case series qualitative research

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J Bras Pneumol
v.46(4); Jul-Aug 2020

Case series: an essential study design to build knowledge and pose hypotheses for rare and new diseases

Série de casos: delineamento de estudo essencial para a construção de conhecimento e a proposição de hipóteses para doenças raras e novas, carlos arturo torres-duque.

1 . Methods in Epidemiologic, Clinical, and Operations Research-MECOR-program, American Thoracic Society/Asociación Latinoamericana del Tórax, Montevideo, Uruguay.

2 . CINEUMO Research Center, Fundación Neumológica Colombiana, Bogota, Colombia.

3 . Universidad de la Sabana, Bogota, Colombia.

Cecilia Maria Patino

4 . Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Juliana Carvalho Ferreira

5 . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil.

PRACTICAL SCENARIO

At the end of December of 2019, a pneumonia outbreak of unknown origin appeared in China. Soon afterwards, the causative virus was identified-SARS coronavirus 2 (SARS-CoV-2), and the disease was named coronavirus disease 2019 (COVID-19). In January of 2020, Chinese investigators published a detailed case series describing the characteristics and outcomes of 41 adults with confirmed COVID-19. 1 The study showed that 15% of those patients died during the study period. That case series 1 was extremely important because it was the first published description of the impact of the new disease, helping clinicians around the world to face a new pandemic.

CONCEPTS AND APPLICATION

A case series includes a description of the characteristics and outcomes among a group of individuals with either a disease or an exposure (which can be an intervention) over a period of time and without a control group. Data are collected retrospectively or prospectively, and there is no randomization. The objective is to describe the population and outcomes, rather than compare risks across groups. Therefore, a case series differs from cohort studies because the latter compares the risk between two groups (exposed and unexposed) and allows for the estimation of an absolute risk for the occurrence of a given outcome in the exposed group and of a relative risk in comparison with the unexposed group.

The case series design is not considered the strongest source of evidence due to the absence of a control group and the risk of bias, in particular selection bias, since typical or severe cases of the disease are more easily identified, and rare presentations or mild cases may not be included. In the Chinese report, 1 for example, patients with less severe COVID-19 were not hospitalized and therefore were not included in the case series. However, case series are particularly important when a new disease or treatment emerges, because it provides descriptive information and contributes to building knowledge and generating hypotheses. Case series is also an appropriate study design to describe new treatments, previously unknown medication adverse events, and rare diseases. 2

METHODOLOGY AND QUALITY OF CASE SERIES STUDIES

Inclusion criteria - A precise operational definition of a “case” is crucial for the reliability of the study.
Sampling - Two strategies are possible: 1) based on disease or exposure; 2) based on a specific outcome.
Selection of variables of interest - A detailed selection and a clear definition of predictive variables of interest are necessary, as well as test results, interventions, complications, adverse events, and outcomes.
Systematic collection of data and robust analysis - They assure the quality of a case series study.

Table 1 presents a tool for evaluating the methodological quality of case series. 2

Domains	Leading explanatory questions
Selection	1. Were all the potentially eligible patients included or is the selection method unclear to the extent that other patients with similar presentations may not have been reported?
Definition of exposure and outcomes	2. Was the exposure adequately and clearly defined?
Definition of exposure and outcomes	3. Was the outcome adequately and clearly defined?
Causality	4. Were other alternative causes that may explain the observation ruled out?
	5. Was there a challenge/rechallenge phenomenon?
	6. Was there a dose-response effect?
	7. Was follow-up long enough for outcomes to occur?
Reporting	8. Are the cases described with sufficient details to allow other investigators to replicate the research or to allow practitioners to make inferences related to their own practice?

Adapted from Murad et al. 2 Questions 4, 5 and 6 are more relevant for adverse drug events.

Quantitative study designs: Case Studies/ Case Report/ Case Series

Quantitative study designs.

Introduction
Cohort Studies
Randomised Controlled Trial
Case Control
Cross-Sectional Studies
Study Designs Home

Case Study / Case Report / Case Series

Some famous examples of case studies are John Martin Marlow’s case study on Phineas Gage (the man who had a railway spike through his head) and Sigmund Freud’s case studies, Little Hans and The Rat Man. Case studies are widely used in psychology to provide insight into unusual conditions.

A case study, also known as a case report, is an in depth or intensive study of a single individual or specific group, while a case series is a grouping of similar case studies / case reports together.

A case study / case report can be used in the following instances:

where there is atypical or abnormal behaviour or development
an unexplained outcome to treatment
an emerging disease or condition

The stages of a Case Study / Case Report / Case Series

Which clinical questions does Case Study / Case Report / Case Series best answer?

