Making Waves in Sonography Research | July 2023

JULY 2023

Making waves IN SONOGRAPHY RESEARCH

CONTRIBUTORS

Matt Adams

Dr Michelle Fenech, FASA

ASA SIG: Vascular

ASA SIG: MSK

Matt trained as a clinical vascular scientist in the UK where he worked with the vascular studies team at the Royal Free Hospital. After 5 busy years scanning, helping with teaching and assisting in research conducted by the University College London, Matt made the move to Australia in early 2017, where he is now in charge of Camperdown Vascular Lab in Sydney.

Helen Beets ASA SIG: Research Helen is a senior sonographer and tutor sonographer at PRC in Perth and an active member of the ASA Research SIG since 2019. She completed her Master of Medical Ultrasound at Monash University and looks forward to continuing with future research projects. She has a strong interest in teaching and mentoring other sonographers in their own interest to join the research field.

Cain Brockley, FASA ASA SIG: Paediatric Cain has been a sonographer at the RCH for over 25 years. He has served on the ASA Board of Directors as both vice president and president. Cain has presented all over Australia and New Zealand and in Malaysia.

He has a strong interest in paediatric hips, transcranial Doppler and liver transplants.

(Not pictured)

Anna Graves, AFASA ASA SIG: Research

Michelle is passionate about musculoskeletal ultrasound, teaching, researching structural anatomy and currently chairs ASA MSK SIG. She is a senior lecturer and head of course of postgraduate medical sonography studies at Central Queensland University, teaching advanced musculoskeletal ultrasound units in the Master of Medical Ultrasound course. She currently mentors sonographers in musculoskeletal ultrasound at the Royal Brisbane and Women’s Hospital and undertakes research with a musculoskeletal ultrasound, anatomical and teaching focus.

Gina Humphries ASA SIG: Women’s Health Gina Humphries is a senior sonographer with a keen interest in women’s ultrasound.

After working as a zoologist, Gina studied radiography in 2007, before pursuing her passion for sonography in 2010. Gina is currently working in the private sector specialising in obstetric, gynaecological and breast imaging.

Leanne Lamborn ASA SIG: Paediatric Leanne Lamborn is supervising sonographer at the Children’s Hospital, Western Australia, with over 20 years’ tertiary level experience in paediatric sonography. She has been on the SIG Paediatric Committee since its inception in 2010. Her areas of expertise include neonatal ultrasound and DDH hip screening with a special interest in paediatric liver transplant, transcranial Doppler and appendix ultrasound imaging.

Lisa McGuire, AFASA ASA SIG: Emerging Technologies Lisa McGuire is a locum general sonographer with a Master of Medical Ultrasound. She has enjoyed volunteering in the mentorship program with Radiology Across Borders. Lisa is a member of the Emerging Technologies SIG.

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CONTRIBUTORS

Donna Oomens, AFASA ASA SIG: Vascular Donna has been a vascular sonographer for 30 years, including training and teaching. Donna is chief sonographer for Western Sydney Vascular Services and undertaking a PhD around arteriovenous fistula ultrasound.

Donna is passionate about quality performance in ultrasound and mentoring. Donna has presented at many ASA meetings nationally and co-convened the 2018 ASA Conference and 2019 Canberra SIG. Donna has held vascular workshops in Singapore and worked in Pakistan to improve vascular ultrasound.

Bridie Roche, AFASA ASA SIG: MSK Bridie has 20 years’ innovative ultrasound practice and teaching experience. Her passion is cutting-edge, simple ultrasound techniques for scanning musculoskeletal injuries.

With over 15 years’ experience as a clinical educator, sonographer and lecturer in medical sonography and anatomy, Bridie is an invited speaker to local and national conferences. She understands that the mastery of ultrasound performance and diagnosis is not just a taught skill, rather a practical experiential journey in the clinical workplace.

Jacqui Roots ASA SIG: Emerging Technologies Jacqui is a sonographer and PhD candidate at QUT, researching ‘Shear wave elastography to assess the stiffness of muscles in the acute stage post stroke’.

She is passionate about musculoskeletal ultrasound and the advancement of technology to improve the diagnostic accuracy of medical imaging and a member of ASA MSK SIG and Emerging Technologies SIG. Jacqui is currently focusing on her research and has published and reviewed papers.

(Not pictured)

Laksmmi Sanal ASA SIG: Women’s Health

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Content EMERGING TECHNOLOGIES

Shear wave elastography as a supplement tool in the assessment

of unsuspicious axillary lymph nodes in patients undergoing breast ultrasound examination

5

EMERGING TECHNOLOGIES

Quantitative diagnosis of rotator cuff tears based on sonographic pattern recognition

6

MUSCULOSKELETAL

Ultrasound and MRI in the assessment of Achilles tendon rupture: are both necessary?

8

MUSCULOSKELETAL

Ultrasound evaluation shows increase in laxity after partial

common extensor origin detachment but not after additional lesion of the radial band of the lateral collateral ligament

9

PAEDIATRIC

Ultrasound of the spine in neonates and infants: a practical guide PAEDIATRIC

Skin sonography in children: a review

11 13

RESEARCH

Rethinking health professionals’ motivation to do research: a systematic review

14

RESEARCH

Ten common statistical mistakes to watch out for when writing or reviewing a manuscript

16

VASCULAR

A retrospective cohort study on diabetic foot disease: ascertainment of ulcer locations by age group

17

VASCULAR

Assessment of arterial stiffness in hemodialysis patients, using speckle tracking carotid strain ultrasonography

