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BMC Medical Education
Open Access
Research article
Instructions to authors for case reporting are limited: A review of a
core journal list
Olanrewaju Sorinola*
1
, Olufemi Olufowobi
2
, Aravinthan Coomarasamy
2
and Khalid S Khan
2
Address:
1
Warwick Hospital. U.K and
2
Birmingham Women's Hospital. U.K
Email: Olanrewaju Sorinola* - sorinola@talk21.com; Olufemi Olufowobi - femi.olufowobi@bwhct.nhs.uk;
Aravinthan Coomarasamy - Arri.coomarasamy@bwhct.nhs.uk; Khalid S Khan - khalid.khan@bwhct.nhs.uk
* Corresponding author
Abstract
Background: Case reports are frequently published in the health care literature, however advice on preparing
such reports using the "instructions to authors" pages of journals is alleged to be limited. However, to our
knowledge, this has not been formally evaluated. As roles of case reports may vary according to the case and the
clinical specialities, one might expect the advice to authors to vary according to journal clinical grouping.
Methods: We surveyed the current advice available to authors of case reports from 'instructions to authors'
pages of a core collection of 249 journals ('Hague' list). These were examined and compared for advice or
recommendation on writing case reports. Of these, 163 (65%) published case reports and provided instructions
on this publication type. Data were extracted on items of style and content of case reports, using a piloted data
extraction form.
Results: Journals that published case reports were grouped into medical (n = 81, 50%), surgical (n = 38, 23%)
and generic or multidisciplinary (n = 44, 27%) categories. There was a difference among the medical, surgical and
generic or multidisciplinary journals in the maximum number of words and pages allowed but no difference in the
number of figures, tables, references, authors, abstract or synopsis, indexing or key words and consent.
Additionally, there was no statistically significant difference among the three different categories of journals
regarding the content of the case reports.
Conclusions: Of the journals reviewed, we found that 'instructions to authors' pages provided limited and varied
information for preparing a case report. There is a need for consensus, and more consistent guidance for authors
of case report.
Background
Case reports are frequently published in the health care
literature – more than 240,000 case reports appeared in
MEDLINE in the last 5 years (1997 to 2002). Advice about
preparing such reports in the "instructions to authors"
pages of journals that publish case reports is alleged to be
limited [1]. However, to our knowledge, this has not been
formally evaluated.
The roles of case reports are reported to be diverse. These
include recognition and description of new diseases,
detection of drug side effects (adverse or beneficial), study
of the mechanism of disease, recognition of rare manifes-
tation of disease, and medical education [2]. As some
roles may be more suited to certain clinical specialities,
one might expect "information for authors" to vary
according to journals' clinical grouping. We surveyed and
Published: 25 March 2004
BMC Medical Education 2004, 4:4
Received: 05 October 2003
Accepted: 25 March 2004
This article is available from: http://www.biomedcentral.com/1472-6920/4/4
© 2004 Sorinola et al; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all
media for any purpose, provided this notice is preserved along with the article's original URL.
BMC Medical Education 2004, 4 http://www.biomedcentral.com/1472-6920/4/4
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compared advice on case reporting in different groups of
healthcare journals included in the core journal list,
'Hague' list [3].
Methods
A total of 249 journals are included in the 'Hague' list and
this served as our survey sample. This core collection of
journals produced by the medical information working
party of the British Medical Association (BMA) is used as
a selection tool for journal subscription in the United
Kingdom health care sector, and also as an accreditation
standard for libraries serving postgraduate medical educa-
tion. The journals' "instructions to authors" posted on
their websites were surveyed from September 2002 to
November 2002. These were examined for advice or rec-
ommendation on writing case reports, and data were
extracted on items of style and content of case reports,
using a piloted data extraction form. Two of us (OS and
OO) extracted the data independently and compared our
findings for any discrepancies on a pilot set of 20 journals
initially. This allowed us to develop an explicit coding sys-
tem for data extraction.
We obtained data on style of reporting including maxi-
mum number of words, pages, figures or illustrations,
tables, references and authors as well as the need for
abstract or synopsis, indexing or key words, and consent
form. For advice on content of case reports, we sought
information on nature of cases to be reported including,
cases with instructive or teaching point, originality (novel
or creative reports), innovative cases (new methods or
ideas, including modifications of existing ones), unusual
or rare cases, and cases leading to hypothesis generation.