Emerging conditions, adverse reactions to treatments, atypical / abnormal behaviour, new programs or methods of treatment – all of these can be answered with case studies /case reports / case series. They are generally descriptive studies based on qualitative data e.g. observations, interviews, questionnaires, diaries, personal notes or clinical notes.

What are the advantages and disadvantages to consider when using Case Studies/ Case Reports and Case Series ?

What are the pitfalls to look for?

One pitfall that has occurred in some case studies is where two common conditions/treatments have been linked together with no comprehensive data backing up the conclusion. A hypothetical example could be where high rates of the common cold were associated with suicide when the cohort also suffered from depression.

Critical appraisal tools

To assist with critically appraising Case studies / Case reports / Case series there are some tools / checklists you can use.

JBI Critical Appraisal Checklist for Case Series

JBI Critical Appraisal Checklist for Case Reports

Real World Examples

Some Psychology case study / case report / case series examples

Capp, G. (2015). Our community, our schools : A case study of program design for school-based mental health services. Children & Schools, 37(4), 241–248. A pilot program to improve school based mental health services was instigated in one elementary school and one middle / high school. The case study followed the program from development through to implementation, documenting each step of the process.

Cowdrey, F. A. & Walz, L. (2015). Exposure therapy for fear of spiders in an adult with learning disabilities: A case report. British Journal of Learning Disabilities, 43(1), 75–82. One person was studied who had completed a pre- intervention and post- intervention questionnaire. From the results of this data the exposure therapy intervention was found to be effective in reducing the phobia. This case report highlighted a therapy that could be used to assist people with learning disabilities who also suffered from phobias.

Li, H. X., He, L., Zhang, C. C., Eisinger, R., Pan, Y. X., Wang, T., . . . Li, D. Y. (2019). Deep brain stimulation in post‐traumatic dystonia: A case series study. CNS Neuroscience & Therapeutics. 1-8. Five patients were included in the case series, all with the same condition. They all received deep brain stimulation but not in the same area of the brain. Baseline and last follow up visit were assessed with the same rating scale.

References and Further Reading

Greenhalgh, T. (2014). How to read a paper: the basics of evidence-based medicine. (5th ed.). New York: Wiley.

Heale, R. & Twycross, A. (2018). What is a case study? Evidence Based Nursing, 21(1), 7-8.

Himmelfarb Health Sciences Library. (2019). Study design 101: case report. Retrieved from https://himmelfarb.gwu.edu/tutorials/studydesign101/casereports.cfm

Hoffmann T., Bennett S., Mar C. D. (2017). Evidence-based practice across the health professions. Chatswood, NSW: Elsevier.

Robinson, O. C., & McAdams, D. P. (2015). Four functional roles for case studies in emerging adulthood research. Emerging Adulthood, 3(6), 413-420.

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Last Updated: May 15, 2024 11:37 AM
URL: https://deakin.libguides.com/quantitative-study-designs

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Methodological quality of case series studies: an introduction to the JBI critical appraisal tool

Affiliations.

1 JBI, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia.
2 The George Institute for Global Health, Telangana, India.
3 Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Sydney, NSW, Australia.
PMID: 33038125
DOI: 10.11124/JBISRIR-D-19-00099

Introduction: Systematic reviews provide a rigorous synthesis of the best available evidence regarding a certain question. Where high-quality evidence is lacking, systematic reviewers may choose to rely on case series studies to provide information in relation to their question. However, to date there has been limited guidance on how to incorporate case series studies within systematic reviews assessing the effectiveness of an intervention, particularly with reference to assessing the methodological quality or risk of bias of these studies.

Methods: An international working group was formed to review the methodological literature regarding case series as a form of evidence for inclusion in systematic reviews. The group then developed a critical appraisal tool based on the epidemiological literature relating to bias within these studies. This was then piloted, reviewed, and approved by JBI's international Scientific Committee.

Results: The JBI critical appraisal tool for case series studies includes 10 questions addressing the internal validity and risk of bias of case series designs, particularly confounding, selection, and information bias, in addition to the importance of clear reporting.

Conclusion: In certain situations, case series designs may represent the best available evidence to inform clinical practice. The JBI critical appraisal tool for case series offers systematic reviewers an approved method to assess the methodological quality of these studies.

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Research article
Open access
Published: 23 April 2014

The clinical case report: a review of its merits and limitations

Trygve Nissen 1 , 2 &
Rolf Wynn 1 , 3

BMC Research Notes volume 7 , Article number: 264 ( 2014 ) Cite this article

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The clinical case report has a long-standing tradition in the medical literature. While its scientific significance has become smaller as more advanced research methods have gained ground, case reports are still presented in many medical journals. Some scholars point to its limited value for medical progress, while others assert that the genre is undervalued. We aimed to present the various points of view regarding the merits and limitations of the case report genre. We searched Google Scholar, PubMed and select textbooks on epidemiology and medical research for articles and book-chapters discussing the merits and limitations of clinical case reports and case series.

