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The Value of an Interesting Case
EDITORIAL
The Value of an Interesting Case Case reports are pervasive throughout the medical literature, and they play an important role in the in the development of an understanding of rare diseases and novel interventions. The presentation of a case report follows a conventional format. ( The Journal of Foot & Ankle Surgery 46(4):211–212, 2007) Key Words: case report, rare disease, novel intervention
On the overall ladder of clinical evidence, the case report can be found near the bottom rung. Case reports, like small case series and cross-sectional studies, have a number of shortcomings that threaten the validity of their results. These include selection and measurement biases, the lack of a comparison group, and the lack of statistical power to determine whether the results observed were due to treatment or merely to chance. Despite these shortcomings, the well-written and interesting case report plays an important role in the medical literature. The value of a case report stems from its ability to convey information about a rare disease, or novel therapy or diagnostic test. Such reports serve to draw attention to these conditions or interventions, and aid clinicians who may encounter similar cases in the future. In turn, clinicians who become familiar with the outcome of the case report (by reading the published report) may be better suited to treat other patients presenting with the rare disorder. If the condition is important enough, either due to the potential ramifications, such as pain and suffering, associated with the disease, or if recognition of the condition becomes prevalent enough to stimulate widespread attention, then case reports and clinical experience may serve as the foundation on which clinical hypotheses are generated. Such hypotheses, in turn, stimulate scientific investigation into the nature of the disorder or intervention, and these efforts may contribute to clinical knowledge. Understanding this chain of events makes clear the important role that the case report plays in the hierarchy of clinical investigation, and also makes clear the fact that clinical research aims to answer questions that evolve in the course of clinical practice. This is also the very reason that clinical research fellowships always entail rotations that involve hands-on patient care. In essence, clinical research questions develop as a result of patient care. Traditionally, the report of a case is divided into 3 sections: Introduction, Case Report, and Discussion. The report should read like a continuous narrative, beginning with an Introduction section that succinctly describes the case to be
reported, and a statement about the uniqueness or unusual nature of the condition or treatment being described. Thereafter, the Case Report section should detail the clinical course, including the presenting concerns of the patient or family, the results of the historical interview and physical examination, any pertinent tests or findings used to support the diagnosis, and a summary of the treatment and follow-up course. Appropriate clinical and intraoperative photographs, diagnostic images, and histopathological micrographs should also be included with the report. The description of the clinical case should be concise, and nonessential details should be avoided. The purpose of the Discussion section is to provide a context for the case. To this end, it is important for the author(s) to know the existing pertinent literature and to have thoroughly searched the available databases (at least Medline, CINAHL, and Embase) for prior documentation of the condition or treatment. If the review of the literature failed to show a preexisting publication describing the condition or novel intervention, then it is appropriate for the authors to point this out. After the literature review, it is useful to discuss the most interesting aspects of the case report, to comment on etiology, and to speculate as to why the case progressed as it did. It is also advisable to mention any important lessons that were learned by those involved with managing the case. The Discussion section should end with a brief summary that reiterates the rarity of the condition or treatment described in the report, and summarizes the findings in a sentence or two. There is no need for a separate Conclusion section. So, do not hesitate to submit for publication the report of an interesting case. Many clinicians do, and these articles usually make for interesting reading. If your case is unique and compelling and associated with a useful lesson for practitioners, it will be considered for publication and may prove to be an important contribution to our knowledge of the evaluation and treatment of the foot and ankle. Ultimately, case reports focus attention and stimulate interest in VOLUME 46, NUMBER 4, JULY/AUGUST 2007
211
rare or unusual diseases, or novel interventions, and promote the scientific investigation of these entities. The interested reader is encouraged to consider the following references pertaining to case reports: D. Scot Malay, DPM, MSCE, FACFAS Editor, The Journal of Foot & Ankle Surgery, Ankle & Foot Medical Centers, Philadelphia, PA.
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THE JOURNAL OF FOOT & ANKLE SURGERY
Recommended Reading 1. Vandenbroucke JP. Case reports in an evidence-based world. J R Soc Med 92(suppl):159 –163, 1999. 2. McCarthy LH, Reilly KE. How to write a case report. Fam Med 32:190 –195, 2000. 3. Fox R. Writing a case report: an editor’s eye view. Hosp Med 61:863– 864, 2000. 4. Cohen H. How to write a patient case report. Am J Health Syst Pharm 63:1888 –1892, 2006.
