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The T2-weighted sequences show left cylinder (LC) posterior extremity migration located outside the corpus cavernosum reaching out to the perineal fat (arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Pacheco Usmayo, A. Torregrosa Andrés, J. Flores Méndez, S. Luján Marco, R. Rogel Bertó" "autores" => array:5 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Pacheco Usmayo" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Torregrosa Andrés" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Flores Méndez" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Luján Marco" ] 4 => array:2 [ "nombre" => "R." 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Patient with high levels of ferritin, and a high transferrin saturation index in blood. Negative genetic study for HFE gene mutations. SIR method with proton density sequences (RT 120<span class="elsevierStyleHsp" style=""></span>ms, ET 4<span class="elsevierStyleHsp" style=""></span>ms, flip angle of 20°), and T2* (RT 120<span class="elsevierStyleHsp" style=""></span>ms, ET 14<span class="elsevierStyleHsp" style=""></span>ms, flip angle of 20°). High iron overload with a great signal reduction in both sequences. LIC: CHH 245<span class="elsevierStyleHsp" style=""></span>μmol<span class="elsevierStyleHsp" style=""></span>Fe/g.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.M. Alústiza Echeverría, M.C. Barrera Portillo, A. Guisasola Iñiguiz, A. Ugarte Muño" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "Alústiza Echeverría" ] 1 => array:2 [ "nombre" => "M.C." "apellidos" => "Barrera Portillo" ] 2 => array:2 [ "nombre" => "A." 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"apellidos" => "Ugarte Muño" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0033833817301303" "doi" => "10.1016/j.rx.2017.07.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0033833817301303?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510717300666?idApp=UINPBA00004N" "url" => "/21735107/0000005900000006/v1_201711202321/S2173510717300666/v1_201711202321/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Update in Radiology</span>" "titulo" => "The clinical case: Validity, values and strategies to approach its writing" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "496" "paginaFinal" => "503" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.M. Mellado, C.D. Packer" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J.M." "apellidos" => "Mellado" "email" => array:1 [ 0 => "jmellado@comz.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C.D." "apellidos" => "Packer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Sección de Radiología Ambulatoria, Servicio de Radiología, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Case Western Reserve University, School of Medicine, Cleveland, OH, USA" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El caso clínico: vigencia, valores y estrategias para abordar su escritura" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The goal of publishing a clinical case is to disclose the experience acquired by its authors after managing a patient. It aims at spreading knowledge and formulating hypotheses from particular observations.<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">1,2</span></a> Unfortunately, many interesting cases do not see the light of day. Training physicians usually do not have too much time to write clinical cases. Maybe they do not like writing, or have a mentor to guide them through the whole process. Or maybe they do not understand how important it is to give it a try. In the meantime, the most prestigious specialists do not usually write clinical cases and focus on more profound issues.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although the clinical case has been alive for centuries, its actual relevance has been put into question. Some journals even ignore it or relegate it. Various authors wonder if it is something more than just an anecdote,<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">3</span></a> like some sort of <span class="elsevierStyleItalic">zebra hunt</span>,<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">4</span></a> or some curious anachronism<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">5</span></a> barely compatible with actual evidence.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">5</span></a> Several books<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">1,2</span></a> and papers<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">3–15</span></a> have analyzed the merits of the clinical case and the keys of how to write it. The medical literature shows that the clinical case is still alive and vindicates its validity.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The clinical case is modest but still essential. It is not in the same level as the scientific paper, but it is much more than just academic training. Our goal is to go over the historic tradition, the recent history, and the actual formats of the clinical case. We wish to advocate for its validity and value as a tool for scientific, educational, and healthcare purposes. We also wish present our view on its educational potential, which is inherent to writing a clinical case. Lastly, we provide a few strategies to approach the writing of a clinical case of radiographic interest aimed for publication.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Historic tradition, recent history, and actual formats</span><p id="par0025" class="elsevierStylePara elsevierViewall">The clinical case is a traditional educational formula.<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">11,16</span></a> Its format and contents have evolved parallel to medical practice and the understanding of medicine in every historic period. During the scientific revolution, the clinical case consolidates itself as the paradigm of the value attributed to observation. At the end of the 19th century, William Osler recommends “<span class="elsevierStyleItalic">Always note and record the unusual. Publish it. Place it on permanent record as a short, concise note. Such communications are always of value</span>”.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">17</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">During the second half of the 20th century, the clinical case adopts its actual format. Between 1946 and 1976, it represents 38 per cent of all periodic journals published.