18

WOMEN’S HEALTH

Routine first-trimester pre-eclampsia screening and risk of preterm birth

19

WOMEN’S HEALTH

Fetal micro and macroglossia – Defining normal fetal tongue size 20

© Australasian Sonographers Association 2023. Disclaimer: The information in this publication is current when published and is general in nature; it does not constitute professional advice. Any views expressed are those of the author and may not reflect ASA’s views. ASA does not endorse any product or service identified in this publication. You use this information at your sole risk and ASA is not responsible for any errors or for any consequences arising from that use. Please visit www.sonographers.org for the full version of the Australasian Sonographers Association publication disclaimer

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EMERGING TECHNOLOGIES

REVIEWED BY Jacqui Roots ASA SIG: Emerging Technologies REFERENCE

Shear wave elastography as a supplement tool in the assessment of unsuspicious axillary lymph nodes in patients undergoing breast ultrasound examination

Authors: Riku Togawa, Leah-Larissa Binder, Manuel Feisst, Richard G Barr, Sarah Fastner, Christina Gomez, André Hennigs, Juliane Nees, André Pfob, Benedikt Schäfgen, Anne Stieber, Fabian Riedel, Jörg Heil, Michael Golatta Journal: British Journal of Radiology Open Access: Yes READ THE FULL ARTICLE HERE

WHY THE STUDY WAS PERFORMED This study assessed the stiffness of unsuspicious axillary lymph nodes by utilising shear wave elastography. It is known that an increased stiffness is a predictor for malignancy, but first we must understand what normal stiffness values should be. The authors aimed to quantify the stiffness values of physiological, healthy lymph nodes, including the hilum, cortex and surrounding fatty tissue, to have a better understanding of normal.

HOW THE STUDY WAS PERFORMED One hundred and seventy-seven lymph nodes (within a total of 177 axillae of 175 patients) were measured with standard ultrasound and shear wave elastography. The Siemens Acuson S2000 and S3000 machines were used, equipped with virtual touch tissue imaging quantification (VTIQ) software. This returns a shear wave velocity in m/s as the stiffness value. Stiffer tissues return faster velocities.

A random representative lymph node was selected in level I or II of the axilla. The lymph node had to have good accessibility and absence of malignancy signs (cortical thickening, rounded node, complete or partial effacement of fatty hilus, or pathological colour Doppler images). The elasticity values from the hilum, cortex and surrounding fatty tissue were measured three times and documented.

This observational study was performed prospectively in a single centre. Written informed consent was obtained from each patient.

WHAT THE STUDY FOUND The velocity of the hilus showed a higher stiffness compared to the cortex of the same lymph node.

The mean shear wave velocity of the cortex was 1.9 m/s (0.34SD), 2.02 m/s (0.37) in the hilus, and 1.75 m/s (0.38SD) in the surrounding fatty tissue. There was no difference detected between the right and left axilla at any of the three locations.

There was a statistically significant difference between the shear wave velocities of the hilus and the fatty tissue, as well as between the cortex and the hilus. The size of the lymph node did not correlate with the shear wave velocities; neither did the depth of the lymph nodes.

RELEVANCE TO CLINICAL PRACTICE Shear wave elastography can be used as a supplementary tool for assessing the stiffness of lymph nodes of the axilla and takes approximately 1 to 2 minutes per side. This study has evaluated healthy, unsuspicious lymph nodes and provided reference values for the hilus, cortex and surrounding fatty tissue. SWE is a reliable tool regardless of the depth and size of the lymph node.

Making waves

“When performing SWE routinely in the breast, extending the examination to the axilla can be performed using the same probe and software while the patient can maintain the same position.”

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EMERGING TECHNOLOGIES

REVIEWED BY Lisa McGuire, AFASA ASA SIG: Emerging Technologies REFERENCE

Quantitative diagnosis of rotator cuff tears based on sonographic pattern recognition

Authors: Ruey-Feng Chang, Chung-Chien Lee, Chung-Ming Lo Journal: PLOS One Open Access: Yes READ THE FULL ARTICLE HERE

WHY THE STUDY WAS PERFORMED The accurate diagnosis of rotator cuff disorders is important to determine treatment strategy.

Ultrasound is operator dependent with a high interoperative variability. This study used a computer-aided tear classification system (CTC) to identify supraspinatus tears and reduce interoperator variability. Computer-aided diagnosis systems provide an objective, quantitative assessment of lesion type and grade.

HOW THE STUDY WAS PERFORMED Data was accumulated from 136 patients. The observed cases included 89 ultrasound images of supraspinatus tendinopathy and 102 images of supraspinatus tears. Each case looked at each lesion with manual or semi-automatic segmentation. Quantitative features including texture and intensity were extracted and combined in a binary logistic regression classifier for lesion classification. All shoulders were imaged using an ALOKA alpha-6 ultrasound scanner. The acquisition frequency used an 8 MHz and a 4 cm scanning depth focusing on the supraspinatus.

Forty-two of the 102 supraspinatus tears were full thickness tears. Ultrasound examinations were performed uniformly.

“The proposed computer-aided tear classification (CTC) system achieved an accuracy rate of 92%.

Based on its diagnostic performance, the CTC system has promise for clinical use.”

Fig 1. Supraspinatus tendon shown in ultrasound images. (a) tendinopathy. (b) supraspinatus tear. (c) and (d) lesions contours.

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EMERGING TECHNOLOGIES

Quantitative diagnosis of rotator cuff tears based on sonographic pattern recognition INTENSITY The grey-scale distribution of tissues in the lesion were presented by a probability distribution in the form of a histogram: Mean: summarises the total pixel values and divides by the sum of the pixel number Variance: indicates how uniform the greyscale values are spread out Skewness: estimates symmetry of the value distribution such as bias to one side or not Kurtosis: sharpness of a peak of a frequency distribution curve (taking normal distribution as a reference).

TEXTURE Tendinopathies have heterogenous patterns, tears appear to have hypoechoic echogenicities.

