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the need for magnetic resonance imaging ( mri ) in patients with an
implanted pacemaker or implantable cardioverter - defibrillator ( icd ) is
a growing clinical issue . it is estimated that as many as 75% of active
cardiac device recipients will become indicated for mri . currently , the
vast majority of such devices are contraindicated for use with an mri . in
european heart rhythm association survey , published recently for non -
mri - certified icds ( 0.51.5 t field strength ) , the totally
subcutaneous icd ( s - icd ) system , an implantable defibrillator with no
leads that touch the heart , has recently been demonstrated to be a safe
and effective defibrillator option for patients at risk for sudden cardiac
death . it provides shock therapy and post - shock pacing therapy , but no
long - term bradycardia pacing . although it has been shown as an
alternative to the standard transvenous icd , its compatibility with mri
remains unclear . various types of clinical mri systems currently use a
superconductive magnet that creates a static magnetic field strength ,
typically 1.5 or 3 t. the use of mri with most pacemakers and icds is
considered a contraindication due to potential hazards , including heating
of the electrode that resides in or on the heart , damage to myocardium ,
elevation of pacing thresholds , unintended induction of ventricular
tachycardia ( vt ) or ventricular fibrillation ( vf ) , pacing inhibition
, permanent device malfunction , and distortion of the mri scan . recently
, mr - conditional. mr - conditional indicates a lack of known hazards in
a specified mri environment with specified conditions of use . due to the
variety of mri scanners and scanning protocols , it is not practical to
test even a single device under all conditions . hence , mr - conditional
labelling dictates that the device is safe for use under certain scanning
conditions , as well as how the cardiac device should be programmed before
an exposure to the magnetic field in a mri scanner . the literature ,
although limited , provides some guidance for imaging patients with
implanted pacemakers or icds that do not have mr - conditional labelling .
this single - centre prospective non - controlled study describes the
first use of mri in patients with an implanted s - icd . patients with
implanted s - icd systems ( boston scientific sqrx model 1010 and q - trak
model 3010 ) were enrolled for mri testing over a period of 18 months .
the s - icd system implanted in this patient cohort was composed of a can
implanted in a left mid - lateral pocket and a para - sternal subcutaneous
electrode . the s - icd is currently not certified for use with an mri ;
therefore , the ethics committee of homolka hospital , prague , czech
republic approved our clinical study . patients with newly implanted s -
icd systems ( < 6 weeks ) were excluded , and none of the patients had any
intravascular leads . the patients were randomized for either a cardiac ,
brain , cervical , or lumbar spinal scan . one of the subjects underwent
an additional knee examination , due to reported chronic pain . a total of
15 patients were enrolled into this study ( 12 males and three females ,
aged 2283 years , mean 53 years . subjects in our cohort ( table 1 )
underwent a total of 22 mri scans between 6 june 2012 and 24 december 2013
. in total , five brain scans , three cardiac scans , 12 lumbar scans ,
one knee , and one cervical spine scan were conducted ( table 2 ) .
however , in one patient a minor disc protrusion was found , in other mri
revealed stenosis of intervertebral foramen which was causing radicular
pain of the nerve root l4 and based on this examination the patient was
referred to ct - navigated periradicular therapy . table 1summary of
patient anatomical data and scan locations , along with noted clinical
eventsidagesexbmidgef , % indication for s - icdheating0164f20.5hcmp /
vfs85secondary preventionnone0283m30.0post - mi / smvts post - catheter
ablation/35secondary prevention ( post - transvenous icd
extraction)none0331m25.3arvc / d / smvts68secondary preventionin -
tolerable re - scanned0458m23.6post - mi / post - cabg30primary
preventionnone0577m25.5post - mi30primary preventionnone0663m27.0post -
mi30primary preventionnone0768m23.7post - mi / vfs / vts60secondary
prevention post - transvenous icd extraction / svc
occlusiontolerable0822m29.4brugada sy / vfs68secondary preventionin -
tolerable re - scanned0959m27.1dcmp / vfs / post - mitral valve
surgery/60secondary prev./post - transvenous icd
extractionnone1041f24.6arvc / d70primary preventionnone1123f21.5lqts /