The major merits of case reporting were these: Detecting novelties, generating hypotheses, pharmacovigilance, high applicability when other research designs are not possible to carry out, allowing emphasis on the narrative aspect (in-depth understanding), and educational value. The major limitations were: Lack of ability to generalize, no possibility to establish cause-effect relationship, danger of over-interpretation, publication bias, retrospective design, and distraction of reader when focusing on the unusual.

Conclusions

Despite having lost its central role in medical literature in the 20th century, the genre still appears popular. It is a valuable part of the various research methods, especially since it complements other approaches. Furthermore, it also contributes in areas of medicine that are not specifically research-related, e.g. as an educational tool. Revision of the case report genre has been attempted in order to integrate the biomedical model with the narrative approach, but without significant success. The future prospects of the case report could possibly be in new applications of the genre, i.e. exclusive case report databases available online, and open access for clinicians and researchers.

Throughout history the clinical case report and case report series have been integral components of medical literature[ 1 ]. The case report genre held a strong position until it was sidelined in the second half of the 20 th century[ 2 , 3 ]. New methodologies for research articles paved the way for evidence-based medicine. Editors had to make space for these research articles and at the same time signaled less enthusiasm for publishing case reports[ 4 ]. This spurred some heated debates in medical journals as readers were worried that the traditional case report was in jeopardy[ 5 , 6 ]. Those who welcomed the new trend with fewer case reports being published pointed mainly to their low quality and inclination to emphasize mere curiosa[ 7 – 9 ]. Some of the proponents of the genre claimed that the case report had been and still was indispensible for furthering medical knowledge and that it was unique in taking care of the detailed study of the individual patient as opposed to the new research methods with their “…nomothetic approach [taking] precedence…”[ 5 ]. Still, the case report got a low ranking on the evidence hierarchy. After a decline in popularity a new interest for the case report emerged, probably beginning in the late 1990s[ 2 ]. A peer-reviewed ‘Case reports’ section was introduced in the Lancet in 1995[ 10 ]. In 2007, the first international, Pubmed-listed medical journal publishing only case reports was established[ 11 , 12 ]. In the following years, several similar journals, for the most part online and open-access, have been launched.

The present debate is not so much focused on whether case reporting is obsolete or not. Some of the discussions after the turn of the century have been about adapting the case report genre to new challenges. One example is the suggestion of incorporating the narrative, i.e. “… stressing the patient’s story”, in the case report[ 13 ]. The authors termed their initiative “The storied case report”. Their endeavor was not met with success. In analyzing the causes for this, they wondered if “… junior trainees find it too hard to determine what is relevant and senior trainees find it too hard to change their habits”[ 13 ]. A similar attempt was done when the editors of the Journal of Medical Case Reports in 2012 encouraged authors to include the patients’ perspectives by letting patients describe their own experiences[ 14 ].

Notwithstanding, we feel there is much to be gained from having an ongoing discussion highlighting the indications and contraindications for producing case reports. This can to some degree be facilitated by getting an understanding of the merits and limitations of the genre. The objective of this article is to present the merits and limitations of case reports and case series reports.

We adopted Taber’s Cyclopedic Medical Dictionary’s definition of the case report : “A formal summary of a unique patient and his or her illness, including the presenting signs and symptoms, diagnostic studies, treatment course and outcome”[ 15 ]. A case report consists of one or two cases, most often only one. The case series or case series report usually consists of three to ten cases[ 16 ]. (In the following we use the term case report to denote both case reports and case series report). Case reports are most often naturalistic and descriptive. Sometimes, however, they can be prospective and experimental.

As literature specifically dealing with the case report genre seemed harder to elicit from the databases than the vast amount of particular case reports, we performed iterative searches. We searched Google Scholar and PubMed using the search terms ‘case report(s)’, ‘case series’, ‘case series report(s)’, ‘case reporting’ in various combinations with ‘clinical’, ‘medical’, ‘anecdotal’, ‘methodology’, ‘review’, ‘overview’, ‘strengths’, ‘weaknesses’, ‘merits’, and ‘limitations’. Further references were identified by examining the literature found in the electronic searches. We also consulted major textbooks on epidemiology[ 17 , 18 ], some scholars of medical genres[ 19 , 20 ] and a monograph on case reporting by the epidemiologist M. Jenicek[ 16 ]. We delimited our review to the retrospective, naturalistic, and descriptive case report, also labeled the “traditional” or “classic” case report, and case series including such reports. Thus we excluded other types, such as the planned, qualitative case study approach[ 21 ] and simulated cases[ 22 – 24 ]. Finally, we extracted the relevant data and grouped the merits and limitations items in rank order with the items we judged to be the most important first.