The grey-scale intensities of echogenicities and statistical correlation between pixel values provide information for differentiation of lesion types. In this study, the grey-scale co-occurrence matrices were proposed as features. The statistics revealed correlations between adjacent pixels with a different combination of grey scales. For diagnosis, 8 levels were quantified and used for pattern interpretation.

ANALYSIS Non-normally distributed features were evaluated with a Mann-Whitney U-test. The resulting p-values < 0.05 indicated whether a feature was significant in distinguishing between the supraspinatus tendinopathy and tear.

Tear probability = 1/(1+exp(-1x(f1 xc1+…fn xCn – constant))) f1, fn are different features which multiply different C1,Cn as coefficients.

Tear classification results with probabilities higher than 50% were classified to be a tear.

WHAT THE STUDY FOUND In the performance evaluation, each case was given a probability indicating the likelihood of tears. Cases with probability values ≥ 0.5 were classified as tears, those < 0.5 were classified as tendinopathy.

The prediction model built by a logistic regression classifier achieved an accuracy of 92% for identifying rotator cuff tears and tendinopathies with sensitivity and specificity both equalling 93%.

RELEVANCE TO CLINICAL PRACTICE The CTC system’s high accuracy suggests it will be useful for assessing the presence of rotator cuff tears. This would enhance current diagnostic practice. The proposed CTC system performed similar performance accuracy to that of experienced operators, including musculoskeletal radiologists and orthopaedic shoulder surgeons. It is proposed that interobserver variability would be improved with the introduction of the CTC system.

Making waves

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MUSCULOSKELETAL

REVIEWED BY Dr Michelle Fenech, FASA ASA SIG: Musculoskeletal REFERENCE

Ultrasound and MRI in the assessment of Achilles tendon rupture: are both necessary?

Authors: Moretti L, Solarino G, Pignataro P, Baglioni M, Vicenti G, Bizzoca D, Piazzolla A, Alberotanza V, Moretti B Journal: Orthopaedics and Traumatology Open access: No READ THE FULL ARTICLE HERE

WHY THE STUDY WAS PERFORMED Achilles tendon rupture is one of the most common tendon injuries in the adult population.

The distinction between complete and partial tears, the gap size between the ruptured ends of the tendon and distance between the tear and the calcaneus are criteria which can guide the treatment of Achilles tendon ruptures. These can be determined sonographically or with magnetic resonance imaging (MRI). This study aimed to define the level of agreement between interoperative findings, US and MRI, regarding reporting of: (1) complete versus partial tears, (2) the gap between tendon ends, (3) the distance of the tear from the calcaneus. This was to determine the best imaging modality to use to plan management of patients post Achilles tendon injury.

HOW THE STUDY WAS PERFORMED A prospective observational study was conducted to evaluate ultrasound and MRI findings in acute Achilles tendon ruptures which were treated surgically. Thirty-four participants were included in the study. Participants were clinically suspected to have a complete Achilles tendon rupture. Thirty-one participants had positive Thompson Test; 33 had a positive Matles Test, and all presented with a palpable gap in the region of the Achilles tendon. They all underwent dynamic US and static MRI examinations within 40 hours of injury to define (1) whether the tear was complete or partial, (2) size of the gap between tendon ends, and (3) the distance of the tear from the calcaneus. The results were compared with interoperative findings and measures.

Measurements of the gap between tendon ends and distance from the calcaneus via US and MRI in this study were performed with the foot in neutral position (0-degree plantar flexion).

During surgery, the foot was placed in the same positioning as imaging and the gap (when present) and the distance of tear from calcaneus was measured.

“Ultrasound, when performed by an experienced sonographer, is accurate in defining the main features of acute Achilles tendon ruptures.”

WHAT THE STUDY FOUND Partial or complete tears: From 34 participants, 4 were intraoperatively identified to have partial tears. US correctly identified all 4 partial tears. MRI had reported complete tears of all 34 participants. MRI reported a partial tear (identified complete sonographically), which was conferred intraoperatively as complete.

Size of the tendon gap and distance from calcaneus: There was good agreement between the size of the gap between torn tendon ends and the distance of the tear from the calcaneus between interoperative evaluation, US and MRI. US was found to be accurate in defining the main features of acute Achilles tendon rupture.

RELEVANCE TO CLINICAL PRACTICE Imaging of the Achilles tendon post injury is used to guide treatment. Treatment of Achilles tendon ruptures can be grouped into surgical and non-surgical (conservative) methods. There is a growing use of functional rehabilitation programs for the treatment of Achilles tendon rupture. Surgical repair has been reported to have a lower re-rupture rate, however, can have surgical complications.

Dynamic ultrasound has the advantage that it can demonstrate the tendon ends moving apart and moving together with altering degrees of plantar flexion. This enhances identification of complete tears of the Achilles tendon. The gap size between the ruptured ends of the tendon can be used as a tool to decide on the treatment of Achilles tendon ruptures. This gap size can be measured with the foot in plantar flexion (toes pointed) or neutral position (plantar aspect of the foot perpendicular to long axis of the lower leg). If the gap size is reported sonographically, the foot position and degree of angulation of plantar flexion should be documented.

Making waves

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MUSCULOSKELETAL

REVIEWED BY Bridie Roche, AFASA ASA SIG: Musculoskeletal REFERENCE

Ultrasound evaluation shows increase in laxity after partial common extensor origin detachment but not after additional lesion of the radial band of the lateral collateral ligament

Authors: Paolo Arrigoni, Davide Cucchi, Francesco Luceri, Andrea Zagarella, Michele Catapano, Alessandra Menon, Valentina Bruno, Mauro Gallazzi, Pietro Simone Randelli Journal: Knee Surgery, Sports Traumatology, Arthroscopy Open Access: Yes READ THE FULL ARTICLE HERE

WHY THE STUDY WAS PERFORMED Dynamic stress ultrasound is widely used in the setting of ulnar collateral ligament injury for detecting valgus instability of the elbow. Stress ultrasound, however, has not yet been validated in the lateral elbow for detection of varus instability. Little is known of the contribution of the radial collateral ligament (RCL) versus the common extensor origin (CEO) to varus stability. The sequential release of the extensor carpi radialis brevis (ECRB), followed by release of the RCL, was performed to investigate the degree of joint space widening under varus stress.

