The first edition of the guidelines for the use of ultrasound contrast agents was published in 2004, dealing with liver applications. The second edition of the guidelines in 2008 reflected changes in the available contrast agents and updated the guidelines for the liver, as well as implementing some nonliver applications. The third edition of the contrast-enhanced ultrasound (CEUS) guidelines was the joint World Federation for Ultrasound in Medicine and Biology-European Federation of Societies for Ultrasound in Medicine and Biology (WFUMB-EFSUMB) venture in conjunction with other regional US societies such as Asian Federation of Societies for Ultrasound in Medicine and Biology, resulting in a simultaneous duplicate on liver CEUS in the official journals of both WFUMB and EFSUMB in 2013. However, no guidelines were described mainly for Sonazoid due to limited clinical experience only in Japan and Korea. The new proposed consensus statements and recommendations provide general advice on the use of Sonazoid and are intended to create standard protocols for the use and administration of Sonazoid in hepatic and pancreatobiliary applications in Asian patients and to improve patient management.

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Background: Based on the histological confirmation of the presence of nerve structure in the fascia, hence, myofascial pain was treated by the mechanism referred to as interfascial block. To date, the studies of physiological saline for treating patients with myofascial pain has been limited. Ultrasound (US) guided with physiological saline injection (PSI) technique has been routinely practiced among patients with myofascial pain in outpatient service at the Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital. The main objective of this present study is to find the overview data including the percentage of patients responding, acceptable pain period, and adverse events. Materials and Methods: Electronic medical reports among 142 patients receiving US-guided PSI from August 1, 2016, to November 20, 2017, at the Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital, were retrospectively reviewed by the first author. Procedures were performed by the last author. The analysis was independently performed by the first author. Results: One hundred and forty-two patients with complete medical records were compatible with analysis. The average age of patients was 55 years. Most of the patients were female (68.3%). Most of the patients (76.8%) had chronic suffering from myofascial pain. Approximately half of the patients (56.4%) are currently received pain-relieving medications. Upper trapezius muscle (19.5%) was the most common muscle receiving the procedure, followed by multifidus (10.0%) and quadratus lumborum (9.5%). Most of the patients (86.8%) received the procedure one muscle. Approximately 30% of the patients were able to stop pain-relieving medications after the procedure. The median of acceptable pain period was 63 days. The percentage of patients having an acceptable pain period >3 months was 43.9%. No major adverse events were demonstrated. Conclusion: US-guided PSI technique demonstrated pain reduction in 72.8% of the analyzed patients, with an acceptable pain period of 63 days. No major adverse events were demonstrated among all the patients. This technique should be considered as another invasive procedure for eradication myofascial trigger point.

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Background: The purpose of this study was to evaluate the usefulness of strain elastography and acoustic radiation force impulse (ARFI) imaging in the differentiation of benign and malignant cervical lymph nodes (LNs). Materials and Methods: In this prospective study, 50 enlarged cervical LNs (33 benign and 17 malignant) were examined by B-mode ultrasound (US), color Doppler, and strain elastography. Elastographic patterns (1–5) were categorized based on distribution of hard area within LN. The shear wave velocity (SWV) of LNs was evaluated by ARFI imaging. Diagnostic performance of sonoelastographic parameters was compared taking histopathology of LN as a reference standard. Optimal cutoff value of the mean SWV values for predicting malignancy was determined using receiver operating characteristic curve analysis. Results: Among US parameters, borders of LN had the highest diagnostic accuracy (80%), while echogenicity had the least (48%). Majority of benign LNs (n = 31) had elastography patterns 1 and 2, while majority of malignant LNs (n = 16) had patterns 3–5 (P = 0.000). The sensitivity, specificity, and accuracy of elastography were 94.1%, 93.9%, and 94%, respectively. The mean SWV of benign LNs (1.670 ± 0.367 m/s) differed significantly from malignant LNs (2.965 ± 0.826 m/s; P = 0.000). A cutoff value of 2.05 m/s predicted malignancy with 88.2% sensitivity and 84.8% specificity and gave an area under the curve of 0.949 (95% confidence interval: 0.70–1.20). Conclusion: Elastography has high diagnostic accuracy in differentiating benign and malignant cervical LNs and can be potentially useful in selecting the LN with high probability of malignancy, on which fine-needle aspiration cytology/biopsy can be performed.

