How to Write A Clinical Case Report

1. Workshop on How to Write A Clinical Case Report Professor Dr MD Abdul Wohab Khan MBBS, FCPS, MMEd Professor and Head Department of surgery And A learner in Medical Educational Science

2. Writings that can be published in journals ? • An original research paper • Describe the findings of an original research • A short/brief communication • Abbreviated description of original research study • A case report • Describe an unusual observation in usual cases or an unusual case

3. Writings that can be published • Letter to the editor • Some data not sufficient to publish a full length of paper • Comment on recently published study • In the journal with a few line reporting your own finding • Statement of a point of view (to the editor) • State your opinion or statement of facts on a topical issue

4. An editorial • Put forward a controversial or a new issue • A review article • Meta-analysis – summarize the literature or series of studies • Systemic review - Literature review focused on a research question to identify, appraise, select and synthesize high quality research evidence. • An informal article • To wider reader to tell a recent event or a personal story of scientific interest

5. The publishing process Author Revisions Accepted/rejected Submit Two references (Peer review) Journal editor Advise Statistical references Referencing for scientific contents Accepted revision Final article Further references if needed (Scientific reference) Queries Copy editor In press Proofs Publication in journal Libraries Readers

6. What is a case? • Please define/what you know about it – 2m • Please come in front (any one interested) and share with others ---3m

7. Case - a happening, an event or an occurrence • Case reports are brief report • Describing and analyzing an isolated or a small number (1 to 3 or 5?) of clinical cases on diagnosis and/or management • “Scientific observations……. carefully documented so that they may be a valuable education and research resource” • ---- Sir William Osler • ‘…Any patient that goes through the door of a hospital is a potential case report…’

8. Would you please mention the hierarchy of evidences in research papers ? Please discuss the place of case report (in groups) and Present it in front of the participants with logic

9. Hierarchy of evidences and its creation RCT Case control/cohort study Case series Case report Case report Case series Meta-analysis Systemic review

10. History • Earliest in papyrus records (Egypt) @ 1600 B.C.. incurable tumors of the breast • Melanoma by Hippocrates, 5th century B.C. • By Rufus of Ephesus, (Greek) - first century A.C. • January 1832, Thomas Hodgkin - Hodgkin’s lymphoma.

11. In 1941, • Stacy Guild (Johns Hopkins University) • Described a glomusbody in the human temporal bone • Harry Rosenwasser (New York) • operated a carotid body tumor from ear of a patient • Dr. Rosenwasser communicated with Dr. Guild and both combinedly gave final case report • Established the clinical entity - glomus tumor • AIDS - discovered on the basis of a case report • Extensively disseminated Kaposi’s sarcoma in the American Journal of Dermato-pathology in 1981

12. In 1985 • AMA reprinted 51 papers that • Had significantly changed the medical science and practice • Published within last 150 years • 5 of these papers were case reports

13. So case report is ----not a “second class” publication It is the foundation of all research

14. Types • Diagnostic/assessment reports • Describe and discusses the rare, confusing, or difficult cases • Treatment or management reports • Full management & assessment with in depth understanding • Educational reports (CME reports) • Brief review of the literature to provide current practice strategies • Old cases with new & innovative perspective view

15. Publishable case reports • Describing an unusual setting for care • Presenting information with ethical question • Illustrating or supporting a hypothesis • Pointing in favor or against a hypothesis • An unusual or unknown disorder/clinical presentation • Pointing to unusual etiology for a case • Present a challenging differential diagnosis • Describing mistakes in health care, their causes and consequences

16. To stimulate further research • To offer new insight into the disease • To describe improved or unique technical procedures • To describe the historical development of a field or movement • To report unusual drug-drug, drug-food, or drug-nutrient interactions • To describe rare or novel adverse reactions to care

17. Study Design of Case Reports • It is a descriptive study • In depth naturalistic and qualitative • Usually it is retrospective as it is not a pre-planned research • Can experimental and prospective design “A case study” • Ligating PDA in 1939 (Anwar ulhaque et al 2009) • Endoscopic Para-thyroidectomy in BSMMU in 2007(Aziz and Khan 2010)

18. In which section will you publish the case report? Sections in peer reviewed journal • ‘Case report’ section • ‘Clinical case conference’ • ‘Technical report’ • ‘Letter to the editor’ and • ‘Evidence based case report’

19. Writing a case report

20. Planning • Careful planning is essential for • All good research project • Good scientific writing So Take time to plan • Sections • Subsections • Paragraphs • Sentences

21. The three question • What I am going to report? • How should I report it ? • In which Journal ?

22. Case report format Please discus among the group 3m Present and discuss (one from each group) 5m

23. Reporting format of scientific article IMRAD • Introduction, objectives, literature review • Methodology • Result • And • Discussion