vf60secondary preventionnone1266m36.9post - mi / vf / post -
cabg50secondary prevention / post - repeat transvenous icd
extractiontolerable1348m22.9dcmp(non - compaction)/vfs35secondary
preventionnone1470m29systolic dysfunction of lv35primary
preventionnone1526m33brugada sy65primary preventionnonehcmp , hypertrophic
cardiomyopathy ; smvt , sustained monomorphic ventricular tachycardia ; mi
, myocardial infarction ; arvc , arrhythmogenic right ventricular
cardiomyopathy ; cabg , coronary artery by - pass graft ; lqts , long qt
syndrom . table 2parmeters of s - icd and patient sensation during
individual mri scansscan # idbody partheating sensationsshock zone (
b.p.m.)condit . shock zone ( b.p.m.)bat % episode
num.101brainnone2302101001202brainnone240220861303l spinein -
tolerable240220831403brainnone240220831504brainnone220190691605l
spinenone220210541706l spinenone240220681807l spinetolerable240220582908l
spinein - tolerablenananana1008brainnonenananana1108l
spinenone2302108411209heartnone2402208911310l
spinenone2301807911410heartnonenananana1511heartnone2301909711612l
spinetolerable2001709721712l spinenone2001709421813c
spinenone23019010041913l spinenone23019010042014l
spinenone2301908612115kneenone25021010012215l spinenone2502101001s - icd
parameters acquired prior- and post - mri were without any change ,
therefore only one value is presented.indices : na , not available ; l
spine , lumbar spine ; c spine , cervical spine . summary of patient
anatomical data and scan locations , along with noted clinical events hcmp
, hypertrophic cardiomyopathy ; smvt , sustained monomorphic ventricular
tachycardia ; mi , myocardial infarction ; arvc , arrhythmogenic right
ventricular cardiomyopathy ; cabg , coronary artery by - pass graft ; lqts
, long qt syndrom . parmeters of s - icd and patient sensation during
individual mri scans s - icd parameters acquired prior- and post - mri
were without any change , therefore only one value is presented . indices
: na , not available ; l spine , lumbar spine ; c spine , cervical spine .
studies were performed using a siemens avanto 1.5 t mri scanner ( vb17
software , quantum gradient coils ) . all scans were run in normal
operating mode , which is limited to 2 w / kg whole body averaged specific
absorption rate ( sar ) . clinically relevant mri sequences were used for
evaluation ( see table 3 ) . table 3types of pulse sequences typically
used for imaging of respective anatomical areasscan locationscan
sequencesflairdwiflashfsehastesestirtruefispbrainxxxxheartxxxxcervical
spinexxkneexxxxlumbar spinexxflair , fluid attenuated inversion recovery ;
dwi , diffusion weighted imaging ; flash , fast low angle shot ; fse ,
fast spin echo ; haste , half acquisition single - shot turbo spin echo ;
se , spin echo ; stir , short tau inversion recovery ; truefisp , true
fast imaging with steady - state precession.fse sequence caused heating in
subjects with a thermistor probe during lumbar spine examination ( see the
text for details ) . types of pulse sequences typically used for imaging
of respective anatomical areas flair , fluid attenuated inversion recovery
; dwi , diffusion weighted imaging ; flash , fast low angle shot ; fse ,
fast spin echo ; haste , half acquisition single - shot turbo spin echo ;
se , spin echo ; stir , short tau inversion recovery ; truefisp , true
fast imaging with steady - state precession . fse sequence caused heating
in subjects with a thermistor probe during lumbar spine examination ( see
the text for details ) . patients were asked to report immediately any
pain , torqueing movement , or heating sensation in the area of the pocket
or the electrode by pressing an emergency bulb . furthermore , all
patients were questioned immediately following the mri procedure to
ascertain any discomfort in the vicinity of the can or electrode . pulse
oximetry and standard lead electrocardiogram ( ecg ) if discomfort
occurred , the patient was asked if the scan could be repeated at a later
time using a revised scan sequence or the subject was again randomized for
another anatomical area . since none of the components of the s - icd
system are on or in the heart , heating near or around however , heating
near the electrode or can with the s - icd system may still cause serious
patient discomfort . therefore , along with education of subjects , each
patient was instrumented by taping an oesophageal temperature probe ( beta
- therm model g22k7mcd8 ) on the skin over the mid - lateral implant site
to record any temperature excursions that might be correlated to patient
symptoms of heating / discomfort near the pocket . to minimize the risk of