HOW THE STUDY WAS PERFORMED The degree of lateral joint space widening before and after surgically introduced CEO and RCL tears was investigated in cadavers. The annular ligament and lateral ulnar collateral ligament were left intact.

Positioning of each cadaveric arm during stress ultrasound was as follows: • The humerus was internally rotated 90 degrees and fixated as if positioned prone.

• The forearm was neutral with the lateral elbow facing up.

• The elbow was either flexed to 60 degrees or fully extended.

“Damage to the CEO of the lateral elbow, and not only the radial collateral ligament, has a massive impact on elbow instability.”

• The transcondylar axis was perpendicular to the floor.

Varus stress was applied using both gravity and with 0.5 kg of weight at the level of the hand.

A longitudinal imaging plane over the midpoint of the radiohumeral joint was used to measure the distance from the capitellum to radial head.

WHAT THE STUDY FOUND Release of the anterior half of the CEO contributed significantly to varus instability causing joint space widening of 200% (an increase of approximately 3 mm) with the elbow at 60 degrees of flexion.

Detachment of the proximal RCL origin following CEO release contributed less than 1 mm additional joint widening.

Prior to either release, lateral joint space widening with either gravity or 0.5 kg on an extended elbow was insignificant. With the elbow at 60 degrees flexion, 0.5 kg did produce significant joint space widening, although minimal.

While detection of the degree of joint widening via stress ultrasound may not help distinguish an RCL tear from an anterior CEO tear, stress ultrasound can indirectly confirm the presence of a significant anterior CEO tear. This study was the first of its kind establishing the significant contribution of the anterior CEO to varus stability of the elbow.

Making waves

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MUSCULOSKELETAL

Ultrasound evaluation shows increase in laxity after partial common extensor origin detachment but not after additional lesion of the radial band of the lateral collateral ligament

RELEVANCE TO CLINICAL PRACTICE Ultrasound guided intratendinous CEO injections aimed at treating recalcitrant lateral elbow pain can cause long-term damage to the CEO and this tendon weakening may contribute to RCL overload. RCL overload will also further compromise the ligament and therefore elbow stability.

The authors advise against repeat hydrocortisone injections into the ECRB. Isolated injuries of the RCL may be arthroscopically addressed; however, the success of reconstruction is contingent on an intact overlying CEO. The sonographer therefore plays an important role in detection of any tendinous injury or avulsion prior to surgical management of a lateral ligament tear.

The results of the study led the authors to advise against open surgical approaches for lateral ligament repair since any iatrogenic injury to the ECRB may escalate instability.

Making waves

JULY 2023 | 10

PAEDIATRIC

REVIEWED BY Leanne Lamborn ASA SIG: Paediatric REFERENCE

Ultrasound of the spine in neonates and infants: a practical guide WHY THE REVIEW WAS PUBLISHED Ultrasound is the imaging of choice when screening the spinal cord for closed dysraphism in neonates and infants. This examination is usually performed prior to the posterior elements of the vertebral column ossifying. Open dysraphism and after ossification occurs, magnetic resonance imaging (MRI) is the modality of choice. Ultrasound is important in assessment of the spinal cord and help in delineating the spinal anatomy, with the most common clinical indication being atypical sacral dimple. Ultrasound being non-ionising provides a quick, non-invasive and relatively inexpensive examination when compared to MRI.

Authors: Emilio J Inarejos Clemente, Maria Navallas Irujo, Oscar M Navarro, Barbara Salas Flores, Paulino Sousa Cacheiro, Enrique Ladera, Monica Rebollo Polo, Marta Tijerin Bueno, Ignasi Barber Martinez de la Torre Journal: RadioGraphics (2023 May) Volume 43, No. 6 Open Access: No READ THE FULL ARTICLE HERE

This article discusses the fundamental role of ultrasound in neonatal and paediatric spinal imaging. It describes in detail the best techniques used, including ultrasound transducer selection, patient/transducer position and protocols for the evaluation of the neonatal spine. It outlines the most common normal variants in neonates and infants. It identifies and describes the US appearance of the most common congenital variations and pathologies in the spine.

Prenatal MRI and postnatal MRI are also discussed.

WHY THE STUDY WAS PERFORMED The aim of the paper was to look at how the ultrasound assessment of the spinal column is performed in neonates and infants younger than 3–4 months. There are several normal variants that the examiner needs to be aware of to avoid misdiagnosis of a spinal abnormality. This information, along with technique and protocol, makes the assessment of the neonatal spine easy with its systematic approach. It describes several other uses of ultrasound in assessing the spine where spinal dysraphism is not the question.

WHAT THE PAPER LOOKED AT Technique Neonatal spinal ultrasound technique is discussed, pointing out the real-time visualisation of spinal pathologies, expressing that a tailored ultrasound exam to answer the clinical question is crucial. The acoustic window and transducer choice depend greatly on the size of the child and if posterior elements are ossified. The protocol, checklist and landmarks used are well described.

Normal variants There are several normal variants seen when assessing the neonatal/infant spine that the sonographer/radiologist should be aware of to ensure more accurate reporting. These are often seen in spinal examinations but are of no clinical significance.

Clinical indication for spinal ultrasound and management There is a table of risks from clinical indications and the likelihood of a spinal abnormality.

