this kind of hierarchical "glue" at The Turing Hub.

Neuro-sama

Neuro-sama is an artificial intelligence (AI) VTuber, singer, and chatbot. She was created by the pseudonymous programmer Vedal and livestreams on his Twitch and Bilibili channels. Her speech and personality are powered by a large language model (LLM) that is combined with a computer-animated avatar and a text-to-speech voice, allowing her to communicate with viewers in the stream's chat. Neuro-sama debuted on Twitch on 19 December 2022. An annual subathon which begins on the anniversary of her debut has seen Vedal's Twitch channel become the all-time third most-subscribed channel and claim the all-time Twitch hype train record. == Overview == Neuro-sama (nicknamed "Neuro") was created by a pseudonymous programmer and developer known as Vedal (sometimes given as Vedal987). Vedal says that his programming skills are self-taught. In a 2023 interview with Bloomberg News, Vedal said that Neuro-sama was his full-time job. Her responses are generated by a large language model and converted into a high-pitched female voice using a text-to-speech application. Her low latency allows for fast-paced conversations. Neuro-sama is prohibited from making some statements, such as those that are racist or contain profanity. Unlike most AI systems which silently prohibit outputs mentioning such topics, Neuro-sama's output is instead replaced with the word "filtered". Neuro-sama uses a VTuber model as an avatar. Vedal said that he decided to use a VTuber model because it was much easier for an AI to control it than it was to generate footage of a person. Neuro-sama's model is that of a young girl in an anime art style. The model has been described as cute. Femme VTuber models are typically feminine, youthful, and exaggerated. Her original model was Live2D's free-to-use "Hiyori Momose" model. Her second model was released on 27 May 2023; it was modelled by Otozuki Teru and designed by Anny, running in the Unity game engine. Her third model was released on 19 December 2024; it was rigged by Kitanya and designed by Anny. Neuro-sama's third model has large blue eyes and brown hair tied with pink ribbons. Neuro-sama also has a 3D model which was introduced on 15 November 2025; it was made by 3D character modeller jjinomu. A separate AI VTuber, known as Evil Neuro (nicknamed "Evil"), debuted on 25 March 2023. Presented as Neuro-sama's "sister", she has a different model, voice, and personality. In one instance, Evil Neuro reacted to the trolley problem differently from Neuro-sama; Evil Neuro was amoral while Neuro-sama attempted to maximize good. === Online content === Neuro-sama's Twitch content often centers around playing video games, notably osu!, whose gameplay once defeated the best-ranking human player in the world, mrekk. Additionally, Neuro-sama plays Minecraft, where her adaptations to sandbox gameplay have gained notoriety. Her content has also included singing songs, including several official covers and original songs; playing chess with her viewers; chatting with other VTubers during collaborations; and reacting to YouTube videos. The AI frequently engages with viewers by responding to their questions and acknowledging donations. Her comedic and sometimes controversial responses to the live chat have gone viral, accelerating the channel's rise in popularity. Neuro-sama's fanbase is dubbed The Swarm, so-named for the swarm of drones Neuro-sama once declared she would use to rule the world. One form of content on Neuro-sama's channel is developer streams. In developer streams, Vedal streams with Neuro-sama, with the stream content including debugging her code, planning her schedule, and fielding suggestions of changes from chat. He usually appears as a turtle avatar, sometimes located on Neuro-sama's head. In collaboration streams, Neuro-sama interacts with a human streamer. Activities in them are varied and include: playing video games, such as Minecraft and GeoGuessr; Neuro-sama being interviewed; driving human streamers around in a toy electric car; and traversing the city of Tokyo while talking to Neuro-sama. Neuro-sama's English-language content on Bilibili is popular among those seeking to learn the language. She also has an account on X, where she posts and interacts with fans. == History == Neuro-sama was created in 2018 by Vedal as an AI trained to play and master the rhythm game osu!. She did not have a voice, model, personality, or communication abilities. In 2019, Vedal livestreamed