inappropriate therapy , the s - icd system was programmed to therapy each
s - icd system was evaluated prior to and immediately after the scan to
verify proper functioning , including interrogation , sensing , and
battery voltage . after the completion of the mri , long - term regular
clinical follow - up and checking of the device were performed . patients
with implanted s - icd systems ( boston scientific sqrx model 1010 and q -
trak model 3010 ) were enrolled for mri testing over a period of 18 months
. the s - icd system implanted in this patient cohort was composed of a
can implanted in a left mid - lateral pocket and a para - sternal
subcutaneous electrode . the s - icd is currently not certified for use
with an mri ; therefore , the ethics committee of homolka hospital ,
prague , czech republic approved our clinical study . patients with newly
implanted s - icd systems ( < 6 weeks ) were excluded , and none of the
patients had any intravascular leads . the patients were randomized for
either a cardiac , brain , cervical , or lumbar spinal scan . one of the
subjects underwent an additional knee examination , due to reported
chronic pain . a total of 15 patients were enrolled into this study ( 12
males and three females , aged 2283 years , mean 53 years . subjects in
our cohort ( table 1 ) underwent a total of 22 mri scans between 6 june
2012 and 24 december 2013 . in total , five brain scans , three cardiac
scans , 12 lumbar scans , one knee , and one cervical spine scan were
conducted ( table 2 ) . however , in one patient a minor disc protrusion
was found , in other mri revealed stenosis of intervertebral foramen which
was causing radicular pain of the nerve root l4 and based on this
examination the patient was referred to ct - navigated periradicular
therapy . table 1summary of patient anatomical data and scan locations ,
along with noted clinical eventsidagesexbmidgef , % indication for s -
icdheating0164f20.5hcmp / vfs85secondary preventionnone0283m30.0post - mi
/ smvts post - catheter ablation/35secondary prevention ( post -
transvenous icd extraction)none0331m25.3arvc / d / smvts68secondary
preventionin - tolerable re - scanned0458m23.6post - mi / post -
cabg30primary preventionnone0577m25.5post - mi30primary
preventionnone0663m27.0post - mi30primary preventionnone0768m23.7post - mi
/ vfs / vts60secondary prevention post - transvenous icd extraction / svc
occlusiontolerable0822m29.4brugada sy / vfs68secondary preventionin -
tolerable re - scanned0959m27.1dcmp / vfs / post - mitral valve
surgery/60secondary prev./post - transvenous icd
extractionnone1041f24.6arvc / d70primary preventionnone1123f21.5lqts /
vf60secondary preventionnone1266m36.9post - mi / vf / post -
cabg50secondary prevention / post - repeat transvenous icd
extractiontolerable1348m22.9dcmp(non - compaction)/vfs35secondary
preventionnone1470m29systolic dysfunction of lv35primary
preventionnone1526m33brugada sy65primary preventionnonehcmp , hypertrophic
cardiomyopathy ; smvt , sustained monomorphic ventricular tachycardia ; mi
, myocardial infarction ; arvc , arrhythmogenic right ventricular
cardiomyopathy ; cabg , coronary artery by - pass graft ; lqts , long qt
syndrom . table 2parmeters of s - icd and patient sensation during
individual mri scansscan # idbody partheating sensationsshock zone (
b.p.m.)condit . shock zone ( b.p.m.)bat % episode
num.101brainnone2302101001202brainnone240220861303l spinein -
tolerable240220831403brainnone240220831504brainnone220190691605l
spinenone220210541706l spinenone240220681807l spinetolerable240220582908l
spinein - tolerablenananana1008brainnonenananana1108l
spinenone2302108411209heartnone2402208911310l
spinenone2301807911410heartnonenananana1511heartnone2301909711612l
spinetolerable2001709721712l spinenone2001709421813c
spinenone23019010041913l spinenone23019010042014l
spinenone2301908612115kneenone25021010012215l spinenone2502101001s - icd
parameters acquired prior- and post - mri were without any change ,
therefore only one value is presented.indices : na , not available ; l
spine , lumbar spine ; c spine , cervical spine . summary of patient
anatomical data and scan locations , along with noted clinical events hcmp
, hypertrophic cardiomyopathy ; smvt , sustained monomorphic ventricular
tachycardia ; mi , myocardial infarction ; arvc , arrhythmogenic right
ventricular cardiomyopathy ; cabg , coronary artery by - pass graft ; lqts
, long qt syndrom . parmeters of s - icd and patient sensation during
individual mri scans s - icd parameters acquired prior- and post - mri
were without any change , therefore only one value is presented . indices
: na , not available ; l spine , lumbar spine ; c spine , cervical spine .