Common pathology It describes and discusses clearly how common pathology is visualised on ultrasound.

Other spinal ultrasound uses It describes several uses of ultrasound not associated with spinal dysraphism.

Making waves

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PAEDIATRIC

Ultrasound of the spine in neonates and infants: A practical guide

RELEVANCE TO CLINICAL PRACTICE The main purpose of this article is a practical guide for the examiner specifying the best way to approach, perform and assess a neonatal spine ultrasound examination. The article provides a systemic and comprehensive description in how to attain this. It is an excellent resource for any department that performs neonatal spine ultrasound from a general ultrasound practice to a tertiary level paediatric ultrasound site. The article helps to optimise patient care by helping ensure that normal anomalies are considered and that any abnormal findings are then investigated with further imaging to help with directing patient management.

Making waves

“Is an excellent resource for any department that performs neonatal spine ultrasound from a general ultrasound practice to a tertiary level paediatric ultrasound site.”

JULY 2023 | 12

PAEDIATRIC

REVIEWED BY Cain Brockley, FASA ASA SIG: Paediatric REFERENCE

Skin sonography in children: a review

Authors: Garcia C, Wortsman X, BazaesNunez D et al.

Journal: Pediatric Radiology Open Access: No READ THE FULL ARTICLE HERE

WHY THE REVIEW WAS PERFORMED To demonstrate the wide range of paediatric skin lesions that occur and to demonstrate the use of clinical and sonographic correlation in the diagnosis of these common skin lesions. The review is a useful reference to help any sonographer and/or radiologist performing these types of examinations. Improved sonographic diagnosis can reduce the need for more complex imaging such as MRI, which is more difficult in the paediatric age group, and also potentially reduce any unnecessary surgery.

WHAT THE REVIEW IS ABOUT The review covers a wide range of lesions, with emphasis placed on the need for good clinical sonographic correlation. The article is broken down into the following categories: Technical recommendations The minimum technical requirements and recommendations for performing dermatological sonographic examinations are described, with emphasis on the use of high frequency ultrasound and the need for B-mode, colour and spectral Doppler.

“A clinical sonographic correlation is required to improve the correct diagnosis rate when scanning paediatric skin lesions.”

Skin anatomy & sonographic appearance A brief review of skin anatomy, including the various layers and their composition, is provided with the corresponding normal sonographic appearance.

Skin lesions The skin lesions are broken down into multiple categories including benign and pseudotumoural, malignant, inflammatory and miscellaneous lesions. It must be noted that this article does not cover vascular anomalies.

Each lesion is well described with both clinical features, common locations and sonographic appearances well detailed, including descriptions of specific features that can help to delineate between similar lesions. Most of the lesions described are benign as these are far more common in children. The benign lesions cover a wide range of cystic and solid lesions that occur superficially. Though malignant skin lesions are rare in the paediatric population, the article does include this topic with emphasis on certain clinical features such as rapid growth, firm consistency, non-mobility, and ulceration to be aware of when performing the examination.

Multiple miscellaneous lesions are covered. One example is fat necrosis in the newborn, which is useful to understand and identify because, though benign itself, it has a strong association with other underlying conditions such as hypercalcemia.

RELEVANCE TO CLINICAL PRACTICE Skin lesions often cause a high level of anxiety in parents and/or patients, therefore are a common presentation for sonographic examination in most practices and departments. Given the range of common lesions that can occur, which thankfully are mostly benign, this review provides a good resource for sonographers and radiologists to assist in narrowing down the diagnosis, but also to help identify those lesions that are more concerning for malignancy and need further examination. Identifying the benign lesions can provide reassurance to parents, help to guide treatment if required, and reduce unnecessary surgery. A sound knowledge of the various common lesions that occur and their sonographic appearances combined with a good clinical history can significantly improve the diagnostic outcomes.

Making waves

JULY 2023 | 13

RESEARCH

REVIEWED BY Anna Graves, AFASA ASA SIG: Research REFERENCE

Rethinking health professionals’ motivation to do research: a systematic review WHY THE STUDY WAS PERFORMED

Authors: Louisa M D’Arrietta, Venkat N Vangaveti, Melissa J Crowe, Bunmi S Malau-Aduli Journal: Journal of Multidisciplinary Healthcare Open Access: Yes READ THE FULL ARTICLE HERE

The literature review was undertaken to investigate the decline of the health professional researcher. Research within the health professional sphere underpins the development of evidence-based practice which, in turn, influences the current skills, knowledge and competence of the health professional. The implications of the current decline in research are concerning and it is expected that this will eventually have a detrimental effect on both patient outcomes and the economy. The research aims to identify the motivational factors and barriers currently influencing the health professional researcher and to correlate the influence these may have on the existing research ethos.

The motivation to do research was explored using both the Expectancy-Value-Cost (EVC) and Self-Determination Theory (SDT) models.

HOW THE STUDY WAS PERFORMED A systematic review of the literature between 2011 and 2021, using the preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, was undertaken. The inclusion and exclusion criteria described the definition of a health professional researcher as a medical graduate, nurse, midwife or other allied health professional engaged in both clinical and research practice. Other criteria specified that all papers were peer reviewed and written in English.

Four thousand and thirty-four (4034) articles were identified at the end of the search period and of these forty-six (46) met the inclusion criteria.

A data extraction form was developed due to the diverse multiple study designs encountered and the Quality Assessment Tool for Studies with Diverse Designs (QATSDD) applied.

WHAT THE STUDY FOUND The study considered the motivational influences affecting research under three main headings: research capacity – competence/confidence and expectancy to do research; health professionals’ attitude towards research, this in turn relates to the value and connection placed on research; and, finally, the barriers preventing or hindering health professional research participation.

