Correspondence: Richard Smith firstname.lastname@example.org
Cases Journal 2008, 1:1 doi:10.1186/1757-1626-1-1
(2008-06-02 11:03) The Queen Elizabeth Hospital, Gayton Road, KIngs Lynn PE30 4ET
Dr Richard Smith
May 26th. 2008.
Re: Why do we need Cases Journal?
Congratulation, commendation and thank you for starting this Cases Journal at BMC.
Congratulation because Cases Journal has Gold shine success from day one.
Commendation is deserved as this simple yet ingenious idea of Cases Journal is of
admirable and enviable bravery. It signifies a seriously important message that intelligence
capable of contribution to the advancement of medicine and science exists outside
research centres of excellence!
Commendation again because with your expertise, capability and history as one of the
most successful, influential and exciting medical editor in the field, starting Cases
Journal is hugely significant and important too. Endorsing case reports as a source
of EBM at the age of worshiping RCT is a revolutionary concept with great gain to
medical community. This is not only because you were a keen supporter of RCT but also
because case reports has regained a deserved right of importance as another source
for EBM that has long been ignored, denied, undervalued and/or discredited.
Thank you because you seem to have heard my prayers! You must have read some of my
letters that I nagged you with in writing and as Rapid Responses (RR) during your
previous life as Editor of BMJ! It all remain there at the RR section- just search
by author's name and you find some eye opening and thought provoking ideas- if a reader
does not find it educational and entertaining- money back guaranteed!)! Or, have been
peeking into my Computer hard disc and reading some of the letters, case reports/series,
observational studies and essays that I have written over the last quarter of a century
awaiting literature asylum. Some were published, most were rejected and many may come
your way as Editor of the new Cases Journal.
Thank you again for making me feel so "excited, young, fool and hungry" again! It
feels magic as if falling in love all over again (with medical sciences and literature
that is!). This is perhaps my way of phrasing what you reported as Cacteau's quote:
"Take a commonplace, clean it and polish it, light it so that it produces the same
effect of youth and freshness and originality and spontaneity as it did originally,
and you have done a poet's job. The rest is literature". In many ways this is what
you did by re-inventing Cases Journal!
This also precisely describes my collection of case reports. They may seem ordinary
usual cases being seen daily by thousands of doctor but few would give them a second
look or thought and non can see through them with the amazement and curiosity I feel
or with the clarity that surpasses their description in a textbook! However, being
as old as I am now, and hopefully a bit wiser, I might avoid some of the foolish mistakes
I did before!
You explained well why do we need Cases Journal". I admire the brilliance of reinventing
a simple idea whose only silliness is why has it took you so long?
I am delighted with your return as Editor-in-Chief of this new Cases Journal. You
have been truly missed when you left the editorial arena. Welcome back. There is one
other great editor I badly miss but I am not mentioning names here!
Conflict of Interest?
Reading both of your editorials and case report at "Cases Journal", has indeed rejuvenated
an old wonderful feelings of delight and satisfaction. I experienced that feeling
when BMJ published my first pieces at the correspondence section in 1985 & 7 [1,2].
This is when I became engaged and married to my greatest love of scientific medical
research and writing. It has since become permanent incurable addiction that no pain,
sleepless nights, frustration, depression, battering of repeated of rejection, endured
over a life sentence, could cure me of it. However, it is the best thing that has
ever happened to me in my whole life and I am grateful to the Editor of BMJ for it!
The Lancet Editor is equally great as he was also kind to publish couple of letters
in 1985-8 [3-5], so did the editor of British Journal of Urology reported a first
letter in 1988 . It all tasted so sweet I just couldn't give it up.
I acted like a deprived child who was allowed a shopping spree in a sweet or toy shop!
I wanted more and always returned for a fix at whatever cost and taxes it took from
me! My list of precious little publications grew bigger and taller while the list
of journals grew broader and wider. I do not wish to make it sound like personal advertising
or recitation of my CV here. This not a conflict of interest either as the point I
am making here is that I found myself best expressed in letters that may contain one
or more Case Reports. Whenever I got a chance to do proper research of RCT or observational
study, I did and reported- or tried to.