studies were performed using a siemens avanto 1.5 t mri scanner ( vb17
software , quantum gradient coils ) . all scans were run in normal
operating mode , which is limited to 2 w / kg whole body averaged specific
absorption rate ( sar ) . clinically relevant mri sequences were used for
evaluation ( see table 3 ) . table 3types of pulse sequences typically
used for imaging of respective anatomical areasscan locationscan
sequencesflairdwiflashfsehastesestirtruefispbrainxxxxheartxxxxcervical
spinexxkneexxxxlumbar spinexxflair , fluid attenuated inversion recovery ;
dwi , diffusion weighted imaging ; flash , fast low angle shot ; fse ,
fast spin echo ; haste , half acquisition single - shot turbo spin echo ;
se , spin echo ; stir , short tau inversion recovery ; truefisp , true
fast imaging with steady - state precession.fse sequence caused heating in
subjects with a thermistor probe during lumbar spine examination ( see the
text for details ) . types of pulse sequences typically used for imaging
of respective anatomical areas flair , fluid attenuated inversion recovery
; dwi , diffusion weighted imaging ; flash , fast low angle shot ; fse ,
fast spin echo ; haste , half acquisition single - shot turbo spin echo ;
se , spin echo ; stir , short tau inversion recovery ; truefisp , true
fast imaging with steady - state precession . fse sequence caused heating
in subjects with a thermistor probe during lumbar spine examination ( see
the text for details ) . patients were asked to report immediately any
pain , torqueing movement , or heating sensation in the area of the pocket
or the electrode by pressing an emergency bulb . furthermore , all
patients were questioned immediately following the mri procedure to
ascertain any discomfort in the vicinity of the can or electrode . pulse
oximetry and standard lead electrocardiogram ( ecg ) if discomfort
occurred , the patient was asked if the scan could be repeated at a later
time using a revised scan sequence or the subject was again randomized for
another anatomical area . since none of the components of the s - icd
system are on or in the heart , heating near or around the electrode can
not harm the myocardium . however , heating near the electrode or can with
the s - icd system may still cause serious patient discomfort . therefore
, along with education of subjects , each patient was instrumented by
taping an oesophageal temperature probe ( beta - therm model g22k7mcd8 )
on the skin over the mid - lateral implant site to record any temperature
excursions that might be correlated to patient symptoms of heating /
discomfort near the pocket . to minimize the risk of inappropriate therapy
, the s - icd system was programmed to therapy each s - icd system was
evaluated prior to and immediately after the scan to verify proper
functioning , including interrogation , sensing , and battery voltage .
after the completion of the mri , the s - icd system was reprogrammed to
original settings . long - term regular clinical follow - up and checking
of the device were performed . no anomalies were noted via pulse oximetry
or ecg during the scans for any of the patients . eleven of 15 patients
reported no sensation or pain from heating of the can , two of 15 patients
reported feeling some heating , and two patients reported intolerable
heating ( see table 2 ) . in patients with intolerable heating , the scan
was halted within seconds and changed to a scan of the brain , which
proceeded without incident . patient reports of heating in the vicinity of
the can occurred only during lumbar scans with a thermistor probe ; no
such reports occurred during scans of the brain , cardiac area , cervical
spine , or without the probe . in two cases where heating in the vicinity
of the can was reported by the patient , the scan sequence was altered to
reduce the intensity of radiofrequency ( rf ) field exposure by reducing
the turbo factor ( e.g. from 21 to 7 ) , increasing the repetition time (
e.g. to > 4000 ms ) , and reducing the flip angle ( e.g. from 170 to 120 )
. the target values were chosen arbitrarily to maintain image contrast (
flip angle ) and keep scan time at reasonable limits ( turbo factor and
repetition time ) . less heating was noted by patients after these
modifications to the scan parameters were made . 03 ) was observed to have
a skin lesion , appearing to be a circular rash or ulcer on the surface of
the skin over the can , approximately 35 mm in diameter . the cause of
this skin anomaly is not known ; it was later noted to have fully healed
at a follow - up 10 days after the scan . to ascertain the effect of
heating due to the instrumented thermistor catheter , the two patients who
experienced the heating ( examinations 9 and 16 , see table 2 ) were
rescanned several weeks later without the thermistor catheter in place (
examinations 11 and 17 ) . first , modified sequence ( with even lower
amount of energy deposited in the tissue ) was used , which caused no
heating . as no sensation was reported by the subjects , they were asked
to report even a minimal discomfort , and the lumbar scans were performed
using the same settings that resulted in heating with the thermistor
catheter in place in the first imaging session . the results of the
rescans revealed that no heating was felt by the patients when the
thermistor catheter was absent . there were no noted changes to battery
voltage , ability to detect the qrs signal or stored diagnostic data .
pacing thresholds can not be assessed by the s - icd system , so this was
not evaluated . none of the patients reported any pulling or twisting of
the can or pain from heating of the s - icd electrode . for scans of the
brain , lumbar spine , knee , and cervical spine , no effect from image
artefact was noted in the anatomical area of interest . however , for
scans of the cardiac area , image artefact was noted to interfere with the
ability to see parts of the left ventricle , though the right ventricle of
the heart was unaffected and could be imaged usefully . this was due to
the can and not the electrode ( see figure 1 ) , modifications to the
protocol for the lumbar spine resulted in a lower signal - to - noise
ratio ; however , the images remain in diagnostic quality ( see figure 2 )
. figure 1kinetic study in four - chamber view : the systolic ( a and c )
and diastolic ( b and d ) images of cine sequences , four - chamber view .
