How to publish a clinical caseFernando Ivanovic-Zuvic,
CLINICAL CASE HISTORY AND CURRENT SITUATION
The first written case report, an Egyptian papyrus, dates back to 1600 BC. It includes the description of 48 head injury cases, in which the knowledge acquired from practical experience is emphasized. In the West, Hippocrates makes references to medical records where descriptions of clinical cases are similar to those found in the Hippocratic Corpus, written in the 5th century BC. (1).
Nowadays, the importance of individual clinical cases is disputed because a single clinical case may not represent reality from a statistical, scientific point of view; meaning, it is not representative of most patients with a particular medical condition. Due to the aforementioned, publications with increasingly higher number of samples and sophisticated statistical analyses are favored, building knowledge acquired by applying mathematical probability analyses. Thus, published works are supported by statistical analyses at the expense of individual cases. Consequently, some medical journals peer reviewers do not consider individual clinical cases relevant, as they would present a distorted reality that is not representative of most subjects and would, therefore, appear to offer limited benefits. On the contrary, the study of the clinical case involves anecdotal, non-scientific situations with lower certainty than group and controlled studies, which has led to less frequent publications of individual cases in scientific literature.
Indeed, research studies with large samples have contributed to clinical knowledge because they include representative samples of a particular population. They become relevant as they include general clinical profiles, response to treatments, and prognosis in higher numbers of subjects. This knowledge has influenced current classifications, such as the DSM 5 and the ICD 10, which try to reflect reality based on consensus as a result of the inclusion of this statistical field research.
Categorical classifications include clinical conditions as discontinuous categories with fixed diagnostic entities, delimited and distinguishable, with precise boundaries. These classifications contribute to greater regularity in diagnosis, prognosis, evolution, and treatment. If the individual clinical case represented an outlier, it would not be included in this analysis.
Dimensional classifications do not establish substantial differences in clinical diversity, because they represent a continuum with quantitative variations between clinical manifestations through an emphasis on the relationships between the studied traits or elements. An individual clinical case could be included, but not in its real dimension and relevance for the objectives of its analysis.
The latest version of the DSM publication by the NIMH (National Institute of Mental Health) stated the objective is the RDoC system. This system is an attempt to create a new type of taxonomy for mental disorders using the modern research approaches of genetics, neuroscience, and behavioural sciences to address the problem of mental illnesses. Arguably, by identifying genetic and molecular foundations of the body or the structure and function of the brain will lead to improved treatment of mental illnesses, easing the prevention, recovery, and healing of these conditions.
In this scheme proposed by the NIMH, only the causality of the clinical conditions is relevant--to which they aspire to attribute a fundamental role. However, at present we only know a part of the etiologies of the subjects that suffer from any clinical condition.
The importance of the clinical case arises from research with large samples of patients, in which the authenticity of the individual case is lost, the particular subject who may be the one really asking for help from the medical consult. How could the patient's history and the significant facts be included, particularly in psychiatry, which in this sense departs from the biological analysis of general medicine or other specialties? However, single-case research is still relevant to other specialties, as it is shown in the relationships between the mind, brain, and body involved in any illness.
It is worth asking how the importance of the individual clinical case may be maintained from a clear and precise point of view of the research study since every individual is different from another. Another question raised involves how psycho-therapeutic analyses, which are based on individual cases specific to each subject, may be incorporated.
A clinical case could be a reliable source of evidence in medical practice, as it may be the first appearance or onset of a new illness. It may have an educational value, both for authors and readers. They are review sources for particular subjects. They may constitute an engaging and didactic channel of communication between clinicians with educational purposes, especially when the case is closed to the regular practice of clinicians.
A new clinical case could be a novelty whose importance should be spread through scientific literature, as medicine has advanced due to the appearance of particular observations that challenge the paradigm used up to date to diagnose and treat illnesses. An example would be the accidental observations that have revealed new knowledge, such as the case of Flemming and penicillin, in which the action of penicillin on bacteria was observed accidentally. In this way, observations are disseminated among those who can see something new and change the established parameters through critical view to contribute to the development of science. (2-13)
Situations that may be included as clinical cases are shown in Table No 1.
