An 83-year-old man was diagnosed with midventricular obstructive hypertrophic cardiomyopathy (MVOHCM) 8 years previously but had no symptoms. Onset of ventricular tachycardia (VT) caused him to lose consciousness 6 months previously, after which an implantable cardioverter defibrillator (ICD) was implanted. However, he continued to experience loss of consciousness due to fever, but there was no evidence of arrhythmia. Therefore, we considered left ventricular obstruction to be the cause of the symptoms and decided to perform echocardiography. The left ventricular pressure gradient (LVPG) was 16mmHg at rest, but it increased to 47mmHg with provocation with nitroglycerin loading. Right ventricular apex pacing decreased the LVPG to 9 mmHg. To optimize the atrioventricular (AV) delay, we evaluated hemodynamics while changing the setting time, and decided the optimal time was 100 msec because hemodynamics improved best at that time. Monitoring hemodynamics using echocardiography was useful for clarifying the efficacy of pacing therapy for MVOHCM and to optimize AV delay.

Purpose: The aim of this study was to verify the utility of second-look ultrasound (US) using real-time virtual sonography(RVS), a magnetic resonance imaging (MRI)/US fusion technique, in identifying MRI-detected breast lesions with non-mass enhancement (NME). Methods: Consecutive patients who had one or more NME lesions detected by MRI yet occult on the subsequent second-look US in conventional B (cB)-mode imaging were enrolled in the study between June 2015 and April 2020. Supine MRI of the lesions was performed and, using its data, second-look US using RVS was performed. Results: Twenty patients with 21 NME lesions were included. The overall median lesion size on prone MRI was 23 mm(range, 5-63 mm). Supine MRI identified all the 21 NME lesions, and second-look US using RVS successfully detected 18(86％) of them. RVS-guided biopsy was performed for histopathological evaluation, showing that nine of the 18 lesions were benign and the other nine malignant. Of the nine malignant lesions, two (22％) were invasive cancer and seven (78％) were ductal carcinoma in situ. In four of five patients who underwent prone MRI for preoperative evaluation, the diagnosis was benign and surgery was conducted as originally planned. In the other patient, the diagnosis was malignant and contralateral breast-conserving surgery was added. Three (14％) of the 21 NME lesions had no RVS correlates and were judged to be benign after 24-month follow-up. Conclusion: The results suggest that second-look US using RVS helps identify MRI-detected NME lesions that are occult on cB-mode second-look US.

Purpose: Although endoscopic ultrasound (EUS) has been widely used for diagnosing chronic pancreatitis (CP), the assessment of fibrosis using the Rosemont criteria (RC) is generally subjective. Shear wave elastography using EUS (EUS-SWE) has been advocated as an objective approach to evaluating pancreatic fibrosis; however, it is unknown which pancreatic region should be selected for measurement. This study aims to compare the diagnostic accuracy in diagnosing CP by measurement site. Methods: Fifty patients with CP or suspected CP who underwent EUS-SWE were retrospectively analyzed. As per the RC, they were classified into two groups: CP and non-CP. Pancreatic stiffness was evaluated by measuring the velocities of the shear wave (Vs) in addition to determining the relevant cutoff value of Vs for diagnosing CP. The correlation between Vs and RC, and the RC factors affecting pancreatic stiffness were evaluated. Results: In the CP group, the Vs were notably higher in all regions (P < 0.001). The Vs for diagnostic accuracy of CP were highest in the body ［area under the curve (AUC): 0.87］. A significant correlation was seen between the number of RC and Vsin all regions, with the correlation coefficient being highest in the pancreatic body (rs = 0.55). Multivariate analysis revealedthat lobularity with honeycombing was an independent factor for pancreatic stiffness (P = 0.02). Conclusion: The pancreatic body is a suitable region for assessing pancreatic stiffness using EUS-SWE. Additionally, quantifying Vs is a valuable objective indicator for diagnosing CP.