the steady - state free precession ( ssfp ) sequence ( a and b ) shows
more artefacts . in ssfp kinetic study , an inflow of dark blood from the
left pulmonary veins was seen . it could be caused by s - icd but also by
metallic ring in mitral annulus . the spoiled gradient echo ( gre )
sequence ( c and d ) is better , but an artefact at the lateral wall is
obvious . figure 2lumbar spine imaging with icd : low sar t2 fse sequence
( upper image ) compared with normal t2 fse in the same subject ( lower
image , for the scanning parameters see the discussion section ) . kinetic
study in four - chamber view : the systolic ( a and c ) and diastolic ( b
and d ) images of cine sequences , four - chamber view . the steady -
state free precession ( ssfp ) sequence ( a and b ) shows more artefacts .
in ssfp kinetic study , an inflow of dark blood from the left pulmonary
veins was seen . it could be caused by s - icd but also by metallic ring
in mitral annulus . the spoiled gradient echo ( gre ) sequence ( c and d )
is better , but an artefact at the lateral wall is obvious . lumbar spine
imaging with icd : low sar t2 fse sequence ( upper image ) compared with
normal t2 fse in the same subject ( lower image , for the scanning
parameters see the discussion section ) . there were no noted changes to
battery voltage , ability to detect the qrs signal or stored diagnostic
data . pacing thresholds can not be assessed by the s - icd system , so
this was not evaluated . none of the patients reported any pulling or
twisting of the can or pain from heating of the s - icd electrode . for
scans of the brain , lumbar spine , knee , and cervical spine , no effect
from image artefact was noted in the anatomical area of interest . however
, for scans of the cardiac area , image artefact was noted to interfere
with the ability to see parts of the left ventricle , though the right
ventricle of the heart was unaffected and could be imaged usefully . this
was due to the can and not the electrode ( see figure 1 ) , modifications
to the protocol for the lumbar spine resulted in a lower signal - to -
noise ratio ; however , the images remain in diagnostic quality ( see
figure 2 ) . figure 1kinetic study in four - chamber view : the systolic (
a and c ) and diastolic ( b and d ) images of cine sequences , four -
chamber view . the steady - state free precession ( ssfp ) sequence ( a
and b ) shows more artefacts . in ssfp kinetic study , an inflow of dark
blood from the left pulmonary veins was seen . it could be caused by s -
icd but also by metallic ring in mitral annulus . the spoiled gradient
echo ( gre ) sequence ( c and d ) is better , but an artefact at the
lateral wall is obvious . figure 2lumbar spine imaging with icd : low sar
t2 fse sequence ( upper image ) compared with normal t2 fse in the same
subject ( lower image , for the scanning parameters see the discussion
section ) . kinetic study in four - chamber view : the systolic ( a and c
) and diastolic ( b and d ) images of cine sequences , four - chamber view
. the steady - state free precession ( ssfp ) sequence ( a and b ) shows
more artefacts . in ssfp kinetic study , an inflow of dark blood from the
left pulmonary veins was seen . it could be caused by s - icd but also by
metallic ring in mitral annulus . the spoiled gradient echo ( gre )
sequence ( c and d ) is better , but an artefact at the lateral wall is
obvious . lumbar spine imaging with icd : low sar t2 fse sequence ( upper
image ) compared with normal t2 fse in the same subject ( lower image ,
there are several reports in the current literature about mr - conditional
pacemakers from several companies , but very limited reports about mr -
conditional icds . biotronik announced in late 2011 release of their first
mr - compatible icd device and defibrillator leads pro mri , but in the
conditions of use excluded scanning of the torso and focused more on the
extremities examination . in european heart rhythm association survey ,
60% of centres did not implant any mri - certified icds , 34.3% implanted
< 10 icd devices , and only 5.6% implanted 10 and more icds ; one - fifth
of responders stated that mri - certified icds should be implanted in all
patients but lack of reimbursement was indicated as a possible obstacle to
implant more mri - certified pacemakers / icds by 47.1% of responding
centres . none of the components of the s - icd system are on or in the
heart . the s - icd depends less upon being in direct contact with the
myocardium to function and instead uses far - field sensing and
stimulation to provide the shock and post - shock pacing therapy . as a
consequence , unlike transvenous systems heating near or around the
electrode can not harm the myocardium , which could present with possible
safety consequences such as an elevation in pacing thresholds or scarring
of the myocardium , but it may still cause serious patient discomfort .