The categories below are linked and all have a direct influence on health professional research motivation.

Figure 2 (taken from the article) condenses and displays the integration between the different components.

Making waves

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RESEARCH

Rethinking health professionals’ motivation to do research: A systematic review The research capacity component involvement was greatly influenced by the level of underpinning research skill and experience. This experience appears to be derived mainly from the educational institutions.

Health professionals that are highly motivated to do research appreciate not only the value in advancing patient care with evidence-based practice but also the continued advancement of their career, the gaining of new knowledge, collaborative practice and publishing. While health professionals who are not motivated seem to lack the ability to perceive these effects and only identify with the benefit for the employer.

The barriers to research continue to be the lack of funding, allocated time, as well as lack of confidence, organisational support and poor prior research knowledge.

“There is a decline in the number of health professionals undertaking research, which has implications for patient health and the economy.”

RELEVANCE TO CLINICAL PRACTICE This research identifies the changes required to motivate health professionals to participate in research. These changes encompass and have bearing on the current clinical workplace, accreditation bodies, and educational platforms.

Making waves

JULY 2023 | 15

RESEARCH

REVIEWED BY Helen Beets ASA SIG: Research REFERENCE Journal: eLife sciences Open Access: Yes

Ten common statistical mistakes to watch out for when writing or reviewing a manuscript

READ THE FULL ARTICLE HERE

WHY THE STUDY WAS PERFORMED After discussion at the Journal Club of the London Plasticity Lab, it was concluded that a lot of research is based around the ideals of reproducibility and how to improve statistical training and learning. Few papers are written addressing the errors and offering practical solutions that can be used as a guide for researchers when planning and developing their own research. Additionally, it was thought that peer-reviewers needed more guidance when assessing manuscripts for mistakes in the peer reviewers process.

Whilst there have been papers in the literature outlining individual research errors, the authors of this review wanted to highlight the most common or critical ones, and list them in one paper to be used as a guide. They felt that much attention had been directed towards non-statistical errors, such as ethics and methodology, but more scrutiny and debate on statistical oversights is needed.

HOW THE STUDY WAS PERFORMED This was a review of papers in neuroscience, psychology, clinical and bioengineering journals related to statistical error and common mistakes in statistical planning. Although the papers were predominantly from the neuroscience area, they were considered relevant because statistical analysis is common across medical sciences, which use similar methods to yield results that can be interpreted and discussed. Mainstream mistakes were included in the review and compiled to make a list of the 10 most common errors.

“Mistakes have their origins in ineffective experimental designs, inappropriate analyses and/or flawed reasoning.”

WHAT THE STUDY FOUND The 10 most common mistakes that were discovered and reviewed were listed as: 1. absence of an adequate control/group 2. interpreting comparisons between two effects without directly comparing them 3. inflating the unit of analysis 4. spurious correlations 5. use of small samples 6. circular analysis 7. flexibility of analysis: p-hacking 8. failing to correct for multiple comparisons 9. over-interpreting non-significant results 10. correlation and causation.

For each category of error, they listed the problem, how the mistake can arise, explained how it can be detected by authors and a solution offered. Many of the mistakes were discovered to be interdependent, which meant that one can affect/create another. Each section was then given a suggested article for further reading.

The majority of these provided errors and solutions were in relation to the p-value analysis; however, this meant that the key assumption was that the p-value is the most important part of the results.

RELEVANCE TO CLINICAL PRACTICE The primary intended use of this paper is as a guide for researchers when planning and designing their own statistical methods. Whilst offering their own solutions, they recognise that there is more than one way to solve each problem.

The authors recommend readers to access the online web version of this review and to contribute using the annotation function. This allows for open discussion by readers and an opportunity to offer further solutions, allowing other readers to benefit.

They believe that one of the best solutions to preventing errors in clinical practice is to publish peer-reviewed research without statistical error.

Making waves

JULY 2023 | 16

VASCULAR

REVIEWED BY Donna Oomens, AFASA ASA SIG: Vascular REFERENCE

A retrospective cohort study on diabetic foot disease: ascertainment of ulcer locations by age group WHY THIS STUDY WAS PERFORMED

Authors: Patrícia Rosinha, Miguel Saraiva, Lia Ferreira, Susana Garrido, André Carvalho, Cláudia Freitas, Cláudia Amaral, Luís Costa, Luís Loureiro, Rui Carvalho Monitoring Editor: Alexander Muacevic and John R Adler Journal: Cureus READ THE FULL ARTICLE HERE

There has been a worldwide increase in both average life expectancy and diabetes mellitus (DM). Therefore, there is an associated increase of diabetic foot ulcers, a major complication of DM. Diabetic foot ulcers carry both an increased risk of mortality and decreased quality of life.

Advanced age has been previously shown to be associated with increased severity of diabetic foot ulcers, potentially due to the limited mobility and functional disability resulting from loss of muscle mass and function. The site of a diabetic foot ulcer has also been shown to be an independent predictor of healing.

This study aimed at evaluating the role that location and age play in the healing of diabetic foot ulcers to better understand the prognosis within different age groups.

HOW THE STUDY WAS UNDERTAKEN This was a retrospective, observational study at a single centre. Initially, 583 patients were recruited; however, after exclusion criteria (no active ulcer or incomplete clinical data) was applied, there were 435 patients remaining.

The cohort was divided by age into two groups: younger adults 18–64 years (YA) and older adults > 64 years (OA). The location of the ulcer was assessed using anatomical descriptors (forefoot, mid foot or above, plantar, non-plantar, right and left) and three different published ulcer classifications (PEDIS/Infectious Diseases Society of America, University of Texas system and Wagner’s classification). Clinical factors such as history of smoking, presence of elevated HbA1c, insulin requirement, dyslipidaemia or hypertension were also included in the statistical analysis.

