Utilizing HTML, one could create graphic pages (a web site) which would then ... attractiveness of e-mail is, in part, related to its low cost compared to the ...
Ultrasound Obstet Gynecol 2000; 15: 56–61.
Ultrasound in cyberspace I.E. ZADOR and R.J. SOKOL Department of Obstetrics and Gynecology, Wayne State University/Hutzel Hospital, Detroit, MI, USA
KE YW OR D S : Internet, World Wide Web, Ultrasound, Obstetrics, Gynecology
Whether we like it or not, the information revolution is becoming an ever-increasing part of our daily personal and professional lives. To keep pace with these rapid changes, the ‘White Journal’ will from time to time focus on technological topics that are relevant to obstetric and gynecological imaging. Since our readership consists predominantly of clinicians, we will pay particular attention to relevant clinical experience in presenting our information. As an introductory review and an expanded follow-up on a recent editorial in our journal1, this article deals with the Internet and the World Wide Web. Future articles will explore topics such as telesonography, ultrasound reporting, image archiving systems and other relevant topics.
BAS ICS OF THE INTE RNE T AND W ORL D WIDE WEB It is hard to believe that the Internet, the widely known medium of communication, is barely 5 years old2,3. During this short period, the Internet has penetrated into our homes, offices and cars, and is making a steady inroad into the medical arena. At home, the Internet has become the main reason people buy a personal computer. It is estimated that in early 1999 about 35% of homes in the USA will be connected to the Internet and about 10 million more will be added by the end of the year. Practically every university/medical institution worldwide has some kind of Internet connection. The Internet was conceived and developed by the United States Department of Defense in conjunction with a number of universities to explore the possibility of a communications network that could survive a nuclear attack. After the cold war was over, the research continued and the Internet proved to be a convenient way to communicate. The early applications included electronic mail (e-mail), online discussion support groups and the transfer of files among government agencies, companies and universities. During the early 1980s, all interconnected research networks were converted to a standard protocol (TCP/IP), which enabled all networks of the Internet to send data back and forth. Hypertext markup language (HTML) was introduced in 1990. This protocol permitted the
communication of graphic information on the Internet. Utilizing HTML, one could create graphic pages (a web site) which would then become part of the huge, virtual, hypertext network referred to as the World Wide Web (WWW). The enhanced Internet was informally renamed the Web.
E L E CTRO NIC M AIL Electronic mail, or e-mail, is the most widely used application of the Internet. In the USA, there are close to 50 million users online who send a total of 500 million emails per day. This number is predicted to triple by the year 2002. E-mail utilization is slower in other parts of the world, but it is predicted that the mark of 50 million users will be reached in Germany by the year 2001. The attractiveness of e-mail is, in part, related to its low cost compared to the alternatives; for some services in the USA e-mail is actually free. In Germany e-mail is charged at the lowest local call rate. That compares very favourably with much higher averaged fax prices and postage costs. Although it is believed that the Internet will make the world smaller, there are still major issues that will have to be resolved. For example, Asia is currently extremely dependent on the USA for its Internet needs. Because of the lack of inter-regional links, an e-mail message sent from Hong Kong to Bangkok, for instance, is almost sure to travel across the Pacific and back, travelling 30 000 km instead of 3000. This is due to the fact that historically Asian countries have communicated much more with the USA than they have among themselves. As the appetite for Internet services spreads worldwide, companies outside the USA are forced to pay for their links in order to tap into the network. This makes accessing the Internet outside of the USA relatively expensive. Considering the enormous impact of the Internet as a global information network, this inequality seems likely to become increasingly resented.