“Panic Findings: Abnormal Findings Requiring Urgent Action” in ultrasonography was published by the Japanese Society of Ultrasound in Medicine. We herein explain the key points of ultrasound panic findings in the urological region. “Urgent findings” in the urological region include fluid retention in the retroperitoneal cavity with internal echogenic spots, caused by renal trauma or rupture of renal tumor, etc. Due to the anatomical characteristics of the kidney being in the retroperitoneum and surrounded by Gerota’s fascia, the mortality rate without immediate treatment is low. By checking ultrasound findings along with vital signs, it is likely that in many cases a urological finding can be treated as a “semi-urgent finding”. There are two “semi-urgent findings” in the urological region. One is dilation of both renal pelvises (calyxes). Extrarenal dilation, where only the renal pelvis is dilated, does not need to be considered a panic finding. If one kidney is non-functioning, dilation of the contralateral renal pelvis and calyx is also a panic finding. The other “semi-urgent finding” is a mass lesion (fluid collection with internal echo) accompanied by fever or tenderness. In renal infection accompanied by fever and tenderness, along with a mass (fluid collection with internal echo), intrarenal emphysema, or renal pelvic distention with debris, is considered a “semi-urgent finding.”

When performing ultrasonography (US) on patients with acute abdomen, it is efficient and useful to rule out more urgent diseases while paying attention to the patients’ response and exacerbation in vital signs first, then screen for more frequent diseases as speculated based on abdominal symptoms, age, and sex. The “Panic Findings: Abnormal Findings Requiring Urgent Action” (panic findings) presented by the Japan Society of Ultrasonics in Medicine classifies abnormal findings in US that should be reported immediately into three groups: 1) “Urgent findings” requiring immediate action, 2) “Semi-urgent findings” requiring prompt action, and 3) “Abnormal findings” requiring early action. “Urgent findings” related to the hepatobiliary-pancreatic region include peritoneal/retroperitoneal fluid collection with debris echo, corresponding to intra-abdominal bleeding, organ damage, and rupture of tumors such as hepatocellular carcinoma. On the other hand, “semi-emergent findings” include multiple solid mass lesions or cluster signs (multiple liver metastases), liver mass lesions with fever and tenderness (liver abscess), extrahepatic bile duct dilation with fever (acute cholangitis), intrahepatic bile duct dilation (obstructive jaundice), enlarged gallbladder with fluid retention (acute cholecystitis), and enlarged pancreas with fluid retention (acute pancreatitis). These panic findings will enable rapid and reliable screening for emergency illness in patients with acute abdomen, which will prevent sudden deterioration of the patients’ condition (death) and contribute to improving the prognosis of emergency patients.

Gynecological disorders are included in the differential diagnosis of acute abdomen. In particular, gynecological disorders such as ectopic pregnancies, ovarian hemorrhage, and torsion of ovarian tumor can remain asymptomatic but can become serious if they progress, so caution is required. It is important to understand the characteristics of these diseases and the signs that should not be overlooked.

“Panic findings” are abnormal observations that may pose a life-threatening risk, requiring an appropriate response. According to the guidelines issued by the Japan Society of Ultrasonics in Medicine in November 2023, panic findings should not merely be considered abnormal observations but should function as an integral part of an emergency response system established by each facility. Ultrasound examinations are often performed by sonographers, who must remain composed when encountering abnormal findings. Echocardiographic examinations are particularly critical as they can detect life-threatening cardiac abnormalities, necessitating immediate action upon identifying a panic finding. Before the examination, it is essential to understand the request and review the latest information, such as the ECG. When a panic finding is discovered, if the patient exhibits symptoms or hemodynamic abnormalities, the sonographer should immediately contact a physician. If the patient is asymptomatic and hemodynamically stable, it is advisable to compare the current findings with previous results to determine the appropriate response. Diseases requiring immediate response/reporting include acute coronary syndrome, cardiac tamponade, acute aortic dissection, acute pulmonary embolism, intracardiac thrombus, cardiac tumors, infective endocarditis, ventricular septal rupture, pseudoaneurysm, papillary muscle or chordae tendineae rupture with acute severe mitral regurgitation, left ventricular outflow tract obstruction, and severe arrhythmias. Diseases requiring prompt reporting include prosthetic valve dysfunction, new onset or acute exacerbation of heart failure, and newly discovered severe valvular disease. In the case of cardiovascular diseases, timely intervention significantly impacts patient outcomes. The panic finding system is crucial for ensuring patient safety, and each facility must establish a system tailored to its specific circumstances.