“Plantar and distal regions of the foot are more prone to trauma and therefore enable an easier ‘gateway’ for infectious agents.”

WHAT THE STUDY FOUND The younger group had a higher percentage of men and smokers, while Type 2 diabetes was more common in the older group, most of which is expected. The older group also had increased comorbidities such as dyslipidaemia and hypertension. There was no significant difference (p < 0.05) in terms of evolution time, antibiotic therapy or laterisation. Also, there was no significant difference between groups for number (p = 0.301) or type (p = 0.055) of amputation. The older group were prone to proximal/non-plantar locations, which have lower healing rates, and the authors suggest the need for individualised treatment plans to ensure the best outcomes.

THE RELEVANCE TO CLINICAL PRACTICE Atherosclerosis is a potentially treatable contributing factor in diabetic foot ulcers leading to frequent referrals for arterial assessment in the elderly. Understanding that the location of ulcers can impact the risk of healing helps sonographers understand the importance of our role in correctly performing the ultrasound to provide the best healing outcome.

A troubling aside in the results is having a greater number of smokers in the younger adult group means that the anti-smoking message is not working in this age group. As this study was undertaken in Portugal, it may not be generalisable to the Australian context; however, serves as a reminder to us that we need to be vigilant in promoting an anti-smoking message to our patients.

Making waves

JULY 2023 | 17

VASCULAR

REVIEWED BY Matt Adams ASA SIG: Vascular REFERENCE

Assessment of arterial stiffness in hemodialysis patients, using speckle tracking carotid strain ultrasonography

Authors: Mustafa Gök, Hakan Akdam, Zeynep Gürlek Akol, Göksel Tuzcu, Yavuz Yeniçerioğlu Journal: Meandros Medical and Dental Journal Open Access: Yes READ THE FULL ARTICLE HERE

WHY THE STUDY WAS PERFORMED There is existing evidence that atherosclerotic disease in the carotid arteries and increased arterial stiffness are both markers for cardiovascular (CV) risk. Arterial stiffness, which is a pathological, functional change to the artery that precedes plaque formation, can be reliably quantified by an emerging function of standard ultrasound called speckle tracking. This study was performed to see if a subclinical level of CV risk could be detected amongst end stage renal disease (ESRD) patients using carotid artery speckle tracking due to the increased incidence of CV death in this patient demographic.

HOW THE STUDY WAS PERFORMED One hundred subjects split up into 50 healthy controls and 50 ESRD patients had carotid artery carotid ultrasound with speckle tracking between April 2021 – May 2022. Groups were matched for age, gender and body mass index and those with a history of significant carotid disease were excluded. Carotid artery stiffness measurements were automated using Samsung ultrasound systems on a segment of the common carotid artery (CCA) 5–10 mm beneath carotid bulb and was successfully performed on all participants.

Arterial stiffness was broken down into 7 different parameters: arterial compliance, arterial distensibility, pulse wave velocity, elastic modulus, displacement, strain and strain rate – all of which were measured in both longitudinal and axial planes.

“Measurement of arterial stiffness and strain parameters with the STCS technique helps in the early detection of potential cardiovascular incidents.”

WHAT THE STUDY FOUND A significant difference was observed between the study and control groups across all study parameters in both imaging planes with the exception of arterial compliance. This observable difference between the two groups corresponds to the vascular remodelling that occurs in ESRD patients as a result of vessel calcification, inflammation and increased collagen deposition.

RELEVANCE TO CLINICAL PRACTICE The findings of this study demonstrate the potential for speckle tracking of carotid strain to be used as a clinical tool in the evaluation of CV risk. Speckle tracking is a largely automated function of standard ultrasound that requires basic training to perform, which may lend itself well to future CV screening programs.

Making waves

JULY 2023 | 18

WOMEN’S HEALTH

REVIEWED BY Gina Humphries ASA SIG: Women’s Health REFERENCE

Routine first-trimester pre-eclampsia screening and risk of preterm birth

Authors: V Giorgione, O Quintero Mendez, A Pinas, W Ansley, B Thilaganathan Journal: Ultrasound in Obstetrics & Gynecology Open Access: Yes READ THE FULL ARTICLE HERE

WHY THE STUDY WAS PERFORMED Preterm birth is a major public health problem affecting between 5–18% of all pregnancies.

Complications associated with preterm birth are the primary cause of death in children under 5 years of age. Preterm births may be iatrogenic or spontaneous. Latrogenic preterm birth accounts for 20–30% of all preterm births. Latrogenic preterm birth may be related to pre-eclampsia, fetal growth restriction, placenta previa or placental abruption. However, most preterm births occur spontaneously. Uteroplacental malperfusion associated with preeclampsia and fetal growth restriction has been proposed as a causative factor for spontaneous preterm birth. The primary objective of this study was to establish whether there is a common uteroplacental etiology in the first trimester between spontaneous and iatrogenic preterm birth.

HOW THE STUDY WAS PERFORMED The study by Giorgione et al. retrospectively examined the risk factors for preterm birth in 11,437 women who had undergone first trimester screening examinations for preterm pre-eclampsia, and the risk of spontaneous preterm birth in those women at high risk for preterm pre-eclampsia.

First trimester screening examinations were undertaken at 11 to 13 weeks’ gestation as confirmed via crown-rump length measurement. Screening for preterm pre-eclampsia was performed as per the Fetal Medicine Foundation (FMF) algorithm, which includes maternal factors, mean arterial pressure (MAP), uterine artery pulsatility index and pregnancy-associated plasma protein-A (PAPP-A). Those patients determined to be at risk of ≥1 in 50 for preterm preeclampsia were classified as high risk for preterm birth. These patients were offered prophylactic aspirin, growth scans at 28 and 36-week gestation and labour induction from 40 weeks’ gestation.

