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Spotting a Publishable Case (… And Working on It!)

Case reports have been published in medical literature for decades. By providing new ideas in medicine – and with a high sensitivity for detecting novelty – case reports remain a cornerstone of medical progress.*

During a presentation at the All India Ophthalmology Society-Young Ophthalmologists Society of India (AIOS-YOSI) forum in New Delhi, Dr. Vinod Agarwal reiterated that case reports are one of the oldest ways of medical reporting.

“Case reports also serve as ‘primers’ leading to new discoveries, such as the development of AIDS, which is a case report of Kaposi Sarcoma in young homosexual males,” said the Mumbai-based surgeon. Another example: The Zika virus outbreak was announced by a case report.

Dr. Vinod Agarwal continued: “Case reports of adverse drug reaction form a fundamental part of pharmacovigilance – for example in the Thalidomide tragedy, the link between malformed limbs in babies and a sleeping pill was first suspected by a case report.”

Most importantly, he emphasized that case reports are a platform for training in scientific writing and critical thinking. 

Is It a Publishable Case?

Dr. Vinod Agarwal noted that it’s difficult to know upon the first interaction whether a case is publishable or not. “You will only know when the progression of the disease is complete. So, by the time you know, it’s often too late as the patient is ‘lost’ and/or the condition of the disease has changed. Hence, the prerequisite for a case report is good documentation at baseline,” he said.

Dr. Vinod Agarwal shared that when he was a resident, he published his first case report by capturing a photo of a patient with dengue fever and bilateral periorbital ecchymosis in the consultation ward with his mobile phone (one of the early Nokia versions). 

“Today, you can use high-tech devices to photograph things which are otherwise un-photographable, like vitreous base avulsion – which I could not find a single photograph of in the literature. You should also take photos even if it’s a common condition. Whenever you see a good case, you should take a photograph. Even the best of cases cannot be published without good documentation,” he shared.

Follow-up is also a must. “Patients should be traceable. So, develop good rapport with the patient,” he said.

In addition, Dr. Vinod Agarwal noted that clinicians should look for what is different in each case: “The inherent vast nature of medicine makes finding differences relatively easy, since no two cases behave similarly in the long run. So, by following up with the patient you could find novelty or an unusual outcome,” he added.

Dr. Vinod Agarwal shared a case of a patient with a fungating mass in the eye. Upon closer inspection, maggots were found crawling in the eye – and he subsequently extracted 50 to 60 of them. Later, the patient was found to have developed invasive basal cell carcinoma. The case was published after two years.

“A deviation from routine provides an opportunity for publication as well. When you have a relatively rare condition, do something extra – do a literature search and call the patient back. The literature search is of the utmost importance. What may appear common, can have scarce publication,” continued Dr. Vinod Agarwal.

“Last but not least, even if your case is not accepted by one journal, do not let the rejection demotivate you. Keep trying with other journals. Remember that a large number of cases we see are publishable; good documentation and follow-up is a must; good knowledge of the subject is always handy; and try to think out of the box,” he concluded.

A Case of Art & Science

“Writing a paper is both an art and a science,” said Dr. Aniruddha Agarwal from Chandigarh, India. He stressed that as an ophthalmologist, writing papers is equally important as seeing and managing patients. “There are multiple reasons for this – writing a paper is not just for documentation, but has the potential to change the management of several patients,” he noted.

The first step, according to Dr. Aniruddha Agarwal, is to organize the data and look for the best representative cases. “With the data from those cases, you’d know exactly what you’re dealing with and would be able to come up with a preliminary conclusion or working hypothesis,” said Dr. Aniruddha Agarwal. “This is the most important stepping stone to begin writing a paper, and opposite to the conventional approach of starting with the introduction.”

Next is the methodology. “Describe how you went about analyzing your representative cases, which may be single or multiple cases, or different sets of data. Define patient recruitment and chronology. You should provide enough information without being too detailed,” he explained. “It’s good to organize your results into headings and subheadings, declutter and give limited information.” “

In the discussion, limit yourself and do not come up with new or unnecessary statements that are not part of your study. In the bibliography, avoid excessive self-citation as doing so means that you don’t know what’s going on in literature. This will be taken into account when your paper is under review,” advised Dr. Aniruddha Agarwal. 

As opposed to traditional writing, in medical reporting, the introduction is the least important part of the paper. “Keep it crisp and concise and limit it to one (or less than one) page preferably. Avoid unnecessary lengthy prologues,” said Dr. Aniruddha Agarwal.

“Then finish off with the abstract, title page and keywords,” he continued. Keywords are very important – your manuscript is only going to come up in the internet search according to the keywords you entered. “The title page is a very sensitive part of the paper as it contains info like authorship,” he said. 

“As a beginner, you must be absolutely sure that all authors [co-authors and corresponding authors] are on board. Remember to acknowledge all who have directly or indirectly contributed to the case,” he concluded.

* Vandenbroucke JP. In defense of case reports and case series. Ann Intern Med. 2001;134(4):330-334.

Editor’s Note: The AIOS-YOSI’s “Young Ophthalmologist – The Way Ahead” Forum was held on 25 November 2018 in New Delhi, India. Reporting for this story also took place at the AIOS-YOSI Forum.

Functions of a case report:

  1. Presents unique or rare features of a disease
  2. Provides unexpected associations between diseases or symptoms
  3. Describes the mechanisms or pathogenesis of diseases
  4. Offers new therapy options
  5. Details unexpected outcomes or side effects of drugs or treatment
  6. Creates an important platform for medical education

Key Takeaways from Dr. Aniruddha Agarwal:

  1. Look for accuracy – Verify your conclusions with colleagues or mentors. Writing a paper is teamwork – you shouldn’t draw conclusions on your own.
  2. Look for novelty – You need to verify (with the literature) whether what you are writing has already been published or not.
  3. Focus on a single aim in the study. Most journals require easy- to-read studies that most readers can follow.
  4. Do not be journal-focused – Readers typically focus on the article of their interest rather than the journal. Most seek quality information and would typically browse the internet to find the article that interests them. Some of the best articles are published in small journals which are not indexed. On the other hand, do not submit your paper to multiple journals, and avoid those that are predatory.
  5. Summarize your results wisely – Understand the scope and limitations of your investigation. Ensure that whatever observations you are providing solve the hypothesis that you are proposing at the beginning of the paper.
  6. Do not format your paper – There isn’t a need to underline or change your fonts, set up margins, etc. It will be a waste of time as each journal will require you to format your paper according to their requirements when it is accepted.
  7. Use reference managers – Reference managers like Zotero and EndNote will make the process of writing a scientific paper much easier.
  8. Keep plagiarism to less than 12% – Check your manuscript with plagiarism software available in libraries.
  9. Get approval from everyone involved – Circulate your manuscript among your colleagues and co-authors and obtain their comments.

Steps to writing a paper, by Dr. Aniruddha Agarwal:

  1. Organize your data, demographics and figures.
  2. Draw preliminary conclusions and a working hypothesis; Do a preliminary literature review.
  3. Work on your methods.
  4. Write down your results and choose the best representative cases.
  5. Write the discussion, extensive literature review and bibliography.
  6. Write the introduction.
  7. Finish off with the abstract, title page and keywords.

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CAKE (Cataract – Anterior Segment – Kudos – Enlightenment) is Asia-Pacific’s Most Delicious Magazine on The Anterior Segment. CAKE Magazine is published by Media MICE Pte Ltd (Singapore).

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