New observations

The major advantage of case reporting is probably its ability to detect novelties[ 16 ]. It is the only way to present unusual, uncontrolled observations regarding symptoms, clinical findings, course of illness, complications of interventions, associations of diseases, side effects of drugs, etc. In short, anything that is rare or has never been observed previously might be important for the medical community and ought to be published. A case report might sensitize readers and thus facilitate detection of similar or identical cases.

Generating hypotheses

From a single, or preferably several single case reports or a case series, new hypotheses could be formulated. These could then be tested with formal research methods that are designed to refute or confirm the hypotheses, i.e. comparative (observational and experimental) studies.

There are numerous examples of new discoveries or major advancements in medicine that started with a case report or, in some cases, as humbly as a letter to the editor. The first concern from the medical community about the devastating side effect of thalidomide, i.e. the congenital abnormalities, appeared as a letter to the editor in the Lancet in 1961[ 25 ]. Soon thereafter, several case reports and case series reports were published in various journals. Case reporting is thus indispensable in drug safety surveillance (pharmacovigilance)[ 26 ].

Sometimes significant advancements in knowledge have come not from what researchers were pursuing, but from “accidental discoveries”, i.e. by serendipity. The story of Alexander Fleming’s discovery of penicillin in 1928 is well known in the medical field[ 27 ]. Psychiatry has profited to a large degree from this mode of advancing medical science as many of the drugs used for mental disorders have been discovered serendipitously[ 27 ]. One notable example is the discovery of the effect of lithium on manic episodes in patients with manic-depressive disorder[ 28 ]. A more recent discovery is the successful treatment of infantile hemangiomas with systemic propranolol. This discovery was published, as a case series report, in the correspondence section in New England Journal of Medicine [ 29 ]. However, the evidence for the effect of this treatment is still preliminary, and several randomized trials are under way[ 30 , 31 ].

Clear and operational entities are prerequisites for doing medical research. Descriptions must come before understanding. Clinical observations that lead to new disorders being described are well suited for case reporting. The medical literature is replete with case-based articles describing new diseases and syndromes. One notable example is the first description of neurasthenia by G. Beard in Boston Medical and Surgical Journal in 1869[ 32 ].

Researching rare disorders

For rare disorders randomized controlled trials (RCTs) can be impossible to run due to lack of patients to be enrolled. Research on drug treatment and other kinds of interventions must therefore be based on less rigorous methodologies, among them case series and case reports. This would be in accordance with the European Commission’s recommendation to its members to improve health care for those with rare disorders[ 33 ].

Solving ethical constraints

Case reporting can be valuable when ethical constraints prohibit experimental research. Take as an example the challenge of how to manage the side effects of accidental extravasation of cytotoxic drugs. As RCTs on humans seem unethical in this clinical situation the current guidelines rest on small observational studies, case reports and animal studies[ 34 ]. Or another example: Physical restraint is sometimes associated with sudden, unexpected death. The cause or causes for this are to some degree enigmatic, and it is hard to conceive of a controlled study that could be ethical[ 35 , 36 ]. Case reports and case series being “natural experiments” might be the only evidence available for guiding clinical practice.

In-depth narrative case studies

Case reporting can be a way of presenting research with an idiographic emphasis. As contrasted to nomothetic research, an idiographic approach aims at in-depth understanding of human phenomena, especially in the field of psychology and psychiatry. The objective is not generalizable knowledge, but an understanding of meaning and intentionality for an individual or individuals. Sigmund Freud’s case studies are relevant examples. This usage of case reports borders on qualitative research. Qualitative studies, although developed in the social sciences, have become a welcome contribution within health sciences in the last two decades.

Educational value

Clinical medical learning is to a large degree case-based. Typical case histories and vignettes are often presented in textbooks, in lectures, etc. Unusual observations presented as published case reports are important as part of doctors’ continuing medical education, especially as they demonstrate the diversity of manifestations both within and between medical diseases and syndromes[ 37 , 38 ]. Among the various medical texts, the case report is the only one that presents day-to-day clinical practice, clinicians’ diagnostic reasoning, disease management, and follow-up. We believe that some case reports that are written with the aim of contributing to medical knowledge turn out to be of most value educationally because the phenomena have already been described elsewhere. Other case reports are clearly primarily written for educational value[ 37 ]. Some journals have regular sections dedicated to educational case reports, e.g. The Case Records of the Massachusetts General Hospital in the New England Journal of Medicine and the Clinical Case Conference found in the American Journal of Psychiatry.

The cost of doing a case report is low compared to planned, formal studies. Most often the necessary work is probably done in the clinical setting without specific funding. Larger studies, for instance RCTs, will usually need an academic setting.

