Case reports and Case series:

Do they still hold a place in academic publishing?

Dr. S. Sham*

Consultant Rheumatologist, Kauvery Hospitals, Chennai

Associate Editor, Indian Journal of Rheumatology, Member, Editorial Board – Rheumatology Advances in Practice

*Correspondence: itsdrsham@gmail.com

We as clinicians are in the era of ‘evidence-based medical practice’. Does ‘practice-based evidence’ still matter, is it still relevant?

Yes indeed! ‘Case reports or case series’ help in generating ‘practise-based evidence’. The idea for research or for generating a hypothesis stem from these case reports. What we report as individual case reports or case series is based on the practical difficulties faced by clinicians in the diagnosis and management of individual diseases. We always need to balance internal and external validity with regard to evidence generation. All the robust study designs like randomised controlled trials (RCTs) with strict inclusion and exclusion criteria compromise on the external validity and may not be always applicable in our daily clinical practice. This is where the ‘case reports’ score over by reflecting the real-life scenario and adding to the external validity.

Case reports come down pretty low in the level of evidence, placed just above editorials and expert opinions. The quality of evidence goes down for case reports, because of the increased risk of bias. But case reports have their own relevance and place in the medical literature. If not for the reporting of ‘Kaposi’s sarcoma in homosexuals’ AIDS (acquired immunodeficiency syndrome) may not have been discovered, same holds good for the disease of kings (Gout) or shaking palsy (Parkinson’s disease). Hence, case reports pave the way for future studies with better research designs.

What one should know before writing a case report?

What are the different types of case reports and how to choose?

Case reports can be related to a diagnostic or therapeutic challenge. It need not always be the ‘rare presentation of a usual disease’ or ‘clinical presentation of an unusual disease’ or usage of a ‘new medical or surgical treatment’. It may be a case with ‘ethical dilemma’ or it can even be a ‘medical error’. But, remember the very purpose of reporting case reports is that they should convey a key learning message to a clinician. Hence, remember case reports are not just about reporting of a rare syndrome, it is about conveying a teaching point to the readers.

How to start?

Keep looking for challenging cases in wards and outpatient departments. Once you find one, do a thorough literature search and discuss it with your mentor or guide. They will be able to guide you on the reportability of a particular case. Do inform your colleagues and form a team of not more than ‘4’. Before investing your time you should be sure about the chances of acceptability of that particular case and make sure you and your friend are not working on the same case. And if needed, get your colleagues permission if he/she had been in charge of that particular case. Then collate all the information (including clinical and radiographic images), choose the appropriate journal and go through the “instructions for the authors” of the concerned journal thoroughly. Some journals may not accept case reports, and some may accept them in a different format like ‘letters to the editor’. Check on the article processing charges (open access models usually charge) and other specifications like word limit, permitted tables and figures etc. Only after doing all this homework, you should start writing the case report.

How to structure a case report?

The following are the components of a case report:

  1. Title and abstract
  2. Introduction
  3. Case report/Summary
  4. Discussion
  5. Conclusion

The case reports are usually structured in the above-mentioned format with or without the sub-headings.

Any ethical issues or publication misconduct to be careful of?

We always have to get a written informed consent from the patient. Ideally, the final proof should be shown to the patient, though may not be possible in all the settings. The identity of the patient should not be revealed. We should not falsify or fabricate the data or images. If there is any added investigation (adding to the patient’s cost) or invasive or non-invasive procedure (with risk of procedure-related side effects), it has to be sorted out with the ethics committee.

What are the common pitfalls?

  1. Understand that the acceptance of case reports for publication is not based on rarity but rather on key learning messages being provided to a practicing clinician.
  2. Always highlight just one or two take-home messages and not bombard the readers with a variety of learning points.
  3. Always do a thorough literature search and discuss with your guide or mentor. Check on the suitability for reporting the case and then invest your time in writing one.
  4. Considering the risk of bias, case reports do come low in the level of evidence, so avoid making sweeping statements or recommendations to the readers.
  5. Stick to standard reporting guidelines (CARE guidelines – Box 1) and also report as per the individual journal’s specifications, as they may differ between journals.

Know your target audience and prepare the manuscript accordingly. Avoid exaggeration, falsification or omission. If the manuscript comes for revision, revise it with utmost care as you may be just a step away from your first publication. If rejected, don’t lose heart! Either start looking for another journal with all the changes incorporated as per the reviewers’ comments or if the case report has too many fallacies, start looking for the next case.

“Always note and record the unusual…Publish it. Place it on a permanent record as a short, concise note. Such communications are always of value,” the wise words of Sir William Osler. Hence, case reports or case series still hold their place even in the current era of RCTs. And remember, writing a ‘Case Report’ may be the beginning of a glorious and successful career in medical writing!

So, let’s start writing

Suggested readings

1) Equator network:www.equator-network.org/

Checklist

Title: The diagnosis or intervention of primary focus followed by the words “case report”.

Keywords: 2 to 5 keywords that identify diagnoses or interventions in this case report (including “case report”).

Abstract – (structured or unstructured)

Introduction:What is unique about this case and what does it add to the scientific literature?

  1. The patient’s main concerns and important clinical findings.
  2. The primary diagnoses, interventions, and outcomes.
  3. Conclusion – What are one or more “take-away” lessons from this case report?

Introduction: Briefly summarizes why this case is unique and may include medical literature references.

Patient Information

  1. De-identified patient specific information.
  2. Primary concerns and symptoms of the patient.
  3. Medical, family, and psychosocial history including relevant genetic information.
  4. Relevant past interventions and their outcomes.

Clinical Findings:Describe significant physical examination (PE) and important clinical findings.

Timeline:Historical and current information from this episode of care organized as a timeline (figure or table).

Diagnostic Assessment

  1. Diagnostic methods (PE, laboratory testing, imaging, surveys).
  2. Diagnostic challenges.
  3. Diagnosis (including other diagnoses considered).
  4. Prognostic characteristics when applicable.

Therapeutic Intervention

  1. Types of therapeutic intervention (pharmacologic, surgical, preventive).
  2. Administration of therapeutic intervention (dosage, strength, duration).
  3. Changes in therapeutic interventions with explanations.

Follow-up and Outcomes

  1. Clinician- and patient-assessed outcomes if available.
  2. Important follow-up diagnostic and other test results.
  3. Intervention adherence and tolerability. (How was this assessed?)
  4. Adverse and unanticipated events.

Discussion

  1. Strengths and limitations in your approach to this case.
  2. Discussion of the relevant medical literature.
  3. The rationale for your conclusions.
  4. The primary “take-away” lessons from this case report (without references) in a one paragraph conclusion.

Patient Perspective:The patient should share their perspective on the treatment(s) they received.

Informed Consent:The patient should give informed consent. (Provide if requested.)

Dr.-S.-Sham

Dr. S. Sham

Consultant – Rheumatologist

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