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Context: Ultrasound (US) is excellent for detection of hydronephrosis but has poor sensitivity for stone detection. In contrast, radiography of the kidney–ureter–bladder has better sensitivity for detection of stone but limited sensitivity for hydronephrosis detection. A combination of these two modalities may improve both sensitivity and specificity for the diagnosis of obstructive ureteric stone. Aims: This study aims to investigate the diagnostic accuracy of combined US with radiography for the diagnosis of obstructive ureteric stone in adult patients. Settings and Design: Retrospective study with retrospective data collection performed in a 1500-bed university hospital. Materials and Methods: A total of 90 patients were included. The electronic medical record, radiological reports, laboratory results, and patient management were extracted and analyzed. Statistical Analysis Used: The diagnostic performance of US, radiography, and combined US with radiography were calculated and compared. The computed tomography was used as diagnostic reference. Results: US alone had a sensitivity of 73.5%, specificity of 92.7%, and negative predictive value (NPV) of 74.5% for hydronephrosis. When US showed both ureteric stone and hydronephrosis, sensitivity dropped to 14.3% but specificity increased to 100%. Radiography alone had a sensitivity of 34.7%, specificity of 100%, and NPV of 56.2% for the detection of ureteric stone. Combining radiography with US raised the sensitivity for diagnosis of obstructive ureteric stone to 88% with a specificity of 93% and accuracy of 90%. Conclusions: Combined US with radiography was accurate for the diagnosis of obstructive ureteric stone in patients presenting with acute flank pain.

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Arterial pseudoaneurysms can develop secondary to a vessel injury, for example, an arterial line installation. We present a case of an 18-year-old female with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes syndrome who developed left radial artery and right brachial artery pseudoaneurysms secondary to arterial line placement and repeated blood draws, respectively. The ultrasonographic features of pulsating mass in connection with an artery and the yin-yang sign, combined with the patient's history, allowed accurate diagnosis. She was referred to vascular surgery for definitive treatment.

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Background: Although lithium is known to cause thyroid dysfunction and increased thyroid gland volume, clinical examination and biochemical assessment are fundamental to thyroid workup of patients on lithium treatment. We aimed to determine thyroid gland volume and the Thyroid hormone levels of patients who have been receiving lithium treatment for affective disorders in comparison to voluntary healthy controls. Methods: This was a cross-sectional, hospital-based observational study which was performed in 43 patients on long-term lithium treatment for bipolar disorder, major depressive and schizoaffective disorders. Patients with documented continuous and adequate serum lithium levels for more than or equal to 6 months recruited consecutively underwent the ultrasonographic examination of the thyroid gland. Ultrasonographic examinations were also done in all gender- and age-matched healthy controls. All cases and controls underwent biochemical thyroid function tests. Results: There were no statistically significant differences in gender (P = 0.198; Chi-square = 1.654) of cases and controls. Most of the cases were married, maximum number of them unemployed and belonged to the lower socioeconomic status. Total thyroid volume was significantly greater in the lithium-treated group than the controls (9.40 ± 1.41 vs. 4.79 ± 0.45). Clinical inspection and palpation only detected goiter in six (n = 6, 13.95%) of patients on lithium and none among controls. The mean triiodothyronine, mean thyroxine, and mean scores for thyroid-stimulating hormone were significantly increased in patients receiving lithium therapy as compared to controls. Conclusion: It would seem wise from a clinical point of view to include ultrasonographic examination of the thyroid gland as part of the standard thyroid workup before initiating lithium treatment.

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Paroxysmal hypertension (PH) can be associated with the carotid artery baroreceptors' failure due to past exposure to radiation treatment. This report presents a patient who experienced repeated PH episodes due to the direct massage of the carotid artery during Doppler ultrasound of the neck. The radiation damage to the carotid artery baroreceptors might have increased their hypersensitivity to the mechanical and ultrasonic stimulation during the diagnostic test, leading to the hypertensive episodes. Patients who had received radiation therapy for head-and-neck cancer and require Doppler ultrasound of the carotid artery should be monitored for PH by recording their blood pressure prior and after the test.

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The decision to biopsy small thyroid nodules (TNs) is controversial. Careful ultrasound (US) evaluation with shear wave elastography (SWE) of TN and cervical lymph nodes (LNs) may aid in the decision to biopsy and subsequently influence the extent of surgery. A 46-year-old female presented with TNs and hypothyroidism. Her target TN in the left lobe measured 4.8 mm × 4 mm × 4 mm. Fine needle aspiration biopsy of the left TN and a left neck level 6 LN was diagnostic for papillary thyroid carcinoma. In the left lateral neck posterior to the jugular vein, there was a LN with possible microcalcifications that could not be sampled due to vascular proximity. SWE examination showed high velocity suspicious for metastatic disease. In summary, risk stratification for small TNs and cervical LNs can be difficult. SWE can provide valuable information for assessing the risk for malignancy.

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A 47-year-old woman consulted a doctor due to a persistent cough. Computed tomography revealed a 30 mm × 60 mm intracardiac mass in the right atrium. Because of lung metastasis, her respiratory status did not allow a more invasive procedure, such as general anesthesia. Although intracardiac echocardiography (ICE) during percutaneous transcatheter biopsy (PTB) is not covered by medical insurance, we performed PTB under ICE guidance. Pathology and immunohistochemistry revealed primary cardiac angiosarcoma. Primary cardiac angiosarcoma is a rare tumor with a poor prognosis. After seven cycles of chemotherapy, the pulmonary metastasis was clearly improved. The patient is alive 18 months after the first consult, even though the mortality of angiosarcoma is high. ICE during PTB allowed us to choose appropriate chemotherapy and improve her pulmonary metastasis. ICE during PTB reduces the need for a diagnostic open-chest procedure that requires a more invasive approach.

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