Fast publication

The time span from observation to publication can be much shorter than for other kinds of studies. This is obviously a great advantage as a case report can be an important alert to the medical community about a serious event. The unexpected side effects of the sedative-antinauseant thalidomide on newborn babies is a telling story. The drug had been prescribed during pregnancy to the babies’ mothers. After the first published observation of severe abnormalities in babies appeared as a letter to the editor of the Lancet in December 16 th , 1961[ 25 ], several case reports and series followed[ 39 , 40 ]. It should be mentioned though that the drug company had announced on December 2 nd , 1961, i.e. two weeks before the letter from McBride[ 25 ], that it would withdraw the drug form the market immediately[ 41 ].

Flexible structure

Riaz Agha, editor of the International Journal of Surgery Case Reports suggests that the case report, with its less rigid structure is useful as it “… allows the surgeon(s) to discuss their diagnostic approach, the context, background, decision-making, reasoning and outcomes”[ 42 ]. Although the editor is commenting on the surgical case report, the argument can be applied for the whole field of clinical medicine. It should be mentioned though, that other commentators have argued for a more standardized, in effect more rigid, structure[ 43 ].

Clinical practice can be changed

Case reporting can lead to or contribute to a change in clinical practice. A drug might be withdrawn from the market. Or a relabeling might change the attitude to and treatment of a condition. During Word War I the shell shock syndrome was labeled and described thoroughly in several articles in the Lancet , the first of them appearing in February 1915[ 44 ]. The author was the British captain and military doctor Charles S. Myers. Before his efforts to bring good care and treatment to afflicted soldiers there had been a common misconception that many of these dysfunctional soldiers were malingerers or cowards.

Exercise for novice researchers

The case report format is well suited for young doctors not yet trained as researchers. It can be an opportunity for a first exercise in authoring an article and a preparation for a scientific career[ 37 , 45 , 46 ].

Communication between the clinical and academic fields

Articles authored by clinicians can promote communication between practicing clinicians and academic researchers. Observations published can generate ideas and be a trigger for further studies. For instance, a case series consisting of several similar cases in a short period can make up the case-group for a case–control study[ 47 ]. Clinicians could do the observation and publish the case series while the case–control study could be left to the academics.

Entertainment

Some commentators find reading case reports fun. Although a rather weak argument in favor of case reporting, the value of being entertained should not be dismissed altogether. It might inspire physicians to spend more time browsing and reading scientific literature[ 48 ].

Studying the history of medicine

Finally, we present a note on a different and unintended aspect of the genre. The accumulated case reports from past eras are a rich resource for researching and understanding medical history[ 49 , 50 ]. A close study of old case reports can provide valuable information about how medicine has been practiced through the centuries[ 50 , 51 ].

Limitations

No epidemiological quantities

As case reports are not chosen from representative population samples they cannot generate information on rates, ratios, incidences or prevalences. The case or cases being the numerator in the equation, has no denominator. However, if a case series report consists of a cluster of cases, it can signal an important and possibly causal association, e.g. an epidemic or a side effect of a newly marketed drug.

Causal inference not possible

Causality cannot be inferred from an uncontrolled observation. An association does not imply a cause-effect relationship. The observation or event in question could be a mere coincidence. This is a limitation shared by all the descriptive studies[ 47 ]. Take the thalidomide tragedy already mentioned as an example; Unusual events such as congenital malformations in some of the children born to mothers having taken a specific drug during pregnancy does not prove that the drug is the culprit. It is a mere hypothesis until further studies have either rejected or confirmed it. Cause-effect relationships require planned studies including control groups that to the extent possible control for chance, bias and confounders[ 52 ].

Generalization not possible

From the argument above, it follows that findings from case reports cannot be generalized. In order to generalize we need both a cause-effect relationship and a representative population for which the findings are valid. A single case report has neither. A case series, on the other hand, e.g. many “thalidomide babies” in a short time period, could strengthen the suspicion of a causal relationship, demanding further surveillance and research.

Publication bias could be a limiting factor. Journals in general favor positive-outcome findings[ 53 ]. One group of investigators studying case reports published in the Lancet found that only 5% of case reports and 10% of case series reported treatment failures[ 54 ]. A study of 435 case reports from the field of dentistry found that in 99.1%, the reports “…clearly [had] a positive outcome and the intervention was considered and described as successful by the authors”[ 55 ].

Overinterpretation

Overinterpretation or misinterpretation is the tendency or temptation to generalize when there is no justification for it. It has also been labeled “the anecdotal fallacy”[ 56 ]. This is not a shortcoming intrinsic to the method itself. Overinterpretation may be due to the phenomenon of case reports often having an emotional appeal on readers. The story implicitly makes a claim to truth. The reader might conclude prematurely that there is a causal connection. The phenomenon might be more clearly illustrated by the impact of the clinician’s load of personal cases on his or her practice. Here exemplified by a young doctor’s confession: “I often tell residents and medical students, ‘The only thing that actually changes practice is adverse anecdote.’”[ 57 ].

