Study Design 101
An article that describes and interprets an individual case, often written in the form of a detailed story. Case reports often describe:
- Unique cases that cannot be explained by known diseases or syndromes
- Cases that show an important variation of a disease or condition
- Cases that show unexpected events that may yield new or useful information
- Cases in which one patient has two or more unexpected diseases or disorders
Case reports are considered the lowest level of evidence, but they are also the first line of evidence, because they are where new issues and ideas emerge. This is why they form the base of our pyramid. A good case report will be clear about the importance of the observation being reported.
If multiple case reports show something similar, the next step might be a case-control study to determine if there is a relationship between the relevant variables.
- Can help in the identification of new trends or diseases
- Can help detect new drug side effects and potential uses (adverse or beneficial)
- Educational â€“ a way of sharing lessons learned
- Identifies rare manifestations of a disease
- Cases may not be generalizable
- Not based on systematic studies
- Causes or associations may have other explanations
- Can be seen as emphasizing the bizarre or focusing on misleading elements
Design pitfalls to look out for
The patient should be described in detail, allowing others to identify patients with similar characteristics.
Does the case report provide information about the patient's age, sex, ethnicity, race, employment status, social situation, medical history, diagnosis, prognosis, previous treatments, past and current diagnostic test results, medications, psychological tests, clinical and functional assessments, and current intervention?
Case reports should include carefully recorded, unbiased observations.
Does the case report include measurements and/or recorded observations of the case? Does it show a bias?
Case reports should explore and infer, not confirm, deduce, or prove. They cannot demonstrate causality or argue for the adoption of a new treatment approach.
Does the case report present a hypothesis that can be confirmed by another type of study?
A physician treated a young and otherwise healthy patient who came to her office reporting numbness all over her body. The physician could not determine any reason for this numbness and had never seen anything like it. After taking an extensive history the physician discovered that the patient had recently been to the beach for a vacation and had used a very new type of spray sunscreen. The patient had stored the sunscreen in her cooler at the beach because she liked the feel of the cool spray in the hot sun. The physician suspected that the spray sunscreen had undergone a chemical reaction from the coldness which caused the numbness. She also suspected that because this is a new type of sunscreen other physicians may soon be seeing patients with this numbness.
The physician wrote up a case report describing how the numbness presented, how and why she concluded it was the spray sunscreen, and how she treated the patient. Later, when other doctors began seeing patients with this numbness, they found this case report helpful as a starting point in treating their patients.
Hymes KB. Cheung T. Greene JB. Prose NS. Marcus A. Ballard H. William DC. Laubenstein LJ. (1981). Kaposi's sarcoma in homosexual men-a report of eight cases. Lancet. 2(8247),598-600.
This case report was published by eight physicians in New York city who had unexpectedly seen eight male patients with Kaposiâ€™s sarcoma (KS). Prior to this, KS was very rare in the U.S. and occurred primarily in the lower extremities of older patients. These cases were decades younger, had generalized KS, and a much lower rate of survival. This was before the discovery of HIV or the use of the term AIDS and this case report was one of the first published items about AIDS patients.
Wu, E. B., & Sung, J. J. Y. (2003). Haemorrhagic-fever-like changes and normal chest radiograph in a doctor with SARS. Lancet, 361(9368), 1520-1521.
This case report is written by the patient, a physician who contracted SARS, and his colleague who treated him, during the 2003 outbreak of SARS in Hong Kong. They describe how the disease progressed in Dr. Wu and based on Dr. Wuâ€™s case, advised that a chest CT showed hidden pneumonic changes and facilitate a rapid diagnosis.
Now test yourself!
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