“Women who are classified in the first trimester as being at high risk of developing preterm pre-eclampsia are also at increased risk of both iatrogenic and spontaneous preterm birth.”

WHAT THE STUDY FOUND The study found that women assessed as a high risk for placental dysfunction in the first trimester were at an increased risk of preterm birth. Of the 11,437 women screened for preterm birth using the FMF algorithm, 4.2% had a preterm birth of which 64.8% were spontaneous and 35.2% were iatrogenic. Compared to women delivering at term, those who delivered preterm were more likely to be assessed as high risk for preterm pre-eclampsia (19.4% vs 6.6%, P < 0.0001). In particular, the data demonstrated that a high risk of preterm pre-eclampsia had a 6-fold higher risk of iatrogenic preterm birth and a 2-fold higher risk of spontaneous preterm birth. Women who had a higher MAP, a higher uterine artery pulsatility index and lower PAPP-A were also significantly more likely to deliver preterm than those women who did not.

RELEVANCE TO CLINICAL PRACTICE Women identified in first trimester screening as at risk for preterm pre-eclampsia should be considered at risk of preterm birth. Maternal factors, mean arterial pressure (MAP), uterine artery pulsatility index and pregnancy-associated plasma protein-A (PAPP-A) should be considered when assessing a patient’s risk. Sonographers play an important role in accurately assessing the mean uterine artery pulsatility index in the first trimester and so play an important role in minimising a patient’s risk of preterm birth.

Making waves

JULY 2023 | 19

WOMEN’S HEALTH

REVIEWED BY Lakshmi Sanal ASA SIG: Women’s Health REFERENCE

Fetal micro and macroglossia – Defining normal fetal tongue size WHY THE STUDY WAS PERFORMED

Authors: Koren N, Shust‐Barequet S, Weissbach T, Raviv O, Abu Snenh S, Abraham E, Cahan T, Eisenberg V, Yulzari V, Hadi E, Adamo L, Mazaki Tovi, S, Achiron R, Kivilevitch Z, Weisz B & Kassif E Journal: Journal of Ultrasound Medicine Open Access: Yes READ THE FULL ARTICLE HERE

Abnormal fetal tongue size is a phenotypic feature of various significant congenital syndromes and conditions including Down syndrome, Beckwith-Wiedemann syndrome, Pierre-Robin sequence, Simpson-Golabi, oromandibular limb hypoplasia, mucopolysaccharidoses, chromosomal abnormalities, and more. Tongue anomalies may present as an isolated finding and, occasionally, it may be the only presenting prenatal feature of a genetic syndrome. Due to lack of a published comprehensive fetal tongue growth curve throughout pregnancy, microglossia and macroglossia were perceived subjectively. The main objective of the study was to establish a contemporary fetal tongue nomogram and a Tongue Centile Calculator, which assists in determining normal fetal tongue dimensions (length, width, circumference, and area) between 13 and 40 weeks of gestation and to examine the clinical value of tongue measurement in suspected or confirmed pathologic cases.

HOW THE STUDY WAS PERFORMED A prospective cross-sectional study was undertaken in singleton pregnancies. Well-established dates based on CRL measurements in dating scans and fetal weight between 10th and 90th percentiles were the applied inclusion criteria. Fetal malformations, genetic aberrations and conditions compromising fetal growth were excluded from the study. Fetal tongues were measured by trained sonographers, using a combination of transvaginal and transabdominal approaches pertaining to the gestational age and the highest quality image was selected. Image acquisition of the tongue was obtained in an axial plane, in supine fetal position, between the maxillary alveolar ridge and the mandibular alveolar ridge. The definition of terminal sulcus improved the clear identification of the posterior tongue margin. Intra- and interobserver variability was assessed. Tongue length, width, area, and circumference 1st to 99th percentiles were calculated for each gestational week. Based on the normal tongue size charts, the researchers created a Tongue Centile Calculator. A pilot study was also done for reproducibility of the measurements on fetuses between 13 and 40 weeks. Statistical analyses were performed using SPSS statistical package version 20 for Windows and Microsoft Excel 2016 software. All tests were 2-tailed, and a p-value of < .05 was considered statistically significant.

“Objective tongue measurement could assist distinguishing a truly pathologically sized tongue from a normal sized tongue erroneously judged abnormal.”

WHAT THE STUDY FOUND A cubic polynomial regression model best described the correlation between tongue size and gestational age. The correlation coefficient (r2) was 0.934, 0.932, 0.925, and 0.953 for tongue length, width, area, and circumference, respectively (P < .001). Intra- and interobserver variability had high interclass correlation coefficients (> 0.9). Using the new charts, Koren et al. were able to identify 2 cases of macroglossia, subsequently diagnosed with Beckwith-Wiedemann, and 4 cases of microglossia, 3 associated with Pierre-Robin sequence, and 1 associated with persistent buccopharyngeal membrane. This established that these nomograms are an essential tool for distinguishing normal from pathological-sized tongues associated with syndromes. The prospective study design with strict adherence to inclusion and exclusion criteria and relatively large sample size for each week effectively contributed to the quality of the nomogram.

RELEVANCE TO CLINICAL PRACTICE Congenital tongue anomalies include growth abnormalities (macroglossia, microglossia/ hypoglossia), positional abnormalities (glossoptosis), and lingual lesions. These conditions can cause chronic speech impairment, feeding and respiratory difficulties, recurrent upper respiratory tract infections, and even life-threatening postnatal airway obstruction. Subjective tongue assessment is not reliable. Therefore, an objective evaluation of the tongue size helps in detecting fetal abnormalities and can aid in the management and counselling of affected pregnancies. These findings can contribute to the overall improvement of prenatal care.

Making waves

JULY 2023 | 20