Emphasis on the rare

As case reporting often deals with the rare and atypical, it might divert the readers’ attention from common diseases and problems[ 58 ].

Confidentiality

Journals today require written informed consent from patients before publishing case reports. Both authors and publishers are responsible for securing confidentiality. A guarantee for full confidentiality is not always possible. Despite all possible measures taken to preserve confidentiality, sometimes the patient will be recognized by someone. This information should be given to the patient. An adequately informed patient might not consent to publication. In 1995 in an Editorial in the British Journal of Psychiatry one commentator, Isaac Marks, feared that written consent would discourage case reports being written[ 59 ]. Fortunately, judged form the large number of reports being published today, it seems unlikely that the demand for consent has impeded their publication.

Other methodological limitations

Case reports and series are written after the relevant event, i.e. the observation. Thus, the reports are produced retrospectively. The medical record might not contain all relevant data. Recall bias might prevent us from getting the necessary information from the patient or other informants such as family members and health professionals.

It has also been held against case reporting that it is subjective. The observer’s subjectivity might bias the quality and interpretation of the observation (i.e. information bias).

Finally, the falsification criterion within science, which is tested by repeating an experiment, cannot be applied for case reports. We cannot design another identical and uncontrolled observation. However, unplanned similar “experiments” of nature can be repeated. Several such observations can constitute a case series that represents stronger indicative evidence than the single case report.

The major advantages of case reporting are the ability to make new observations, generate hypotheses, accumulate scientific data about rare disorders, do in-depth narrative studies, and serve as a major educational tool. The method is deficient mainly in being unable to deliver quantitative data. Nor can it prove cause-effect relationship or allow generalizations. Furthermore, there is a risk of overinterpretation and publication bias.

The traditional case report does not fit easily into the qualitative-quantitative dichotomy of research methods. It certainly shares some characteristics with qualitative research[ 16 ], especially with regard to the idiographic, narrative perspective – the patient’s “interior world”[ 60 ] – that sometimes is attended to. Apart from “The storied case report” mentioned in the Background-section, other innovative modifications of the traditional case report have been tried: the “evidence-based case report”[ 61 ], the “interactive case report”[ 62 ] and the “integrated narrative and evidence based case report”[ 63 ]. These modifications of the format have not made a lasting impact on the way case reports in general are written today.

The method of case reporting is briefly dealt with in some textbooks on epidemiology[ 17 , 18 ]. Journals that welcome case reports often put more emphasis on style and design than on content in their ‘instruction to authors’ section[ 64 ]. As a consequence, Sorinola and coworkers argue for more consensus and more consistent guidance on writing case reports[ 64 ]. We feel that a satisfactory amount of guidance concerning both style and content now exists[ 12 , 16 , 65 , 66 ]. The latest contribution, “The CARE guidelines”, is an ambitious endeavor to improve completeness and transparency of reports[ 66 ]. These guidelines have included the “Patient perspective” as an item, apparently a bit half-heartedly as this item is placed after the Discussion section, thus not allowing this perspective to influence the Discussion and/or Conclusion section. We assume this is symptomatic of medicine’s problem with integrating the biomedical model with “narrative-based medicine”.

In recent years the medical community has taken an increased interest in case reports[ 2 ], especially after the surge of online, exclusive case report journals started in 2007 with the Journal of Medical Case Reports (which was the first international, Pubmed-listed medical journal publishing only case reports) as the first of this new brand. The climate of skepticism has been replaced by enthusiasm and demand for more case reports. A registry for case reports, Cases Database, was founded in 2012[ 67 ]. On the condition that it succeeds in becoming a large, international database it could serve as a register being useful for clinicians at work as well as for medical research on various clinical issues. Assuming Pamela P. Powell’s assertion that “[a]lmost all practicing physicians eventually will encounter a case worthy of being reported”[ 60 ] is valid, there should be no shortage of potential cases waiting to be reported and filed in various databases, preferably online and open access.

Limitations of this review

There are several limitations to this study. It is a weakness that we have not been able to review all the relevant literature. The number of publications in some way related to case reports and case report series is enormous, and although we have attempted to identify those publications relevant for our purpose (i.e. those that describe the merits and limitations of the case report genre), we might have missed some. It was difficult to find good search terms for our objective. Still, after repeated electronic searches supplemented with manual searches in reference lists, we had a corpus of literature where essentially no new merits or limitations emerged.

As we point out above, the ranking of merits and limitations represents our subjective opinion and we acknowledge that others might rank the importance of the items differently.

The perspective on merits and limitations of case reporting has been strictly medical. As a consequence we have not analyzed or discussed the various non-medical factors affecting the publication of case reports in different medical journals[ 2 ]. For instance, case reports are cited less often than other kinds of medical research articles[ 68 ]. Thus they can lower a journal’s impact factor, potentially making the journal less attractive. This might lead some high-impact journals to publish few or no case reports, while other journals have chosen to specialize in this genre.

