Case Reports Are Leaving ANESTHESIOLOGY, but Not the Specialty

Abstract

Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina. editor-in-chief@anesthesiology.orgEFFECTIVE January, 2013, ANESTHESIOLOGY will no longer publish case reports, either as a separate article type or as a letter to the editor. We make this decision with some reluctance, but believe it is appropriate, both for the ongoing role of case reports in advancing the specialty and for the mission of this journal.Before the advent of clinical trials, case descriptions, either those of a single case or a case series, reigned as the primary mechanism to communicate breakthroughs in medical treatment. The case report of general anesthesia by Henry Jacob Bigelow in 18461was recently voted by readers to be the most important article published in the New England Journal of Medicine in its 200-yr history. Roughly 50 yr later, spinal anesthesia was described by August Bier2as a short case series. Nearly all advances in medicine before 1950, from antibiotics to chemotherapy to surgical procedures, moved forward from case reports.Since the advent of the randomized trial design, described and advocated by Bradford Hill in the 1940s,3case reports moved from primacy in shaping medical practice to alerting us to special circumstances. With the explosion of new drugs and techniques in the last half of the 20th century came the description of rare and not-so-rare toxicity associated with these therapies when they were widely applied. Malignant hyperthermia and hepatitis from halothane and other volatile anesthetics, cauda equina syndrome from intrathecal injection of local anesthetics, delayed respiratory depression from epidural or intrathecal injection of morphine, and acute respiratory depression from sufentanil by these routes were unknown as diseases or not predicted to occur before their descriptions as case reports. In addition to informing us regarding toxicity, case reports also contribute to our treatment in special settings. If we are caring for a patient with a rare disease, an Internet search may only yield case reports that provide hints regarding how to approach this care. Similarly, in planning how to handle unusual complications, from epidural hematoma to unable-to-ventilate and unable-to-intubate, we rely on consensus statements often deriving from case reports.The mission of ANESTHESIOLOGY is, “promoting scientific discovery and knowledge in perioperative, critical care, and pain medicine to advance patient care.” During the process of creating this statement, the Editorial Board listed and rated words and phrases that were important to its perception of the central goal of the journal. Words such as “discovery,” “seminal,” and “definitive” rose to the top. We strive to provide both fundamental and practical knowledge that is new and can be trusted. As noted above, case reports were traditionally considered to reflect these characteristics, but one could argue that a century of individual reports has often misled us in a manner that harms patients. There is a role for case reports to inform us of rare toxicities or how to innovatively handle rare circumstances, but ANESTHESIOLOGY strives to present the future of our specialty, and we strive to choose study designs rather than case descriptions to more accurately meet this goal.We will no longer routinely publish case reports, in part because they no longer directly address our mission and in part because a new venue, Anesthesia & Analgesia Case Reports , has been established to highlight them. This new journal, edited by Lawrence Saidman, M.D., former Editor-in-Chief of ANESTHESIOLOGY, will choose the best case reports to generate hypotheses and to inform practice under unusual circumstance.This is not to say that we will turn our back entirely on the description of individual cases. In the Education Section of the journal, the Invited Case Scenario article type will share case-based perspectives from multiple specialties, on the care of challenging clinical problems, the Mind to Mind article type will share individual perspectives of patients and care givers, and the Images in Anesthesiology article type will share visual aspects of clinical problems. We also plan to expand our efforts to highlight specific areas of the specialty with thematic Requests for Submissions, three of which are planned for 2014; case reports relevant to those themes may be submitted for review under the article type Special Articles. But we intend to focus our attention and energy on bringing you trustworthy guidance on scientific advancement and high quality, multispecialty education related to individual patient care. The introduction of Anesthesia & Analgesia Case Reports as a new venue for case reports in anesthesiology is a welcome addition to the specialty, which allows us to focus on our mission. We wish the fledgling journal focused on case reports well, and know that this special article type will continue to advance the specialty.Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina. editor-in-chief@anesthesiology.org