The first letter  reported at BMJ in 1985 was brainstorming on a new hypothesis
on the transurethral resection syndrome (TURS) that lead to some serious research
and results on related physics, physiology and medicine. Full research articles of
unique quality and original contents were reported later in 1991  and 2001 .
As this arena became closed shut in my face, I changed the subjects in 2002 [9,10].
The second letter  reported at BMJ in 1987, in fact, contained two case reports
as anecdotal evidence on the life-saving effectiveness of 5% Hypertonic Sodium Chloride
(5%NaCl) in treating acute hyponatraemia and the TURS patients. This was at an era
when such therapy was contra-indicated! I had affirmed the effectiveness of 5%NaCl
in my first research article reported in 1991 - rejuvenating the therapy from its
original introduction into clinical practice for treating the TURS by Harrison et
al  as based on earlier animal research reported in series of articles by Danowski
TS, Winkler AW, Elkington JR . The therapy of 5%NaCl was later restored and approved
by the authorities in 1993 as the treatment of choice of acute hyponatraemia.
The remaining of some 15+ TURS case series stayed dormant in my MD Thesis book 
after an article was rejected by some journals while the prospective RCT study was
reported  . The research was done at the DGH Eastbourne, UK and Thesis presented
at The Institute of Urology, Mansoura Egypt in 1988 . I gave The article on Cases
Series on the TURS a musical name of "Hypo-osmotic Shock", also used as a chapter
heading in my MD Thesis ( I would still use it today on merits!). The pain and drag
of repeated rejections of case reports and observational studies had put me off re-submission
and caused withdrawal lasting at times a couple of dormancy years. I tried to nurse
it as some form of "writer's retreat" and waited patiently for the right opportunity
in order to re-bounce back!
Having said that, I can't help expressing a sense of shame here talking about my personal
pains due to obstruction of publication when compared to that of the fellow who- I
think- said the Earth is not flat: Isn't he the one the crowd throw alive into boiling
oil? Thank God, and I am grateful, for being in an Era and Land of Her Majesty that
values diversity, tolerance and freedom where nobody gets fried or tortured for expressing
an opinion or trying to advance science or medicine!
The pain and frustration that I have never really been able to adapt to was not the
personal one of being rejected but that caused by persistent obstruction preventing
the publication of knowledge that could have saved thousands of patients much pain
and misery, and might also have saved millions of lives the World over! Meantime the
dormant documents seem to mature like wine over the years! Those years have just affirmed
and strengthened my believe that my observations have proved dead accurate and my
hypotheses are precisely correct!
The TURS vanishing or reincarnating "Back to the Future"?
The TURS is currently vanishing from urology for various reasons, but please do not
hold its burial service yet! It will resurrect itself "Back to the Future" perhaps
with a new name and features. Not only in the future but it is here yesterday and
today and tomorrow! It remains to affect patients in many medical and surgical specialties.
The incidence and prevalence of morbidity and mortality of acute hyponatraemia in
current hospital practice as evidenced by many recent reports is overwhelming and
astonishing! Has the lesson of the TURS been learned, its cause been understood and
the effective life-saving therapy of 5%NaCl been correctly used?
No. No. No..
More important than the TURS, is demonstrating its link with the adult respiratory
distress syndrome (ARDS) that was later renamed as the multiple vital organ failure
(MVOF) syndrome, and renamed again as the systemic inflammatory response syndrome
(SIRS). Has the importance of such link been realized? Can RCT provide answers on
any of these conditions under currently received wisdom and knowledge?
No and not in a million, respectively!
The answers are in fact available today, at least in part, and it has been in print
since 1991 and 2001 when I reported an impeccable prospective study at The British
Journal of Urology  and another unique work at the Medical Hypothesis - thanks
to another two great late Editors. (I do not mention names because some guy wrote
somewhere that authors can't use names without "consent for acknowledgement"- please
see comments on "The policies of Cases Journal").