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">18</span></a> During the1980s there is a reversal of the trend. Evidence-based medicine erupts together with its defense of the clinical trial to the detriment of the clinical case.<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">19</span></a> The industry promotes clinical trials, and journals also have a preference for clinical trials for their greater contribution to the impact factor.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">8</span></a> The scant demand and the quality of many clinical cases end up restricting their publication.<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">20</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">However, the clinical case is still alive<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">21</span></a> and is being vindicated in different settings.<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">1–15</span></a> New guidelines and papers on how to write it confirm that the clinical case is alive and kicking.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">9,14,22</span></a> New formats appear such as the problem case,<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">23</span></a> the narrative case<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">24</span></a> and the evidence-based case.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">5</span></a> The huge educational potential of writing a clinical case justifies the growing interest and large number of advocates. Various authors suggest that writing clinical cases may be relevant in the curricular training of undergradute students and residents.<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">25–28</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Scientific value of the clinical case</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Rarity</span><p id="par0040" class="elsevierStylePara elsevierViewall">In many cases published, rarity is the main ingredient. Rare conditions, called <span class="elsevierStyleItalic">zebra</span> in the U.S. medical slang, are hard to diagnose, but they can be rewarding to those who identifies these conditions.<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">29</span></a> Unfortunately, both pragmatism and experience make us to rule out these conditions without even paying much attention to them. Their publication as clinical cases reminds us of their existence and draws everyone's attention.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Novelty</span><p id="par0045" class="elsevierStylePara elsevierViewall">Novelty is another common trait of clinical cases. However, novelty can be relative. Sometimes, adopting an original point of view is all we need to find new approaches to different ailments.<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">30</span></a> On the other hand, many clinical cases inform the radiologist on what other specialists already know. But this does not mean that they do not accomplish their mission which is, basically, the spread of knowledge.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Anecdote</span><p id="par0050" class="elsevierStylePara elsevierViewall">Most clinical cases are just anecdotic.<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">31</span></a> Although the anecdote has pejorative connotations in the scientific setting, it may be a useful tool in the field of medical training.<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">32</span></a> We should not forget that the history of science is full of anecdotes and coincidences,<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">33</span></a> and the history of radiology is not an exception.<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">34,35</span></a> The resilience of the clinical case shows the historic role that the anecdote plays in the advancement of medical knowledge.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Knowledge</span><p id="par0055" class="elsevierStylePara elsevierViewall">Scientific knowledge consists of facts verified and widely accepted.<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">36</span></a> Also, scientific knowledge includes beliefs, opinions, and other intuitive elements whether chaotic or complex, that evidence-based medicine tends to ignore.<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">37</span></a> The clinical case acts as an effective proxy for many of them. Scientific knowledge is particularly heterogeneous.<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">33</span></a> It includes contents and skills in different areas such as anatomy; physics; statistics; ethics; pathology; reasoning; communication; risk; instrumentation; and the radiographic appearance of the disease. In all these areas, the role that the clinical case can play is very important.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Evidence</span><p id="par0060" class="elsevierStylePara elsevierViewall">The approach of evidence-based medicine is also population-based medicine, but the approach of healthcare is individual.<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">38</span></a> The clinical case is very aware of this. Although it is not as valid as the clinical trial, this does not mean it is not scientific or is not valuable. The clinical case is an observational, descriptive, and idiographic research always aware of singularities. Its nature is retrospective and can include one or various indiviuals.<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">39</span></a> Given its narrative nature, it can show the patient's own opinions and experiences. The clinical case is always aware of what is going on, and is the first line of evidence. Guidelines on how to write clinical cases<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">22</span></a> can improve the quality of the clinical case or make it compatible with the postulates of evidence-based medicine; however, they put its creativity at risk, which is, as we will see below, one of its main traits.