The Value of an Interesting Case Case reports are pervasive throughout the medical literature, and they play an important role in the in the development of an understanding of rare diseases and novel interventions. The presentation of a case report follows a conventional format. ( The Journal of Foot & Ankle Surgery 46(4):211–212, 2007) Key Words: case report, rare disease, novel intervention
On the overall ladder of clinical evidence, the case report can be found near the bottom rung. Case reports, like small case series and cross-sectional studies, have a number of shortcomings that threaten the validity of their results. These include selection and measurement biases, the lack of a comparison group, and the lack of statistical power to determine whether the results observed were due to treatment or merely to chance. Despite these shortcomings, the well-written and interesting case report plays an important role in the medical literature. The value of a case report stems from its ability to convey information about a rare disease, or novel therapy or diagnostic test. Such reports serve to draw attention to these conditions or interventions, and aid clinicians who may encounter similar cases in the future. In turn, clinicians who become familiar with the outcome of the case report (by reading the published report) may be better suited to treat other patients presenting with the rare disorder. If the condition is important enough, either due to the potential ramifications, such as pain and suffering, associated with the disease, or if recognition of the condition becomes prevalent enough to stimulate widespread attention, then case reports and clinical experience may serve as the foundation on which clinical hypotheses are generated. Such hypotheses, in turn, stimulate scientific investigation into the nature of the disorder or intervention, and these efforts may contribute to clinical knowledge. Understanding this chain of events makes clear the important role that the case report plays in the hierarchy of clinical investigation, and also makes clear the fact that clinical research aims to answer questions that evolve in the course of clinical practice. This is also the very reason that clinical research fellowships always entail rotations that involve hands-on patient care. In essence, clinical research questions develop as a result of patient care. Traditionally, the report of a case is divided into 3 sections: Introduction, Case Report, and Discussion. The report should read like a continuous narrative, beginning with an Introduction section that succinctly describes the case to be
reported, and a statement about the uniqueness or unusual nature of the condition or treatment being described. Thereafter, the Case Report section should detail the clinical course, including the presenting concerns of the patient or family, the results of the historical interview and physical examination, any pertinent tests or findings used to support the diagnosis, and a summary of the treatment and follow-up course. Appropriate clinical and intraoperative photographs, diagnostic images, and histopathological micrographs should also be included with the report. The description of the clinical case should be concise, and nonessential details should be avoided. The purpose of the Discussion section is to provide a context for the case. To this end, it is important for the author(s) to know the existing pertinent literature and to have thoroughly searched the available databases (at least Medline, CINAHL, and Embase) for prior documentation of the condition or treatment. If the review of the literature failed to show a preexisting publication describing the condition or novel intervention, then it is appropriate for the authors to point this out. After the literature review, it is useful to discuss the most interesting aspects of the case report, to comment on etiology, and to speculate as to why the case progressed as it did. It is also advisable to mention any important lessons that were learned by those involved with managing the case. The Discussion section should end with a brief summary that reiterates the rarity of the condition or treatment described in the report, and summarizes the findings in a sentence or two. There is no need for a separate Conclusion section. So, do not hesitate to submit for publication the report of an interesting case. Many clinicians do, and these articles usually make for interesting reading. If your case is unique and compelling and associated with a useful lesson for practitioners, it will be considered for publication and may prove to be an important contribution to our knowledge of the evaluation and treatment of the foot and ankle. Ultimately, case reports focus attention and stimulate interest in VOLUME 46, NUMBER 4, JULY/AUGUST 2007
211
rare or unusual diseases, or novel interventions, and promote the scientific investigation of these entities. The interested reader is encouraged to consider the following references pertaining to case reports: D. Scot Malay, DPM, MSCE, FACFAS Editor, The Journal of Foot & Ankle Surgery, Ankle & Foot Medical Centers, Philadelphia, PA.
212
THE JOURNAL OF FOOT & ANKLE SURGERY
Recommended Reading 1. Vandenbroucke JP. Case reports in an evidence-based world. J R Soc Med 92(suppl):159 –163, 1999. 2. McCarthy LH, Reilly KE. How to write a case report. Fam Med 32:190 –195, 2000. 3. Fox R. Writing a case report: an editor’s eye view. Hosp Med 61:863– 864, 2000. 4. Cohen H. How to write a patient case report. Am J Health Syst Pharm 63:1888 –1892, 2006.