SE ARC HING FOR INFOR MAT ION ON TH E WE B With Internet technology, we are immediately in a world of
Correspondence: Dr I. Zador, Hutzel Hospital, Department of Obstetrics and Gynecology, 4707 St Antoine Street, Detroit, MI 48201, USA Received 9-2-99, Revised 7-4-99, Accepted 7-5-99
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REVI EW PAPE R
Ultrasound companies 2D Imaging Acuson ATL Ultrasound GE Ultrasound Hitachi America Medison Siemens Ultrasound World Wide Medical Sonus Pharmaceuticals Pie Medical Toshiba America
Internet site
Description
www.2dimaging.com www.acuson.com www.atl.com www.ge.com/medical/ultrasound www.hitachi.com www.medison.co.kr www.siemens-ultrasound.com www.worldwide-medical.com www.sonuspharma.com www.pie-data.co.uk www.toshiba.com/tams/
Used medical ultrasound equipment, sales and services Useful reference image library; online CME Useful reference image library Online CME; links to ultrasound societies General purpose information Excellent links to a variety of ultrasound-related sites General purpose information Used medical ultrasound equipment, sales and services Medical supplies and accessories A broad range of ultrasound products; a lot of graphics so it might take a while to download Good links to a variety of imaging societies; limited information on obstetrics and gynecological ultrasound
Obstetrics and gynecology and related information and databases MedNets www.internets.com/mednets/sobgyn.htm MDConsult www.mdconsult.com OBGYN.net www.obgyn.net/intro.htm Rock Hill Women’s HealthNet rockhill.womenshealthnet.com/ Rotunda-India WHA-Dr. Jeanty Pediatric Database (PEDBASE) Personal home pages Dr J. Woo Dr D. Nyberg
Dr Dr Dr Dr
G. DeVore N. Shinozuka S. Degani P. Jeanty
home.hkstar.com/⬃joewoo/anomaly.html www.nwlink.com/⬃nyberg/ultrasound/
Searchable databases on a large number of topics related to women’s health Comprehensive online medical information service; membership required Update with news and featured articles monthly; many useful related links and information A nice site to visit for those interested in a full-service private USA-based obstetrics and gynecological practice Society of Indian Obstetricians, Gynaecologists and Specialists in Reproductive Medicine Contains descriptions of over 550 pediatric disorders
www.fetalecho.com www.shinozuka.com members.tripod.com/⬃ObstUltrasound/index.html sasha.pov.net/wo menshealth
A catalogue of web pages describing particular abnormalities diagnosable by ultrasound A catalogue of web pages describing particular abnormalities devoted to diagnostic ultrasound in obstetrics and gynecology. Contains information of ultrasound risk assessment for Down syndrome (URADS) Promotes excellent CD-ROMs on fetal echocardiography A bilingual site containing some useful collections of ultrasound images Common drugs and chemicals described in association with fetal malformations Informative site featuring pregnancy and non-pregnancy-related topics
www.aium.org/Conventions/conv.htm www.efsumb.org/futcong/htm www.wfumb.org.au/congress.htm
1999 annual convention, full program Conventions through year 2002 Contains a listing of past and future congresses
www.isuog.com www.prenataldiagnosis.com
No web site yet for the annual meetings in Zagreb (2000) Course for sonologists and sonographers with experience in fetal ultrasound. A CD-ROM lecture series on ‘The ultrasound detection of chromosomal anomalies’ can be ordered. A sample of ‘The normal second trimester examination’ lecture can be downloaded free of charge
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I.E. Zador and R.J. Sokol
Meetings and courses AIUM conventions Euroson conventions World Federation of Ultrasound in Medicine and Biology ISUOG Prenatal diagnosis of congenital malformation
www.rotundaindia.com zack.pov.net/womenshealth/ www.icondata.com/health/pedbase/pedlynx.htm
Ultrasound in cyberspace
Ultrasound in Obstetrics and Gynecology
Table 1 Selected Internet sites for obstetric and gynecological imaging
Journals Journal of Clinical Ultrasound
Internet site
Description
www.interscience.wiley.com/jpages/0091-2751/
International journal dedicated to applications of medical sonography. Not many obstetrics and gynecology applications The official journal of AIUM. Dedicated to original articles dealing with all aspects of diagnostic ultrasound The official journal of ISUOG. The journal goes to over 2000 subscribers in 77 different countries
Journal of Ultrasound in Medicine
www.aium.org/Journals/jumindex.htm
Ultrasound in Obstetrics and Gynecology OB-GYN Ultrasound Online
www.blacksci.co.uk
European Journal of Ultrasound
www.elsevier.co.jp/inca/publications/store/s/2/4/6/3/7/
Ultrasound Diagnosis Ultrasound Review
www.drgdiaz.com www.usreview.com.au
An interactive diagnostic ultrasound text and journal focusing on obstetrics and gynecology by Dr P. Callen. Membership required Forum for the European scientific and clinical community working in the fields of ultrasound in medicine and biology Information related to diagnostic ultrasound, telesonography and medical informatics An overview from over 50 journals that are scanned each month for the latest research on medical ultrasound
www.aium.org
General purpose information on all the aspects of diagnostic ultrasound; online CME
www.ardms.org/
Administration of examinations and award credentials in the areas of cardiac, obstetric and gynecological, abdominal and vascular sonography Promotion, advancement and education of its members and the medical community in the science of diagnostic medical ultrasound Promotion of standards of medical ultrasound practice in Australia and New Zealand
www.go-digital.net/SDMS www.medeserve.com.au/asum www.wfumb.org.aug www.efsumb.org
Federation of affiliated organizations consisting of Regional Federations and National Societies for Ultrasound General purpose information about the activities and programs
www.tip.cs iro.au/Medicallmaging members.tripod.com/⬃ObstUltrasound/society.htm
Interesting site highlighting research of Drs Kossoff, Gill, et al. Site of a very active society with useful links
ultrasound.ucsf.edu
Excellent site for teaching and education—Drs Filly, Callen, et al.
