Internet Nuclear Medicine

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REVIEWAnnals of Nuclear M edicine Vol. 11, No. 1, 7-13, 1997

Internet in Nuclear Medicine

Yutaka SuzuKI * and Masahiko NAKAMUR A **

Departments of *R adiology and * *B iomedical Engineering,Tokai University Medical School, Japan

INTRODUCTION

Recently, the Internet has been widely used in nuclearmedicine. Development of the In ternet has brought a newcomm unicat ion tool for us . With this tool , we can ea s i lyand quickly exchange a large amount of information,regardless t ime and distance. The In ternet is anticipated tohave a great impact on clinical practice, education andresearch in nuclear medic ine .

In this paper, we, first , describe the outline and functionof the Internet , and then int roduce i t s appl ications in thevarious f ie lds of nuclear medic ine .

OVE RVI E W OF THE I N TE RN E T 1-3

The Internet is a world-wide network of computer net-works that communicate with ea ch o ther u sing the Trans-mission Control Protocol/Internet Protocol (TCP/IP). Ithas the following functions: electronic mail, electronicnews, f i le t ransfer protocol , remote login, and h ypertextt ransfer protocol (World-Wide Web).1. Electronic MailElectronic mail (e-mail) provides a private communica-tion between individuals. The basic concepts behind e-mail parallel those of regular or snail mail . You send mailto people at their particular addresses. In turn, they writeto you at your e-mail address .

For example, "[email protected]" is the e-mail address of one of the authors . The e-mail address isgenerally composed by user name (ysuzuki), machinename ( is) and do main nam e ( icc.0-tokai .ac. jp) . Mai l mes-sages are com posed of two port ions: the header and body.

Based on an invited educational lecture at the 6th Asia andOceania Con gress of Nuclear Medicine and B iology, and the36th Ann ual Scient i fic M eet ing of the Japanese Society ofNuclear Medicine, Kyoto, October 1996.For reprint contact: Yutaka Suzuki, M.D., Departmen t ofRadiology, Tokai University Medical Scho ol, Bohseidai, Isehara259-11, JAPAN.

The header lists information about the sender of themessage, the rec ipient , the pos t ing date of the message,and a su bject f ield. The body h olds the text of the me ssagei tsel f , usual ly in A SCII forma t . The advantages of e -mai lare that i t provides very rapid commu nication; of the orderof seconds to hour to reach the destination. It allows tosend large volume of data such as source code. Theconfidenc e of the mail can not always be warra nted, but ismuch bet ter than those of o ther com municat ion methods.

Via e-mail we can also send a message to groups ofindividuals . In this case , the m ail f i rs t sends to the c om-puter, called "listserv," or "mailing lists" and then it isdistributed to large n umber of individuals on the l ist . Withth is system indiv iduals on the l i s t can excha nge opin ionswith each other on the particular topics. The advantages ofmailing lists are that they provide for sh aring of informa -tion to large groups of individuals and facilitate the on linediscuss ion of topics of interes t.2. Electronic NewsElect ronic news is d i f ferent from news on other med ia, inwhich new s runs in one way direct ion from the media toind iv iduals . In elect ronic new s, in format ion runs in terac-tively among the individuals who are interested in thatin format ion . Elect ronic news is d iv ided in to newsgroups,which c overs specif ic areas of interes t . There are a la rgenumber of newsgroups in the world . The news groups arearranged in a hierarchica l or t ree fashion, with each ro otof the t ree devo ted to a ma jor topic (Fig. 1) . Like a t ree ,each of these roots has many branches, with each branchfurther defining subject area. There are many programsthat can be used to read news and upload a n ews into thenewsgroups.3. File Transfer ProtocolThe file transfer protocol (FTP) makes it possible to movea f i l e f rom one computer to another , even i f each computerhas a different operat ing sys tem and f i le s torage format .

