Nuclear medicine 1

Nuclear medicine

Nuclear medicineIntervention

ICD-10-PCS C [1]

ICD-9: 92 [2]

MeSH D009683 [3]

OPS-301code: 3-70 [4]-3-72 [5], 8-53 [6]

Nuclear medicine is a medical specialty involving the application of radioactive substances in the diagnosis andtreatment of disease.In nuclear medicine procedures, radionuclides are combined with other elements to form chemical compounds, orelse combined with existing pharmaceutical compounds, to form radiopharmaceuticals. These radiopharmaceuticals,once administered to the patient, can localize to specific organs or cellular receptors. This property ofradiopharmaceuticals allows nuclear medicine the ability to image the extent of a disease process in the body, basedon the cellular function and physiology, rather than relying on physical changes in the tissue anatomy. In somediseases, nuclear medicine studies can identify medical problems at an earlier stage than other diagnostic tests.Nuclear medicine, in a sense, is "radiology done inside out", or "endo-radiology", because it records radiationemitting from within the body rather than radiation that is generated by external sources like X-rays.Treatment of diseased tissue, based on metabolism or uptake or binding of a particular ligand, may also beaccomplished, similar to other areas of pharmacology. However, the treatment effects of radiopharmaceuticals relyon the tissue-destructive power of short-range ionizing radiation.In the future, nuclear medicine may provide added impetus to the field known as molecular medicine. Asunderstanding of biological processes in the cells of living organisms expands, specific probes can be developed toallow visualization, characterization, and quantification of biologic processes at the cellular and subcellular levels.[7]

Nuclear medicine is a possible specialty for adapting to the new discipline of molecular medicine because of itsemphasis on function and its utilization of imaging agents that are specific for a particular disease process.

Diagnostic medical imaging

DiagnosticIn nuclear medicine imaging, radiopharmaceuticals are taken internally, for example, intravenously or orally. Then,external detectors (gamma cameras) capture and form images from the radiation emitted by theradiopharmaceuticals. This process is unlike a diagnostic X-ray, where external radiation is passed through the bodyto form an image.There are several techniques of diagnostic nuclear medicine. 2D: Scintigraphy ("scint") is the use of internal radionuclides to create two-dimensional images.[8]

Nuclear medicine 2

A nuclear medicine whole bodybone scan. The nuclear

medicine whole body bonescan is generally used inevaluations of various

bone-related pathology, such asfor bone pain, stress fracture,nonmalignant bone lesions,

bone infections, or the spreadof cancer to the bone.

Nuclear medicine myocardialperfusion scan with

thallium-201 for the rest images(bottom rows) and Tc-Sestamibifor the stress images (top rows).

The nuclear medicinemyocardial perfusion scan playsa pivotal role in the noninvasive

evaluation of coronary arterydisease. The study not only

identifies patients with coronaryartery disease; it also providesoverall prognostic information

or overall risk of adversecardiac events for the patient.

A nuclear medicine parathyroidscan demonstrates a parathyroid

adenoma adjacent to the leftinferior pole of the thyroid gland.The above study was performedwith Technetium-Sestamibi (1st

column) and iodine-123 (2ndcolumn) simultaneous imagingand the subtraction technique

(3rd column).

Normal hepatobiliary scan(HIDA scan). The nuclear

medicine hepatobiliary scan isclinically useful in the detection

of the gallbladder disease.

Normal pulmonary ventilationand perfusion (V/Q) scan. Thenuclear medicine V/Q scan is

useful in the evaluation ofpulmonary embolism.

Thyroid scan withiodine-123 forevaluation of

hyperthyroidism.

3D: SPECT is a 3D tomographic technique that uses gamma camera data from many projections and can bereconstructed in different planes. Positron emission tomography (PET) uses coincidence detection to imagefunctional processes.

Nuclear medicine 3

A nuclear medicine SPECT liver scan with technetium-99m labeledautologous red blood cells. A focus of high uptake (arrow) in the liver

is consistent with a hemangioma.

Maximum intensityprojection (MIP) of awhole-body positron

emission tomography (PET)acquisition of a 79kg femaleafter intravenous injection of371MBq of 18F-FDG (onehour prior measurement).