www.rad.tju.edu/
Excellent site covering every aspect of diagnostic ultrasound imaging—Dr Goldberg, et al.
tanya.ucsd.edu
3D ultrasound group site—Dr Pretorius, et al.
I.E. Zador and R.J. Sokol
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Organizations and universities American Institute of Ultrasound in Medicine (AIUM) American Registry of Diagnostic Medical Sonography Society of Diagnostic Medical Sonographers Australasian Society for Ultrasound in Medicine (ASUM) World Federation of Ultrasound in Medicine and Biology (WFUMB) European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Csiro–Ultrasonics Laboratory Israel Society of Ultrasound in Obstetrics & Gynecology University of California— San Francisco Thomas Jefferson University— Philadelphia University of California—San Diego
www2.ultrasoundedu.com/ultrasoundedu/
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58 Table 1. continued
Ultrasound in cyberspace information overload. We need tools and technology to get at things ‘quickly’. To obtain information from the Internet, we utilize programs (browsers) that help us to navigate through the Web. The two most commonly used browsers are Netscape’s Navigator and Microsoft’s Internet Explorer. With the help of these browsers we can then search for particular information on the Web utilizing programs known as search engines. The most commonly used search engines include Yahoo (http://www.yahoo.com), Excite (http://www.excite.com), Lycos (http://www.lycos. com), AltaVista (http://www.altavista.com) and Infoseek (infoseek.go.com). Using these (or any other) search engines for finding information on the Web can be a challenge. Choosing the right search engine can make all the difference in the effectiveness with which the information is retrieved. Be prepared to spend a significant amount of time to streamline your searching skills. To determine which search engines to use depends on the type of information you are looking for. For broad topic queries, such as ‘ultrasound’, Yahoo would be the preferred search engine. Yahoo is also best when looking for a particular web site, such as the World Health Organization’s web site. On the other hand, when you are looking for specific information, such as a query of how Down’s syndrome got its name, you may want to use a search engine like AltaVista. This search engine provides tools to compose a more specific query that should ultimately deliver what you are looking for. To demonstrate the point, a good exercise is to search for the web page of our society (ISUOG) (http://www.isuog. org). Typing ‘International Society of Ultrasound in Obstetrics and Gynecology’ into the various search engines, one would not find it easily in Yahoo but it would come up quickly in the AltaVista or Lycos search engines. Searching Yahoo for fetal ultrasound, one would find 7864 matching web pages. There would be 2827 matches in Infoseek and 7740 in AltaVista. Putting fetal ultrasound in quotes would lower these numbers. This technique commands the system to search only for fetal ultrasound topics as a whole, rather than as fetal and as ultrasound separately. Nonetheless, this way still yields 96 sites in Yahoo and 684 matches in AltaVista. The future of searching on the Web will bring more sophisticated customization features and a continued proliferation of sites focused on individual needs.
U LTRA SOU N D IMA G I N G In ultrasound imaging, the Web can be a source of useful information and applications. Some selected web sites and their particular focus that are worth exploring for ultrasound in obstetrics and gynecology are summarized in Table 1.