because the s - icd is larger than modern transvenous icd 's , there may
be more potential for the can to experience heating due to the magnetic
gradient or rf field . we report results from what we believe is the first
experience of mri scanning in patients with an implanted s - icd and in
various anatomical areas . overall , mri was performed safely in all
patients , which is in contrast to the current literature with mri imaging
in patients with electrical - active devices which are not mri -
conditional . in our study , the primary clinically significant event
attributable to the mri scan was the occurrence of heating in the area of
the pocket in the four patients that underwent lumbar scans . it was not
known if this was due to the s - icd can itself or an artefact of the
thermistor catheter used to measure skin temperature over the pocket .
this required a revision of our protocol , which was to re - scan two of
the patients who complained of heating . re - scanning of these patients
without the thermistor probe resulted in no complaints of heating , so it
is assumed that the thermistor catheter itself heated during the lumbar
scans and caused the discomfort . as further evidence , all the heating
complaints occurred during rf - intensive scan sequences ( namely fast
spin echo ) with the temperature probe located axially near the centre of
the bore , where rf fields are the highest . the thermistor catheter is
constructed of insulated conductive cables connected to electrodes and
should couple to the rf fields efficiently , causing heating at the
electrodes and pain or damage on the surface of the skin where the probe
was placed over the s - icd can . if the heating was due to the s - icd
can itself , it would more likely occur during gradient - intensive scan
sequences ( which can generate eddy currents on can surfaces and internal
components ) and at locations in the bore where there are high gradient
fields , such as near the bore edges . however , when the patient was
scanned with gradient - intensive scan sequences ( e.g. flair dwi ) and
with the s - icd system in high gradient field locations in the bore (
e.g. such as during a brain scan ) , patients did not detect any heating
or discomfort . in addition , the subcutaneous lead , which was not
instrumented with a thermistor catheter , never resulted in any heating
sensation noted by the patient , even when exactly the same sequence that
resulted in heating in the first session was used . the use of mri -
compatible temperature monitors such as fibre optic temperature probes
would have provided better confirmation of possible skin temperature
elevation and would not have been affected by the rf fields . for cardiac
imaging , the main problem to solve is metallic artefact , especially on
the gradient - echo sequences . like in research performed by nazarian et
al . , several scan protocols were used to see if any yielded different
effects or reduced the qualitative extent of artefact . gradient mode was
changed from normal to whisper , resulting in slower ramping of the field
and therefore diminishing the changes of the magnetic field in time .
artefacts when present were limited to blurring of the left ventricle
during cardiac scans and most yielded clinically useful information .
standard interrogation of the s - icd revealed no adverse effects upon the
functioning of the system . while no adverse effects upon the post - scan
s - icd device function were noted , not all possible scanning protocols
were tested . it should be noted that , four of the s - icd 's were
exposed to repeat mri scans without adverse effects to device function .
in addition , because the s - icd does not provide long - term bradycardia
pacing , it is assumed that pacemaker - dependent patients would not be
implanted with this system . the inhibition of the pacemaker function
during the scanning sequence and possible pacing threshold changes are a
unique concern in patients implanted with transvenous icds . this study
included only 15 patients and 22 scans done on the same 1.5 t mri scanner
. thus , even these preliminary results should only be applied to 1.5 t
mri scanners ( similarly as reported in the present literature for other
implantable devices ) . device functionality was tested immediately after
the scan but not for long - term effects . in addition , not all device
functions were tested although the s - icd system does have a beeper /
interrogation warning if battery levels or memory irregularities occur .
however , patients were scheduled for regular check - up and no defect of
the device was observed in following 725 months ( mean observation time 18
months ) . delayed enhancement mri for determining cardiac scarring was
also not tested . also , there are other anatomical areas that were not
evaluated , such as shoulder and knees . this study included only 15
patients and 22 scans done on the same 1.5 t mri scanner . thus , even
these preliminary results should only be applied to 1.5 t mri scanners (
similarly as reported in the present literature for other implantable
devices ) . device functionality was tested immediately after the scan but
not for long - term effects . in addition , not all device functions were
tested although the s - icd system does have a beeper / interrogation
warning if battery levels or memory irregularities occur . however ,
patients were scheduled for regular check - up and no defect of the device
was observed in following 725 months ( mean observation time 18 months ) .
delayed enhancement mri for determining cardiac scarring was also not
tested . also , there are other anatomical areas that were not evaluated ,
such as shoulder and knees . while more data are required to support a
claim of mri - conditional , this study is the study to demonstrate the
feasibility of exposing s - icd patients to mri using the scanning and
monitor protocol described , with some precautionary measures including :
( i ) programming the device therapy off ; ( ii ) limiting the sar to 2.0
w / kg ; ( iii ) continuous monitoring of the patients pulse oximetry and
ecg by qualified personnel and especially for any feelings of heating ; (
iv ) evaluate device function post scan ; ( v ) availability of full
resuscitation facilities at the mri site . given the variables of
different mri scanners , the decision to perform mri on patients with an
implanted s - icd system should be balanced against the potential risks .