Files may be data, programs, and texts; anything thatcan be stored. Users are required to log in to each com-puter and to have permission to access the f i les you w ish

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sci.med

----- sci.med. aidssci.materials ---sci.med sci.med.informaties

sei.military

sci sci.misc sci.med.physics

sci.aanotech

---

sci.med.radiology

--- sci.med.telemedicinesci.physics

Fig. 1 Arrangement of newsgroups.to re t r ieve or t ransfer . F i le t ransfer across the Internet isrel iab le because the m achines involved can comm unicatedirectly, without relying on intermediate machines tomake copies of the file along the way. With using FTP,la rge f i les can be t ransferred in sho rt t ime.

Several host s provide the username a nonymous for f tpretrieval of files from their system. This service called"anonymous FTP." The hosts that al low anonymous log indo so by estab lish ing a special anonymous log in account ,which wo rks only with FTP, and can not be accessed forgeneral use of that host. The anonymous account is aspecial one with access limited to the FTP archivesoffered by that hos t . In anonymo us FTP, the login namefor remote host will always be anonymous. The remoteFTP program wil l often reques t the user 's e -mail addressas the password.4. Remote LoginIn remote login, the Telnet protocol is used. This protocolal lows an In ternet user to log in to a rem ote host f rom hisor her local host. Once connected and logged in to theremote ho st, a user can do an y operation just as if he or shewere logged in directly to the remote host. Every key-s t roke on the user 's local com puter is sent direct ly to theremote system. Telnet is a powerful tool in resourcesharing. Telnet protocol some times require that youarrange for access in advance. Such arrangements usual lyinclude the ass ignment of an account name and passw ordon the remote hos t ..5. World-Wide-WebWorld-Wide-We b (WWW) is cons t ructed by the fol low-ing three com ponents; Uniform Resource Locator (URL),Hypertext Markup Language (HTML) and HypertextTransfer Protocol (HTTP).

1) URLAn URL is basically an expression of specifing thelocat ion of resources on the Internet .URLs can be used to describe just about any kind ofconnect ion on the In ternet, including WWW, FTP, an de-mail, as shown in the following examples:

Table 1 Applications of the Internet in the Nuclear M edicineCommunity

1. Open forums for discussion.2. Construction of teaching files.3. Construction of da ta base of nuclear med icine.4. Exchange of the information between the acad emicorganization and its members.5. Provided by the companies related to nuclear medicine.

http://mfs.med.u-tokai.ac.jpftp://mfs.med.u-tokai.ac.jp/pub..jpns/workshop/R E A D M E2) H T M LHTM L is language to describe hypertext or tag docu-ments for electronic format and structural uses. Thefundamental concept behind hypertext is that informa-tion can be stored and retrieved in a nonhierarchicals t ructure . So ins tead of moving through directories ofinformat ion, you can jump from on e place to the nextthrough a series of links created by some one. Thehypermedia is the extended concept of the hypertextwhich inc ludes images , movies and sounds .3 ) HTTPHTTP is the descr ip t ion how to t ransfer the doc umentsdescribed by HTML between a computer to a com-puter. An access to a WWW usually can be done onuser 's personal computer by us ing a software , te rmeda "browser." Netscape Navigator and Internet Explorerare the commonly used browsers. Running on thecl ient 's compu ter , the browsers re t r ieve HTM L docu -ments f rom the server and in terpret markup commandsembedded in the documents. The interpretation andexecution of these markup commands result in thedisplay of the documents. The user browses or navi-gates through hypermed ia screens con ta ining l inks toinformation located around the world. The user doesnot have to be concerne d with the network address orgeographical locat ions . With the browser, navigat ionis ent ire ly accomplished throu gh mo use c l icks .Recently the functions of the browsers have beengreat ly expanded and e-mai l , FTP, and elect ronic newscan be handled on W WW by the browsers .

INTERNET IN NUCLEAR MEDICINE'The appl icat ions of the Internet in nuclear medic ine , canbe divided in two categories : one is use in nuclear medi-c ine comm unity and the other is use for commun icat ionwith outs ide of the nuclear m edic ine com mun ity. In thissection, these two applications will be described sepa-rately.1. Use in Nuclear Medicine CommunityIn nuclear m edic ine com munity, 5 different applicat ionscan be ment ioned as show n in the Table 1 .