Ultrasound equipment manufacturers’ Web sites We encourage our readers to visit the home pages of the major ultrasound equipment manufacturers. Most vendors of ultrasound equipment and supplies maintain web sites with information about products, prices, content and
Ultrasound in Obstetrics and Gynecology
I.E. Zador and R.J. Sokol specifications. These sites are a source of information about the companies’ latest products, but, in addition, many of them contain educational information, links to other ultrasound sites, societies, meetings and information on other useful sites. Some companies are easier to find on the Web than others. The former group includes ultrasound manufacturers which are dedicated solely to ultrasound (the web address is usually the company’s name) such as Acuson (http://www.acuson.com) or ATL (http://www.atl.com) while the latter group includes more diversified companies such as Siemens (http://www.siemensultrasound.com), Toshiba (http://www.toshiba.com/tams) and General Electric (http://www.ge.com/medical/ultrasound).
From your ultrasound machine to the Web An emerging exciting use of the Internet in ultrasound imaging is a feature that enables the newer generation of ultrasound scanners to be linked directly to the Web. This technology, marketed under such names as WebLink (ATL) or WebPro (Acuson), uses Internet technologies to provide low-cost image communication. It comes as an optional feature with most of the scanners, and it does not require any additional computer system to be purchased. This feature can he useful for remote review, consultation, reporting, or publication. This solution can be implemented across a local area network, a wide area network, or the Internet. From anywhere on the globe with an access to the Internet, a physician working at a computer with a web browser can pull an entire ultrasound examination, images and patient data from an ultrasound system. Webfacilitated retrieval of these images requires a valid user identification and password. To enhance confidentiality of the information transmitted in cyberspace, patient identification is stripped from the images as well as scan site information. Current limitations include retrieval of only static images, although some work is being done to view cine loops. The quality of the images is slightly compromised, owing to the compression techniques used.
U LTRAS OU N D -RE L ATE D APPL ICATION S Literature searches It is now common among professionals to seek medical information on a given topic by accessing the Internet4,5. This can be done at any time of the day or night from the home, the office, or any location around the world with an access to the Internet. It is obviously a much more efficient method of searching the literature than visiting a library with its limited service hours and the tedium of looking through journals. A worthy site to perform a general medical search is http://www.mwsearch.com, which contains nearly 100 000 medical sites for articles and documents. An interesting glimpse into the future can be seen at http://www.neoforma.com, which provides a webbased community for health-care professionals that uses panoramic, three-dimensional photographic technology.
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Ultrasound in cyberspace On that site you can take a virtual tour of the University of Chicago’s Center for Advanced Medicine facility. A Medline search does not require any specific training or knowledge. The web site of the National Library of Medicine (NLM) in Washington DC (http://www.nim.nih. gov) offers a vast scope of information on education and research. In addition, the NLM web site provides free Medline and health service technology assessment text searches. Medline is the NLM’s bibliographic database covering medicine, health-care systems and other related fields. Full text articles can be ordered through the web site. The search engine attached to Medline translates key words or free text entries (e.g. premature labor and ultrasound) to a vocabulary called MESH (Medical Subject Headings) and matches these terms to the article title or subject headings in all publications in the collection of the National Library of Medicine. Currently, there is approximately a 4-week delay between the time of publication and the appearance on Medline. An abstract with all the pertinent information about the authors, language, journal, etc., is usually provided for each such article found. The information obtained from the Medline search can be downloaded into your computer and can be easily incorporated into any application.
Medical publishing A related emerging trend relates to changes in the nature of medical publishing. The leading medical journals, such as the New England Journal of Medicine, the British Journal of the American Medical Association and the Lancet, are now online, as are several leading journals in our speciality5–7. The leading scientific publishers are making their entire journal collections available over the Internet. For example, John Wiley & Sons has recently announced the launch of its Interscience project which will provide online access to nearly all of its more than 400 scientific journals. Interscience will feature searchable content listings, abstracts and, by 1999, access to full-text electronic files for all articles published in its journals. Other publishers are implementing similar strategies. Consequently, some publishers of scientific journals are concluding that the publication of annual subject and authors indices in the respective journals would be of limited value to their readers and have decided to abandon the practice.
Teaching and education Universities and hospitals are taking advantage of the Internet to promote education8–10. A peek into ‘online learning’ can be experienced at http://radiologycme.stanford. edu. This web site represents a balanced blend of the stateof-the-art technology and superior clinical expertise to create unique distance-based learning experiences. Currently the site offers medical education courses in ‘Applications of Power Doppler’ and ‘Breast Ultrasound’ in addition to other radiological imaging topics. It is our hope that ISUOG will develop a series of educational courses in the
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I.E. Zador and R.J. Sokol near future that will promote worldwide education in obstetric and gynecological imaging.
