LAUSR

In this issue of the Journal a new set of European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) guidelines is reported [1]. Some years ago it was discussed how guidelines are prepared, but things are continuously changing [2, 3]. Initially, guidelines were mainly based on expert opinions due to the limited availability of high-quality evidence. Within recent years the paradigm that guidelines should be based on evidence has prevailed. However, if evidence was not available, recommendations continued to be based on expert opinions, which were not necessarily correct nor objective. The differences in the methodology of clinical guidelines are sometimes considerable, without this always being apparent to the reader at first glance. This concerns in particular the formulation of clinical key questions guiding the systematic retrieval of evidence, its evaluation, the process of transforming evidence into recommendations, and the rules for reaching agreement in the guideline panel on conflicting conclusions from the research evidence. Other issues that affect the trustability of guidelines are the constitution of expert panels, the handling of potential conflicts of interest, the funding of guidelines, the voting and update rules. Therefore, several academic institutions have proposed standards for "trustworthy clinical guidelines" as well as instruments for their assessment [4–8]. Since different systems were used to grade the evidence, as it was the case also in previous EFSUMB guidelines, the international Grading of Recommendations Assessment, Development and Evaluation (short GRADE) working group was gathered in order to design consistent and widely accepted criteria [9]. The GRADE approach, last updated in 2016, aims at an unification of the systems, reducing unnecessary confusion arising from multiple systems for grading evidence and recommendations. Moreover, rules were established to weigh the benefits and risks of recommended care options. Many guidelines have adopted the new modality since then, including some EFSUMB guidelines [10–12]. Aiming at improving the “trustworthiness” of EFSUMB guidelines, EFSUMB published new rules for the development of guidelines and other policy documents in 2019 [3], which have been adopted also by WFUMB [13]. More recently, the PICO process [14] in conjunction with GRADE is more widely used. PICO is a mnemonic used to describe the four elements of a good clinical key question: P = Population/Patient/Problem – How would I describe the problem or a group of patients like mine? I = Intervention – What main intervention, prognostic factor or exposure am I considering? C = Comparison – Is there an alternative to compare with the intervention? O = Outcome – What do I hope to accomplish, measure, improve or affect? The adoption of these systems is obviously a benefit but also encounters limitations. Using this methodology some guidelines (e. g., that on the treatment of hepatocellular carcinoma published by the American Association for the Study of Liver Diseases) only addressed a few selected clinical key questions and excluded issues when prospective randomized trials were not available [15]. Even though this process certainly facilitates the delivery of answers based on strong Vito Cantisani Christian Jenssen Christoph Frank Dietrich Caroline Ewertsen Fabio Piscaglia Editorial