Before deciding on producing a case report or case series based on a particular patient or patients at hand, the observant clinician has to determine if the case report method is the appropriate article type. This review could hopefully assist in that judgment and perhaps be a stimulus to the continuing debate in the medical community on the value of case reporting.

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http://orcid.org/0000-0001-5502-5975 Mohammad Hassan Murad 1 ,
Shahnaz Sultan 2 ,
Samir Haffar 3 ,
Fateh Bazerbachi 4
1 Evidence-Based Practice Center, Mayo Clinic , Rochester , Minnesota , USA
2 Division of Gastroenterology, Hepatology, and Nutrition , University of Minnesota, Center for Chronic Diseases Outcomes Research, Minneapolis Veterans Affairs Healthcare System , Minneapolis , Minnesota , USA
3 Digestive Center for Diagnosis and Treatment , Damascus , Syrian Arab Republic
4 Department of Gastroenterology and Hepatology , Mayo Clinic , Rochester , Minnesota , USA
Correspondence to Dr Mohammad Hassan Murad, Evidence-Based Practice Center, Mayo Clinic, Rochester, MN 55905, USA; murad.mohammad{at}mayo.edu

https://doi.org/10.1136/bmjebm-2017-110853

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epidemiology

In 1904, Dr James Herrick evaluated a 20-year-old patient from Grenada who was studying in Chicago and suffered from anaemia and a multisystem illness. The patient was found to have ‘freakish’ elongated red cells that resembled a crescent or a sickle. Dr Herrick concluded that the red cells were not artefacts because the appearance of the cells was maintained regardless of how the smear slide was prepared. He followed the patient who had subsequently received care from other physicians until 1907 and questioned whether this was syphilis or a parasite from the tropics. Then in 1910, in a published case report, he concluded that this presentation strongly suggested a previously unrecognised change in the composition of the corpuscle itself. 1 Sickle cell disease became a diagnosis thereafter.

Case reports and case series have profoundly influenced the medical literature and continue to advance our knowledge in the present time. In 1985, the American Medical Association reprinted 51 papers from its journal that had significantly changed the science and practice of medicine over the past 150 years, and five of these papers were case reports. 2 However, concerns about weak inferences and the high likelihood of bias associated with such reports have resulted in minimal attention being devoted to developing frameworks for approaching, appraising, synthesising and applying evidence derived from case reports/series. Nevertheless, such observations remain the bread and butter of learning by pattern recognition and integral to advancing medical knowledge.

Guidance on how to write a case report is available (ie, a reporting guideline). The Case Report (CARE) guidelines 3 were developed following a three-phase consensus process and provide a 13-item checklist that can assist researchers in publishing complete and meaningful exposition of medical information. This checklist encourages the explicit presentation of patient information, clinical findings, timeline, diagnostic assessment, therapeutic interventions, follow-up and outcomes. 3 Yet, systematic reviewers appraising the evidence for decision-makers require tools to assess the methodological quality (risk of bias assessment) of this evidence.

In this guide, we present a framework to evaluate the methodological quality of case reports/series and synthesise their results, which is particularly important when conducting a systematic review of a body of evidence that consists primarily of uncontrolled clinical observations.

Definitions

In the biomedical published literature, a case report is the description of the clinical course of one individual, which may include particular exposures, symptoms, signs, interventions or outcomes. A case report is the smallest publishable unit in the literature, whereas case series report aggregates individual cases in one publication. 4

If a case series is prospective, differentiating it from a single-arm uncontrolled cohort study becomes difficult. In one clinical practice guideline, it was proposed that studies without internal comparisons can be labelled as case series unless they explicitly report having a protocol before commencement of data collection, a definition of inclusion and exclusion criteria, a standardised follow-up and clear reporting of the number of excluded patients and those lost to follow-up. 6

Evaluating methodological quality

Pierson 7 provided an approach to evaluate the validity of a case report based on five components: documentation, uniqueness, objectivity, interpretation and educational value, resulting in a score with a maximum of 10 (a score above 5 was suggested indicate a valid case report). This approach, however, was rarely used in subsequent work and seems to conflate methodological quality with other constructs. For case reports of adverse drug reactions, other systems classify an association as definite, probable, possible or doubtful based on leading questions. 8 9 These questions are derived from the causality criteria that was established in 1965 by the English epidemiologist Bradford Hills. 10 Lastly, we have adapted the Newcastle Ottawa scale 11 for cohort and case–control studies by removing items that relate to comparability and adjustment (which are not relevant to non-comparative studies) and retained items that focused on selection, representativeness of cases and ascertainment of outcomes and exposure. This tool was applied in several published systematic reviews with good inter-rater agreement. 12–16

Proposed tool

The previous criteria from Pierson, 7 Bradford Hills 10 and Newcastle Ottawa scale modifications 11 converge into eight items that can be categorised into four domains: selection, ascertainment, causality and reporting. The eight items with leading explanatory questions are summarised in table 1 .