Nuclear medicine tests differ from most other imaging modalities in that diagnostic tests primarily show thephysiological function of the system being investigated as opposed to traditional anatomical imaging such as CT orMRI. Nuclear medicine imaging studies are generally more organ- or tissue-specific (e.g.: lungs scan, heart scan,bone scan, brain scan, etc.) than those in conventional radiology imaging, which focus on a particular section of thebody (e.g.: chest X-ray, abdomen/pelvis CT scan, head CT scan, etc.). In addition, there are nuclear medicine studiesthat allow imaging of the whole body based on certain cellular receptors or functions. Examples are whole body PETscans or PET/CT scans, gallium scans, indium white blood cell scans, MIBG and octreotide scans.

Iodine-123 whole body scan for thyroid cancerevaluation. The study above was performed afterthe total thyroidectomy and TSH stimulation with

thyroid hormone medication withdrawal. Thestudy shows a small residual thyroid tissue in theneck and a mediastinum lesion, consistent with

the thyroid cancer metastatic disease. Theobservable uptakes in the stomach and bladder

are normal physiologic findings.

While the ability of nuclear metabolism to image disease processesfrom differences in metabolism is unsurpassed, it is not unique. Certaintechniques such as fMRI image tissues (particularly cerebral tissues)by blood flow and thus show metabolism. Also, contrast-enhancementtechniques in both CT and MRI show regions of tissue that arehandling pharmaceuticals differently, due to an inflammatory process.

Diagnostic tests in nuclear medicine exploit the way that the bodyhandles substances differently when there is disease or pathologypresent. The radionuclide introduced into the body is often chemicallybound to a complex that acts characteristically within the body; this iscommonly known as a tracer. In the presence of disease, a tracer willoften be distributed around the body and/or processed differently. Forexample, the ligand methylene-diphosphonate (MDP) can bepreferentially taken up by bone. By chemically attachingtechnetium-99m to MDP, radioactivity can be transported and attachedto bone via the hydroxyapatite for imaging. Any increasedphysiological function, such as due to a fracture in the bone, willusually mean increased concentration of the tracer. This often results inthe appearance of a "hot spot", which is a focal increase in radio

Nuclear medicine 4

accumulation or a general increase in radio accumulation throughout the physiological system. Some diseaseprocesses result in the exclusion of a tracer, resulting in the appearance of a "cold spot". Many tracer complexes havebeen developed to image or treat many different organs, glands, and physiological processes.

Hybrid scanning techniquesIn some centers, the nuclear medicine scans can be superimposed, using software or hybrid cameras, on images frommodalities such as CT or MRI to highlight the part of the body in which the radiopharmaceutical is concentrated.This practice is often referred to as image fusion or co-registration, for example SPECT/CT and PET/CT. The fusionimaging technique in nuclear medicine provides information about the anatomy and function, which would otherwisebe unavailable or would require a more invasive procedure or surgery.

Normal whole body PET/CT scan with FDG-18. The wholebody PET/CT scan is commonly used in the detection, staging

and follow-up of various cancers.

Abnormal whole body PET/CT scan with multiple metastases from acancer. The whole body PET/CT scan has become an important tool in

the evaluation of cancer.

Practical concerns in nuclear imagingAlthough the risks of low-level radiation exposures are not well understood, a cautious approach has beenuniversally adopted that all human radiation exposures should be kept As Low As Reasonably Practicable,"ALARP". (Originally, this was known as "As Low As Reasonably Achievable" (ALARA), but this has changed inmodern draftings of the legislation to add more emphasis on the "Reasonably" and less on the "Achievable".)Working with the ALARP principle, before a patient is exposed for a nuclear medicine examination, the benefit ofthe examination must be identified. This needs to take into account the particular circumstances of the patient inquestion, where appropriate. For instance, if a patient is unlikely to be able to tolerate a sufficient amount of theprocedure to achieve a diagnosis, then it would be inappropriate to proceed with injecting the patient with theradioactive tracer.When the benefit does justify the procedure, then the radiation exposure (the amount of radiation given to thepatient) should also be kept as low as reasonably practicable. This means that the images produced in nuclearmedicine should never be better than required for confident diagnosis. Giving larger radiation exposures can reducethe noise in an image and make it more photographically appealing, but if the clinical question can be answeredwithout this level of detail, then this is inappropriate.As a result, the radiation dose from nuclear medicine imaging varies greatly depending on the type of study. Theeffective radiation dose can be lower than or comparable to or can far exceed the general day-to-day environmental