The journals were independently categorised into medical
(e.g. Annals of Internal Medicine and Respiratory Medicine),
surgical (e.g. Journal of Neurosurgery and Archives of Sur-
gery), and generic (e.g. Lancet, British Medical Journal, and
New England Journal of Medicine). The agreement between
the reviewers regarding classification of journals was 95%
(weighted kappa value of 0.89). Differences in style of
reporting or content of case reports between the three
groups of journals were tested using chi-square for trend
and Kruskal-Wallis analysis of variance.
Results
Of the 249 journals review, 163 (65%) published case
reports. These included 81 (50%) medical, 38 (23%) sur-
gical and 44 (27%) generic journals. (Table 1).
Style of reporting
There was more information on style (i.e. limitation on
words, pages, figures or illustrations, tables, references,
authors, need for abstract or synopsis, indexing or key
words and consent form) than content. Most of the infor-
mation provided was on the need for abstract or synopsis,
required by 150 (92%) journals, closely followed by
indexing or key words required by 145 (89%) journals.
However information on number of authors allowed for
case reporting and the need for consent was provided by
only a small number of journals 16 (10%) and 29 (18%)
respectively. Out of the 29 journals requesting consent
only four (14%) actually provided a consent form. There
were significant statistical differences between the medi-
cal, surgical and generic groups in the maximum number
of words and pages allowed, but there was no statistical
difference in the number of figures, tables, references,
authors, abstract or synopsis, indexing or key words and
consent (Table 1).
Table 1: Comparison of advice on style of reporting and content of case report presented as no (%) or median with interquartile ranges.
All journals n = 163 Medicine n = 81 Surgery n = 38 Generic n = 44 p value
Advice on style of reporting
*Limit on words 1000 (750,1000) 1000 (750,1500) 750 (500, 1000) 1000 (925,1000) 0.70
*Limits on pages 4 (2,5) 3 (2,6) 4 (2.75, 6) 1 (1,1) 0.0001
*Limit on figures 1 (1,1) 1 (1,2) 2 (1,2) 1 (1,1) 0.30
*Limit on tables 1 (1,1) 1 (1,1) 1 (1,2) 1 (1,1) 0.45
*Limit on references 8 (5,10) 8 (6,10) 5 (4,8) 9 (5,10) 0.74
*Limit on Authors 6 (4,6) 5 (3,6) 5.5 (3.5, 6) 6 (5.25,9) 0.31
Abstract/Synopsis 149 (91%) 72 (89%) 37 (97%) 40 (91%) 0.30
Indexing/Key word 145 (89%) 70 (86%) 36 (94%) 39 (89%) 0.40
Consent required 29 (18%) 14 (17%) 5 (13%) 10 (23%) 0.52
Advice on content of case report
Instructive 91(55%) 50 (62%) 16 (42%) 25 (57%) 0.90
Originality 42 (26%) 19 (23%) 8 (22%) 15 (34%) 0.07
Innovative 42 (26%) 15 (19%) 10 (26%) 17 (39%) 0.25
Unusual/Rare 99 (61%) 53 (65%) 18 (47%) 28 (64%) 0.63
Hypothesis generation 9 (6%) 4 (6%) 2 (5%) 3 (7%) 0.55
Data are reported as median with interquartile ranges, the others as actual numbers with percentages in bracket.
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Content of case reports
The majority of information provided was on whether the
case has to be unusual or not, provided by 99 (60%) jour-
nals, or have an instructive or teaching point required by
91 (55%) journals. This was followed by original and
innovative cases required by 42 (26%) journals each,
while only 9 (6%) journals considered hypothesis gener-
ation a reason for reporting the case. There was no signif-
icant statistical difference between the three groups of
journals. The results for style of reporting and content of
case reports in the three groups are summarised in Table
1, while Figure 1. summarises the advice on style and con-
tent for all journals considered.
Discussion
There was a wide variation in the instructions given by the
journals to authors on case reporting. The instructions to
authors provided more information on style of reporting
than on the content of the case report. Statistically, there
was no difference between the three groups of journals
with regards to the information provided on content. The
recommended length of case reports varied from 500 to
Summary of journals' instructions to authors on case reportingFigure 1
Summary of journals' instructions to authors on case reporting
39
42
42
91
29
61
104
16
68
62
73
34
95
60
84
45
19
14
9
0% 20% 40% 60% 80% 100%
Hypothesis generation
Unusal/Rare
Innovative
Originality
Instructive/Teaching point
Content of reporting
Consent form required
Indexing/Key words
Abstract/Synopsis reqd.
Authorship #
Limit on references
Limit on tables
Limit on figures/illustrations
Limit on pages
Limit on words
Style of reporting
Yes
No
Unreported
Legend:
Yes – If the criterion was required by the journal.
N
o - If criterion was specifically not required by the journal.