Accreditation Ultrasound departments using web resources can find information on topics ranging from safety to health-care financing. For example, the Joint Commission of Accreditation of Health Care Organizations (JCAHO) has information on the accreditation process and the development of the standards of care (http://www.jcaho.org). The American Institute of Ultrasound in Medicine (AIUM) web site (http://www.aium.org) contains information on the accreditation process for ultrasound laboratories. The American College of Radiology web site (http://www.acr. org) contains information on economics and health-care policy, new and proposed legislation, and appropriate criteria for imaging and treatment decisions.
Research funding For those who are looking for information on grant-related web sites, a good starting point is the grant tracker web site (http://www.granttracker.com) which hosts a comprehensive list of funding agency links. Incidentally, this site offers software to organize grant writing and administration. The link to the National Institutes of Health (NIH) funding opportunities page (http://www.nih.gov/grants) contains information on current grants and contacts, as well as information on NIH institutes and centres. A search engine allows the researcher to find information on specific topics. In addition to announcements and deadlines, the site has a downloadable guide to the NIH contracting process.
C O N CL U S I O N As yet, the Web has no regulation policy or quality control, so that sometimes an excursion into the Web can resemble a trip to the ‘Wild West’. Anyone with a PC, a modem and an Internet service provider can get onto a web site. Physicians and other health-care professionals, as well as our patients, must be concerned with issues such as who provides the information, what are their affiliation and credentials, whether the information is up to date, what are the sources and references, and so forth. A significant amount of clinical information on the net is unscientific, anecdotal and very often misleading. To avoid these pitfalls and to weed out unwanted medical information, one should search for credible medical information on the Web by accessing university-based web sites and linking onto the university medical institution’s home page. Currently the worst technological problem of the Internet is its intervals of slow response; this issue is under investigation from many sides. Segments of the communication industry are working feverishly to produce the best solution for broadening the bandwidth in order to increase the speed of data through the network. The network that composes the Internet’s backbone was never designed for today’s heavy Internet traffic. Data lines, servers and
Ultrasound in Obstetrics and Gynecology
Ultrasound in cyberspace software were not designed to carry media-rich pages and multimedia content. The Next Generation Internet (NGI), also referred to as Internet II, is designed to relieve the network’s bandwidth bottleneck. Any advances will be available to all Internet users in 3–5 years. Additionally, the Internet has problems with organization (site names), standards (disputes between Microsoft and Netscape), access for the cost conscious, governmental interference, fraud, security breaches and the lack of privacy. Nevertheless, it is fair to say that the difficulties are dwarfed by the usefulness of what the Internet can already do and what it promises to do in the future.
RE FER E N CES 1 Degani S. Internet: personal use by obstetric and gynecological sonologists. Ultrasound Obstet Gynecol 1998; 12: 375–6
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I.E. Zador and R.J. Sokol 2 McKeown MJ. Use of Internet for obstetricians and gynecologists. Am J Obstet Gynecol 1997; 176: 271–4 3 Feingold M, Keualramani R, Kaufman GE. Internet and obstetrics and gynecology. Acta Obstet Gynecol Scand 1997; 76: 718 4 Blanchard SM. The World Wide Web: a new tool for biomedical engineering education. Biomed Sci Instrum 1997; 33: 400 5 Fornage BD. JCU in the on-line era [Editorial]. J Clin Ultrasound 1998; 26: 1–2 6 Seufert R, Merz E, Lelle´ R. The Internet: new communication structures for ultrasound diagnosis in gynecology? Zentralbl Gynakol 1997; 119: 571–3 7 Henri CJ, Rubin RK, Cox RD, Bret PM. Design and implementation of World Wide Web-based tools for image management in computed tomography, magnetic resonance imaging, and ultrasonography. J Digit Imaging 1997; 10: 77–9 8 Larkin M. Interactive pregnancy, parenting, and ob/gyn websites. Lancet 1998; 352: 916 9 Smith RP. Internet update. MD Comput 1998; 15: 10–27 10 Smith RP. The Internet for continuing education. MD Comput 1997; 14: 414–18
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