What is the value of continuing to publish case reports?

Case reports are a kind of scientific publications representing the simplest form of clinical research and are classified within the category of observational, descriptive trials.¹ This type of studies usually presents thorough and detailed information about a patient with an unusual clinical condition, not previously published and posing a diagnostic dilemma with a novel approach or suggesting an intervention that has not been previously described.

It is undeniable that case reports have played a key role in the history of medicine. Our current knowledge about many diseases began with one of such publications.²

The first descriptions are attributed to the ancient Egyptians (1600 BC). They recorded in their papyrus detailed information of patients with head and chest trauma for which novel interventions were offered, some of which are still being used. The most important legacy from that age translates into the knowledge gained from practical experience.^2,3

Later on, during the years of Hippocrates (400 BC), case reports with detailed descriptions of clinical findings flourished and a strong emphasis was placed on the chronological sequence of the disease and its evolution, including a proposal for the etiology of the patient's condition, since at that time these pathologies were not usually attributed to supernatural phenomena.^2,3

In times of Galen (130–200 AC), follower of Hippocrates, the descriptions were more conversational, using a first person narrative and evidencing the participation of professionals form various disciplines in the discussion of the particular case.²

During the Middle Ages the development of Medicine in the Western World became stagnant or dormant as a result of the influence of the church on culture. It was then that the Islamic Medicine flourished in the Eastern World (around 1000 AC), contributing with a lot of medical literature, with detailed descriptions and the use of clinical judgment in the diagnostic process.²

During the XVII and XVIII Centuries, the cases presented in the medical literature followed the Galen approach, with particular emphasis on the patient's subjective experience, highlighting the importance of the physician–patient relationship. The narratives had more a literary than scientific style with a strong dramatic component; this was the period of strongest growth of this category of scientific literature.²

From the XIX Century on to our days, a soberer style was adopted, using a scientific language and organized by sections, but the patient's perspective was missing²; however, it has been recently retrieved in the CARE checklist for case reports.⁴

Case reports have submitted detailed descriptions of rare clinical conditions, including the pathophysiological explanation, proposed diagnoses and novel therapeutic approaches, consistent with the mechanisms discovered in the thorough analytical process, favoring the generation of hypotheses and the advancement of clinical research. Furthermore, their value for educating the new generations is irrefutable.^1,3–5

Case reports are often used by undergraduate and graduate students as the first step in their learning process of scientific writing, since they involve the development of competencies for searching evidence and a critical analysis of the literature, in addition to communication skills that demand organizing ideas in a summarized, consistent, and pleasant manner for the reader.^6,7 Furthermore, usually well-known clinical specialists or opinion leaders who are too busy to do comprehensive research and to find the resources needed, contribute to the design of case reports so that their intellectual productivity is maintained.^1,6

In reviewing the evolution of this type of publications in the most prestigious scientific journals, it is evident that numerous serial publications have restricted the inclusion of case reports,⁸ partially or totally; some of the reasons include: the advent of evidence-based evaluation that places case reports in the lowest category of research design, considering the inability to control the impact of biases and random occurrence, the difficult repeatability of their findings, and their limited conclusions. Moreover, an analysis of the scientific publications – for instance in pediatrics,⁸ shows that there is a differential impact of the journals that accept case reports versus those that do not; probably this is due to the limited references of this type of studies that apparently imposes a penalty to those serial publications that include case reports.

Those that still consider case reports for their editorial processes, occasionally instruct the potential authors about the desirable characteristics of such case reports so that there is a chance of being considered for publication. In general, these journals take into account the originality of the subject, an unusual clinical presentation, a challenging diagnostic process, recognition of a new adverse event, the clinical or educational relevancy, the interest that the case may have for the potential readers of the journal, and the introduction of novel interventions that may lead to resolution of the clinical situation from the pathophysiological point of view, inter alia.⁹

Hence it is obvious that these potential publications have been pushed into the background.

In the light of this situation, it is then worthwhile to ask a number of questions to the editors of scientific journals:

Is there any value in continuing to publish case reports?

What would be the reason to continue doing it?

What characteristics or requirements shall the manuscript meet to be eligible for publication?

The view of the Colombian Journal of Anesthesiology (RCA) and of its editorial committee in response to these questions is that case reports have an undeniable value for the education process and for generating scientific hypotheses. There is no doubt that keeping this type of publication may have consequences on the journal's impact; however, the RCA is determined to continue publishing case reports on account of their importance for clinical education and training of healthcare professionals, and because case reports are studies with the most stringent methodology. The position of the RCA had been already expressed in an editorial early this year,³ when the journal decided to ask the authors to adopt the CARE Checklist^4,10 when submitting case reports for publication.

One additional factor to be considered by the authors before embarking on writing a case report is that some minimum baseline conditions have to be met. The author may ponder on the following questions and if one of them is positive, then he/she may move forward with the tasks:

Is it a novel or rare case, with clear lessons for the reader?

Is a diagnostic or therapeutic process being suggested that introduces new elements that may be further assessed in future research projects?

Are any new hypotheses generated?

Could the case pave the way to new research agendas?

Would this case be of interest to the readers of the Journal on account of its presentation and potential lessons?

The Colombian Journal of Anesthesiology is strongly determined to acknowledge the value of case reports and hence presents in this issue a select number of interesting and novel articles of this type.^11–26 The readers may identify novel strategies in the management of these cases, such as “Insufflation–Exsufflation devices in the postoperative respiratory failure”,¹⁹ or “Sedation for trans-catheter valve exchange of a Melody^® pulmonary valve” ²², to mention just a couple of the case reports you may enjoy in this issue.

Financing

The author was not sponsored to carry out this article

Conflicts of interest

The author is a Editorial Committee member of the Colombian Journal of Anesthesiology.