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Volume 15, Number 1, March 2003
| | The Role of Case Reports in a Surgical Journal |
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A surgical journal, like any other clinical journal, is responsible for offering the reader information that will be helpful in making sound diagnostic and therapeutic decisions and improving patient care. Moreover, a journal is responsible for ensuring that what is presented on the printed page is based on fact rather than opinion. These objectives can be accomplished in a number of ways, including peer-reviewed scientific articles, clinical presentations, and case reports.
From a therapeutic standpoint, the most reliable and objective information comes from systematic reviews, or meta-analyses, of multiple well-designed, randomised, controlled, clinical trials, that use these data to produce a single, objective estimate of therapeutic effectiveness. However, meta-analyses are difficult to produce because of the small number of such trials on specific subjects found in the oral and maxillofacial surgery literature. Therefore, it is generally necessary to rely on single, properly designed, randomised, controlled studies of adequately large patient populations as the best source of such information. However, more often than not, such studies are retrospective rather than prospective, contain small numbers of patients, and lack randomisation and adequate controls. These weaknesses highlight the need to objectively evaluate the accuracy of the findings and conclusions before making therapeutic decisions that affect patient care.
Case reports probably make up the majority of submissions to surgical journals. However, when questions can be raised about the potential value of some multi-case clinical studies, it raises the issue of whether it is even worth publishing single case reports. A look at some of the new clinical entities that have been identified as well as some of the significant treatment methods that have originated from single case reports indicates that the answer is definitely yes! Nonetheless, editors have a responsibility to determine which case reports are sufficiently important to be published and authors have a responsibility to submit only those reports that provide significant new diagnostic or therapeutic information.
First and foremost, editors should not publish a report of a common condition unless it presents an unusual diagnostic problem, there is something unique about the way the case was treated, or it involved an unexpected complication. Reports of rarely seen conditions should always be published because they add to the data pool and subsequently allow for a synthesis of information that permits clinicians to make sound diagnostic and therapeutic decisions. Editors also need to see that the reports contain sufficient information to allow the reader to critically evaluate the accuracy of the diagnosis and the outcome benefits of the treatment when a therapeutic approach has been used.
The author's responsibilities mirror those of the editor. One should not clog the review process with case reports of frequently seen conditions that do not add to our knowledge. Bigger may be better, but not when it serves as the sole criterion for a case submission. On the other hand, reports of rarely seen conditions should always be submitted for publication. In this way, there will eventually be sufficient documentation of the signs and symptoms, clinical behaviour, radiological appearance, histological pattern, and treatment outcomes to permit a rational approach to patient management. For this goal to be accomplished, authors must provide all of the essential information.
The proper case report should contain a detailed description of the condition and the relevant information that led to the diagnosis and treatment selected. The report must also provide adequate demographic information, a detailed history, a careful listing of the signs and symptoms, as well as a complete description of the pathology, including exact location, size, colour, and physical characteristics. When applicable, radiographs or other diagnostic images, as well as clinical photographs, should be provided.
An exact description of the manner in which the patient was treated is also an essential part of a proper case report. When medical management is involved, drug dosages, and times and routes of administration, as well as the medications used, must be documented. The value of the report is also diminished when precise details of the surgical procedure are not presented. Exact boundaries of excision are frequently not stated and ill-defined terms are used to describe the procedures so that comparisons between case reports are difficult. Use of modifiers such as small, large, radical, aggressive, conservative, wide, narrow, partial, total, en bloc, and marginal, without further explanation, are not only inaccurate, but uninformative. As Gold et al have noted, "One surgeon's aggressive may be another's conservative!".1
A case report involving the removal of tissue must also contain an adequate description of the gross specimen, as well as of the microscopic findings. The latter needs to be accompanied by sufficient photomicrographs of proper magnification to support the diagnosis. Such documentation not only allows the reader to judge the accuracy of the diagnosis, but also allows for future comparison with similar cases so that an accurate description of the characteristic histopathology can be formulated, which can be correlated with the clinical features of the lesion.
Finally, a case report in which the treatment was a significant component requires adequate follow-up of the patient to allow proper evaluation of the outcome. For a benign condition, this generally means documentation of complete healing, whereas for a malignant lesion it means sufficient time to ensure that there has been no recurrence. The literature contains many examples of case reports involving a new therapeutic approach in which the observation period was inadequate and the ultimate result was not really a success. Unfortunately, the long-term status of such patients is rarely reported and, in the interim, non-discriminating surgeons may use the procedure and obtain a similar unsuccessful outcome.
As noted previously, case reports can make a significant contribution to the literature by providing information that can ultimately lead to better diagnostic and therapeutic approaches to known conditions, as well as to the recognition of new clinical entities. However, their ultimate benefit will only be derived if authors are careful to include the necessary clinical details and the proper documentation to confirm the diagnosis and treatment outcome so that future comparisons and compilations can be made.
Reference
1. Gold L, Upton GW, Marx RE. Standardized surgical terminology for the excision of lesions in bone. J Oral Maxillofac Surg 1991;49:1214-1217.
Daniel M Laskin
Professor and Chairman Emeritus
Department of Oral and Maxillofacial Surgery
Schools of Dentistry and Medicine
Virginia Commonwealth University
Richmond, Virginia, USA
Asian J Oral Maxillofac Surg. 2003;15:5-6.
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