|Author Guidelines for The American Acupuncturist|
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Writing a Case Report
by Sivarama Prasad Vinjamury, MD (Ayurveda), MAOM, MPH
(This updated article was originally published in The American Acupuncturist, 2008, vol 46.)
A case report is the collection and publication of important, detailed information about an individual by a practitioner for publication in a journal. It presents the clinical features, diagnosis, investigation, and treatments of cases that are either under reported or unusual in presentation or treatment outcome. This article discusses the different types of case reports and the stages involved in writing a case report.
Key Words: case report, case study, medical writing, acupuncture case report
A case report is the collection and publication of important, detailed information about an individual patient within a medical journal. Many acupuncturists or health care practitioners have, at some point in time, encountered an unusual outcome or presentation while treating an individual. Dissemination of this information is invaluable to others in clinical practice. Case reports also provide information on errors in diagnosis, previously unreported adverse reactions to a treatment, and unanticipated beneficial responses to a treatment.
In general, case reports help describe important scientific information that is either un-investigated or undetectable in clinical trials or other large studies. They aid in hypothesis generation but do not prove cause and effect relationship. Therefore, the writer must avoid drawing conclusions that prove causation or attempt to generalize the findings of a single case report.
Case report writing is one of the best ways to begin medical writing. Still in its formative stage in the Western clinical setting, acupuncture reporting requires careful documentation of treatment styles and varying responses to needling. Only a systematic recording of procedures and findings will help identify the most beneficial protocols among the myriad complex forms of TCM treatments in use.
There seems to be a lack of case reporting within the field of acupuncture, perhaps due to time constraints or inexperience with clinical writing. Here, then, is a brief overview of the types of case reports, stages of case report writing, and the anatomy of a case report. In addition, some tips on medical writing are included which can further help acupuncturists develop the skills necessary for publication.
Types of Case Reports
Case reports are broadly classified into two types: retrospective and prospective.
Retrospective case reports examine the details of a case after the care has been provided. Information is provided from the patient’s record such as history, examination findings, laboratory or imaging results, diagnosis, and the details of intervention and follow-up care. Prospective case reports, on the other hand, are developed prior to the initiation of patient care. They follow the same protocol required of larger studies, from writing a brief proposal to collecting data in a systematic manner.
The planning for a case report includes determination of objectives, logistics of data collection, standardized outcome measures, details of study intervention, and data analysis methods. Although the prospective case reports require a great amount of work initially, the early planning and preparation makes it easy to organize for publication later. In addition, two important things to consider when choosing a journal are whether or not you wish to submit to a peer-reviewed journal and whether its readership includes the target audience intended for that case report.
Regardless of the type of case report, it is necessary to obtain consent from the patient. Approval from an Institutional Review Board (IRB) or Human Ethics Committee might be required for some prospective case report writing. Clinicians are recommended to refer to the Human Subject Protection guidelines provided by the Office for Human Research Protections (OHRP) within the U.S. Department of Health and Human Services (DHHS) and also contact an IRB for clarification purposes.
Stages in Writing a Case Report
There are six stages in writing a case report: Selection of a case, literature search, collecting related information, choosing a journal, writing and summarizing, and final review and editing.
1. Selection of a case: Identify a compelling case to report. This may be someone who was treated in the past or has yet to be treated. A specific purpose for reporting this case must be contemplated at this stage.
2. Literature search: Perform an extensive literature search on your topic of interest, including searches in PubMed (National Library of Medicine Database), MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health), AMED (Allied and Complementary Medicine Database), Acubriefs.com (comprehensive database of references on acupuncture established by Medical Acupuncture Research Foundation), and Google Scholar. Many educational institutions subscribe to the above databases or/and online journals, and full-text articles are available for a flat fee per article. If the search results are very few, this indicates the condition selected to report on is rare and stands a good chance for publication (Anwar, 2002). A thorough and critical review of literature provides the background and the current environment of the topic.
3. Collecting information related to the case: A detailed history of the subject’s present illness must be collected from his/her records. This includes onset, severity, aggravating and relieving factors, examination findings, laboratory results, radiographs, photographs, treatment, and outcome Treatment outcomes supported with an objective measure are highly recommended.
4. Choosing a journal: Each journal has different requirements regarding topics of interest, length, and formatting, which all should be considered. Most acupuncture and Chinese medicine journals provide instructions and submission guidelines to authors. It is important that the case report strictly follows these guidelines.
5. Writing and summarizing: Once the material has been collected, a rough draft can be developed based upon the case description and full literature review. Some of the issues to consider during this stage are the number of tables, figures, formatting, and the minimum number of references that will be required to provide complete information about the case. Furthermore, the number and order of authors should be decided at this stage. If you have a question about who must be considered as an author, refer to Uniform Requirements for Manuscript Submitted to Biomedical Journals.
6. Final review and editing: After the report is drafted, thoroughly review the article to assess the quality of the overall content. Attention must be paid to word count, punctuation, jargon words, length of sentences, spelling, grammar, and adherence to the journal’s requirements. It is also wise to evaluate the case report using available checklists.
Anatomy of a Case Report
Although the formats that journals use for case reports do vary, a majority of them follow a pattern similar to the one used for reporting clinical studies. The following sub-headings are advised: title, abstract, introduction (or background), case history (or case description), treatment, outcomes (or results), discussion (or comments) and conclusion.
