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Archive for November, 2008

Haemorrhagic transformation of a recent silent cerebral infarct during thrombolytic stroke treatment

14 Nov, 08 | by Dr Dean Jenkins

This case report highlights the challenge of radiology interpretation in acute cases especially where effective treatment is time critical. Often an investigation will have an obvious abnormality that accounts for the presenting symptoms but elsewhere, in an unrelated part of the scan, another abnormality may be present. Even in experienced teams such other findings may be overlooked. This case also documents the effect and outcome of thrombolysis in a recent silent cerebral infarct with petechial haemorrhages.

Haemorrhagic transformation of a recent silent cerebral infarct during thrombolytic stroke treatment
Karsten Bruins Slot, Eivind Berge and Joanna Wardlaw

Iatrogenic vitamin K deficiency and life threatening coagulopathy

14 Nov, 08 | by Dr Dean Jenkins

This is a reminder of an important clinical lesson that highlights the risk of vitamin K deficiency in the critically ill. The authors give a thorough account of the presentation, possible consequences and literature review in this case making it a rewarding and educational report. I note with interest the reviewer’s comments about not wanting to suggest yet another ‘guideline’. Sometimes protocols and guidelines can make medicine appear ‘routine’ and it takes case reports such as this to remind us that the challenge is often in the unexpected.

Iatrogenic vitamin K deficiency and life threatening coagulopathy
Samuel John Ford, Alistair Webb, Richard Payne, and Norbert Blesing

Bilateral breast metastases of a renal carcinoma

14 Nov, 08 | by Dr Dean Jenkins

Although rare – this is only the second case report of bilateral breast metastases from renal carcinoma – it has a strong clinical message that recognising the possibility of metastases can save the patient from more radical surgery. It also reminds us all of the importance of the past medical history. In this case Ganapathi and colleagues describe an elderly lady presenting with bilateral breast lumps who was initially thought to be primary breast carcinoma but who, on investigation, was found to have metastatic breast disease.


S Ganapathi, G Evans, and R Hargest

What shall we do with case reports?

14 Nov, 08 | by Dr Dean Jenkins

Case reports are popular and well-known but they have attracted criticism. They can distract the reader with the unusual. They are often not cited and mainstream journals are reluctant to publish them since they may lower impact factor. Their conclusions are rarely investigated further and may not be relevant outside the novelty of the case.

However, we feel there is great value in a well written case report.

The challenge of medicine is not only in managing the routine and well researched, but in recognising the strange. For example in my experience the majority of cases in an acute medical ward round consist of well documented common conditions. Communication with patients, relatives and staff is the skill that ensures the safe management of these cases and there are plenty of sources of evidence should the correct pathway or protocol be in doubt. It is the minority of cases, that are not what they seem, that present the greatest challenge and risk.

Being able to suspect that a case presentation or set of clinical findings does not fit the usual is a skill. Teaching this skill is difficult. Researching the cases that are exceptions, including the quite rare, is even more difficult. Experience certainly helps. But why? Experience helps in reinforcing the lessons learnt on logic and clinical decision making such as: not to close on a diagnosis too early, and to return to the differential diagnosis if the management of a case does not go to plan. Experience also helps in making the clinician more doubtful and therefore applying more rigorous methods of thought before acting. To paraphrase Oliver Wendall Holmes, a 19th Century physician, – the young doctor knows the rules, but the wise doctor knows the exceptions.

Case reports stimulate learning and research. As a time-honoured tradition of medicine they are capable of developing new subject areas, providing educational material and are among the most read content in journals. Case reports are very sensitive for detecting novelty which is useful in recognising new diseases as well as new side effects of drugs, both adverse and beneficial.

They complement evidence-based medicine. Decisions to withdraw drugs from the market because of harm are usually made on scientific evidence coming from spontaneous case reports (or case series) rather than randomised controlled trials.

A report that is well observed and linked to the published literature can be valuable even if there is nothing unique in the detail of the case. Lessons learnt, documented and shared, even if they are old lessons, are beneficial.

We welcome a range of styles of cases to BMJ Case Reports but they must, at least, identify some new scientific information or have a clear educational message that is useful to a general audience.

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