This article is protected by copyright. To share or copy this article, please visit copyright.com. Use ISSN#1945-7081.

To subscribe, visit imjournal.com

EDITORIAL

Case Reports, Clinical Practice Guidelines, and Evidence

David S. Riley, MD, Associate Editor

Without clinical expertise, practice risks becoming

tyrannized by evidence, for even excellent evidence may be
inappropriate for an individual patient. David Sackett1
Case reports that adhere to the CARE guidelines can
be sufficiently rigorous to inform clinical practice, clinical
practice guidelines, and clinical trial design. These
reporting guidelines define a framework for the systematic
reporting of data from the point of care. We believe that
high-quality case reports, written with adherence to these
reporting guidelines, provides early evidence of not only
adverse events, but also effectiveness and cost.
Case reports have historically been important, but the
quality has been uneven.2 Gagnier et al3 wrote,
They have proved helpful in the identification of adverse
and beneficial effects, the recognition of new diseases,
unusual forms of common diseases, and the presentation of
rare diseases. For example, our understanding of the
relationship between thalidomide and congenital
abnormalities and the use of propranolol for the treatment
of infantile hemangiomas began with case reports.

Data analysis of systematically collected information from

the point of caresome published as case reportshas
created opportunities for close-to-real-time signals from
clinical encounters. In 2011, Joel Gagnier, ND, MSc, PhD, of
the University of Michigan; Gunver Kienle, Dr med, of the
University of Witten Herdecke; and David Riley, MD, of
the National College of Natural Medicine led the
development of reporting guidelines for case reportsthe
CARE guidelines. These guidelines were presented at the
triannual International Congress on Peer Review and
Biomedical Publication sponsored by the Journal of the
America Medical Association and the British Medical
Journal in Chicago, Illinois, in 2013, and they were
published in multiple medical journals.3 The CARE
guidelines and checklist are currently available in multiple
languages and are accepted as the standard for published
case reports by many medical journals, and they are part
of the Equator Networks health research reporting
guidelines library. The CARE guidelines, CARE checklist,
and other documents are available on the CARE-Statement
Web site.i Members of the CARE group steering group
78

Integrative Medicine Vol. 14, No. 5 October 2015

have participated in the incorporation of the CARE

guidelines into clinical data collection research projects at
academic medical centers and helped write CARE
guidelines extensions for specific medical specialties.
The publisher InnoVision Professional Media and the
peer-reviewed, indexed medical journalIntegrative
Medicine: A Clinicians Journal (IMCJ)support the CARE
guidelines and will begin to publish high-quality case
reports that follow these reporting guidelines. Please visit
the IMCJ Web site for author guidelines for case reports.ii
We believe that evidence from case reports can be
integrated with the data from controlled clinical trials
(both efficacy and pragmatic trials), systematic reviews,
and observational studies to form an evidence mosaic that
provides a more complete and accurate picture of the
effectiveness of therapeutic interventions and outcomes.
High-quality case reports (1) support expanded
therapeutic options for patients; (2) support enhanced
critical thinking for clinicians, residents, and students;
(3) facilitate the ongoing evaluation of clinical practice
guidelines so that they are more useful; (4) generate
hypotheses for clinical research; and (5) support innovation
and postmarketing surveillance tools for the health care
industry. The continued growth of published case reports
today in the peer-reviewed medical literature suggests they
contain valuable information. Patients often do not fit into
neat boxes defined by the inclusion and exclusion criteria of
clinical trials and clinicians are forced to adapt. Clinical
practice is a complex interplay between experience and
external evidence and must draw on data from a variety of
sources. The editors of IMCJ believe that part of the value of
case reports lies in their inherently individualized
informationincreasingly important in an era of genomic
testing, chronic disease, and individualized medicine.
References

1. Sackett D. Evidence based medicine: what it is and what it isnt. BMJ.

1996;312(7023):71-72.
2. Richason TP, Paulson SM, Lowenstein SR, Heard KJ. Case reports describing
treatments in the emergency medicine literature: missing and misleading
information. BMC Emerg Med. June 2009;9:10.
3. Gagnier J, Kiene G, Altman DG, Moher D, Sox H, Riley DS, and the CARE
group. The CARE guidelines: consensus-based clinical case report guideline
development. Global Adv Health Med. 2013;2(5):38-43.

i. To view the documents, please visit http://www.care-statement.org/.

ii. The IMCJ Web site is located at http://www.imjournal.com.

RileyEditorial