Being overlooked, not really understood or deliberately ignored by peers of the scientific
and medical community is hard to tell. Hence, I have long come to realize- like you
have- that describing the cases as I saw them and reporting it perhaps as series,
or with some luck as observation study may help others to see what I could clearly
and unmistakably recognize over the years! I never really had much luck with research
articles and observational studies since 1991 (Save those mentioned [6-10]-thanks
only to the bravery and caliber of these journal' Editors) so I continued with case
reports and communication letters. Then when you invented the RR section of BMJ, I
showered it with series of articles. Is Cases Journal the one I have been waiting
Only case reports and observational studies can provide understanding and solutions
to current most complex medical problems of patients with multiple co-morbidities
such the MVOF syndrome where thousands of expensive RCT have failed to deliver. This
is particularly so when reported at Cases Journal supported by an editor of your caliber!
For the same reason I can predict that your Cases Journal shall prove be a phenomenal
success! The role of RCT and statistics as well as team work comes later to affirm
or refute the evidence or hypothesis outlined in case reports or series or an essay
article on new hypothesis- so far a challenging closed door for me. Please also note
that observational studies like case reports have been discredited until recently,
again because of the trendy era of worshiping RCT and Statistics!.
As I stated before in some of my RR letters at the BMJ: "RCT cannot investigate an
unknown condition or hypothesis and certainly cannot make a discovery neither in science
nor in medicine". Case reports and observational studies can and will!". Observation
and mental experimentation are the most potent tools for discovery and invention,
and their practitioners have accurate visions that can tell if an experiment, study
or test may succeed or not- even before it is done in a laboratory or in a clinical
trial! In other words, one cannot find something unless he knows exactly what is he
looking for: observation spots at first sight while mental experiments analyze it,
extract its value and importance, and conjure experiments that are safe and ethical
needed to prove it. A lone researcher or team should deliver results in 25 or 1-2
Hence, in fact, thanks to an energy boost induced by your announcement of Cases Journal
I did some considerable digging today in order to excavate some of the buried case
reports and articles from a mass Graveyard on my Hard Disc Drive! The most recent
case report was written over 6 years ago and some go as far back as 15 or 20 years.
They require nothing more than little "clean and polish" putting it in the format
of Cases Journal, and I have already downloaded the template. Then there you have
it "clean and polished"! for Cases Journal to "light it so that it produces the same
effect of youth and freshness and originality and spontaneity as it did originally,
and you have done a poet's job. The rest is literature".
Many of it were rejected by your previous and other journals in the field when the
whole medical community was blinded by the illusion that EBM can only come from RCT!.
Some thoughts were later reported as correspondence and many as RR at BMJ- hopefully
your colleagues and students there may realize their mistake and bring it back from
that cyber graveyard into a proper section of their journal- just wishful thinking!?
I am not really sure where does it stand and whether reporting it again elsewhere
may be considered "Duplicate Publication"? However, your quality as editor with pioneering
vision, originality and bravery is rare and may be hard even to imitate. Major articles
on studies remain unreported. But, no experience is wasted and no knowledge is forgotten.
In fact, as you mentioned and demonstrated above, every study of both observational
and prospective types that I had done during my career life had always started with
one case that became a series that became study worthy of reporting its results. Such
full studies may just have to wait for your next true Science 2.0 journal. Cases Journal
is currently version 1.2 in my estimation- explanation shall follow. I just can't
face sending mine again to rejecting journals and I do not care what Impact Factor
they might have. Your Case Journal currently have Zero Impact Factor as a new journal
but watch its steep curve- you may have to raise your chin to the level of your eye
brows to see where it is going!
Science 2.0 and Medicine 1.2 judged by Art 1.0
A true Science 2.0 journal in medicine such as an imaginary journal "Observational
Studies Journal" and/or "The Free Scientific Medical Author Journal" of true Net 2.0)
need total liberation from all the old restrictive rules of RCT, complete disinfection
from its the bugs, viruses and Trojans - without discarding or discrediting the importance
of Science and Medicine 1.0, and a new role of the editorial team their journal's
policies! The editorial team and peer reviewers will remain most important with a
challenging and exciting new task but need to evolve and adapt. They may perhaps continue
to use the same old tools1.0 used for judging art, poetry and literature. The journal
will have a style too but the author should remain free of all restrictions. Such
new virtual " Intellectual Products Journal" like a supermarket should have a system
and rules with organization tools. Such true 2.0 may attract the best fresh produce
of "grey matter juice" of varied most delicious flavours from all over the World!