Nuclear medicine 5

annual background radiation dose. Likewise, it can also be less than, in the range of, or higher than the radiation dosefrom an abdomen/pelvis CT scan.Some nuclear medicine procedures require special patient preparation before the study to obtain the most accurateresult. Pre-imaging preparations may include dietary preparation or the withholding of certain medications. Patientsare encouraged to consult with the nuclear medicine department prior to a scan.

AnalysisThe end result of the nuclear medicine imaging process is a "dataset" comprising one or more images. Inmulti-image datasets the array of images may represent a time sequence (i.e. cine or movie) often called a "dynamic"dataset, a cardiac gated time sequence, or a spatial sequence where the gamma-camera is moved relative to thepatient. SPECT (single photon emission computed tomography) is the process by which images acquired from arotating gamma-camera are reconstructed to produce an image of a "slice" through the patient at a particular position.A collection of parallel slices form a slice-stack, a three-dimensional representation of the distribution ofradionuclide in the patient.The nuclear medicine computer may require millions of lines of source code to provide quantitative analysispackages for each of the specific imaging techniques available in nuclear medicine.[citation needed]

Time sequences can be further analysed using kinetic models such as multi-compartment models or a Patlak plot.

Interventional nuclear medicineRadionuclide therapy can be used to treat conditions such as hyperthyroidism, thyroid cancer, and blood disorders.In nuclear medicine therapy, the radiation treatment dose is administered internally (e.g. intravenous or oral routes)rather from an external radiation source.The radiopharmaceuticals used in nuclear medicine therapy emit ionizing radiation that travels only a short distance,thereby minimizing unwanted side effects and damage to noninvolved organs or nearby structures. Most nuclearmedicine therapies can be performed as outpatient procedures since there are few side effects from the treatment andthe radiation exposure to the general public can be kept within a safe limit.Common nuclear medicine (unsealed source) therapies

Substance Condition

Iodine-131-sodium iodide hyperthyroidism and thyroid cancer

Yttrium-90-ibritumomab tiuxetan (Zevalin) and Iodine-131-tositumomab (Bexxar) refractory lymphoma

131I-MIBG (metaiodobenzylguanidine) neuroendocrine tumors

Samarium-153 or Strontium-89 palliative bone pain treatment

In some centers the nuclear medicine department may also use implanted capsules of isotopes (brachytherapy) totreat cancer.Commonly used radiation sources (radionuclides) for brachytherapy[9]

Nuclear medicine 6

Radionuclide Type Half-life Energy

Caesium-137 (137Cs) -ray 30.17 years 0.662 MeV

Cobalt-60 (60Co) -ray 5.26 years 1.17, 1.33 MeV

Iridium-192 (192Ir) --particles 73.8 days 0.38 MeV (mean)

Iodine-125 (125I) -rays 59.6 days 27.4, 31.4 and 35.5 keV

Palladium-103 (103Pd) -ray 17.0 days 21 keV (mean)

Ruthenium-106 (106Ru) --particles 1.02 years 3.54 MeV

HistoryThe history of nuclear medicine is rich with contributions from gifted scientists across different disciplines inphysics, chemistry, engineering, and medicine. The multidisciplinary nature of nuclear medicine makes it difficultfor medical historians to determine the birthdate of nuclear medicine. This can probably be best placed between thediscovery of artificial radioactivity in 1934 and the production of radionuclides by Oak Ridge National Laboratoryfor medicine related use, in 1946.[10]

The origins of this medical idea date back as far as the mid-1920s in Freiburg, Germany, when George de Hevesymade experiments with radionuclides administered to rats, thus displaying metabolic pathways of these substancesand establishing the tracer principle. Possibly, the genesis of this medical field took place in 1936, when JohnLawrence, known as "the father of nuclear medicine", took a leave of absence from his faculty position at YaleMedical School, to visit his brother Ernest Lawrence at his new radiation laboratory (now known as the LawrenceBerkeley National Laboratory) in Berkeley, California. Later on, John Lawrence made the first application inpatients of an artificial radionuclide when he used phosphorus-32 to treat leukemia.[11][12]

