Ultrasonic diagnostic methods have come into wide use even among an enormous number of small-sized medical facilities distributed widely across Japan. Therefore, there is a significant difference in the method of examination and the interpretation of the findings among medical facilities and among the examiners. With a view to enhancing the quality of community medicine by overcoming these problems, it is important to standardize diagnostic techniques among the facilities and examiners. For that purpose, guidelines and recommendations published by medical associations should be utilized after being customized according to the needs of each facility. Additionally, quality control of a facility’s testing system and the diagnostic capability of examiners is also necessary. Of various issues related to the standardization and quality control to be addressed, ultrasonography-related multi-tiered educational activities in the community are of particular importance. In this article, I intend to raise the issues related to the standardization of ultrasound diagnosis.

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Although echocardiography has been performed in many institutions, differences between institutions in echocardiographic diagnosis need to be addressed. For example, there is a difference in the implementation rate depending on the measurement item in Hokkaido Prefecture. To achieve better examinations, the expertise of the examiner, securing a sufficient number of examiners and time allocated for echocardiography, and the presence of a cardiovascular specialist who can be consulted are necessary. Standardization of measurement items and measurement methods plays a big role. Determining measurement items is a difficult problem, but it is desirable to standardize echocardiography to aim for uniform treatment policies based on echocardiographic findings. In order to maintain the knowledge level and technical level of examiners, education and training in a way that does not create regional disparities are necessary. Organized efforts are also desired for examiners at institutions that do not have cardiovascular specialists who can be consulted.

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The prognosis of congenital heart disease has dramatically improved due to advances in fetal diagnosis and improvement of surgical outcomes. Therefore, the number of patients with adult congenital heart disease now exceeds 400,000 (There are approximately 1.7 million patients with adult cardiovascular diseases.), nearly surpassing the number of pediatric patients. In contrast, pediatric cardiology specialists certified by the Japanese Pediatric Cardiology and Cardiovascular Surgery Society number about 500 people, which is a surprisingly small number compared with the approximately 13,500 specialists certified by the Japanese Circulation Society. Therefore, transition of patients with adult congenital heart disease to adult cardiovascular medical care will proceed inevitably. Under such circumstances, it is obvious that it is greatly harmful in clinical practice that echocardiography measurement is quite different between the fields of pediatric cardiology and adult cardiology. For example, in the case of measurement of left ventricular systolic function, it is common for left ventricular (LV) fractional shortening (FS) to be obtained from M-mode of the left ventricular short axis view, and then the LV ejection fraction (EF) calculated from Teichholz, etc., in pediatric cases. The reason why the biplane EF method is not used in children is that, first, there is little thought given to obtaining a four-chamber view including a true apex, resulting in unfamiliarity with obtaining an accurate four-chamber view; second, it is sometimes impossible to obtain a two-chamber view covered by the lungs, because the children usually cannot stop breathing when instructed. On the other hand, neither the pediatrician nor the cardiovascular physician has the deterministic methodology for measurement of right ventricular systolic function. Biplane EF cannot be used in the right ventricle because of its morphological complexity, and right ventricular FS in the short axis section cannot be applied. With regard to diastolic function, in childhood it changes dramatically at the developmental stage. Normal values of E wave, A wave, and early diastolic mitral annulus velocity (E′) itself are different, so it is not possible to simply use the same diastolic parameters for adults. Under these circumstances, taking into consideration changes in ventricular morphology and diastolic function at the developmental and aging stages, we should investigate standardized indices for systolic and diastolic function that can be used in both children and adults. Furthermore, how to spread awareness of standardization will be a crucial problem. In this chapter, we will present specific problems at present and explore what solutions are available.

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Vascular ultrasonography is widely used in routine clinical practice today to address needs in various fields. Various issues are thought to be common to all areas of vascular ultrasonography, including equipment problems, examiner problems, and interpretation problems. The visualization performance of equipment has improved significantly, but there are problems with objectivity and differences in how images appear depending on a machine’s internal software. Between institutions, as well, there are concerns about different equipment and differences in test procedures depending on the doctor and technician supervising the vascular ultrasonography, the items thought to be necessary in the procedure, and the interpretation in making a diagnosis. To minimize differences between institutions, an educational system with a uniform purpose is needed for examiners, and their level of proficiency with the equipment needs to be increased. The interpretation of findings also needs to be evidence-based. Standard evaluation methods are a promising tool for uniformity.

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Abdominal ultrasound examinations are noninvasive and relatively easy to perform. Therefore, they are widely used for voluntary clinical screenings. However, there are no clear regulations or standardized examination criteria for such examinations. To achieve inter-facility standardization, all procedures must be evaluated objectively, following the same guidelines and diagnostic criteria. In 2014, the Manual for Abdominal Ultrasound in Cancer Screening and Health Checkups was created. This is a standardized manual used by the Japan Society of Ultrasonics in Medicine, the Japanese Society of Gastrointestinal Cancer Screening, and the Japan Society of Ningen Dock. In the same year, the National Federation of Industrial Health Organization began a survey on abdominal ultrasound accuracy control. Wide use of the manual will improve testing conditions and help in standardizing criteria, which should enhance the accuracy of abdominal ultrasound screenings. Implementing third-party accuracy control and undergoing objective evaluations will also contribute to enhancing the accuracy of the screenings. This report summarizes the current status of abdominal ultrasound screening and discusses the challenges faced in its standardization.

