Volume 100: Case reports: should they be confined to the dustbin?
A tale should be judicious, clear, succinct;The language plain, and incidents well linked;
Tell not as new what ev'ry body knows,
And new or old, still hasten to a close.
Conversation, 1782.
William Cowper, English Poet
Since time immemorial, editorial boards have agonized about publishing case reports in their journals. Will they denigrate the standards of their journal and most importantly, will they have a disadvantageous effect on their impact factor? The agony continues as most of us enjoy reading a tale of horror (especially if we do not experience it first hand). It must be acknowledged that case reports attract readers, often clinicians, who may not, alas, look at other parts of the British Journal of Anaesthesia in the same detail. But most importantly, a case report should only be published if it adds to our knowledge or improves our practice. Tales of woe, especially followed by the death of a patient, are insufficient.
Almost all medical journals publish case reports. Historically, they have been an integral component of any clinical journal. However, for the reasons given, there has been a gradual decline in the numbers published in leading medical journals in recent years. For instance, we have estimated that, in the British Journal of Anaesthesia, over the last decade, the number of case reports has decreased by one-third. In contrast, with the ever-increasing numbers of online journals, there is now a journal dedicated only to publishing case reports (www.jmedicalcasereports.com).
Editors of medical journals are under growing pressure only to publish articles that will be cited. Although the number of citations of an article does not necessarily reflect how widely the article has been read, currently the citation index is the most accepted method of assessing the credibility of an article. Thus, if editors are only subservient to external pressures, they would fill their journals with randomized controlled trials and no case reports. In the medical literature, randomized controlled trials, which are considered to be Class 1 scientific evidence, are undoubtedly the most-cited. They are most likely to increase the citation index and hence the impact factor of the journal.1 This is of great importance to any editor as the status of their journal is ranked according to its impact factor. It affects academic promotion in Europe. One may argue about the fairness of this ranking system, but editors cannot ignore the harsh reality.
Recently, we surveyed the Oxford University Press website to study the 50 ‘most-read’ articles since the British Journal of Anaesthesia went online (2003), and the 50 ‘most-cited’ articles over the past 25 yr. Interestingly, there were three case reports in the ‘most-read’ section,2–4 but among the 50 ‘most-cited’ articles, there were none. This is in contrast to 1998, when Hall listed the top 50 BJA Citation Classics from 1945 to 1992.5 Second in the list was Denborough's report of anaesthetic deaths in a family, probably from malignant hyperthermia.6 In the current climate, we have undertaken to appraise the value of publishing case reports and their credibility in the twenty-first century.
Let us first consider why we as practising anaesthetists should want to publish a case report? Sharing new experiences, challenges, or discoveries with our colleagues is an essential ingredient of medical culture, indeed of human nature. It has been the basis of the growth in medical knowledge and education. It is instinctive human behaviour that, when we experience some new or unusual clinical situation, we feel urged or even duty-bound to share it with the wider medical community. Not to do so may be considered psychopathic; or is it all simply showmanship?
In the anaesthetic literature, including the British Journal of Anaesthesia, case reports have been the first to document adverse reactions to anaesthetic drugs or procedure-related complications, often highlighting rare but important clinical problems.7–12 A good example is the very rare but potentially life-threatening anaphylaxis to pancuronium.11 Such reports have been the original source of an introduction to a new technique,13 and a reminder of an established but often forgotten way of managing a particular clinical problem.14 Some case reports have explored interesting physiological changes, which have subsequently been utilized in clinical practice.15 For example, early reports of end-tidal carbon dioxide tension being an indicator of pulmonary blood flow16 became one of the reasons for routine measurement of end-tidal carbon dioxide in clinical practice. Case reports have also been important early records of life-threatening albeit rare complications such as malignant hyperthermia,17 18 or acid aspiration syndrome.19 20 By providing new information at an early stage, case reports have been the basis for defining new subject areas, and stimulated subsequent prospective investigations. In addition, case reports have continued to provide exciting new educational material.21 On occasion, they have been clustered together along with a review of the literature to provide a comprehensive summary of a problem from which important lessons can be learnt and guidelines for management developed.22–25 This can be most useful in the management of those rare diseases which are challenging to the anaesthetist such as the excellent article by Aldridge25 in 1985 on myotonic dystrophy. Some reports have described incredible events, such as the incorrect filling of oxygen cylinders,26 or have gone against perceived wisdom, reminding us all that medicine is not a perfect science.27 28 Hence, case reports have been crucial in enhancing our understanding of practical, anaesthetic-related problems, improving clinical management, and minimizing risk.
The conundrum is that the editorial team want all anaesthetists to read the British Journal of Anaesthesia. We acknowledge that some clinicians may only open this journal to read the case reports. It is very important to us that they do so. An unread but highly cited journal is sterile. A recent analysis by Oxford University Press has demonstrated that on the British Journal of Anaesthesia website (http://www.oxfordjournals.org/our_journals/bjaint/for_authors) where it is possible to view accepted manuscripts ahead of print (BJA Advance Access) several of the downloads each month are of case reports. They must be stimulating the browser's interest.
Although adding to the growth of knowledge in its field is the prime object of any medical journal, it should not be affected excessively by fashionable trends. The fact that a case report can albeit rarely increase our medical understanding should not be ignored. Editors and reviewers have the hard task of ensuring that a case report which has been submitted for their consideration will add new information to the existing literature. In these reports, they will search for:
- Unexpected and unreported presentations of a disease.6 17 18
- Management of new and emerging diseases.21
- An unexpected and under-reported event in treating a patient.15
- A novel and unreported method of management.14 16
- Unreported adverse drug reactions.7–11
- Findings that shed new light on pathogenesis.22
- Equipment problems.26
- A short review of the existing literature on an unusual scenario, along with a case report.21 25
On balance, we believe that case reports should not be confined to the dustbin. They should in a small way remain integral to the growing medical literature in the field of anaesthesia. However, authors, reviewers, and editors need to ensure that these reports continue to provide new insights into our specialty and that their numbers are controlled. The challenge for editors is to be innovative in turning such material into a product that will enhance the journal's impact. In the last 100 volumes, the British Journal of Anaesthesia has published more than 13 000 case reports in various formats including reviews and letters. Several have described important adverse drug effects, rare clinical conditions, and physiological phenomena that have triggered further clinical studies, and have added significantly to the clinical management of patients undergoing anaesthesia. We sincerely hope that case reports, in whatever form their publication takes in volumes 100–200 of the British Journal of Anaesthesia, will continue to advance existing knowledge, ultimately benefiting our specialty and patient care. However, they must not be:
Like all gossip—it's merely one of those half-alive things that try to crowd out real life.A Passage to India
EM Forster, 1924
1 Nottingham, UK
2 Liverpool, UK
* E-mail: bja{at}nottingham.ac.uk, mszrpm{at}gwmail.nottingham.ac.uk
References
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25 Aldridge LM. Anaesthetic problems in myotonic dystrophy. A case report and review of the Aberdeen experience comprising 48 general anaesthetics in a further 16 patients. Br J Anaesth (1985) 57:1119–30.
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28 Birkhahn HJ, Heifetz M. Accidental intra-arterial injection of amphetamine: an unusual hazard of drug addiction. Case report. Br J Anaesth (1973) 45:761–3.
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