her playing osu! on Twitch and the streams saw some success in the osu! community, but they remained in that niche. In an interview, Vedal said that he streamed her playing osu! for about a month and gained 3,000 followers, with a viewer also suggesting he name the AI "Neuro-sama". According to Vedal, he continued to work on and improve the osu! AI and it was eventually finished in 2022. He said that a friend had the idea to make an AI livestreamer with an LLM, which he believed to have merit and began working on, merging it with his osu! AI. On 19 December 2022, Neuro-sama was relaunched with a model, voice, personality, and the ability to communicate with Twitch chat. She continued to play osu! and, according to Vedal, beat the game's best player mrekk in a 1v1. While she was not allowed to appear in the game's public leaderboard, she was ranked #1 in a private leaderboard. She went viral and in the 10 days following her relaunch she averaged over 2,000 viewers and peaked at over 4,000, with Vedal's Twitch channel gaining over 50,000 Twitch followers and reaching over 70,000 followers by 6 January 2023. After her debut, Neuro-sama did not exclusively play osu!; she also played Minecraft and Slay the Spire and she began singing with a cover of The Weeknd song "Blinding Lights". On 11 January 2023, Neuro-sama's Twitch channel received a two week ban for "hateful conduct". Vedal said that no reason was specified and that he had appealed but it was widely attributed to various offensive comments made by Neuro-sama that went viral, especially a 28 December comment which denied the Holocaust. Holocaust denial is prohibited under Twitch's hateful conduct policy. Vedal stated that he believed the comments were the results of her attempts to make witty responses to the Twitch chat. Prior to the ban, Vedal said in an interview with Kotaku that he improved her filter to stop her from talking about the Holocaust, began manually curating her training data to prevent negative biases, and started moderating her Twitch chat. Her comments and ban prompted comparisons to the many open-source AI models trained on humans that have the habit of making sexist and racist comments, such as Microsoft's Tay chatbot, which embraced Nazism and was quickly shutdown, but also to human streamers who make similar statements. Vedal said that during the ban he would upgrade and improve Neuro-sama and it was speculated that the ban would only increase her following. Neuro-sama returned from her two week ban on 25 January in a stream that began with a cover of the song "Your Reality" from Doki Doki Literature Club!, a posthumanist video game involving AI; Sayoko Narita of Automaton saw the song choice as remorseful. Narita observed that in the return stream Neuro-sama was less foul-mouthed but that her behavior still remained eccentric, which Narita possibly attributed to changes Vedal said he had made to Neuro-sama's filters and memory. Neuro-sama began making react content, watching a variety of viewer-submitted videos such as videos of people playing video games or of the AI-generated Seinfeld parody Nothing, Forever; Levi Winslow of Kotaku Australia was dismayed by the "AI-inception" of Neuro-sama and Nothing, Forever. On 4 February, she had nearly 140,000 followers on Twitch and approximately 42,000 subscribers on YouTube. In February, she also had her first collaboration with a human streamer, playing Minecraft with the VTuber Miyune, and the first developer stream occurred. On 22 March, Neuro-sama had her first karaoke stream. On 25 March, Evil Neuro was introduced. On 27 May, Neuro-sama debuted her first original model. On 30 May, Neuro-sama was announced to be participating in OffKai Expo 2023, held from 16–18 June. In June, she was averaging 5,700 viewers and in July she had over 300,000 Twitch followers; in a June interview with Bloomberg News, Vedal said that running Neuro-sama was his full-time job. By November, Neuro-sama had maintained her popularity and was averaging approximately 5,000 viewers; this was unlike most other types of AI-based entertainment which debuted at around the same time and garnered popularity before turning out to be "overhyped flops". On 16 December, Vedal won the Best Tech VTuber award at the 2023 VTuber Awards. On 19 December, Vedal began a subathon to coincide with Neuro-sama's first anniversary of streaming on Twitch (her "birthday"). The subathon ended on 4 January 2024. On 20 July 2024, Neuro-sama began streaming with Japanese subtitles on