The title should be short, descriptive, and must draw the reader’s attention. It must include the words "case report” or "case study.”
The abstract is a summary of the case report, which provides a succinct description of the case, the interventions used, and the outcome. It should contain 100-250 words. The main purpose of an abstract is two-fold. First, it provides clinicians easy retrieval from electronic databases. Second, it gives a glimpse of the information contained in the case report and provides an opportunity to compel the reader to read the full text.
The introduction should clearly define the purpose of the case report while providing background information about the patient’s condition. This information should include one or two sentences each about the disease incidence and prevalence rates, etiology, and current available treatments. A brief literature review is required in this section. Any unusual terms must be defined in this section.
The description of the case is the main body of the text and provides the most important information. The patient’s history of present illness, past illnesses, family history, and personal history, as well as patient demographics, should be detailed in a concise, narrative form. Following this history, all diagnostic data, including laboratory results and examination findings, should be provided. Please remember to provide the normal range for diagnostic tests, whenever it is applicable.
The treatment section should describe the treatment plan and details of the administered treatment(s) according to STRICTA criteria (Macpherson, H, White, A, Cummings, M, Jobst, K, Rose, K, & Niemtzow, R, 2002). These guidelines require rationales that explain why the point selection, diagnosis, and treatment procedures were used. It also requires description of needling details such as depth, laterality, de qisensation, stimulation of needles, and the number of points used, all of which allow for treatment replication by other practitioners. If it is a non-acupuncture intervention such as Chinese herbal therapy, qi gong therapy, or moxibustion, then the exact dosage, duration, and details of providers’ experience may need to be provided. Other requirements include treatment regimen, co-interventions, and control interventions, if applicable. Finally, any adverse events should be reported in this section, regardless of severity.
A results (or outcomes) section should report the exact outcome at the end of the treatment period. Both positive and negative outcomes need to be reported. It is always recommended to describe what happened to each of the outcome measures that were used to determine improvement or the lack of. Specific values (in numbers) are recommended to indicate change rather than a single, generalized sentence, i.e., "patient indicated that his/her pain has reduced at the end of the treatment.”
The discussion section is a summarization of the patient’s condition and the obtained results. Explain the outcome with other possible mechanisms such as regression to the mean or any influence of co-interventions. Briefly discuss the rationale for choosing the management plan used and compare it with others.
The conclusion is a statement of how the case report contributes to the relevant body of knowledge, but it avoids drawing conclusions that indicate a cause and effect relationship due to the inherent weakness of the case-study design. Usually a sentence on recommendations for future studies on the topic is allowed here.
All references must be from peer-reviewed journals or other peer-reviewed sources. Ten-fifteen references are standard, though individual journals may have varying requirements. To accurately format the references, refer to the journal’s author guidelines. Software such as EndNote and RefWorks may be useful in this process.
Despite the limitations of case reports, they are valuable resources of new information and are useful for generating new hypotheses in future, large-scale trials. As case reports are under-represented in acupuncture literature, there is a considerable need to further this body of knowledge in an attempt to understand the role of acupuncture in new and emerging diseases. A well-written case report with ample supportive literature and a detailed description of the management of the case has the greatest chance for publication.
Alwi, I. Tips and tricks to make case reports. Indonesian Journal of Internal Medicine, 39, 2, 96-98.
Anwar, R. (2004). How to write a case report. Student British Medical Journal, 12, 45-48.
Begg C, Cho M, Eastwood S, Horton R, et al. (1996). Improving the quality of reporting randomized controlled trials: the CONSORT statement. Journal of American Medical Association,276, 637-639.
Cohen H. (2006). How to write a patient case report. American Journal of Health System Pharmacy. 63, 19, 1888-1892.
Dixon N. (2001). Writing for publication – a guide for new authors. International Journal of Quality in Health Care 13, 5, 417-421.
Green B. & Johnson CD. (2000). Writing patient case reports for peer-reviewed journals: Secrets of the trade. Journal of Sports Chiropractic and Rehabilitation, 14, 3, 51-59.
Kidd M, Hubbard C. (2007). Introducing Journal of Medical Case Reports. Journal of Medical Case Reports, 1, 1, 1-2.
Macpherson H, White A, Cummings M, Jobst K Rose, K, & Niemtzow R. (2002). Standards for reporting interventions in controlled trials of acupuncture: The STRICTA recommendations. Acupuncture Medicine, 20, 1, 22-25.
Ramulu VG , Levine RB, Hebert RS, & Wright SM. (2005). Development of a case report review instrument. International Journal of Clinical Practice, 59, 4, 457-461.
White A. (2004). Writing case reports – author guidelines for Acupuncture in Medicine, Acupuncture in Medicine, 22, 2: 83-86.
Table 1. Checklist for Case Reports
Sivarama Prasad Vinjamury, MD (Ayurveda), MAOM is a professor of research at the Southern California University of Health Sciences, Whittier, California. He teaches research methodology to students of acupuncture and Oriental medicine. Dr. Vinjamury is also a licensed acupuncturist and Ayurvedic practitioner at the University Health Center at the University. He can be contacted at: firstname.lastname@example.org
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