Case reports and case series versus modern evidence-based medicine: Merit for an individual patient and public health

Abstract is not required for Editorialis not required for Editorial (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 8 No.8, August 2017. ISSN – [0976-3198] Int J Case Rep Images 2017;8(8):487–490. www.ijcasereportsandimages.com Tantisattamo E 487 CASE REPORT OPEN ACCESS Case reports and case series versus modern evidence-based medicine: Merit for an individual patient and public health

case series from general sense for managing individual patient through their impacts on public health aspect.
Several scientific knowledge arise from observation of people and scientists. Sir Isaac Newton studied and worked on the theory of gravity from observing a fall of an apple [1]. Many invention came from inspiration. Wright brothers dreamed to fly after having a toy helicopter [2]. In addition, the previously unsuccessful experiments make scientists to further observe and research. Thomas Alva Edison who was not the first light bulb inventor, but was the first inventor of the light bulb, which can be used in a practical way, successfully invented a light bulb after several people failed to do so at that time [3].
Similar to any scientific fields, medical knowledge started from an observation from a single patient who has unusual presentations of common diseases or even usual presentations of uncommon conditions. Documentation and sharing experiences about the things that are still unclear lead the young generation to extend that knowledge to become more evidence and innovation.
Among non-experimental studies, case reports and case series are the most basic type of the study, but they are often the fundamental knowledge of all other types of non-experimental studies including case series, cross sectional, case-control, or cohort studies and experimental study like clinical trial [4] (Figure 1). Figure 1: Conceptual framework demonstrates the potential relationship and a 'cycle of medical knowledge' generating from observation, different processes of obtaining information, and the impact of different types of research study designs on an individual patient through public health. The goal of these studies is to discover and add on to new medical knowledge. However, there are some different aspects that unique for each study design ( Table 1).

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All clinicians and healthcare providers practice and learn from their patients. Most clinicians consult their colleagues or specialists whenever they encounter with unclear clinical situations in terms of clinical manifestations, diagnosis, interpretation of laboratory data or investigation, and management particularly in the setting of rare conditions or diseases as well as rare manifestations in common diseases. Nevertheless, uncertainties sometimes remain. Previously published clinical case reports or case series are therefore other resource that are helpful to assist in their clinical decision making.
Not only the benefit of case reports to help in the management for a single patient, they also potentially extend the benefit to societies at large or even to public health. The recent example that emphasizes this benefit is Zika virus epidemic. A clinical case report [5,6] can lead to subsequent analytic studies to characterize clinical manifestations, investigations, transmission, and complications of Zika virus infection in human and further studies during Zika virus outbreak [7][8][9][10][11][12][13] as well as discovery of management and prevention such as vaccine [14,15].
Several values of case reports and case series are not only contributing to the field of medicine, but also impacting or changing regulation or even public health policy. Particularly, the initial step of analytic research for drug safety often starts with case reports or case series [16]. This can be demonstrated by one of the new field of public health, pharmacoepidemiology involving in drug utilization, effectiveness, and safety. With so many innovative drugs, biological, biosimilars, or medical devices undergoing accelerated approval process, uncertainties and uncovered information particularly adverse drug experiences (ADE) or unintended side effects may arise. For instance, a report of new or unusual ADE can guide drug consumers, providers, manufacturers, and governmental organizations responsible to the regulation of drug utilization, effectiveness, and safety like Food and Drug Administration (FDA) to be alerted. This subsequently leads to further investigation, conducting research to prove the causal inference of the ADE and drug utilization. Ultimately, the action of these research leads to new regulation and management of the drug utilization for the public [17][18][19][20][21].
Therefore, case report and case series are actually the origin of several observational and experimental studies and can expand observation from characteristics of a single or multiple cases to more complex studies and eventually evidence-based knowledge, which can be applied for patient care through public health. The experiences from this application can subsequently lead to further observation of unknown knowledge requiring additional processes of obtaining knowledge from selfstudy, consultation, or research. This becomes a "cycle of medical knowledge" as demonstrated in the Figure 1.
Although several merits of case reports and case series, some disadvantages may take into the consideration when utilizing the information from case reports or case series mainly due to limitation of making causal inferences from a small number of studied patients ( Table 2).

CONCLUSION
From the past, nowadays, and in the future, case reports and case series tell us the stories and clinical entities of rare conditions or diseases or rare presentations of the common diseases. They are also the foundation of many descriptive as well as analytic studies and eventually experimental trials. Case reports and case series can not only be a way to help and communicate other physicians and healthcare providers about unusual aspect of individual case or a small group of patients, but also a foundation of idea and motivation in conducting. In addition, case reports and case series are also another method to formally inform involved and responsible stakeholders to further examine and again conduct further more complex research studies to determine causal inferences and this subsequently leads to further action and regulation to ultimately improve patient care. Therefore, case reports and case series should remain one of the efficient tools to inform and educate our colleagues, extend further medical knowledge for patient care, and potentially involve in public health.
Integration for teaching since pre-clinical years through all of medical professional careers as well as lesson to avoid repeated pitfalls Promoting scholarly activity for medical trainees Special case report sessions for trainees in several specialty medical scientific meetings Case repot section in medical journals Foundation of more complex medical research A motivating factor to conduct further complex observational and experimental medical research to determine causal inferences Zika epidemic [5,6] Alternative way for experimental studies Unethical to conduct randomized clinical trial Study of rare diseases or condition Re-challenge criteria of causal inference which may be unethical for clinical trials [20].

Public regulation
Initial trigger for drug utilization, effectiveness, and safety in pharmacoepidemiology Disadvantages Unable to make causal inferences Lack of quantitative data, epidemiologic and statistic methods Not representative and generalizability Anecdotal fallacy [21] Over interpretation and personal emotional aspect of the readers [4]. Biases Subjective Incomplete information from a retrospective in nature EDORIUM JOURNALS

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