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Fig. 3 Home page o f Biomedical Engineering, Tokai University M edical School.1) Forums for discuss ionFor establishing forums, mailing lists, WWW andnewsgroups are now used. One of the most activel i s tsery in nuclear medic ine is "nuc med@largnet .uwo.

ca" which ha s been estab l ished by Prof . Cradduck TDin the Department of Nu clear Me dic ine , Univers i ty ofWest Ontario , London On tario Can ada. In this server ,the topics about bas ic aspects of nuc lear medic ine are

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Weight loss and gastric abnormalities: A 73-year-old maleA 7 3-year-o ld man was admit ted to a h osp i ta l because o f gas t r ic tumor . He had vague d iscomfor t in the ep igass tr ium6 months before admission. He lost his appetite and had a weight loss of 5kg during past 6 months. He had a upper GIseriease elsewhere and a submucosal gastric tumor was suspected. He was transferred to the hospital for furtherexamination.On ph ysical examination the patient appeared ch ronically il l . No lymphad enopathy was foun d. Epigast ic tendernesswas found , but m ass was n ot pa lpable , and l iver and sp leen we re not en la rged .Laboratory data on admission were as fo llowing: WB C 10,800/microl, Hb 16.2g/dl, platelet count 250,000/microl, totalprotein 5.8g/dl , a lbumin 3 .4g/dl , GOT 21 U /I, GPT 12U/I and LDH 557U /I.An upper GI senese , and u l t rasound and C T of the upper abdomen were ob ta ined . Whole body images with Ga - 67citrate and Tc-9m methyle ne d p ho sph o nate were carried out. A r adiograph of the r ight femur was o b ta ined

What is your diagnosis?

Fig. 4 a: Brief history, and clinical and laboratory data of the case uploaded.Whole body image with Ga -67 citrate

Anter io r and pos te r io r whole body images were ob ta ined 72 hours a f te r in jec t ion of 111 M Bq of Ga -67 citrate. Theanterior image reveals a large localized hot area in the epigastrium corrresponding to the stomach. Lung activity isdiffusely increased with several localized hot spots, corresponded to the abnormal shadows on the chest radiograph.There is an area of mildly increased act ivity in the right inguinal region. Colonic act ivity is a normal finding.The posterior image shows an intense hot area in the left upper abdomen. Three hot spots are demonstrated in theright lung.

Fig. 4 b: Images and description along them.

mainly discussed. A mail ing l is t for individuals inter-ested in PET nuclear medicine has been establishedand managed by Beth A Harkness, MS at theDepartment of Radiology, Bowman Gray School ofM edicine , Winston Salem, North Ca lorina , US A. Thismailing list covers broad aspects of the PET nuclearmedicine such as basic technology and reimbursementpolicy.There is a very act ive bul le t in board, ca l led LU NIS(Loyola U nivers ity Nuclear M edicine Informat ion Ser-v ice) in the d iv is ion of N uclear M edicine, Department

of R adio logy, Loyola Univers i ty M edical School , C hi-cago I l l ino is , USA (Fig . 2) . You can access to LU NISvia telnet or WWW (U RL: http://wwwd.lunis.][uc.edu:80/lunis/), but you have to get permission in a dvanc e toparticipate in the discussion.

There is no newsgroup dedicated solely to nuclearmedicine, but you will find many interesting topics inthe following newsgroups; sci.med.informatics,sci.med.physics, sci.med.radiology, and sci.med.t elemedicine.

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Diagnosis: Adult Tell lymphomaGastric mucosal biopsy was crr ied out, and histological and histochem ical diagnosis was non Ho dgkin lymphoma;medium size and diffuse Tcell type. Serum anti HTLVI an tibody was demon strated.

Comments

Adult Tc ell lymphoma(ATL) is etiologically linked to the human Tce ll lymphotrophic virus type l(HTLVI). HTLVI, artrovirus, is endemic in southern Japan and Caribean basin. ATL occurs less than 5% of people with HTLVI withaverage latency period o f more than 30 years. ATL ce lls frequently infilt rate the GI tract . ATL is poor in prognosisand resistant to the che mothe rapy. I t has a tend ency to involve skeletal system.Ga -67 citrate has strong affinity to the ATL, so whole body image with Ga -67 citrate is useful for evaluating thedistr ibution of the disease and the therapeutic effect. Bone scan is highly sensitve in detection of the skeletalinvolvement.