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Hypothesis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Clinical trials are good to validate hypotheses. Some of these hypotheses are inspired by clinical cases. As a matter of fact, the hypothesis is an undeniable part of the clinical case. Generating plausible hypotheses requires knowledge, thorough reviews, creativity and caution. The clinical case is valuable to the extent that hypothesis makes it interesting or comprehensible. This hypothesis is later assessed by other authors. If it works, it is accepted; if it is not, a different hypothesis is proposed. Once the clinical case has been published, its hypothesis evolves both independently and unpredictably.<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">40</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Generalization</span><p id="par0070" class="elsevierStylePara elsevierViewall">Science can advance general principles from particular observations. On the other hand, medicine is not a science but a practice based on scientific facts.<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">38</span></a> Although formulating universal laws is not the main goal of medicine, some clinical cases generate valid principles for similar patients. This is exactly what happens, for instance, with the genome sequencing of patients with an exceptional response to therapy.</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">The value of the clinical case as a tool for educational and healthcare purposes</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Concision</span><p id="par0075" class="elsevierStylePara elsevierViewall">Concision facilitates the reading of clinical trials and is one of the key elements of their huge popularity. A well-written and illustrated clinical case is easy to read. Its plot is entertaining, its hypothesis is intriguing, and its message simply gets there. From this point of view, the clinical case can be considered an appropriate vehicle to spread knowledge in the field of radiodiagnosis.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Continuous education</span><p id="par0080" class="elsevierStylePara elsevierViewall">The reading of clinical cases is an exceptional modality of continuous education. Its study provides knowledge that the professional experience barely reaches. Although this statement is only disputed by very few centers that are rich in cases, it is probably true for most practicing radiologists.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Aunt Minnie</span><p id="par0085" class="elsevierStylePara elsevierViewall">Aunt Minnie is a problem case that shows one rather obvious and always patognomonic radiographic finding.<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">41</span></a> Traditional Aunt Minnie–of free access through AuntMinnie.com, is a self-learning tool that puts the radiologist's own perspective capacity and his ability to recognize patterns to the test.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Global atlas</span><p id="par0090" class="elsevierStylePara elsevierViewall">When facing a dilemma, we always look for similar cases. The existence of these cases guarantees that someone else has thought of or experienced the feeling we are about to have. Every case published spreads or reinforces the credibility of a pattern, an association, a sign or a piece of information. Once published, the case becomes part of a large global atlas that includes the almost endless varieties and interpretations of the disease opened to be systematized at some point in the future.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Individual management</span><p id="par0095" class="elsevierStylePara elsevierViewall">Evidence-based medicine provides effective standards for prototypical patients; however, it is not very useful if we wish to individualize healthcare. Many patients have atypical ailments of uncertain management. This uncertainty can be reduced at the heart of interdisciplinary committees, but this is not always the case. Clinical cases can be useful to individualize the diagnosis and management of patients who do not match the canonical pattern of population-based evidence.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Reversal of the trend</span><p id="par0100" class="elsevierStylePara elsevierViewall">When the entity of the documental strength coming from the clinical case is strong enough, it can activate certain epidemiological alerts into responses to poisonings; epidemic outbreaks; or adverse events secondary to vaccines and other drugs. On the other hand, clinical cases of radiographic interest are the perfect vehicle to inspire or suggest new uses and possibilities of the different kids of diagnostic modalities available.</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Surprise and availability</span><p id="par0105" class="elsevierStylePara elsevierViewall">The capacity to surprise is an essential part of the mental activity.<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">42</span></a> Where the eye sees a finding, the radiologist sees a pattern. Repeated exposure to a few patterns eclipses our capacity for surprise. Luckily, the exposure to singular cases can rescue such a capacity and pave the way for the always surprising and tough observational process.<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">43</span></a> Nevertheless, the reading of clinical cases influences our inclination to diagnose them. Our wish to apply something we have read recently, or the memory of it tends to prevail over the neutral analysis of what has been found. This makes us consider likely certain low prevalence diagnoses.<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">44</span></a></p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Educational value of the clinical case for its author</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Curiosity</span><p id="par0110" class="elsevierStylePara elsevierViewall">Specialization requires profound knowledge on a few issues. Writing clinical cases allows the specialist to clear his mind and explore new horizons. On the other hand, the feeling of being before something new promotes the radiologist's innate curiosity. For many this experience is beneficial; not for the answers, that are not always there, but for the questions that are being asked.<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">45</span></a> The questions that our inner curiosity asks makes us part of the scientific community that never ceases to wonder.