Your Story, My Story!
Now back to your exciting new Cases Journal, and why am I so excited about it too?
You put it in a punch word: "Story". A story that will not only cure a state of boredom
by providing quality entertainment but will also prove educational and useful! Tell
me a good story that grabs my attention, delight and entertain, even if you stole
it from the One Thousands and One Arabian Nights Book, and do not you worry about
your message being received or lesson being learnt- trust me it always does"
You made me laugh when I read your statement: "Perhaps some of our contributors will
attempt to write case histories like those of Sigmund Freud." And again: "if somebody
can produce a report that has both the length and nuance of a Dostoevsky novel or
a Freud case report then the world will be a richer place." I wondered if you were
careful enough when you made such wish- and what will you do if it comes true? The
reason was that just shifting through some titles as I searched my hard disk made
me realize that you may regret saying that- if I decided to send you every case report
I have and article I wrote! This document is a sample written specially and freshly
for you! On second thought I have divided it, the one you are reading and more will
As I laughed, an old true story that happened back in 1977 came to mind that I think
is relevant and with which I reciprocate. After passing the PLAB test and before finishing
a month of clinical attachment in Northampton, I was desperate to find my first job
due to cash running short fast. I asked the consultant if there was a job for me,
he said no. I asked how can I find one and would he give me a reference? He said the
back section of BMJ is full of it and he would be happy to. I sat down the whole next
weekend and systematically wrote application letters to every advertisement of SHO
jobs at the latest couple of issues of BMJ (Not realizing some were repeated), and
posted it on a Monday morning! While at it I had my first look at the front section
and thought someday I should be a contributor!
Before the end of that week, I was summoned by the consultant at his office in private.
The furious look at his face triggered thoughts: "Oh my God! I must have done something
drastically wrong. I couldn't have killed a patient while acting in an observant capacity-
could I!?. I do not know what is it but I know I have done nothing wrong". As a matter
of fact I didn't, or rather couldn't, say much at that meeting. The gentleman explained
the problem as he must have diagnosed my condition of "no condition to talk", he did
all the talking and reassurance as he was making coffee.
I could not take mine but only nodded thanks so he put it on a side table. He at last
smiled as he talked: "I have received over 200 requests for references from hospitals
all over the country! How many interviews have you been called for and where do want
to work? I answered briefly in a barely heard voice: "Only 8 and I want to work in
UK!". He burst into laughter while I watched in bewilderment being clueless why was
he laughing! (To be continued if life continues!).
Ahmed Ghanem, MBChB, MD (Urology), FRCS
The Urology Department,
The Queen Elizabeth Hospital,
Gayton Road, Kings Lynn, Norfolk PE30 4ET
(Future Address from mid June will be provided as soon as confirmed)
1. Ghanem AN. Hypoalbuminaemic hyponatraemia: a new syndrome. Br Med. Jour. 1985;
2. Ghanem AN. Wojtulewski JA, Penney MD. Dangers in treating hyponatraemia. Br Med
J. 1987; 294: 837.
3. Ghanem AN, Powley JM. Hepatic outflow obstruction. Lancet 1985; ii: 675.
4. Ghanem AN. Serum Osmolality Gap. Lancet 1987; ii: 223-4.
5. Ghanem AN. Hyponatraemia and hypo-osmolality. Lancet 1988; ii: 572.
6. Ghanem AN, Ward JP. Fluid absorption during urological surgery. Br J Uro, 1988;
7. Ghanem AN, Ward JP. Osmotic and metabolic sequelae of volumetric overload in relation
to the TURP syndrome. Br J Uro 1990; 66: 71-78 (Award Winner of Princess Alice Memorial
Award, UK 1988).