Fig. 4 c: Diagnosis of the case and brief comments about i t.

Table 2 Teaching Fi les on WWW Sites1 . Tokai Univ. Medical School

(h ttp://m fs. med. u - t ok a i . a c . j p )2 . Harvard Univ. Medical School(http://www.med.harvard.edulradiology/JPNM

/TF.html)3 . Washington Univ. Medical School(http://www.gamma.wustl .edu/home.html)4. New York Univ. Buffalo(http://www.nucmed.buffalo.edu)

Table 3 Data Base on WWW Sites1 . SNM Computer & Instrumentation Council

(http: //g amma. wu s tl. edu/tf/cai c . html )2 . Univ. West Ontario, Nuc. Med.(h ttp://johns.l argnet. u wo. ca/nu med. i nde x. html )3 . Harvard Univ. Radiology(http://www.med.harvard.edu/JPNM)4. Univ. Texas Health Science Center(http: lnuc-med-read.uthscsa. edu)

5. Iowa Univ. Rad iology(http://vh.radi of ogy.uiowa.edu)

2) Teaching filesThere are many WWW sites uploading nuclear medi-cine teaching files. Some sites are sampled in the Table2. Figure 3 shows the English version of our home pageat the Department of Biomedical Engineering, TokaiUniversity Medical School. We have uploaded 25cases in which nuclear medicine is useful for thediagnosis and elucidating the pathophysiology. Ourteaching files are constructed of 3 components; briefclinical history and data, images, and diagnosis andcomments (Fig. 4).

The WWW-based teaching files have several advan-tages over the film-based ones: 1, Network access

Table 4 Home Pages of the Acad emic Organizat ions1. Society of Nuclear Medicine(http://www.snm.org)2. SNM Computer & Instrumentation Council(http://gamma. wustl.edu/tf/caic. html)3. British Nuclear Medicine Soc iety(http://www.bnms.org.uk/bnms)4. R S N A(http://www.rsna.org)5. Institute for Clinical PET(http://www.icppet.org)6 . Spanish Nuclear M edicine Society

(http://www.semm.es)

permits use at multiple sites, both within an institutionand cross multiple institutions. 2, The space for keep-ing teaching files can be saved. 3, Loss of teaching filecases due misfiling of films is prevented, and rear-rangement of files is easily carried out. 4, Because ofthe small size of nuclear medicine images and readyaccess to the imaging data in digital form, nuclearmedicine is particularly well suited for creating adigital teaching f ile . 5, Incorporation of best cases frommultiple institutions enhances the quality of teachingfiles. Development of teaching file material is time-consuming. By being able to link to materials devel-oped at other institutions, the f inal product is multipliednumber of collaborators. Each institution can invest amoderate effort but the endproduct can be very impres-s ive .3) Data base of nuclear medicineWhen you want to get the information related to thebasic science of nuclear medicine, nuclear medicineprocedures and softwares, you can find the specificinformation on the many WWW sites. Some such sitesare tabulated in the Table 3. For example, if you accessto the Texas Health Science Center, there are many

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Fig. 5 Table of contents of the review and reference n otes on nuclear medicine uploaded on the website at University of Health Science Ce nter at San Antonio.

Table 5 Home Pages of the Com panies Related to NuclearMedicine1. Toshiba U.S.A.(http://www.toshiba.com:80/rpoducts/home

/home.html)2. Siemens(http://www. si emen. com/nmg)3 . A D A C(http://www.adaclabs.com)4. Picker(http://www.picker.comlpicker-Home.html)5. Mall inckrodt(http://www.mallinckrodt.nl/nuc!ear)

useful review manuals covering the entire field ofnuclear m edic ine (Fig. 5) .4) Home pages of the academ ic organizat ionsNow many academic organizations in nuclear medi-cine and related fields have their own home pages(Table 4). These home pages contribute to enhance-ment of comm unicat ions between the organizat ion andits members, and among the members. Each homepage is expected to be useful for promo tion of nuclearmedicine toward the outside of the nuclear medicinecommunity.