</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Objectivity</span><p id="par0115" class="elsevierStylePara elsevierViewall">Objectivity is essential for the scientific method.<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">46</span></a> Its different interpretations show the successive reinterpretations of the scientific fact.<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">47</span></a> In the 18th century it aimed at identifying prototypical traits; in the 19th century at showing interindividual variations; and in the 20th century it aimed at the specific recognition of patterns. Ever since its origins, radiology has aimed at an ideal of objectivity that it never seems to achieve.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Can the clinical case be objective? Well, at least, it should be genuine. Its strength comes from telling what really happened. However, in the attempt to publish the case, it can distort its authenticity. Inconsistently, the author tends to mask the facts. Criticism about it is very educational. Reality does not always meet our interpretations and there is no reason why it should. When we write, we learn and always remember.</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Narrativity</span><p id="par0125" class="elsevierStylePara elsevierViewall">Medicine likes the telling and the reasoning. Like it or not, doctors need to know how to communicate their message and how to process the stories. The boom of the clinical case shows the actual growing interest in the medical narrative mastered by authors such as Oliver Sacks,<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">48</span></a> and Jerome Groopman.<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">49</span></a> The patient's clinical history contains experiences that the narrative medicine vindicates.<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">50</span></a> With the narrative text we can capture what is really singular, whether it is undetermined or a total surprise.<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">51</span></a> The clinical case uses narrative tools. It is concise and chronological, has a plot, draws our attention, and leads to educational outcomes. It comes as no surprise that he who knows how to write a clinical case is better skilled to summarize it, consult it, or expose it.</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Reasoning</span><p id="par0130" class="elsevierStylePara elsevierViewall">Writing cases takes logic, rhetoric, and summary skills. In a saturated setting of automatisms, and requirements, all opportunities to exercise clinical reasoning are welcomed as beneficial. Writing clinical cases exercises our reasoning and puts it to the consideration of fellow peers, reviewers, and readers. For the radiologist, so used to judging how adequate or inadequate someone else's thinking is behind the orders they receive every day, this sporadic reversal of roles is so welcomed.</p><p id="par0135" class="elsevierStylePara elsevierViewall">On the other hand, clinical reasoning combines pattern recognition and the association of ideas.<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">52</span></a> In modern medicine, expert intuitions seem to have replaced analytic-deductive reasoning.<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">49</span></a> This does not have to be negative, although it is good to have certain competition in both methods. Writing clinical cases means walking back the road of intuition, and quietly re-thinking the findings, while exploring the other side of the same coin.</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Biases</span><p id="par0140" class="elsevierStylePara elsevierViewall">In a clinical trial, the convenience of obtaining satisfactory results leads to biased interpretations. Although the author of the clinical trial is not subject to such pressure, that does not mean he is immune to methodological biases. Of all the biases that the authors of clinical cases can have, the correlation bias, and the retrospective bias deserve special consideration.</p><p id="par0145" class="elsevierStylePara elsevierViewall">All diagnoses simply the patients’ stories. The clinical case should avoid that implication and show the reasoning process that led to the diagnosis. The author needs to take caution with causal hypotheses. The correlation bias tends to interpret the association between two key facts of causality. If hypothesis is plausible, then we say it is likely. However, the inner coherence of that interpretation is not a measure of its likelihood.<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">53</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The retrospective bias represents the author of the story prematurely seduced by a weird and certain diagnostic hypothesis. This distorted story lifts the author's spirit, makes him believe that he understood the past, and will certainly know how to interpret the future.<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">54</span></a> On the other hand, it can generate inadequate expectations in training physicians. The retrospective bias shows the inability to understand and assume clinical uncertainty. True writing requires its full acceptance. Nothing was ever too easy,<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">55</span></a> although retrospective looks always try to make us think outside the box.</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Errors and complications</span><p id="par0155" class="elsevierStylePara elsevierViewall">The clinical case has a self-promotional legitimate dimension.<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">16</span></a> What is to be made out of errors, complications, and poor results then? One educational way to assume all this is publishing. It promotes self-satisfaction and somehow a culture of self-improvement and transparency. Publishers value this. Whenever the clinical case points in this direction, even before it is accepted, the author can feel closer to a certain professional maturity.</p><p id="par0160" class="elsevierStylePara elsevierViewall">On the other hand, all manuscripts have errors, and some of these errors make it to the paper format too. If writing means proofreading and correcting,<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">30</span></a> publishing means assuming errors and mistakes. Heavy reasons invite to thorough proofreading processes, and justify the use of statements put into context. We never know how present uncertainties will evolve in the future, or how long will it take to overcome them.