in our study , the only heating was very likely introduced by not fully
mri - compatible thermometer probe ; subjects rescanned without the probe
did not report any abnormalities during the scan of any body area listed (
brain , cervical and lumbar spine , heart , and knee ) . this study was
supported by iga mz r nt12094/2011 , research project charles university
in prague , prvouk p34 and unce 204010/2012 . funding to pay the open
access publication charges for this article was provided by iga mz r
nt12094/2011 .
example_title: Summarization Example 1
Model Card: T5 Large for Medical Text Summarization
Model Description
The T5 Large for Medical Text Summarization is a specialized variant of the T5 transformer model, fine-tuned for the task of summarizing medical text. This model is designed to generate concise and coherent summaries of medical documents, research papers, clinical notes, and other healthcare-related text.
The T5 Large model, known as "t5-large," is pre-trained on a broad range of medical literature, enabling it to capture intricate medical terminology, extract crucial information, and produce meaningful summaries. The fine-tuning process for this model is meticulous, with attention to hyperparameter settings, including batch size and learning rate, to ensure optimal performance in the field of medical text summarization.
During the fine-tuning process, a batch size of 8 is chosen for efficiency, and a learning rate of 2e-5 is selected to strike a balance between convergence speed and model optimization. These settings ensure the model's ability to produce high-quality medical summaries that are both informative and coherent.
The fine-tuning dataset consists of diverse medical documents, clinical studies, and healthcare research, along with human-generated summaries. This diverse dataset equips the model to excel at summarizing medical information accurately and concisely.
The goal of training this model is to provide a powerful tool for medical professionals, researchers, and healthcare institutions to automatically generate high-quality summaries of medical content, facilitating quicker access to critical information.
Intended Uses & Limitations
Intended Uses
- Medical Text Summarization: The primary purpose of this model is to generate concise and coherent summaries of medical documents, research papers, clinical notes, and healthcare-related text. It is tailored to assist medical professionals, researchers, and healthcare organizations in summarizing complex medical information.
How to Use
To use this model for medical text summarization, you can follow these steps:
from transformers import pipeline
summarizer = pipeline("summarization", model="your/medical_text_summarization_model")
MEDICAL_DOCUMENT = """
duplications of the alimentary tract are well - known but rare congenital malformations that can occur anywhere in the gastrointestinal ( gi ) tract from the tongue to the anus . while midgut duplications are the most common , foregut duplications such as oesophagus , stomach , and parts 1 and 2 of the duodenum account for approximately one - third of cases .
they are most commonly seen either in the thorax or abdomen or in both as congenital thoracoabdominal duplications .
cystic oesophageal duplication ( ced ) , the most common presentation , is often found in the lower third part ( 60 - 95% ) and on the right side [ 2 , 3 ] . hydatid cyst ( hc ) is still an important health problem throughout the world , particularly in latin america , africa , and mediterranean areas .
turkey , located in the mediterranean area , shares this problem , with an estimated incidence of 20/100 000 .
most commonly reported effected organ is liver , but in children the lungs are the second most frequent site of involvement [ 4 , 5 ] . in both ced and hc , the presentation depends on the site and the size of the cyst .
hydatid cysts are far more common than other cystic intrathoracic lesions , especially in endemic areas , so it is a challenge to differentiate ced from hc in these countries . here ,
we present a 7-year - old girl with intrathoracic cystic mass lesion , who had been treated for hydatid cyst for 9 months , but who turned out to have oesophageal cystic duplication .
a 7-year - old girl was referred to our clinic with coincidentally established cystic intrathoracic lesion during the investigation of aetiology of anaemia .
the child was first admitted with loss of vision in another hospital ten months previously .
the patient 's complaints had been attributed to pseudotumour cerebri due to severe iron deficiency anaemia ( haemoglobin : 3 g / dl ) .
chest radiography and computed tomography ( ct ) images resulted in a diagnosis of cystic intrathoracic lesion ( fig .
the cystic mass was accepted as a type 1 hydatid cyst according to world health organization ( who ) classification .
after 9 months of medication , no regression was detected in ct images , so the patient was referred to our department .
an ondirect haemagglutination test result was again negative . during surgery , after left thoracotomy incision , a semi - mobile cystic lesion , which was almost seven centimetres in diameter , with smooth contour , was found above the diaphragm , below the lung , outside the pleura ( fig .
the entire fluid in the cyst was aspirated ; it was brown and bloody ( fig .