Unreported- If no information was provided by the journal.
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2000 words with a median of 1000 words. Tables, figures
or illustrations are usually limited to one. One-quarter of
the journals require the case to be original or innovative,
while the others place a greater emphasis on succinctly
illustrating a single educational point. Consent was specif-
ically requested by only 29 journals (one-sixth), in spite of
the fact that there may be information within these
reports that may allow identification of the patients. How-
ever, opinion is divided on whose responsibility it is to
provide the consent. Is it that of the journal or the institu-
tion? With the Health Insurance Portability and account-
ability (HIPAA) regulations in the United States, the
responsibility somehow lies with the hospital and their
legal department to develop an informed consent docu-
ment for publication in medical journal [4].
Also the scientific importance of the key aspects of the
structure of a case report were variably acknowledged and
emphasised. Consequently, the quality and standard vary
among the journals reviewed.
"In this era of outcome studies and evidence-based medi-
cine, the value of case reports, physician intuition, and
serendipity is often overlooked. All science is rooted in
observations, and full-time clinicians are in ideal position
to observe unusual cases, develop rational explanations
for the findings, and follow progress to determine if their
hypothesis appear to be valid" [5]. Thus, the collected
findings from case reports may provide the bases for
future researches that will lead to evidence-based treat-
ment. Therefore, it is imperative these cases are reported
in the highest possible standard and with great
enthusiasm.
We acknowledge that some roles and structure of case
reporting might be more suited to certain clinical special-
ities, therefore, it is conceivable that 'instructions to
authors' might vary according to journal categories. How-
ever, this does not negate the need for a minimum stand-
ard for reporting cases reports. Common sense standards
provide a 'method in madness', which is likely to be better
than no methods at all.
Our findings make explicit the limited amount of advice
available to authors of case reports. The generalisation of
these findings is limited to the extent to which, 'Hague' list
is representative of the healthcare journals published
worldwide. Our study highlights a need for consensus
about a minimum standard for case reporting. Based on
our review of the author's instructions in this paper and
other published literature on case reporting [6-8] a sug-
gested checklist for reporting cases in the medical litera-
ture is provided in Table 2.
Authors' contributions
OS downloaded half (50%) of the journals used in the
survey from their website, extracted the data, and drafted
the manuscript.
Table 2: A suggested checklist for writing case reports (based on advice in existing literature)
Title:
• Should facilitate retrieval with electronic searching.
Introduction
• Describe whether the case is unique. If not, does the case have an unusual diagnosis, prognosis, therapy or harm?
• Describe how the case contributes to scientific knowledge.
• Describe the instructive or teaching points that add value to this case.
Methods and Results
• Describe the history, examination and investigations adequately. Is the cause of the patient's illness clear-cut? What are other plausible
explanations?
• Describe the treatments adequately. Have all available therapeutic options been considered? Are outcomes related to treatments?
Discussion
• Report a literature review of other similar cases. Describe how is this case different.
• Explain the rationale for reporting the case. What is unusual about the case? Does it challenge prevailing wisdom?
• In the future, could things be done differently in a similar case?
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BMC Medical Education 2004, 4 http://www.biomedcentral.com/1472-6920/4/4
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OO downloaded half of the journals from their website,
extracted the data, and made critical revisions to the
manuscript.
AC carried out the statistical analysis and made critical
revisions to the manuscript.
KSK provided the original idea, gave guidance during data
extraction, and made critical revisions to the manuscript.
References
1. Wright SM, Kouroukis C: Capturing zebras: what to do with a
reportable case. CMAJ 2000, 163(4):429-431.
2. Vandenbroucke JP: In defence of case reports and case series.
Ann Int Med 2001, 134:330-332.
3. British Medical Association Medical Information Working Party: Col-
lection of Medical Books and Journals. Core 42001.
4. [http://www.biohealthmatics.com/healthinformatics/hippa
].
5. Brodell RT: Do more than discuss that unusual case: Write it
up. Postgrad Med 2000, 108(2): [http://www.postgradmed.com/
issues/2000/08_00/editorial.htm].
6. Bignall J, Horton R: Learning from stories – The Lancet's case
reports. Lancet 1995, 346(8985):1246.
7. Huston P, Squires BP: Case reports: Information for authors
and peer reviewers. CMAJ 1996, 154:43-44.
8. Khan KS, Thompson PJ: A proposal for writing and appraising
case reports. BJOG 2002, 109(8):849.
Pre-publication history
The pre-publication history for this paper can be accessed
here:
http://www.biomedcentral.com/1472-6920/4/4/prepub