</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Academic debut</span><p id="par0165" class="elsevierStylePara elsevierViewall">The clinical case is the best way to start in the world of scientific writing. It allows the new writer to give in to creativity and contribute to the global scientific discourse without even leaving his office. However, not many writers will achieve their goal if they try without conviction. Writing requires tension like any other goal in life. On the other hand, it is good that the author is fully aware of his own motivations.<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">56</span></a> Getting to know them and how to use them is part of the challenge.</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Ethics and authorship</span><p id="par0170" class="elsevierStylePara elsevierViewall">The clinical case is the best format to approach a given hypothesis that cannot be validated for ethical reasons. However, the clinical case is also subject to restrictions.</p><p id="par0175" class="elsevierStylePara elsevierViewall">The author who approaches the writing of his first case should have elementary notions on informed consent issues; confidentiality, the ethics behind scientific publications; responsible authorship; possible conflicts of interests; unlawful duplicity; and plagiarism.<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">57</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">When it comes to authorship, the author should understand that the most interesting cases is no one's property. One thing is to manage the clinical process, and a totally different thing is to publish it. One case should not have too many different authors, and those who provide the significant intellectual contributions should be called the real authors only. However, it is recommended to look for coauthors out of the field of radiodiagnosis to make the contents richer.</p></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">How to write and publish a clinical case of radiographic interest</span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">How to choose the case</span><p id="par0185" class="elsevierStylePara elsevierViewall">The case selected needs to have a known diagnosis, pose a clinical dilemma, and contain some new, rare, important, or interesting element.<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">58</span></a> It can be about diseases, adverse events, etiological agents, physiopathological mechanisms, unexpected manifestations, surprising associations, or unforeseen outcomes. Also it can be about new anatomical, or semiological aspects, and about new uses of diagnostic modalities.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Using what we have learned, the author needs to know what he wants to tell, and who is audience is going to. Also, he must be able to summarize his message in one sentence only. That “something” is the reason why the case is eligible and will eventually be published. It is useful to consult people who have seen many cases and have the habit of sharing information. Just explaining the case to a colleague may be the key. A quick look at the medical literature will help us focus on the topic of discussion. Patients should never be approached as if they were cases subject to publication.</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Where to start from</span><p id="par0195" class="elsevierStylePara elsevierViewall">The sooner you start, the better.<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">59</span></a> The first thing you need to do is ask the patient to fill out the informed consent document. Then, you should collect the patient's clinical history, his personal information, and the images you want to use. You may need to do some follow-up, but you also need to know that unnecessary tests will not be admitted. Thirdly, you need to identify all coauthors. The email will allow you to share tasks. Then, you need to know what journal you’ll use for publication and study all its rules and regulations. The best thing to do is focus on peer-reviewed journals. Finally, it is useful to write a list, a summary, or put some ideas down on paper; anything to avoid the dreaded writer's block.</p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">How to choose a title, summarize and present the case</span><p id="par0200" class="elsevierStylePara elsevierViewall">The title, the abstract, and the introduction are important. They stimulate the reader and seduce the reviewer. The title needs to be consistent with the message and easy to track down.<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">40</span></a> Some authors prefer imaginative titles; other authors, neutral, and descriptive ones. It is not recommended to appeal to the reader's sense of humor, but the reader's innate curiosity. The abstract summarizes the case, exposes its main attributes, and justifies its publication. The introduction reproduces some of these components with greater detail, although it should not be a thorough review of the sources. The last sentence in the introduction summarizes the author's main goals.</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">How to tell the story of the case</span><p id="par0205" class="elsevierStylePara elsevierViewall">The case describes, in formal language, the clinical presentation, the physical exploration, and any additional tests. All unnecessary information should be eliminated. Then the author tells the story of the thinking that is behind his differential diagnosis or presumptive diagnosis. Finally, the ultimate diagnosis; therapy; and results are presented. Narration needs to be chronological. A table or a timeline may be useful to illustrate the cases using further tests or interventions.<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">40</span></a> A broken timeline that makes it hard for readers to understand the facts or builds up a different story from the actual one is not acceptable.