Prof. Dr. Chaturbhuja Nayak
DHMS (Hons.), Dip.NIH (Hons.) MD (Hom.)
Chairman, Homoeopathic Pharmacopoeia Committee & Chairman, Special Committee on Fundamental Research, Central Council for Research in Homoeopathy, Ministry of AYUSH, Govt. of India, New Delhi. Formerly: Director General, Central Council for Research in Homoeopathy.
“You can have brilliant ideas, perform a ground breaking research, write results with great proficiency, but if the paper is not published so that it can be cited, criticized or praised, all efforts are wasted.” – Robert B. Taylor
This statement of Taylor explains the significance of publishing the research outcomes in reputed journals. But if we do not meaningfully communicate the research findings through publication, we fail to meet the ultimate purpose of the medical research, i.e. benefiting the ailing folk, since the medical research has a direct bearing with the people’s health. Scientific writing of a research is an important art that every author must adapt in order to share his researches in an efficient way. Documenting the case reports treated in Homoeopathy with the evidences is also a kind of scientific writing. With challenges to Homoeopathy increasing, documentation of homoeopathic cases has become a serious issue in the field of medical writing. It is pertinent that clinicians learn to report their successful cases following the right method, so that the editorial team will take interest to publish their case reports. Improper case reporting often gets rejected for publication, in spite of the best results and their supporting evidences.
Before writing a case report, it is pertinent that the author/researcher should go through the instructions/guidelines laid down by the journal for authors how to write case reports. The number of words of a case report should ideally be limited to 1500-2000 words.
Why to publish Case Reports?
It is pertinent to know the important points that make a case worth reporting in medical journals, including Homoeopathy journals. These may cover the following:
Relating to general medical domain1,2:
- To present: a case of unusual disorder; of unusual etiology; a challenging differential diagnosis; a new insight into the pathogenesis of disease; unusual or puzzling clinical features of a condition.
- To confirm/reject a clinical hypothesis.
- To highlight the lacuna(e) in health care, their causes, consequences and remedial measure(s).
- To describe improved or unique technical procedures.
- To report unusual drug-drug, drug-food, or drug-nutrient interactions or describe rare or novel adverse drug reactions.
- To make an original contribution to the literature.
- To stimulate further research.
- To benefit the entire medical community.
Relating to Homoeopathy:
- To present profile of a patient recorded following a standard case –recording format, as per homoeopathic principles.
- To illustrate case-processing, according to the principles of Homoeopathy, which includes analysis and evaluation of symptoms, miasmatic diagnosis, totality of symptoms.
- To demonstrate the unique method(repertorial/non-repertorial) adopted for determining the similimum for the patient.
- To justify which potency, dosage & repetition schedule worked for the patient.
- To justify the first and subsequent prescriptions and present their responses.
An interesting, puzzling or surprising case adds to the acumen of homoeopathic physicians, and benefit the profession as well as patients at large. A well-documented case report will not only improve the knowledge of the clinicians, teachers and students, but also inculcate confidence in them for dealing with similar cases in future.
Case Reporting: Limitations2
- The management of patients in the OPDs of a hospital occurs primarily in an uncontrolled environment. As a result, the clinician can do a little to prevent patients from introducing a variety of confounding factors into their lives. These factors may affect patient’s response to the medical care provided to him/her. One may argue that the results thus obtained may not be due to the treatment provided.
- The single-case reports cannot be generalized. It will be difficult to conclude, based upon the observations of a single patient, that any particular treatment strategy will be effective for other patients.
- As per homoeopathic principles, the choice of remedy is customized, individualistic and personalized. The totality of symptoms covering the mental symptoms, physical generals and characteristic particular features of each patient will determine the selection of remedy for that particular patient. Thus, even if a group of patients suffer from a particular disease, each of them may require different medicines, basing upon individual personalities and characteristics. This individualistic approach is also applicable to the choice of potencies, dosage and repetition schedule for each patient.
Thus, case-recording, case-processing and treatment strategies documented in a particular case report may not be applicable to other cases, even if suffering from same clinical condition.
Study designs for Case Reporting2
- Retrospective Design
This is the most common design used by the authors, for documenting their case reports. But, such designs have a potential weakness too. Here, the authors may provide the best possible care for the management of the case, but may not have used the best available outcome measures to record any real change in patient’s health.
- Prospective Design
In this design, the author determines the plan for patient care and data collection, before- hand. The clinician reviews the literature to determine the best outcome measures to assess patient’s progress. The clinician has prior knowledge how to evaluate the patient and deliver a specified predetermined management plan. Measurements of the patient’s condition can be done before, during and after managing the case and can be tracked in future. Thus, such design improves the patient management in practice.
COMPONENTS OF A CASE REPORT1,2,3,4
Title of a case report should be brief but informative. It should be succinct and clearly suggest the theme of the case. It should be neither too short nor too long. It may contain the clinical condition (diagnosis) and the intervention. Sensationalisation of the title is to be avoided.