5) Home pages of the companies related to nuclearmedicine

In the Table 5, a couple of the homepages of thecompanies related to nuclear medicine are l isted. Thesehome pages give us useful information about the prod-ucts of each company.

2. Use for Communication with Outsides of NuclearM edicine Comm unity

Using the In ternet, we can send a m essages to the profes-sionals in medicine as well as to lay person. WWW is avery powerful method for this purpose. As for the profes-sionals in medicine, we can teach them the indications,contra indicat ions , advantages and d isadvantages of eachs tudy, and have a discuss ion about the specif ic case withthem. U ploading the s tudy protocol wi l l be c onvenient toall professionals in medicine. Introduction of new methodand new d eveloped indicat ions of the old methods to thedoctors in other specialties are our important duties.WWW is sui table for a l l of these purposes .

The b ig problem in nuclear medicine i s that we n uclearphysicians play a great role in clinical practice, but layperson does not know anything about nuclear medic ine ,our role in medicine and its benefit to them. We alwayshave to cont inue sending c lear m essages to them .

In the home pages of the Society of Nuclear Me dicine,

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there are messages to lay person. Here people can learnmany things about nuclear medicine from its history tocharacteristics. They can get information about radiationdose of each examination in nuclear medicine comparedwith the other modalities. The home page of Mallinckrodthas also useful documents for lay person. They can getgeneral information about nuclear medicine and also howto do each examination. They can get knowledge ofnuclear medicine procedures in comparison with othermethod.

CONCLUSIONThe internet has various functions which are very usefulfor the clinicians and scientists in nuclear medicine. Withthe Internet we can exchange opinions very convenientlyand transfer an y type of . information very quickly, regard-less time and distance. The Internet will greatly contributeto promote the international collaboration among thepersonnel in nuclear medicine.

REFERENCES1. Digital Networks and Communication in Nuclear Medi-

cine, edited by Cradduck TD, The Michener Inst itute forApplied Health Science, Toronto, Canad a, 1993.

2. Internet Getting S tarted, edited by Marine A, K irkpatrick S,Neou V . Ward C, PTR P retince Hall, Englewood Cliffs, NJ,1994.

3 . Thomas BJ. The Internet for Scientists and En gineers, 1996Edition SPIE The International Society for O ptical Engi-neering, Bell ingham, WA, 1996 .

4. Craduck TD. The wide world of internet. J Nucl Med 35 (8):30N-34N, 1994.5 . McEney KW. The internet, world-wide web, and mosaic:an overview. A mer J Roentgenol 164: 469-473, 1995.6 . Galvin JR, D'Alesandro M P, Kuriha ra Y, et al. Distributing

an electronic thoracic imaging teaching file using the Internet,Mosaic, and personal computer. A mer J Roentgenol 164:475-478, 1995.7 . Richardson ML. A world-wide web radiology teaching fileserver on the Internet. Amer J Roentgenol 164: 479-483,1995.

8. Wall is JW, Mil ler M M , Mil ler TR, e t a l . An Internetbased nuclear med icine teaching file. JNucl Med 36: 1520-1527, I995.9 . M a m m o n e G L, Ho l ma n B L , Greenes RA, et al. InsideBrighamRAD: providing radiology teaching cases on theInternet. Radiographics 15: 1489-1498, 1995.10. Mezrich R S, DeMarco JK, N egin S, e t a l. Radiology on theinformation superhighway. Radiology 195: 73-81, 1995.11 . Parker JA, Wallis JW, Halama JR, et al. Collaboration usingInternet f rom the development of case based teachingf i les: report of the computer and instrumentation councilInternet focus group. J Nucl Med 37: 178-184, 1996.12 . Wil liams SC, M ay CC, C ontre ras M. A nuc lear medic inereview manual on the internet. Amer J Roentgenol 167:585-586, 1996.

13. Glowniak JV. An introduction to the Internet, Part 4:Medical Resources. J Nuc l M ed Technol 24: 10-19, 1996.

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