8. Ghanem AN. Magnetic field-like fluid circulation of a porous orifice tube and relevance
to the capillary-interstitial fluid circulation: Preliminary report. Medical Hypotheses
2001 Mar; 56 (3): 325-334.
9. Ghanem AN. Experience with cystoprostadenectomy with “prostatic capsule sparing”
for orthotopaeic bladder replacement: overcoming the problems of impotence, incontinence
and difficult urethral anastomosis. BJU Int. October 2002; 90(6): 617-620
10. Ghanem AN. Leading Article. Features and Complications of Nephroptosis Causing
the Loin Pain and Haematuria Syndrome: Preliminary Report. Saudi Med. J. 2002 Feb;23(2):
11. Harrison III RH, Boren JS, Robinson JR. Dilutional hyponatraemic shock: another
concept of the transurethral prostatic reaction. J Uro. 1956; 75 (1): 95-110.
12. Danowski TS, Winkler AW, Elkington JR. The treatment of shock due to salt depression;
comparison of isotonic, of hypertonic saline and of isotonic glucose solutions. J.
Clin. Invest. 1946; 25: 130.
13. Ghanem AN. The Transurethral Prostatectomy (TURP) Syndrome: An Investigation of
the Osmotic and Metabolic sequelae of Volumetric Overload (VO). MD Thesis. Institute
of Urology & Nephrology, Mansoura University, Egypt. November 6, 1988.
Competing intersts: None other than declared in the text.
(2008-06-02 09:27) Faculty of Medicine, Egypt.
launching Cases Journal is a very smart idea, it will help in buidling a very good
evidence based medicine data base. Physicians from all over the world need to learn
about all cases not only the unique ones. Cases Journal will provide help to all physicians
to manage their cases and to share their experiences.
(2008-05-23 09:47) St. Isabel's Hospital, Chennai, India
For a doctor practicing medicine in a country of vast disparities like India, the
hierarchy of evidence is often a source of discomfort. For one thing, the evidence
is mainly from the Caucasian West, because they are the only ones with the money to
mount expensive randomised trials. For another, there may be plenty of evidence on
the lifestyle diseases now common in the West, but very little on the many horrible
pathogens still common in the hot zones of the world. But worse than all this, is
the situation where your patient fits the evidence, but your resources do not. Take
for example, a poor patient aged 50 with rheumatoid arthritis of the hip affecting
both joint surfaces. The patient is in severe pain. The best option is a replacement
where both the acetabular surface and the femoral surface are replaced. But this costs
ten times what a replacement of the femoral head alone will. The patient, who has
to pay for the surgery cannot afford it. The surgeon who does the hemireplacement
with the knowledge that it will give some relief of pain but will last perhaps only
for five years, has to contend with his conscience, because he has not followed the
evidence. He also has to contend with the ridicule of his peers. The so-called best
can often be the enemy of the good.
(2008-05-21 15:24) James Lind Library
I am sure that I am not the only person to be delighted by the return of the prodigal
Richard Smith to medical editing, and by his obvious commitment to this new publishing
venture. Case reports can indeed lead to improved care of patients; but it is important
to remember that they can also be lethal (1). For over twenty years I have been drawing
attention - most recently through The James Lind Library (www.jameslindlibrary.org)
- to Geoffrey Venning's pioneering cohort study done to assess the extent to which
interpretation of case reports had been validated subsequently by more carefully controlled
research (2). Indeed, I have noted that Venning actually underestimated the value
of case reports in detecting adverse effects of drugs. However, as Richard Smith quotes
Enkin and Jadad with approval for suggesting that randomized trials should be "taken
off their pedestal", I thought that it might be worth reproducing a passage (1) about
case reports published in a book co-authored by Murray Enkin 20 years ago (3).
In 1952, Austin Bradford Hill - the medical statistician who play such an important
part in introducing the randomized controlled trial to medical research –'In
my indictment of the statistician, I would argue that he may tend to be a trifle too
scornful of the clinical judgments, the clinical impression. Such judgments are, I
believe, in essence, statistical;. The clinician is attempting to make a comparison
between the situation that faces him at the moment and a mentally recorded but otherwise
untabulated past experience' (4). Twenty years later, Sam Shuster - a clinician -
warned that these impressions can be seriously misleading: 'There are lies, damned
lies, and clinical impressions' (5). Both Bradford Hill and Shuster are right, of
course: informal evaluation of care based on impressions, and formal evaluation based
on well-controlled comparisons of alternative forms of care, both play essential roles
in the promotion of more effective care during pregnancy and childbirth.
