Clinical Case Reports is celebrating!

Clinical Case Reports (CCR) is celebrating! 2018 is our fifth birthday, and during these first five years, our authors, editors, journal team and, crucially, our readers have achieved a massive amount. As Editor in Chief for the Journal's launch, I remember many debates about whether the concept of an open‐access, high impact, case report journal could be a success, and whether our strategy of publishing important but common case descriptions as well as rare events was appropriate.

After five years of amazing teamwork, we are now certain that in both respects the answer is “YES.” Over that period of time, CCR has grown from an idea into an important global health publication, delivering best clinical practice messages to diverse audiences around the world. As a measure of this success, our submission and publication rates have seen dramatic year‐on‐year growth. In 2013, CCR published 176 cases, itself a significant achievement for a new open‐access publication. During 2017 that annual total has grown to an amazing 707 case reports, or around 60 reports each month, each describing a real patient with real clinical problems with an important clinical teaching message. As well as CCR publishing more articles, we also know that more and more readers are looking at those articles and downloading them. In 2013, readers downloaded our articles 5592 times – a very significant number for a new journal. In 2017, readers have downloaded an astonishing 156,420 CCR articles which in its own right is a testament to the importance of the cases our authors describe and their utility in clinical medicine. Our most downloaded articles can be seen here: http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)2050-0904/homepage/top_downloaded_articles_of_all_time.htm

One particularly important aspect of CCR's development has been the feedback we receive. CCR is very fortunate to receive feedback from a broad range of stakeholders including our authors, peer reviewers, and readers. Feedback is essential for us to understand the needs of our stakeholder groups, to improve the way we work, and to improve the quality of our processes and publications. Much of the feedback we receive is extremely complimentary and positive, and this is always very pleasing to receive. Other feedback draws our attention to areas we could improve, and this is vital to the development of CCR. Some feedback we receive includes common misconceptions about case report publications and it is interesting to examine some of these misconceptions in a little more detail.

“Several of the cases presented are not unique…”

Case reports do not need to be unique to be of value. In many respects, rare or esoteric cases are less useful than more common cases, because their low incidence/prevalence means that few clinicians will see similar patients. More common cases will be seen by a larger number of clinicians and so have the potential to inform and improve a broader range of clinical practice which is why CCR is so keen on publishing them.

“Editors should be careful about publishing a case report that purports to demonstrate a causal link e.g. “Iron deficiency anemia due to excessive green tea drinking.””

This is exactly the type of association which should be suggested by case reports. It is unlikely that causality could ever be proved in a case report, but unless tentative associations are suggested future confirmation of important causal relationships will be impeded, with negative consequences for health. Case reports have a long and well‐substantiated history of identifying clinically important causal relationships that are subsequently validated and have important consequences for clinical practice 1, 2, 3.

“Informed consent policy didn't seem consistently enforced; pictures include facial shots with eyes blacked out (still identifiable) and no mention of consent in the paper to show these images.”

It is well established in medical ethics that a patient's data (including images) are their possession, and if clinicians wish to use that data, they need the patient's explicit consent to do so [https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html (accessed 15 June 2017)]. This concept applies whether or not a patient is identifiable from their data. It is also clear that black bars across a patient's eyes in an image of their face provide limited, if any, protection of their identity – it is easy to recognize people while they are wearing sunglasses. In CCR, as with most high‐quality medical journals, every article requires fully informed patient consent prior to publication regardless of whether that patient may or may not be identified. As a result, our view is that it is not necessary to publish a statement about consent with every CCR publication.

“Some papers could use editorial assistance with English.”

In our current global society, much of the world communicates using variations of English language. It is essential in scientific communications that meaning is clear, but this does not always require the level of precision with English language that some publications aspire to. Our view is that if the meaning of a publication is clear, it is not necessary for authors to spend more time refining their use of English. However, we are always happy to provide assistance to authors in this area if they need or want us to.

“Some articles have no discussion at all, others have very cursory discussion. It seems that much of the value of a case presentation would be found here…..”

The amount of discursive content that forms part of a case report publication is directly related to the case presented, and the meaning the authors wish to draw from that case. The real value of a case report publication is not the discussion section, but the clinical message the report delivers. To convey this message effectively, it may require a substantial discussion or it may require little or no discussion at all.

“Case reports are most useful when they provide a useful perspective, and ideally common conditions should be, at a minimum, aggregated as case series to find interesting patterns.”

Case reports and case series are entirely different publication types with very different structure and uses, and the two should not be confused. In contrast to case reports, case series are typically used to identify similarities between the different cases presented, to continue the process toward substantiating a likely causal relationship, and to draw conclusions about the case group overall. In doing this, they clearly contain more cases than a single case report; they are usually longer and usually have more detailed discussion sections. It is always an error to try to publish a case series as if it were a single case report, or to use a singles case report as if it were a case series.

“…an express strategy to publish single cases of common conditions with the aim to “have a broader impact on improving global clinical practice” arguably elevates the lowest form of evidence over more high quality study designs.”

There is a common misconception that the “highest quality” study design or evidence is a systematic review plus meta‐analysis of randomized controlled trials, and the “lowest quality” study design or evidence is a case report with observational/cohort data appearing somewhere just above case reports or case series in this hierarchy. This concept is entirely wrong. A systematic review plus meta‐analysis of randomized controlled trials probably is the best study design to assess treatment effectiveness. However, if there is a requirement to investigate a rare but important adverse drug reaction, a systematic review of randomized controlled trials would not be the best study design, a large long‐duration cohort study being preferable. In this context, it is clear that the “highest quality” study design is determined by the question being addressed and not by a set hierarchy. Case reports, as a type of research study, have a defined purpose and like all study types may themselves be seen to be high or low quality. There is no doubt that high‐quality case reports have the ability to improve clinical practice.

Another area in which CCR is very fortunate is in being able to work with authors and editors who are early in their academic or research careers. CCR has a large and extremely supportive team of Associate and Senior Editors who on a daily basis support and mentor junior editorial colleagues and who also very effectively support authors who sometimes submit their first article as a case report to our Journal. To quote from one of recent authors, Elena Infante, who published her first article with CCR (http://onlinelibrary.wiley.com/doi/10.1002/ccr3.1010/full)

“Clinical Case Reports team made it very straightforward and simple along the way … will be sure to let our colleagues know about our positive experience and encourage others to submit to this journal.”

Our ambition for CCR of the next five years is to continue with our significant growth in the numbers of articles we publish each month, to work with more authors of every level of experience to help them publish their work, to increase the size of our editorial team further to accommodate this growing submission rate, and to continue to fulfill our vision to directly “Improve global health and increase clinical understanding”

(http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)2050-0904/homepage/ProductInformation.html)

As Editor in Chief, one of the most rewarding aspects of working with CCR is the sense of being part of such a committed team. When I asked the editorial team whether anyone could help with the peer review of a submission which was proving difficult recently, the almost immediate response I received summed up in a few words why CCR is, and will continue to be, such a success:

“I will review, nothing to worry (about). We are a family.”

Conflict of Interest

None declared.

Clinical Case Reports 2018; 6(1): 5–7