Clinical ultrasound research influences clinical ultrasound practice

Occasionally, patients ask me, ‘Why am I having this ultrasound examination done?’ Sometimes, I hear colleagues ask, ‘Does anyone really pay attention to my reports?’ And often, I am asked, ‘Can you scan this patient urgently, so we can discharge the patient today?’ The answer to all these questions is inevitably, ‘It depends’. A more nuanced reply to the question as to why the examination is being done might be, ‘To assist your doctor make decisions about your management’. As to whether the report is useful, ‘If you answered the clinical question and provided measurements and information that will help guide management it was useful’. And to the third question, the ubiquitous pre-discharge examination, my typical reply is almost always, ‘Do it as an outpatient, or if it's critical to your management decisions, keep them in and we will do it next week’. This always seems to happen on a Friday afternoon.

It should be obvious how every ultrasound examination we perform fits into clinical care, but this is not always explicitly stated either amongst ourselves, from our referring colleagues, or to our patients. And whilst some examples, such as using ultrasound to guide IV access, are clearly understandable to patients and clinicians alike, some are less obvious.

In this issue of AJUM, we present new research showing the added clinical benefit of ultrasound in different clinical specialities and scenarios. Clinical research undertaken in groups of patients, including audits, outcome studies, comparison of techniques, and measurement reliability provides the evidence base that informs both the practice of ultrasound and the implementation of ultrasound imaging into clinical management of individual patients. This issue of AJUM has several excellent examples of clinical research showing that measurements, and how they are obtained, play an important role in clinical management.

Using a retrospective clinical audit approach, Hill et al.¹ undertook an examination of their patient cohort referred for the investigation of abdominal aortic aneurysm. They compared their ultrasound measurements with those obtained on CT scanning, with particular focus on ultrasound measurement taken in three planes—transverse, sagittal and coronal diameters. Their main finding was that coronal diameter of the abdominal aorta measured in the decubitus window was best correlated with CT measurements.

Applying a comparison of techniques, Alfuraih et al.² compared the measurements of vastus lateralis, rectus femoris and vastus intermedius muscles by novice operators using a handheld ultrasound device (HUD) with the measurements made with a standard machine (also by the same novice) and found good agreement. As we transition to smaller devices, we expect a degradation in image quality based on transducer resolution and less processing capability, so it is reassuring that HUD measurements are comparable. Similarly, we are seeing a shift from highly experienced sonographers to novice users, so again reliability of measurements becomes an important consideration.

Using a case–control multicentre study design, Stamatopoulos et al.³ compared measurements of first trimester crown–rump length in smokers with non-smokers and found no difference, despite the evidence that cigarette smoking affects fetal growth. In order to make such a conclusion, the study design should document the robust and reliable measurements used to reach their conclusion.

One of the simplest clinical research designs is a case series, such as presented by Hosokawa et al.⁴ who investigated the role of ultrasound in predicting a successful management of testicular torsion. They found that the presence of hyperperfusion in the affected testes after manual detorsion predicted a successful outcome (avoidance of testicular atrophy).

Despite all of the clinical research being undertaken, it often takes time for new evidence to transfer into clinical practice. Knowledge transfer is a slow process and happens organically. Professional guidelines attempt to include new research, but even then, the guidelines have to be adopted, and this too is an organic process that is difficult to manage. This is the reason why I was particularly interested in reading the survey results of Guscott et al.⁵ regarding the knowledge and uptake of the 2018 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome (2018 IEBG). They found that only 52% of survey respondents knew of the guideline but that only 31% used it in the workplace, which begs the question, is it a problem with awareness or avoidance?

Often clinical research creates more questions than it answers, and this is exciting to me as an ultrasound researcher, and as an editor of this journal. Ultrasound, as a relatively safe imaging technique, is the perfect tool for clinical research in almost all specialities.