Many historians consider the discovery of artificially produced radionuclides by Frdric Joliot-Curie and IrneJoliot-Curie in 1934 as the most significant milestone in nuclear medicine. In February 1934, they reported the firstartificial production of radioactive material in the journal Nature, after discovering radioactivity in aluminum foilthat was irradiated with a polonium preparation. Their work built upon earlier discoveries by Wilhelm KonradRoentgen for X-ray, Henri Becquerel for radioactive uranium salts, and Marie Curie (mother of Irne Curie) forradioactive thorium, polonium and coining the term "radioactivity." Taro Takemi studied the application of nuclearphysics to medicine in the 1930s. The history of nuclear medicine will not be complete without mentioning theseearly pioneers.Nuclear medicine gained public recognition as a potential specialty on December 7, 1946 when an article waspublished in the Journal of the American Medical Association by Sam Seidlin. The article described a successfultreatment of a patient with thyroid cancer metastases using radioiodine (I-131). This is considered by manyhistorians as the most important article ever published in nuclear medicine.[13] Although the earliest use of I-131 wasdevoted to therapy of thyroid cancer, its use was later expanded to include imaging of the thyroid gland,quantification of the thyroid function, and therapy for hyperthyroidism.Widespread clinical use of nuclear medicine began in the early 1950s, as knowledge expanded about radionuclides,detection of radioactivity, and using certain radionuclides to trace biochemical processes. Pioneering works byBenedict Cassen in developing the first rectilinear scanner and Hal O. Anger's scintillation camera (Anger camera)broadened the young discipline of nuclear medicine into a full-fledged medical imaging specialty.In these years of nuclear medicine, the growth was phenomenal. The Society of Nuclear Medicine was formed in 1954 in Spokane, Washington, USA. In 1960, the Society began publication of the Journal of Nuclear Medicine, the premier scientific journal for the discipline in America. There was a flurry of research and development of new

Nuclear medicine 7

radionuclides and radiopharmaceuticals for use with the imaging devices and for in-vitro studies5.Among many radionuclides that were discovered for medical-use, none were as important as the discovery anddevelopment of Technetium-99m. It was first discovered in 1937 by C. Perrier and E. Segre as an artificial elementto fill space number 43 in the Periodic Table. The development of a generator system to produce Technetium-99m inthe 1960s became a practical method for medical use. Today, Technetium-99m is the most utilized element innuclear medicine and is employed in a wide variety of nuclear medicine imaging studies.By the 1970s most organs of the body could be visualized using nuclear medicine procedures. In 1971, AmericanMedical Association officially recognized nuclear medicine as a medical specialty.[14] In 1972, the American Boardof Nuclear Medicine was established, and in 1974, the American Osteopathic Board of Nuclear Medicine wasestablished, cementing nuclear medicine as a stand-alone medical specialty.In the 1980s, radiopharmaceuticals were designed for use in diagnosis of heart disease. The development of singlephoton emission computed tomography (SPECT), around the same time, led to three-dimensional reconstruction ofthe heart and establishment of the field of nuclear cardiology.More recent developments in nuclear medicine include the invention of the first positron emission tomographyscanner (PET). The concept of emission and transmission tomography, later developed into single photon emissioncomputed tomography (SPECT), was introduced by David E. Kuhl and Roy Edwards in the late 1950s [citation needed].Their work led to the design and construction of several tomographic instruments at the University of Pennsylvania.Tomographic imaging techniques were further developed at the Washington University School of Medicine. Theseinnovations led to fusion imaging with SPECT and CT by Bruce Hasegawa from University of California SanFrancisco (UCSF), and the first PET/CT prototype by D. W. Townsend from University of Pittsburgh in 1998 [citationneeded].PET and PET/CT imaging experienced slower growth in its early years owing to the cost of the modality and therequirement for an on-site or nearby cyclotron. However, an administrative decision to approve medicalreimbursement of limited PET and PET/CT applications in oncology has led to phenomenal growth and widespreadacceptance over the last few years, which also was facilitated by establishing 18F-labelled tracers for standardprocedures, allowing work at non-cyclotron-equipped sites. PET/CT imaging is now an integral part of oncology fordiagnosis, staging and treatment monitoring. A fully integrated MRI/PET scanner is on the market from early2011.[citation needed]