An abstract allows the readers to quickly scan the contents of an article to determine whether it is relevant to merit further reading. It may be written within a range of 100-200 words. An abstract should convey the gist of the case report covering the areas like: Introduction, Methods, Results and Discussion (IMRAD).This section may also include: case presentation and conclusion. But the structure of an abstract mainly depends upon the instructions of a particular journal.
The keywords unlock the doors to get useful information about the case. Such key elements of the presented case should be written in 2-5 words. These keywords will facilitate easy retrieval from electronic databases and create interest in the readers for further reading.
In this section, background information about the patient as well as his/her clinical condition should be provided. An explanation should be given why the case report is novel or deserves review. Then, a comprehensive literature review corroborating the author’s claims should be given with adequate citations chronologically. The literature review should list the strategy and extent of the search and include the particulars of the database searched. This will provide enough material for the readers to reproduce search easily. The literature review should be brief and concise, provide back-drop and uniqueness of the case.
- Case Profile (Methods & Results)
Under this heading, the author should describe the clinical setting, like the place and period of study; and also the study design. This section should include the demographic information about the patient, e.g. age, gender, ethnicity, occupation; presenting complaints, h/o present complaints; physical generals, mental symptoms and characteristic particulars; past, family, personal, treatment and psycho-social history of the patient; relevant physical examination findings; diagnostic methods, laboratory findings, imaging and questionnaires; final diagnosis; criteria for assessment/outcome measures etc.
Thorough case-processing should be reflected which includes: analysis & evaluation of symptoms; totality of symptoms; miasmatic assessment; repertorial analysis; prescribing strategy; first prescription (choice of remedy, potency, dosage, repetition of remedy) etc. An adequate follow-up including subsequent prescriptions of the patient should be given in this section, besides any adverse drug reactions and unanticipated events; the patient’s present status at the time of reporting and any further prosed treatments.
In this section, one should be careful to include only the information needed to convey the case. Tables that demonstrate ‘before and after’ care measurements may help the reader better understand the outcome.Photographs or illustrations of diagnostic procedures, radiographs or treatment procedures can be included which will be helpful in conveying a clear message to readers. Authors should not provide confusing and superfluous data, e.g. vital signs reported as normal, routine laboratory tests etc.
This is a very vital part of case reporting where the author explains and discusses the case and provides his/her opinion about it. Discussion should compare the case with previously published literature, evaluate the case for accuracy and derive new knowledge and/or applicability to practice. Salient differences between the case and what is known in the literature should be presented. The rationale for the management of the case should also be discussed here.
The limitations of the case, along with the significance of each limitation, faults in the case or quality of reporting also need to he stressed upon in this section. The author can also share other possible reasons for the outcome of the case, such as the natural history of the disorder or other factors. Suggestions or hypotheses regarding the significance or outcome of the case and why the care provided may or may not have been beneficial should also be highlighted. This should be followed by some suggestion for future inquiry into the topic.
While concluding the case report, an author must mention what has been learnt from the case report. He must relate to the original purpose of the paper. However, it is advisable that the author refrains from far reaching, unsupported or general statements. In this section, the author should write briefly the take-home message and lesson he/she learnt from treating the present case. Recommendations for future research on the related areas of the case should also be included in conclusion.
The staff who have assisted the author(s) in the treatment of the case and preparation of the manuscript, but who do not meet the criteria necessary to be named as author(s), should be acknowledged in this section.
One must be cautious in the use of tables. These should not be used for small amounts of data that could be conveyed clearly and succinctly in a sentence. The tables should be simple and self-contained but require no further explanation. The data shown in a table should not be reiterated in sentences within the text.
Figures, graphs, photographs or illustrations make case reports interesting to read. These should be self-contained and fully interpretable. Captions for each figure should he provided. If the author wishes to use previously published figures of the patient or illustrations, permission must be obtained from the concerned publisher. Photographs/photocopies of those relating to lab test reports (including histopathology, x-rays, ECG etc.); skin lesions; wounds and other anatomical parts may be provided. If identifiable people appear in figures, a signed document from the patient should be submitted to the journal in which the paper is to be published. In all other cases, the author must block out any identifiable features of the patient.
Take home points for an ideal Case report are –the report should be objective, focused and devoid of any fantastic claims or far reaching consequences. Observations of the case should not be generalized to other patients. Such a case report, when submitted to a journal, is likely to be accepted by the editors for publishing it in the journal. Even if a case is submitted to a journal as per its guidelines, the editor(s) might still ask for some revisions or clarifications in the paper and in such cases, the author(s) should comply to the suggestions of the reviewers or editorial team.
- McCarthy Laine H, Reilly Kathryn EH. How to write a case report. Family Medicine. March 2000;32(3):190-195.
- Green Bart N, Johnson Claire D. How to write a case report for publication. Journal of Chiropractic Medicine. Summer 2006;5(2):72-82.
- Cohen Henry. How to write a patient case report. Am. J. Health – Syst. Pharm. October 2006;63:1888-92.
- Gagnier Joel J, Kienle Gunver, Altman Douglas G, Moher David, Sox Harold, Riley David. The CARE Guidelines: consensus-based clinical case reporting guideline development. Journal of Medical Case Reports. 2013;7:223.