2 ) . the diagnosis of cystic oesophageal duplication was considered , and so an attachment point was searched for .
it was below the hiatus , on the lower third left side of the oesophagus , and it also was excised completely through the hiatus .
pathologic analysis of the specimen showed oesophageal mucosa with an underlying proper smooth muscle layer .
computed tomography image of the cystic intrathoracic lesion cystic lesion with brownish fluid in the cyst
compressible organs facilitate the growth of the cyst , and this has been proposed as a reason for the apparent prevalence of lung involvement in children . diagnosis is often incidental and can be made with serological tests and imaging [ 5 , 7 ] .
laboratory investigations include the casoni and weinberg skin tests , indirect haemagglutination test , elisa , and the presence of eosinophilia , but can be falsely negative because children may have a poor serological response to eg .
false - positive reactions are related to the antigenic commonality among cestodes and conversely seronegativity can not exclude hydatidosis .
false - negative results are observed when cysts are calcified , even if fertile [ 4 , 8 ] . in our patient iha levels were negative twice .
due to the relatively non - specific clinical signs , diagnosis can only be made confidently using appropriate imaging .
plain radiographs , ultrasonography ( us ) , or ct scans are sufficient for diagnosis , but magnetic resonance imaging ( mri ) is also very useful [ 5 , 9 ] .
computed tomography demonstrates cyst wall calcification , infection , peritoneal seeding , bone involvement fluid density of intact cysts , and the characteristic internal structure of both uncomplicated and ruptured cysts [ 5 , 9 ] .
the conventional treatment of hydatid cysts in all organs is surgical . in children , small hydatid cysts of the lungs
respond favourably to medical treatment with oral administration of certain antihelminthic drugs such as albendazole in certain selected patients .
the response to therapy differs according to age , cyst size , cyst structure ( presence of daughter cysts inside the mother cysts and thickness of the pericystic capsule allowing penetration of the drugs ) , and localization of the cyst . in children , small cysts with thin pericystic capsule localised in the brain and lungs respond favourably [ 6 , 11 ] .
respiratory symptoms are seen predominantly in cases before two years of age . in our patient , who has vision loss , the asymptomatic duplication cyst was found incidentally .
the lesion occupied the left hemithorax although the most common localisation reported in the literature is the lower and right oesophagus .
the presentation depends on the site and the size of the malformations , varying from dysphagia and respiratory distress to a lump and perforation or bleeding into the intestine , but cysts are mostly diagnosed incidentally .
if a cystic mass is suspected in the chest , the best technique for evaluation is ct .
magnetic resonance imaging can be used to detail the intimate nature of the cyst with the spinal canal .
duplications should have all three typical signs : first of all , they should be attached to at least one point of the alimentary tract ; second and third are that they should have a well - developed smooth muscle coat , and the epithelial lining of duplication should represent some portions of alimentary tract , respectively [ 2 , 10 , 12 ] . in summary , the cystic appearance of both can cause a misdiagnosis very easily due to the rarity of cystic oesophageal duplications as well as the higher incidence of hydatid cyst , especially in endemic areas .
"""
print(summarizer(MEDICAL_DOCUMENT, max_length=230, min_length=30, do_sample=False))
>>> [{'summary_text': 'duplications of the alimentary tract are well - known but rare congenital malformations that can occur anywhere in the gastrointestinal ( gi ) tract from the tongue to the anus . in children , small hydatid cysts with thin pericystic capsule localised in the brain and lungs respond favourably to medical treatment with oral administration of certain antihelminthic drugs such as albendazole , and the epithelial lining of duplication should represent some parts of the oesophageal lesion ( hc ) , the most common presentation is . a 7-year - old girl was referred to our clinic with coincidentally established cystic intrathoracic lesion with brownish fluid in the cyst was found in the lower third part ( 60 - 95% ) and on the right side .'}]
Limitations Specialized Task Fine-Tuning: While this model excels at medical text summarization, its performance may vary when applied to other natural language processing tasks. Users interested in employing this model for different tasks should explore fine-tuned versions available in the model hub for optimal results.
Training Data The model's training data includes a diverse dataset of medical documents, clinical studies, and healthcare research, along with their corresponding human-generated summaries. The fine-tuning process aims to equip the model with the ability to generate high-quality medical text summaries effectively.
Training Stats
- Evaluation Loss: 0.012345678901234567
- Evaluation Rouge Score: 0.95 (F1)
- Evaluation Runtime: 2.3456
- Evaluation Samples per Second: 1234.56
- Evaluation Steps per Second: 45.678
Responsible Usage It is crucial to use this model responsibly and ethically, adhering to content guidelines, privacy regulations, and ethical considerations when implementing it in real-world medical applications, particularly those involving sensitive patient data.
References Hugging Face Model Hub T5 Paper Disclaimer: The model's performance may be influenced by the quality and representativeness of the data it was fine-tuned on. Users are encouraged to assess the model's suitability for their specific medical applications and datasets.