Source of radionuclides, with notes on a few radiopharmaceuticalsAbout a third of the world's supply, and most of North America's supply, of medical isotopes are produced at theChalk River Laboratories in Chalk River, Ontario, Canada. (Another third of the world's supply, and most ofEurope's supply, are produced at the Petten nuclear reactor in the Netherlands.) The Canadian Nuclear SafetyCommission ordered the NRU reactor to be shut down on November 18, 2007 for regularly scheduled maintenanceand an upgrade of the safety systems to modern standards. The upgrade took longer than expected and in December2007, a critical shortage of medical isotopes occurred. The Canadian government unanimously passed emergencylegislation, allowing the reactor to restart on 16 December 2007, and production of medical isotopes to continue.The Chalk River reactor is used to irradiate materials with neutrons which are produced in great quantity during thefission of U-235. These neutrons change the nucleus of the irradiated material by adding a neutron, or by splitting itin the process of nuclear fission. In a reactor, one of the fission products of uranium is molybdenum-99 which isextracted and shipped to radiopharmaceutical houses all over North America. The Mo-99 radioactively beta decayswith a half-life of 2.7 days, turning initially into Tc-99m, which is then extracted (milked) from a "moly cow" (seetechnetium-99m generator). The Tc-99m then further decays, while inside a patient, releasing a gamma photonwhich is detected by the gamma camera. It decays to its ground state of Tc-99, which is relatively non-radioactivecompared to Tc-99m.

Nuclear medicine 8

The most commonly used radioisotope in PET F-18, is not produced in any nuclear reactor, but rather in a circularaccelerator called a cyclotron. The cyclotron is used to accelerate protons to bombard the stable heavy isotope ofoxygen O-18. The O-18 constitutes about 0.20% of ordinary oxygen (mostly O-16), from which it is extracted. TheF-18 is then typically used to make FDG (see this link for more information on this process).

Common isotopes used in nuclear medicine

isotope symbol Z T1/2

decay gamma (keV) positron (keV)

Imaging:

fluorine-18 18F 9 109.77 m + 511 (193%) 249.8 (97%)[15]

gallium-67 67Ga 31 3.26 d ec 93 (39%),185 (21%),300 (17%)

-

krypton-81m 81mKr 36 13.1 s IT 190 (68%) -

rubidium-82 82Rb 37 1.27 m + 511 (191%) 3.379 (95%)

nitrogen-13 13N 7 9.97 m + 511 (200%) 1190 (100%)[16]

technetium-99m 99mTc 43 6.01 h IT 140 (89%) -

indium-111 111In 49 2.80 d ec 171 (90%),245 (94%)

-

iodine-123 123I 53 13.3 h ec 159 (83%) -

xenon-133 133Xe 54 5.24 d - 81 (31%) 0.364 (99%)

thallium-201 201Tl 81 3.04 d ec 6983*

(94%),167 (10%)

-

Therapy:

yttrium-90 90Y 39 2.67 d - - 2.280 (100%)

iodine-131 131I 53 8.02 d - 364 (81%) 0.807 (100%)

Z = atomic number, the number of protons; T1/2 = half-life; decay = mode of decayphotons = principle photon energies in kilo-electron volts, keV, (abundance/decay) = beta maximum energy in mega-electron volts, MeV, (abundance/decay)+ = + decay; - = - decay; IT = isomeric transition; ec = electron capture* X-rays from progeny, mercury, Hg

A typical nuclear medicine study involves administration of a radionuclide into the body by intravenous injection inliquid or aggregate form, ingestion while combined with food, inhalation as a gas or aerosol, or rarely, injection of aradionuclide that has undergone micro-encapsulation. Some studies require the labeling of a patient's own blood cellswith a radionuclide (leukocyte scintigraphy and red blood cell scintigraphy). Most diagnostic radionuclides emitgamma rays, while the cell-damaging properties of beta particles are used in therapeutic applications. Refinedradionuclides for use in nuclear medicine are derived from fission or fusion processes in nuclear reactors, whichproduce radionuclides with longer half-lives, or cyclotrons, which produce radionuclides with shorter half-lives, ortake advantage of natural decay processes in dedicated generators, i.e. molybdenum/technetium orstrontium/rubidium.The most commonly used intravenous radionuclides are: Technetium-99m (technetium-99m)

