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A practitioner ponders

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The current emphasis on evidence-based veterinary practice in veterinary schools and journals is very necessary, but an unacknowledged victim of this progress is the humble case report. I thought it was just my imagination, until a friend sent me an editorial from the recently launched Journal of Medical Case Reports, which stated that ‘case reports have become a casualty of the pursuit of the impact factor’ (Kidd and Hubbard 2007).

In other words, case reports have low citation value and may therefore negatively affect a journal's impact factor – so it is no surprise that the prevalence of case reports in high-impact journals is decreasing.

Don't get me wrong – large studies are critically important to the future of veterinary medicine. Systematic reviews and meta-analyses, particularly in human medicine but increasingly in the veterinary field, have demonstrated that some treatments that we have relied upon for decades may be of zero to marginal benefit – and worse still, could be harmful to patients. This is life-saving information, not something easily derived from n=1.

But I can't help feeling that the case report is a little hard-done-by. As a practitioner, I often find reading these reports, which are necessarily more detailed than case series or large-scale studies, more interesting. They're an excellent source of information about previously unreported or unusual adverse effects of drugs and unexpected complications. For example, adrenal necrosis associated with trilostane treatment of hyperadrenocorticism came to the world's attention via a case report, and what practitioner in their right mind doesn't secretly enjoy reading about the hair-raising unexpected events their colleagues have had to manage?

It was via a case report that I learned that a dog can aspirate barium-impregnated polyethylene spheres and cough up those not retrieved by an endoscope without any apparent ill effects. At the very least, a case report tells us that something is possible. It might not always be directly applicable, but because so much detail is provided about the circumstances of the patient and the manifestation of a condition or adverse effect, it is often much easier to recall than pure statistics.

As an aside, the most gripping case report I ever read detailed an auto-appendectomy by a physician on a Russian Antarctic expedition in 1961. Leonid Rogozov, the only doctor on the expedition, came to the chilling realisation that he had appendicitis, and the only possible way to survive was to perform the surgery himself under local anaesthetic. The case report, written by his son and published in the British Medical Journal (Rogozov and Bermel 2009), describes Rogozov instructing his colleagues (mechanics and meteorologists) on how to set up a makeshift theatre, clean instruments and revive him in the event of loss of consciousness. Impossibly, the operation was a success. Rogozov passed out once or twice but managed to isolate the offending appendix and wrest it from his abdomen before it could perforate.

One of the aspects of practice I enjoy most is interacting with individual patients. Case reports document the idiosyncrasies of patients and clients – perhaps with less flourish and embellishment than a traditional narrative, but the storyline is present nonetheless.

While it is critical that we further our knowledge and seek the most robust, powerful evidence to support our diagnostic and treatment modalities, it is essential that we don't lose the ability to write (and appreciate) case reports in the process.

If you would like to contribute to ‘A practitioner ponders’, please e-mail inpractice{at}bva-edit.co.uk for further information.

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