|1||Rare disorders New, infrequent, or poorly communicated illnesses|
|2||Unusual presentation of a common disease|
|3||An unexpected association between infrequent symptoms or signs|
|5||Complex differential diagnosis|
|6||Rare association between two or more pathologies Impact of some over others|
|7||To present sensitive information about ethical aspects|
|8||To illustrate a clinical hypothesis To test new hypotheses To rule out or confirm a hypothesis|
|9||To foster research on a topic|
|10||To teach a subject for educational purposes|
|11||To make an original contribution to the literature|
|12||New approaches to the pathogenesis of the disease. Links to clinical practice|
|13||To show new procedural techniques and new treatments|
|14||To establish a treatment in a new setting|
|15||Unusual developments in the course of treatments|
|16||Treatments errors and their consequences|
|17||To describe reactions and responses to drugs, adverse reactions, interactions, and side effects not described.|
|18||Novel psychosocial aspects of a disease|
Table No 1. Situations that merit publication as clinical cases
Although each journal has its format regarding the presentation of a clinical case, there are regulations for the formal aspects of the presentation. The Vancouver reference style is the best-known standard (Table No 2). (see quote)
|1||Title: Brief, clear, precise, and engaging|
|2||Summary: Short, easy to read, 250 words. Key points of the case, why it deserves to be published, and why it is being published|
|3||Introduction: Why it is being published, clinical justification, and its implications for health. A review of other cases in the literature is implicit.|
|4||Presenting the case: Patient's description and evolution. Include the complete study. Drugs with generic names. Protection of the patient's identity|
|5||Discussion: The essentials of the case, differential diagnosis, and its contribution. Do not make generalizations.|
|6||Conclusion: A clear message, pointing at its relevant particularities. Recommendations for similar future situations and lines of research.|
|7||References: Relevant and related to the case. No more than ten articles of reference.|
|8||Appendixes. Figures and tables may be included.|
Table No 2 Vancouver reference style for clinical cases
For publishing purposes, single case limitations should be considered. No conclusions should be drawn from epidemiological cases, as they are not representative cases. Avoid emphasizing rare cases to the detriment of common ones. Thus, their causality is limited because, usually, descriptive research is included where it is not possible to make generalizations. To establish definite cause-effect link samples of greater probabilistic value are required.
An aspect to keep in mind is that current literature usually selects therapeutically successful cases, but not those without favourable evolution. For example, in The Lancet, only 5% showed unfavourable cases. Today, this aspect is increasingly important, particularly for research conducted by the pharmaceutical industry. There should be regulations about the duty to publish all empirical studies' results, whether with favourable therapeutic results or unfavourable ones, especially regarding the use of pharmacological therapies.It is possible to include over-report the results where anecdotal cases are difficult to over or under-report.
Given that it is an individual case, the patient's privacy may be compromised. Prior to 2003, a patient's consent was not required in the U.S. Since then, a patient's consent is required. Some journals have a form for informed consent. However, even under that legislation, a case in which all possible evidence was removed could be included, which was an area of uncertainty in terms of completing the survey and the informed consent form. On the other hand, there are doubts about the use of informed consent since it has not been demonstrated that this situation affects the frequency of clinical case publications (14,15).
The ethical aspects vary depending on the legislation of each country. In Chile, article 13 of law 20.548 establishes that people not related to health care cannot have access to clinical records without the patient's authorization or informed consent. Research and retrospective studies require the patient's consent. If it the patient's personally identifiable information is removed, then it can be approved by the Research Ethics Committee. In this vein, editors would be qualified to demand the patient's and the Institutional Ethics Committee's authorization as a requisite for the publication of the clinical case, in addition to the terms to protect the patient's anonymity (16,17). The aforementioned law indicates that consent may be verbal, the written form being only necessary for surgical interventions or invasive diagnostic or therapeutic procedures.
Another benefit of the publication of a clinical case is that it is possible to carry out the phenomenological method more appropriately. Jaspers, an essential contributor to phenomenology, mentions that phenomenology "has the mission to intuitively represent the psychic states experienced by the ill; according to their conditions of affinity, precise terms are limited, differentiated, and applied. With this aim, external manifestations of the mood are described and their conditions studied. These states are compared in relation to the the self-descriptions and confidences of the ill individuals". This is executed through what surfaces from the communication with the patients. The experience described through systemic categories, formulations, and comparisons, relatedness among the phenomena, its order in series, and its transitions through impartiality in the contemplation of the phenomenon through a critical effort and laborious work constitutes an aspect of the clinical practice that can be tackled through the clinical case. This would be a method that pretends to capture directly, without prejudices, how the illness manifests itself (18).
The journal Revista Trastornos del Animo (Mood Disorder Journal) publishes original articles from researches, reviews, clinical studies, brief reports, letters to the editor, and personal communications. It receives papers from diverse areas of psychopathology and subjects linked to mood disorders. It is the representative body of the Unidad de Trastornos Bipolares CPU (Bipolar Disorders Unit) and the SOCHITAB, and has, as part of its editorial line, original articles, clinical studies, brief reports, art and mood disorders, and subject and author indexes.
In this journal, we have published a clinical case in practically every number. The case is described preserving the patient's confidentiality. Three specialists are eventually invited to comment on it. Only exceptionally two or one are invited. The specialists are experts on the topic and usually from the field of psychiatry. The format is the introduction, importance of the case, and a detailed clinical history of the patient with emphasis on the clinical descriptive characteristics. Subsequently, the corresponding examinations and the course of the disease if it is relevant to the case are discussed. Finally, conclusions are included. Only references that refer to the subject are included.Experience has shown that this section, called Case reports/clinical cases, has been one of the most read and commented by the readers. We have not encountered difficulties with the patients studied since their identity and references for their possible identification have been protected with zeal. Exhibitors and commentators are referenced per their place of belonging and their contribution to the journal. Expertise has been developed in this regard since this section requires more intervention by the editors so that the specialists that present on the subject and those who comment on the topic adhere to the format and extension of the comments. An appropriate proportion between the extension of each author's comments should be kept. This section of the journal has been particularly rewarding. International commentators have expressed their gratitude for their inclusion in the journal, which they receive in their particular workplaces, particularly universities abroad. Our editorial committee will continue promoting this section to encourage both students and specialists' interest concerning mental illnesses.
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