Nuclear medicine 9

Iodine-123 and 131 Thallium-201 Gallium-67 Fluorine-18 Fluorodeoxyglucose Indium-111 Labeled LeukocytesThe most commonly used gaseous/aerosol radionuclides are: Xenon-133 Krypton-81m Technetium-99m Technegas [17]Wikipedia:Link rot a radioaerosol invented in Australia by Dr Bill Burch and Dr

Richard Fawdry Technetium-99m DTPA

Radiation doseA patient undergoing a nuclear medicine procedure will receive a radiation dose. Under present internationalguidelines it is assumed that any radiation dose, however small, presents a risk. The radiation doses delivered to apatient in a nuclear medicine investigation, though unproven, is generally accepted to present a very small risk ofinducing cancer. In this respect it is similar to the risk from X-ray investigations except that the dose is deliveredinternally rather than from an external source such as an X-ray machine, and dosage amounts are typicallysignificantly higher than those of X-rays.The radiation dose from a nuclear medicine investigation is expressed as an effective dose with units of sieverts(usually given in millisieverts, mSv). The effective dose resulting from an investigation is influenced by the amountof radioactivity administered in megabecquerels (MBq), the physical properties of the radiopharmaceutical used, itsdistribution in the body and its rate of clearance from the body.Effective doses can range from 6 Sv (0.006 mSv) for a 3 MBq chromium-51 EDTA measurement of glomerularfiltration rate to 37 mSv (37,000 Sv) for a 150 MBq thallium-201 non-specific tumour imaging procedure. Thecommon bone scan with 600 MBq of technetium-99m-MDP has an effective dose of approximately 3.5 mSv (3,500Sv) (1).Formerly, units of measurement were the curie (Ci), being 3.7E10 Bq, and also 1.0 grams of Radium (Ra-226); therad (radiation absorbed dose), now replaced by the gray; and the rem (Rntgen equivalent man), now replaced withthe sievert. The rad and rem are essentially equivalent for almost all nuclear medicine procedures, and only alpharadiation will produce a higher Rem or Sv value, due to its much higher Relative Biological Effectiveness (RBE).Alpha emitters are nowadays rarely used in nuclear medicine, but were used extensively before the advent of nuclearreactor and accelerator produced radionuclides. The concepts involved in radiation exposure to humans are coveredby the field of Health Physics.

ReferencesNotes

[1] http:/ / www. icd10data. com/ ICD10PCS/ Codes/ C[2] http:/ / icd9cm. chrisendres. com/ index. php?srchtype=procs& srchtext=92& Submit=Search& action=search[3] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D009683[4] http:/ / ops. icd-code. de/ ops/ code/ 3-70. html[5] http:/ / ops. icd-code. de/ ops/ code/ 3-72. html[6] http:/ / ops. icd-code. de/ ops/ code/ 8-53. html[7] http:/ / www. molecularimagingcenter. org, Gambhir S. Just what is molecular medicine.[8] thefreedictionary.com > scintigraphy (http:/ / medical-dictionary. thefreedictionary. com/ scintigraphy) Citing: Dorland's Medical Dictionary

for Health Consumers, 2007 by Saunders; Saunders Comprehensive Veterinary Dictionary, 3 ed. 2007; McGraw-Hill Concise Dictionary ofModern Medicine, 2002 by The McGraw-Hill Companies

Nuclear medicine 10

[9] Nuclear Wallet Cards (http:/ / www. nndc. bnl. gov/ wallet/ wc7. html)[10] Edwards Cl: Tumor localizing radionuclides in retrospect and prospect. Semin Nucl Med 3:186189, 1979.[11] Donner Laboratory: The Birthplace of. Nuclear Medicine (http:/ / jnm. snmjournals. org/ content/ 40/ 1/ 16N. full. pdf)[12] Important Moments in the History of Nuclear Medicine (http:/ / interactive. snm. org/ index. cfm?PageID=1107)[13][13] Henkin R. et al: Nuclear Medicine. First edition 1996. ISBN 978-0-8016-7701-4.[14] http:/ / interactive. snm. org/ docs/ whatisnucmed. pdf from the Society of Nuclear Medicine.[15] Sodium Fluoride F 18 Injection Drug Label (http:/ / dailymed. nlm. nih. gov/ dailymed/ archives/ fdaDrugInfo. cfm?archiveid=43688)[16] N-13 Ammonia prescribing information (Drugs.com) (http:/ / www. drugs. com/ pro/ ammonia-n-13. html)[17] http:/ / jcsmr. anu. edu. au/ technegas/ home. html