Two anecdotes may help to illustrate the strengths and dangers of impressions about
the effects of care based on case reports. During the 1960s, an obstetrician interested
in the physiology of parturition had the impression that lambs whose mothers had been
given corticosteroids to initiate labour showed signs of respiratory distress less
often than might have been expected. Further observations made in the context of controlled
experiments in sheep confirmed that lambs born after maternally-administered corticosteroids
were indeed less likely than control lambs to develop respiratory distress. Together
with a paediatric colleague, the obstetrician went on to conduct further well-controlled
investigations in humans, and demonstrated that ante¬natal administration of
corticosteroids prior to preterm delivery resulted in an important reduction of neonatal
morbidity. Because of the possibility that there might be long term adverse consequences
of fetal exposure to corticosteroids, long term follow-up of the steroid-exposed and
control babies was conducted; so far no adverse effects have been detected.
The second anecdote refers to another obstetrician who, in the early 1950s, encountered
a number of research reports from prestigious institutions in the United States in
which the clinical investigators had concluded that diethylstilboestrol (DES) was
an effective drug for the 'support of placental function'. Consulted by a woman who
had had two previous stillbirths, the obstetrician prescribed the drug from early
pregnancy onwards. The pregnancy ended with the birth of a liveborn child, as did
a subsequent pregnancy similarly managed. Reasoning that the woman's 'natural' capacity
for successful childbearing may have improved over this time, the obstetrician withheld
medication during the woman's fifth pregnancy: the baby died in utero from 'placental
insufficiency'. During her sixth and final pregnancy, the obstetrician and the woman
were in no doubt that prescription of diethylstilboestrol should be resumed: the pregnancy
ended with the birth of another liveborn child. The impression gained of the apparent
effects of diethylstilboestrol (three livebirths following treatment with diethylstilboestrol,
and three intrauterine deaths when the drug had not been used) led both the obstetrician
and the woman to infer that it was a useful drug.
As these two anecdotes illustrate, impressions about the effects of care are sometimes
right, and sometimes wrong. In the first, an informal impression initiated a series
of well-designed investigations and a discovery which must rate as one of the most
important ever made in obstetrics. In the second case the impression left on the obstetrician
and the mother was never substantiated in the properly controlled studies that were
being conducted and reported during the years over which the woman was receiving care.
Tragically, this evidence was widely ignored, for not only was diethylstilboestrol
ineffective, it was actually harmful. The drug caused a variety of abnormalities,
including cancer, in many of the children of the millions of women who had taken it
during pregnancy (1).
Validated case reports can lead to improvements in the care of patients; invalid case
reports can kill them. I wish the new Cases Journal well; but if it does indeed wish
to support the counter-reformation called for by Enkin and Jadad, I hope it will follow
the methodological lead set by Geoffrey Venning quarter of a century ago (2). The
journal should establish a prospective cohort study now to assess the extent to which
its case reports about purported treatment effects lead to reliable evidence about
ways of improving the care of patients.
1. Chalmers I. Evaluating the effects of care during pregnancy and childbirth. In:
Chalmers I, Enkin M, Keirse MJNC, eds. Effective care in pregnancy and childbirth.
Oxford: Oxford University Press, 1989:3-38.
2. Venning GR. The validity of anecdotal reports of suspected adverse drug reactions
– the problem of false alarms. BMJ 1982;284:249-252.
3. Jadad AR, Enkin MW: Randomized controlled trials: questions, answers and musings.
Oxford: Blackwell Publishing; 2007.
4. Chalmers I, Enkin M, Keirse MJNC, eds. Effective care in pregnancy and childbirth.
Oxford: Oxford University Press, 1989.
5. Hill AB. The clinical trial. New England Journal of Medicine 1952;247:113-119.
6. Shuster S. Primary cutaneous virilism or idiopathic hirsutes? BMJ 1972;2:285-286.
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