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Level of Evidence during the COVID-19 Pandemic: Making the Case for Case Series and Case Reports

Level of Evidence during the COVID-19 Pandemic: Making the Case for Case Series and Case Reports COMMENTARY Level of Evidence during the COVID-19 Pandemic: Making the Case for Case Series and Case Reports recently peer-reviewed case report and case series manuscripts of reports and case series with petechial hemorrhage in patients with 3,4 ISevere Acute Respiratory Syndrome coronavirus 2 (SARS-CoV- COVID-19. There were also no changes in enhancement or cer- 2) and coronavirus disease 2019 (COVID-19). Case reports and ebral perfusion for this case series, but we have observed these 5 2 case series can lack the power to distinguish a statistically significant changes in other reported cases. Publication of this case series difference, which could hide a potential risk or benefit to diagnostic without any hemorrhages, enhancement, or cerebral perfusion ab- testing or treatment. The hierarchy of research evidence has worked normality is not necessarily to contradict the literature, but instead its way into medical education and clinical practice. The research adds data to the scientific community when we have a new illness applied to clinical practice is often considered more trustworthy in evolution. Combined with other publication findings, this case when using higher levels of research evidence (such as high-pow- series will perhaps, in the future, help distinguish patient variables ered, prospective, randomized controlled trials or a meta-analysis protective from hemorrhage (or clarify risk factors for hemor- of high-quality studies). Several national organizations, scientific rhage) in COVID-19. Hopefully, these data motivate the clinical panels, and clinical academies give case reports and case series and scientific communities to do further research for better infor- some of their lowest rankings with regard to level of research evi- mation so that one day we might have good knowledge for evi- dence. Some journals have gone a step further and discontinued dence-based medical practice and eventual medical wisdom. case reports, accepting only higher-level research study designs for In a busy clinical practice, it can be difficult to piece together publication. Academic promotions also consider the rigor of the vast array of case series with inconsistent variables being research, giving little credit for case reports and case series. reported. Maybe an ambitious researcher will tie it all together, perhaps with a meta-analysis. I remain hopeful that good evi- However, we still need case reports and case series. They pro- dence-based medical knowledge will eventually be available from vide us with data for rare diseases, as well as early news and high-level research evidence, but until then, careful incorporation potential clinical insights for evolving illnesses. Initial cases may of case reports and case series may have to suffice. provide the impetus for more organized, higher-level research. Higher-powered, prospective, randomized controlled trials pro- vide a high quality of research evidence but may require funding, REFERENCES organization, and time to collect and analyze data, and a delay in 1. Committee on Standards for Developing Trust and Institute of Medicine. information publication during a rapidly evolving global pan- Clinical Practice Guidelines We Can Trust. The National Academies Press; 2011 demic may not be optimal. A meta-analysis requires other 2. Lang M, Buch K, Li MD, et al. Leukoencephalopathy Associated with research to be completed and published before one can even con- Severe COVID-19 Infection: Sequela of Hypoxemia? AJNR Am J sider taking the time to do the meta-analysis. Applying higher Neuroradiol 2020 levels of research evidence is absolutely vital to the practice of 3. Sachs JR, Gibbs KW, Swor DE, et al. COVID-19-associated leukoencephal- medicine, but lower levels of research evidence should not be opathy. Radiology 2020. May 14. [Epub ahead of print] CrossRef Medline 4. Radmanesh A,Derman A,Lui YW,et al. COVID-19-associated diffuse dismissed. leukoencephalopathy and microhemorrhages. Radiology 2020 May 21. During this COVID-19 pandemic, I have seen neuroimaging [Epub ahead of print] CrossRef Medline findings differ between separate case series. The astute radiologists 5. Helms J,Kremer S,Merdji H,et al. Neurologic features in severe SARS- CoV-2 infection. NEngl J Med 2020;382:2268–70 CrossRef Medline and ordering clinicians may assimilate case series into their prac- tice, realizing that the limitations will necessitate adaptation when I. Ikuta additional information and better research become available. For Department of Radiology & Biomedical Imaging example, the article “Leukoencephalopathy Associated with Severe Yale University School of Medicine New Haven, Connecticut COVID-19 Infection: Sequela of Hypoxemia?” found a lack of hemorrhage in their entire case series, but we have seen case http://dx.doi.org/10.3174/ajnr.A6676 1646 Commentary Sep 2020 www.ajnr.org http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png American Journal of Neuroradiology American Journal of Neuroradiology

Level of Evidence during the COVID-19 Pandemic: Making the Case for Case Series and Case Reports