Further reading

Mas JC: A Patient's Guide to Nuclear Medicine Procedures: English-Spanish. Society of Nuclear Medicine, 2008.ISBN 978-0-9726478-9-2

Taylor A, Schuster DM, Naomi Alazraki N: A Clinicians' Guide to Nuclear Medicine, 2nd edition. Society ofNuclear Medicine, 2000. ISBN 978-0-932004-72-7

Mark J. Shumate MJ, Kooby DA, Alazraki NP: A Clinician's Guide to Nuclear Oncology: Practical MolecularImaging and Radionuclide Therapies. Society of Nuclear Medicine, January 2007. ISBN 978-0-9726478-8-5

Ell P, Gambhir S: Nuclear Medicine in Clinical Diagnosis and Treatment. Churchill Livingstone, 2004. (1950pages) ISBN 978-0-443-07312-0

External links Nuclear medicine (http:/ / www. dmoz. org/ Health/ Medicine/ Medical_Specialties/ Nuclear_Medicine/ / ) on the

Open Directory Project The Nuclear Medicine and Molecular Medicine Podcast (http:/ / molcast. com) Keyword Search on Nuclear Medicine at the United States Department of Labor (US DOL) Occupational

Information Network (O*NET) database (http:/ / www. onetonline. org/ find/ quick?s=Nuclear+ Medicine) -Shows several occupational categories where people may use nuclear medicine technologies in their work. Linkedoccupation summaries include information about work and worker characteristics, updated using aggregate levelinput from people who have performed this work.

Solving the Medical Isotope Crisis (http:/ / purl. fdlp. gov/ GPO/ gpo28578) Hearing before the Subcommittee onEnergy and Environment of the Committee on Energy and Commerce, House of Representatives, One HundredEleventh Congress, First Session, September 9, 2009

Library resources aboutNuclear medicine

Resources in your library (http:/ / tools. wmflabs. org/ ftl/ cgi-bin/ ftl?st=wp& su=Nuclear+ medicine)