</p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">How to select the pictures</span><p id="par0210" class="elsevierStylePara elsevierViewall">The selection, editing, numbering, and description of pictures are all crucial steps. Having them beforehand can facilitate the writing. Three or four conveniently zoomed pictures ought to be enough. The pictures of specimens or histological samples make the clinical case more interesting. We need to be extremely careful with the picture size, orientation, arrangement, confidentiality, and footnote. In all cases of radiographic interest, it is important to pick expressive pictures. Nonetheless, pictures do not say it all. We should not focus on just the pictures, since they ignore other important things that have to do with the patient.<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">60</span></a></p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">How to elaborate discussions</span><p id="par0215" class="elsevierStylePara elsevierViewall">The discussion includes a context, an explanation, the speculation, and the educational side.<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">40</span></a> Contextualization should be more detailed than the introduction. A table with similar cases already published can be useful. The explanation of the original aspects of the case should focus on aspects confirming, rebutting, or suggesting something. Including speculative or hypothetical elements enhances the importance of observation and justifies its publication. The hypothesis should be prudent, but it needs to be included. Eventually, the education side of the discussion should be expressed as a conclusion or closure, and should be brief, restrained, and never exaggerate or loud. In some cases, it is convenient to admit some methodological limitations between the speculation and the conclusion.</p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Before sending the manuscript</span><p id="par0220" class="elsevierStylePara elsevierViewall">Setting-up the manuscript requires attention and can be a boring experience.<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">61</span></a> We should not forget that there is a great abundance of cases and only the best are published. No hurries. Really long sentences can look unnatural after reading them too many times. Showing the manuscript to people who have nothing to do with the project may help. We should avoid full paragraphs of the manuscript looking exactly like the original source. Medical journals have tools capable of detecting plagiarism. It is a crime, and means the automatic rejection of the piece. All coauthors need to approve the final version. Before sending the final version, the rules and regulations from the publishing house picked should be reviewed again. The manuscript needs to observe these rules, no matter what. We need to pay special attention and limit the number of authors, words, images, and sources used. The use of inappropriate formats with the sources of the manuscript is also a cause for rejection. Stubborn attempts to ignore the rules of the publishing house may delay the publication of the clinical case.</p></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Reviews</span><p id="par0225" class="elsevierStylePara elsevierViewall">The review requested by the journal is based both on the publisher's view and the reviewers’ opinions.<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">62</span></a> Although request for review is always a reason for hope, there is no guarantee that the clinical case will be published. The response letter from the reviewers should be respectful, formal, and systematic, and the language used short and restrained. Jumping into controversies is not a good idea at this point. Repeated comments, and detailed answers from different reviewers deserve special attention. All changes suggested do not need to be included in the final version, but it is a good idea to make comments to all the suggestions made by the reviewers.</p></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Publication and rejection</span><p id="par0230" class="elsevierStylePara elsevierViewall">Publishing is always a reason for satisfaction.<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">63</span></a> The writing and publishing of one's first clinical case, means the author becomes familiar with the editorial process.<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">63</span></a> It transforms the way the scientific fact is perceived. It improves or should improve his capacity to accept scientific criticism. It should be an invitation to reconsider the notions of objectivity and evidence. It makes the author feel part of a scientific community with shared interests.</p><p id="par0235" class="elsevierStylePara elsevierViewall">Rejection is the most likely outcome. Authors usually re-send their clinical case to a different journal. When the manuscript has been rejected by different journals, the moment has come to put an end to the whole process. It is frustrating but educational too. It teaches the author the lesson that he still needs to learn how to address the appropriate audience. It reminds him of the need to observe the rules of the publishing house. It speaks of that fragile matter that stands at the core of our effort (our opinion). It shows than not all opinions are plausible.</p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Opportunities</span><p id="par0240" class="elsevierStylePara elsevierViewall">Publishing a clinical case can be the beginning of a promising academic career.<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">63</span></a> It makes other specialists consult similar cases. It makes this or that journal send us similar cases for the assessment of quality or interest. The topic we choose will always be with us. Without much effort, we can have access to all news published on that particular field. Collecting similar cases can be our ticket to come back to the same topic years later.</p></span></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">Conclusion</span><p id="par0245" class="elsevierStylePara elsevierViewall">We looked into the validity and values of the clinical case. We described its importance as a tool for scientific, educational, and healthcare purposes. We also discussed the educational potential inherent to the writing of clinical cases and provided strategies to approach its writing within the field of radiodiagnosis. The clinical case has a present, with an unknown future.