Ikuta, I.
American Journal of Neuroradiology , Volume 41 (9) – Sep 1, 2020
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Publisher
American Journal of Neuroradiology
Copyright
© 2020 by American Journal of Neuroradiology. Indicates open access to non-subscribers at www.ajnr.org
ISSN
0195-6108
eISSN
1936-959X
DOI
10.3174/ajnr.A6676
Publisher site
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Abstract

COMMENTARY Level of Evidence during the COVID-19 Pandemic: Making the Case for Case Series and Case Reports recently peer-reviewed case report and case series manuscripts of reports and case series with petechial hemorrhage in patients with 3,4 ISevere Acute Respiratory Syndrome coronavirus 2 (SARS-CoV- COVID-19. There were also no changes in enhancement or cer- 2) and coronavirus disease 2019 (COVID-19). Case reports and ebral perfusion for this case series, but we have observed these 5 2 case series can lack the power to distinguish a statistically significant changes in other reported cases. Publication of this case series difference, which could hide a potential risk or benefit to diagnostic without any hemorrhages, enhancement, or cerebral perfusion ab- testing or treatment. The hierarchy of research evidence has worked normality is not necessarily to contradict the literature, but instead its way into medical education and clinical practice. The research adds data to the scientific community when we have a new illness applied to clinical practice is often considered more trustworthy in evolution. Combined with other publication findings, this case when using higher levels of research evidence (such as high-pow- series will perhaps, in the future, help distinguish patient variables ered, prospective, randomized controlled trials or a meta-analysis protective from hemorrhage (or clarify risk factors for hemor- of high-quality studies). Several national organizations, scientific rhage) in COVID-19. Hopefully, these data motivate the clinical panels, and clinical academies give case reports and case series and scientific communities to do further research for better infor- some of their lowest rankings with regard to level of research evi- mation so that one day we might have good knowledge for evi- dence. Some journals have gone a step further and discontinued dence-based medical practice and eventual medical wisdom. case reports, accepting only higher-level research study designs for In a busy clinical practice, it can be difficult to piece together publication. Academic promotions also consider the rigor of the vast array of case series with inconsistent variables being research, giving little credit for case reports and case series. reported. Maybe an ambitious researcher will tie it all together, perhaps with a meta-analysis. I remain hopeful that good evi- However, we still need case reports and case series. They pro- dence-based medical knowledge will eventually be available from vide us with data for rare diseases, as well as early news and high-level research evidence, but until then, careful incorporation potential clinical insights for evolving illnesses. Initial cases may of case reports and case series may have to suffice. provide the impetus for more organized, higher-level research. Higher-powered, prospective, randomized controlled trials pro- vide a high quality of research evidence but may require funding, REFERENCES organization, and time to collect and analyze data, and a delay in 1. Committee on Standards for Developing Trust and Institute of Medicine. information publication during a rapidly evolving global pan- Clinical Practice Guidelines We Can Trust. The National Academies Press; 2011 demic may not be optimal. A meta-analysis requires other 2. Lang M, Buch K, Li MD, et al. Leukoencephalopathy Associated with research to be completed and published before one can even con- Severe COVID-19 Infection: Sequela of Hypoxemia? AJNR Am J sider taking the time to do the meta-analysis. Applying higher Neuroradiol 2020 levels of research evidence is absolutely vital to the practice of 3. Sachs JR, Gibbs KW, Swor DE, et al. COVID-19-associated leukoencephal- medicine, but lower levels of research evidence should not be opathy. Radiology 2020. May 14. [Epub ahead of print] CrossRef Medline 4. Radmanesh A,Derman A,Lui YW,et al. COVID-19-associated diffuse dismissed. leukoencephalopathy and microhemorrhages. Radiology 2020 May 21. During this COVID-19 pandemic, I have seen neuroimaging [Epub ahead of print] CrossRef Medline findings differ between separate case series. The astute radiologists 5. Helms J,Kremer S,Merdji H,et al. Neurologic features in severe SARS- CoV-2 infection. NEngl J Med 2020;382:2268–70 CrossRef Medline and ordering clinicians may assimilate case series into their prac- tice, realizing that the limitations will necessitate adaptation when I. Ikuta additional information and better research become available. For Department of Radiology & Biomedical Imaging example, the article “Leukoencephalopathy Associated with Severe Yale University School of Medicine New Haven, Connecticut COVID-19 Infection: Sequela of Hypoxemia?” found a lack of hemorrhage in their entire case series, but we have seen case http://dx.doi.org/10.3174/ajnr.A6676 1646 Commentary Sep 2020 www.ajnr.org

Journal

American Journal of Neuroradiology – American Journal of Neuroradiology

Published: Sep 1, 2020

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