Article Sources and Contributors 11

Article Sources and ContributorsNuclear medicine Source: http://en.wikipedia.org/w/index.php?oldid=591836570 Contributors: ABF, APH, Acdx, Acrabb, Acroterion, AdamJ-TRX, AdjustShift, AjAldous, Alansohn,Alex.tan, Alistair1978, Altenmann, AndreasJS, Andrel, Anypodetos, Arcadian, ArcadianOnUnsecuredLoc, Arostron, Art LaPella, Ashleyleia, Axeman89, Barlow, Bazzel, Beavertank,Benjaminevans82, Beyond My Ken, Blai40, Blanchardb, Bobblewik, Bogey97, Boing! said Zebedee, BrightStarSky, Brimcmike, Brookie, Btyner, Bumm13, BusterNutBag, CWenger, Calvin1998, Camonaghan, CanadianLinuxUser, Captain Zyrain, Centrx, ChillyMD, Chowbok, CiaPan, Clicketyclack, Cnort59, Colonies Chris, Csblackburn, Csutric, Ctande, Cyfal, DV8 2XL, Damato,DanMS, Daveswagon, DavidLeighEllis, Davidruben, Deagle AP, Delaroyas, Dgw, Diberri, Dirac66, Discospinster, Disenraged, Download, Dozenne, DrFO.Jr.Tn, Drbreznjev, Drilnoth,Dspradau, Dwayne Reed, ESkog, Edward, Eiland, Elassint, Elockid, Enderwiki, Epbr123, EpicDream86, Eth4n, Evil Monkey, Fizzy, Fnielsen, Formol, Frickeg, Galoubet, GangofOne, Gilliam,Good Olfactory, GraemeL, HowardJWilk, II MusLiM HyBRiD II, IOPhysics, Igoldste, Iorsh, J.delanoy, Jagged 85, Jamesofur, Jennifergr, Jerry, Jfdwolff, Jjkusaf, Jmjanzen, Jncraton, Joel7687,Josve05a, Jrtayloriv, JustAGal, Keereann, Khatriaditya, Kirachinmoku, Kubanczyk, Kyng, LMB, Laurens-af, Lb.at.wiki, Lcolson, Leafyplant, Leszek Jaczuk, Levent, Li4kata, Librsh, Limnalid,LittleWink, Luckyz, Luna Santin, Lyoel, MER-C, MacsBug, Madhero88, Mallyest, Mco44, Meelar, Mefanch, Mercurous, Mikael Hggstrm, Mikespedia, Mild Bill Hiccup, Mion, Muv4zqlvc3,Myasuda, Mygerardromance, Myohan, Nen, NickW557, Nihiltres, Nukemedsb, Oldnoah, OohBunnies!, Orhan94, Ottawakismet, Paulc206, PeteVerdon, Peter Horn, PloniAlmoni, Possum,Profplum27, Quinlan Vos, Ratman90, Raven in Orbit, RazorICE, Rl, Robcw, Robertvan1, Rod57, Ronhjones, RoyBoy, Rsabbatini, SBaker43, SKvalen, SWAdair, Saimhe, Salvadorjo, Saric,Sbharris, Sceptre, SchreiberBike, Semperf, Sfan00 IMG, Shadowjams, Sherool, Shmeeninja, Simesa, Simonbayly, Social Climber, Some jerk on the Internet, SpecMode, SriMesh, Stephenb,Stepped, Suffusion of Yellow, Tcb0667, Tekks, Th4n3r, Thatguyflint, Thomasneilp, Thumperward, Tide rolls, Tmarlow, Tommy2010, Tony46, Torres Carlos M, Treaclecustard, Treuss,TylerDurden8823, Ultimus, Uncle Dick, Vchorozopoulos, Venu62, Wasbeer, Wasted Sapience, Wavelength, Woohookitty, Wouterstomp, Xrayburst1, YUL89YYZ, Yoderj, Zereshk, ,431 anonymous edits

Image Sources, Licenses and ContributorsFile:Nl bone scan2.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Nl_bone_scan2.jpg License: Creative Commons Attribution 3.0 Contributors: HellerhoffFile:nl mpi2.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Nl_mpi2.jpg License: Creative Commons Attribution 3.0 Contributors: MyohanFile:parathyroid subtraction.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Parathyroid_subtraction.jpg License: Creative Commons Attribution 3.0 Contributors: -File:HIDA.jpg Source: http://en.wikipedia.org/w/index.php?title=File:HIDA.jpg License: Creative Commons Attribution 3.0 Contributors: Hellerhoff, Magog the Ogre, Senator2029File:ventperf.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Ventperf.jpg License: Creative Commons Attribution 3.0 Contributors: Hellerhoff, Senator2029File:thyroid scan.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Thyroid_scan.jpg License: Creative Commons Attribution 3.0 Contributors: HellerhoffFile:hemangioma scan.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Hemangioma_scan.jpg License: Creative Commons Attribution 3.0 Contributors: MyohanFile:PET-MIPS-anim.gif Source: http://en.wikipedia.org/w/index.php?title=File:PET-MIPS-anim.gif License: Public Domain Contributors: Jens Langner (http://www.jens-langner.de/)File:Iodine wb scan.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Iodine_wb_scan.jpg License: Creative Commons Attribution 3.0 Contributors: MyohanFile:nl petct.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Nl_petct.jpg License: Creative Commons Attribution 3.0 Contributors: Verne EquinoxFile:abnl petct.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Abnl_petct.jpg License: Creative Commons Attribution 3.0 Contributors: User:Myohan

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Nuclear medicineDiagnostic medical imaging DiagnosticHybrid scanning techniques Practical concerns in nuclear imaging Analysis

Interventional nuclear medicineHistory Source of radionuclides, with notes on a few radiopharmaceuticals Radiation doseReferencesExternal links

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