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Ultrasonic diagnosis is superior in terms of convenience and minimal invasiveness; therefore, its use has become widespread irrespective of the disease or age group, and unique diagnostic systems have emerged in each field. Ultrasonic diagnosis, which was once the exclusive patent of a single doctor, has also become widespread among laboratory technicians as diagnostic systems advance, and it has enabled remote real-time ultrasonic diagnosis. Thus, use of ultrasonic diagnosis may spread more and more in the future, beyond occupational categories and areas. On the other hand, in the process of sharing ultrasonic diagnosis, we encounter various differences in imaging methods, measurement methods, and reference ranges, etc. In recent years, in the era in which various fields have fused in an interdisciplinary, inter-institutional, and occupational manner, it is undeniable that it is necessary to aim for a certain standardization in ultrasonic diagnosis that has been developed independently. In this paper, we present problems and countermeasures discussed at the symposium on standardization of ultrasonic diagnosis between generations, institutions, and occupations, in the hope that it will serve as a resource for future standardization of ultrasonic diagnosis.

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Purpose: Fatal necrosis of the myocardium can be avoided by prompt reperfusion at the onset of myocardial ischemia. Therefore, rapid identification of the range and degree of the ischemic regions is essential for diagnosis and subsequent correct treatment in the early stage of ischemic heart disease. In this paper, the decrease in the propagation velocity of the myocardial contraction response after ischemia is detected quantitatively in several seconds by ultrasonic measurements in multiple swine hearts. Methods: Ultrasonic measurement was applied to the interventricular septum (IVS) of five open-chest swine under normal conditions. Ischemia in the IVS was then induced by avascularizing the left anterior descending (LAD) coronary artery, and ultrasonic measurement was applied to the ischemic IVS within several seconds. By applying the phased-tracking method to the acquisition RF signals under each condition, velocity waveforms with minute vibration were simultaneously obtained at about 3,000 points in the IVS. Moreover, using cross-correlation between the resultant vibration velocity waveform at each measurement point and that at the reference point, the propagation of the myocardial contraction response was visualized as spatial transition of the delay time. Results: In the IVS of five open-chest swine, the myocardial contraction response propagated from the basal side to the apical side. The propagation velocity was almost constant at 2.7±0.5 m/s under normal conditions. On the other hand, an approximately 31% decrease in the propagation velocity to 1.9±0.5 m/s was observed about 5 seconds after LAD avascularization. Furthermore, about 7 seconds after LAD avascularization, an approximately 50% decrease in the propagation velocity to 1.4±0.3 m/s was observed. Conclusion: In five swine, the propagation velocity of the myocardial contraction decreased by about 50% in about 7 seconds from a normal to ischemic state. This suggests that myocardial ischemic regions can be identified noninvasively by ultrasonic measurement.

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The possibility of estimating the culprit lesion on the basis of the radial artery resistance index (RI) was investigated in 38 subjects who underwent ultrasound-guided vascular access during the period from January 2014 to April 2017, and who had a brachial artery RI of >=0.60. Ten out of 11 patients with radial artery RI of >=0.60 exhibited occlusion due to stricture with a lumen of less than 1.5 mm near the arteriovenous fistula (AVF) anastomosis. Fourteen out of 27 patients with a radial artery RI of <0.60 exhibited occlusion due to stricture with a lumen of <=1.5 mm away from the anastomosis site, and in nine cases there was no stricture with a lumen of <=1.5 mm. Based on the present study, we believe that it is possible to estimate and examine abnormal findings (location) by verifying RI in both the brachial and radial arteries by ultrasound-guided vascular access.

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“Mimic breast cancer” involves irregularly shaped hypoechoic areas with Doppler flow signals suggesting invasive cancer on breast ultrasonography in one section view that are non-reproducible in others. The ultrasonographic features in four cases of mimic breast cancer are discussed. These findings may represent areas where a penetrating breast artery emerges through the mammary zone. The cancer-like appearance may be due to irregular mammary zone disconnection by the penetrating artery and perivascular fat tissue, and shadowing from arteries adjacent to the anterior mammary fascia. Such lesions may be interpreted as breast cancer by inexperienced examiners, and are associated with risk of vessel injury as a result of needle biopsy.

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A 9-month-old girl visited our hospital with intermittent colic, bloody diarrhea, and poor ingestion for 1 day. Abdominal ultrasound revealed concentric rings formed by multiple layers of bowel wall in the right lower quadrant compatible with an ileocolic intussusception. The patient subsequently underwent fluoroscopically guided hydrostatic reduction enema, which revealed an intraluminal filling defect in the proximal ascending colon. In spite of two procedures, the defect persisted and we performed surgical exploration. However, the intraoperative findings showed there was no evidence of intussusception, and a solid mass was palpated inside the cecum. In consideration of neoplastic lesions, ileocecal resection was performed. The mass was proven to be an edematous ileocecal valve without any neoplasm. To avoid unnecessary surgery, a prompt and appropriate diagnosis of intussusception is necessary, and ultrasound images play a crucial role. In our case, however, an edematous ileocecal valve mimicked an intussusception on ultrasound and post-reduction fluoroscopic images. In order to avoid a misdiagnosis, it is important to evaluate the stratification of the bowel wall carefully by ultrasound imaging.

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