24. Introduction and objective with a literature review • Description of the case • Discussion with a detailed explanation of the literature review • Summary of the case, and a conclusion

25. Submission for publication • Read the information for the Authors for The intended Journal • Write in separate pages • Title • Abstract and key words • Introduction and objectives with (literature review) • Description of the case report • Discussion with Case summary

26. Conclusion • Supplementary materials • Tables • Figures • Graphs • Illustrations • 1500 to 2500 words • 20-30 references

27. Tea break 10 m

28. Title Page • Provide the title • Full name(s) of the author(s), • Institutional addresses and • Email addresses • Indicate the corresponding author The title should be • Descriptive • Accurate • Succinct

29. Practices on title • “A 4-month-old boy presenting with anaphylaxis to a banana: a case report” • “Spontaneous ejaculation’ A rare symptom in post traumatic stress disorder” • “Neurofibromatosis induced hip arthritis. An unusual presentation”

30. Abstract • Write the abstract lastly • Polish it till it s just right • Word limit’ Structured (with headings) or unstructured (single paragraph) • No abbreviation or references

31. Abstract • Please state briefly the conclusion and • State how it will influences in practice or advancement in knowledge • Keywords • Words representing the main content (Three to ten)

32. Apply reviewers check list • Introduction and objective • Case report • Discussion • Conclusion

33. Introduction • Describe the subject (Concise and salient )to clarify - background information/evidences • State and the strategy and extant of literature search • Date, database, language, search terms/key words. • Easily reproducible • Must cover the relevant database

34. Narrate the purpose and merit with review of the reports • Justify the case report (focused comprehensive literature review) • Begin what is known • Move to what is new • Highlight the implication • Introduce the case to the reader • Select references carefully • Limit the length • Do not overinflate than discussion

35. Apply reviewer check list • Subject matter described • Purpose stated • Background information provided • Pertinent definitions given • Merit of the case report justified; using literature review • Case introduced to the reader • Introduction is brief (< 3 Paragraph)

36. Case Presentation Follow the basic clinical rule • Think what question might be asked by your colleagues • Ensure the answer within the report • Add photographs, line diagrams, graphs, measurements and summary tables • To enhance readers understanding • Not to decorate • It is wise to obtain written consent

37. Apply reviewers check list • Describe the case in a narrative form • Provide patient demographics (age, sex, height, weight, race, occupation) but avoid identification • Avoid patient identifiers (date of birth, initials) • Describe the patient’s complaint. • List the patient’s present illness

38. Reviewers check list • List the patient’s family, social, medication, allergic, drug reaction, dietary history • Provide pertinent findings on physical examination • Provide pertinent laboratory values that support the case • Renal and hepatic organ function data

39. List the completed diagnostic procedures that are pertinent and support the case • Paraphrase the salient diagnostic procedures • Provide photographs of • histopathology, X-rays, ECG, skin manifestations, or anatomy as they relate to the case

40. Obtain permission from the patient to use the patient’s photographs or follow institutional guidelines • Provide the patient’s events in chronological order to • Ensure a temporal relationship • Ensure a causal relationship • Ensure that the patient case presentation provides enough detail for the reader to establish the case’s validity.

41. Discussion • Compare and contrast with literature review to - • Evaluate the case for accuracy, validity and uniqueness • Explain and Justify - • differences and similarities • List - • the limitations and relevancies • Summarize the essential features • To justify uniqueness of the case, conclusion and recommendation

42. Compare and contrast with critically evaluated literature review • Explain or justify with valid literature • Franck to list the limitations and describe their relevance • Confirm the accuracy of the descriptive patient case report

43. Summarize the salient features of the case report • Justify the uniqueness of the case • Draw recommendations and conclusions • Logical and succinct • Well referenced

44. Conclusion and recommendation • This should be brief and not exceeding one paragraph • Justified and evidence based • Recommend and list opportunities for future research • Give guideline for utilizing the information in practice

45. Practical sequences • Write the case description in detail first • Discussion next • Then conclusion • Now finalize the ‘Title’ • Introduction • Abstract – should be the last thing to write

46. Don’ts in A Case report • Does not need to be headed as “Introduction” • Should not contain confusing information • No headings in history • No verbatim description of physical and laboratory findings

47. Don’t provide patient identity in any form • Don't duplicate information in in other part of the text • Don’t make firm judgment • No speculative or sweeping recommendation

48. Case report and law/ethics

49. Research is a systematic investigation to develop or contribute to generalizable knowledge • A case report is anecdotal medical/ educational activity that does not meet the definition of research • So case or case series presenting at a teaching conference does not require IRB review

50. Authorship • One dealing with and be responsible for everything • One having significant input