<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">64</span></a> Infinite knowledge awaits and the more than 1.7 million clinical cases published so far should not be a cause for discouragement.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Authors</span><p id="par0250" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0255" class="elsevierStylePara elsevierViewall">Manager of the integrity of the study: JMM and CDP.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0260" class="elsevierStylePara elsevierViewall">Study idea: JMM and CDP.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0265" class="elsevierStylePara elsevierViewall">Study design: JMM and CDP.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0270" class="elsevierStylePara elsevierViewall">Data mining: N/A.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0275" class="elsevierStylePara elsevierViewall">Data analysis and interpretation: N/A.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6.</span><p id="par0280" class="elsevierStylePara elsevierViewall">Statistical analysis: N/A.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7.</span><p id="par0285" class="elsevierStylePara elsevierViewall">Reference: JMM and CDP.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8.</span><p id="par0290" class="elsevierStylePara elsevierViewall">Writing: JMM and CDP.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9.</span><p id="par0295" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant remarks: JMM and CDP.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10.</span><p id="par0300" class="elsevierStylePara elsevierViewall">Approval of final version: JMM and CDP.</p></li></ul></p></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Ethical disclosures</span><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">Protection of human and animal subjects</span><p id="par0310" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0235">Confidentiality of data</span><p id="par0315" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article.</p></span><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0240">Right to privacy and informed consent</span><p id="par0320" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">Conflict of interest</span><p id="par0305" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests associated with this article whatsoever.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => 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"titulo" => "Where to start from" ] 2 => array:2 [ "identificador" => "sec0155" "titulo" => "How to choose a title, summarize and present the case" ] 3 => array:2 [ "identificador" => "sec0160" "titulo" => "How to tell the story of the case" ] 4 => array:2 [ "identificador" => "sec0165" "titulo" => "How to select the pictures" ] 5 => array:2 [ "identificador" => "sec0170" "titulo" => "How to elaborate discussions" ] 6 => array:2 [ "identificador" => "sec0175" "titulo" => "Before sending the manuscript" ] 7 => array:2 [ "identificador" => "sec0180" "titulo" => "Reviews" ] 8 => array:2 [ "identificador" => "sec0185" "titulo" => "Publication and rejection" ] 9 => array:2 [ "identificador" => "sec0190" "titulo" => "Opportunities" ] ] ] 10 => array:2 [ "identificador" => "sec0195" "titulo" => "Conclusion" ] 11 => array:2 [ "identificador" => "sec0200" "titulo" => "Authors" ] 12 => array:3 [ "identificador" => "sec0210" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0215" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0220" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0225" "titulo" => "Right to privacy and informed consent" ] ] ] 13 => array:2 [ "identificador" => "sec0205" "titulo" => "Conflict of interest" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-03-26" "fechaAceptado" => "2017-07-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec915106" "palabras" => array:9 [ 0 => "Case report" 1 => "Scientific publication" 2 => "Rare diseases" 3 => "Evidence-based medicine" 4 => "Knowledge" 5 => "Hypothesis" 6 => "Objectivity" 7 => "Ethics" 8 => "Authorship" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec915105" "palabras" => array:9 [ 0 => "Caso clínico" 1 => "Publicación científica" 2 => "Enfermedades raras" 3 => "Medicina basada en la evidencia" 4 => "Conocimiento" 5 => "Hipótesis" 6 => "Objetividad" 7 => "Ética" 8 => "Autoría" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The case report is used to communicate the experience acquired by its authors with a patient. Although its relevance has been doubted, the case report deserves to be vindicated and contextualized. We review the case report's historical tradition, recent evolution and current formats. We describe its utility as a scientific tool, a continuing education resource and an aid to diagnosis. We reflect on the teaching potential its writing entails. Finally, we provide strategies to address the writing of a radiological case report.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El caso clínico sirve para dar a conocer la experiencia adquirida por sus autores con un enfermo. Aunque se ha cuestionado su relevancia, el caso clínico merece ser reivindicado y contextualizado. Revisamos la tradición histórica, la evolución reciente y los formatos actuales del caso clínico. Describimos su vigencia y valor como instrumento científico, divulgativo y asistencial. Reflexionamos sobre el potencial formativo que su escritura entraña. Finalmente, aportamos estrategias para abordar la escritura de un caso clínico de interés radiológico.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Mellado JM, Packer CD. El caso clínico: vigencia, valores y estrategias para abordar su escritura. Radiología. 2017;59:496–503.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:64 [ 0 => array:3 [ "identificador" => "bib0325" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical case reporting in evidence-based medicine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. Jenicek" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "fecha" => "1999" "paginaInicial" => "5" "editorial" => "Butterworth-Heinemann" "editorialLocalizacion" => "Oxford" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0330" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Writing case reports. 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