Behind the Peer Reviewer’s Desk: Common Recurring Pitfalls in Case Reports Submitted to the Journal of Orthopaedic Case Reports

Introduction

“A case report is the detailed report of an individual including aspects like exposure, symptoms, signs, intervention and outcome. A case report may describe an unusual etiology, an unusual or unknown disorder, a challenging differential diagnosis, an unusual setting for care, information that cannot be reproduced due to ethical reasons, unusual or puzzling clinical features, improved or unique technical procedures, unusual interactions, rare or novel adverse reactions to care, or new insight into pathogenesis of disease.” [1,2,3]. Case reports can reveal novel ideas, which can generate new hypotheses, thus facilitating innovative research [1]. Although case reports are at the bottom of the pyramid of evidence, they do have value because the bottom of a pyramid serves as the foundation [4]. Although journal guidelines for reporting and drafting of case reports vary, an uniform standard reporting checklist of CAse REport; however, is available, which ensures transparency, replication, and publication of high-quality case reports [5]. Haq and Dhammi [6] are of the opinion that every case report should follow the “Rule of Cs,” meaning that it should be Clear, Concise, Coherent, and deliver a Crispy message.

I have been associated with Journal of Orthopaedic Case Reports (JOCR) as a peer reviewer since 2018. I have reviewed over 1000 case reports for JOCR till date. I am honored to be awarded JOCR “Best Reviewer Award” for the years 2016, 2018, and 2023. Over the years, I have noted that the majority of the case reports that I have reviewed for JOCR had consistently one or more pitfalls (in order of frequency) as shown in Table 1.

In the majority of the case reports, the authors failed to disclose the patient perspective or experience. It would be more appropriate to mention the patient’s perspective about the treatment that they receive. This is particularly important in the case of novel intervention which rely heavily on patient motivation. The patients can also share the impact of the intervention on their quality of life.

All journals, including JOCR, have displayed author guidelines on the official journal website, which guide the authors about word count, font size, and sections and sub-sections of case reports. The authors should strictly follow these instructions while drafting their case reports. Shyam [7] has rightly pointed out that desk rejection of a case report can be due to modifiable causes (formatting and writing) and non-modifiable (lack of novelty). To increase the chances of publication of case reports in JOCR, the authors should avoid both causes.

It is mandatory to mention the strengths and limitations of a case report. The strengths can be the innovative teaching or learning tool, cost-effective, feasibility of test or intervention, or enhanced safety in contrast to conventional intervention. The limitations can be the lack of generalizability, retrospective nature of case reports, and possibility of selection and reporting bias. Other specific imitations of case reports, such as incomplete medical records, difficulty to access medical records, and inadequate follow-up should be mentioned and reasons explained.

The follow-up period mentioned in the case report is variable and depends upon the nature of the disorder, intervention, and outcome. It can range from months to years. Generally, however, the follow-up period should be proportional to the disorder or intervention. Adequate follow-up is critical because it confirms the diagnosis, proves the long-term efficacy of the intervention, and shows any delayed adverse events. The authors can determine whether the given intervention has a long-lasting effect or whether its beneficial effects diminish with time. The follow-up should be adequate for that particular disorder with a feasible frequency of visits. Both subjective (patient-reported) and objective (laboratory, imaging) outcomes, including adverse events, should be reported. Radiographs and high-resolution clinical images of the past follow-up visit should be provided. Assurance of long-term adherence to an intervention, if any, should be described in detail. Issues related to follow-up, such as patient retention, collection of data, and results interpretation, should be discussed.

A case report must add to the present literature. If the references are old, it suggests that the authors have not verified that if the “Rare” case has already been widely documented recently. The author is responsible for confirming the accuracy, validity, and citation style of references [8]. The authors should avoid errors in referencing. Vancouver, the most commonly preferred referencing style, should be learnt. Many software, such as EndNote and Mendeley, can assist in reference management. In a case report, about two-thirds of the total cited references should be <5 years old. Inclusion of recent relevant references in a case report confirms that the diagnostic techniques or interventions are not obsolete and an up-to-date literature review has been conducted by the author.

Many authors failed to mention informed consent and institutional approval in case reports. This ethical oversight is a non-negotiable gatekeeper. Additional consent (for sharing images or videos or identifiable personal information), if taken, should also be disclosed [9].

The conclusion of a case report should be brief and should focus on the primary findings of the case report. It should be evidence-based and justifiable. Avoid unnecessary details and do not mention results in this section.

Every case report should have a list of all possible differential diagnoses. Mentioning the differential diagnosis in a case report prevents biases and errors in diagnosis. The readers understand how the author reached the final diagnosis. A list of all possible relevant differential diagnoses should be compiled, and the final diagnosis drawn logically with supportive laboratory and imaging data.

A good title of a case report should be clear, brief but comprehensive and should mention the word “Case Report” along with the main focus of the case report, such as diagnosis, symptoms, intervention, tests, and complications. Vague terms should be avoided. It is very beneficial that a case report is identified as a case report because it will facilitate for indexing in various databases and prompt search retrieval, resulting in citations for the authors.

Conclusion

We believe that every case report is an inspiration for further research and may open a door to future research. Peer review is not a barrier, but a bridge to better research. The hierarchy of pitfalls identified in this editorial is the primary filters that determine whether a case report survives peer review or faces rejection or major revision. By recognizing and actively avoiding these ten common pitfalls, authors can significantly increase the chances of publication of their case reports.

References

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About the Authors

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  Faaiz Ali Shah

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  Javed Iqbal

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  Ashok Shyam