View inline

Tool for evaluating the methodological quality of case reports and case series

For example, a study that explicitly describes all the cases who have presented to a medical centre over a certain period of time would satisfy the selection domain. In contrast, a study that reports on several individuals with unclear selection approach leaves the reader with uncertainty to whether this is the whole experience of the researchers and suggests possible selection bias. For the domain of ascertainment, self-report (of the exposure or the outcome) is less reliable than ascertainment using administrative and billing codes, which in turn is less reliable than clinical records. For the domain of causality, we would have stronger inference in a case report of an adverse drug reaction that has resolved with cessation of the drug and reoccurred after reintroduction of the drug. Lastly, for the domain of reporting, a case report that is described with sufficient details may allow readers to apply the evidence derived from the report in their practice. On the other hand, an inadequately reported case will likely be unhelpful in the course of clinical care.

We suggest using this tool in systematic reviews of case reports/series. One option to summarise the results of this tool is to sum the scores of the eight binary responses into an aggregate score. A better option is not to use an aggregate score because numeric representation of methodological quality may not be appropriate when one or two questions are deemed most critical to the validity of a report (compared with other questions). Therefore, we suggest making an overall judgement about methodological quality based on the questions deemed most critical in the specific clinical scenario.

Synthesis of case reports/series

A single patient case report does not allow the estimation of an effect size and would only provide descriptive or narrative results. Case series of more than one patient may allow narrative or quantitative synthesis.

Narrative synthesis

A systematic review of the cases with the rare syndrome of lipodystrophy was able to suggest core and supportive clinical features and narratively summarised data on available treatment approaches. 17 Another systematic review of 172 cases of the infrequently encountered glycogenic hepatopathy was able to characterise for the first time patterns of liver enzymes and hepatic injury in this disease. 18

Quantitative synthesis

Quantitative analysis of non-comparative series does not produce relative association measures such as ORs or relative risks but can provide estimates of prevalence or event rates in the form of a proportion (with associated precision). Proportions can be pooled using fixed or random effects models by means of the various available meta-analysis software. For example, a meta-analysis of case series of patients presenting with aortic transection showed that mortality was significantly lower in patients who underwent endovascular repair, followed by open repair and non-operative management (9%, 19% and 46%, respectively, P<0.01). 19

A common challenge, however, occurs when proportions are too large or too small (close to 0 or to 1). In this situation, the variance of the proportion becomes very small leading to an inappropriately large weight in meta-analysis. One way to overcome this challenge is to transform prevalence to a variable that is not constrained to the 0–1 range and has approximately normal distribution, conduct the meta-analysis and then transform the estimate back to a proportion. 20 This is done using logit transformation or using the Freeman-Tukey double arcsine transformation, 21 with the latter being often preferred. 20

Another type of quantitative analysis that may be utilised is regression. A meta-analysis of 47 published cases of hypocalcaemia and cardiac dysfunction used univariate linear regression analysis to demonstrate that both QT interval and left ventricular ejection fraction were significantly correlated with corrected total serum calcium level. 22 Meta-regression, which is a regression in which the unit of analysis is a study, not a patient, can also be used to synthesise case series and control for study-level confounders. A meta-regression analysis of uncontrolled series of patients with uveal melanoma treated with proton beam therapy has shown that this treatment was associated with better outcomes than brachytherapy. 23 It is very important, however, to recognise that meta-regression results can be severely affected by ecological bias.

From evidence to decision

Several authors have described various important reasons to publish case reports/series ( table 2 ). 7 24 25

Role of case reports/series in the medical literature

It is paramount to recognise that a systematic review and meta-analysis of case reports/series should not be placed at the top of the hierarchy in a pyramid that depicts validity. 26 The certainty of evidence derived from a meta-analysis is contingent on the design of included studies, their risk of bias, as well as other factors such as imprecision, indirectness, inconsistency and likelihood of publication bias. 27 Commonly, certainty in evidence derived from case series/reports will be very low. Nevertheless, inferences from such reports can be used for decision-making. In the example of case series of aortic transection showing lower mortality with endovascular repair, a guideline recommendation was made stating ‘We suggest that endovascular repair be performed preferentially over open surgical repair or non-operative management’. This was graded as a weak recommendation based on low certainty evidence. 28 The strength of this recommendation acknowledged that the recommendation might not universally apply to everyone and that variability in decision-making was expected. The certainty in evidence rating of this recommendation implied that future research would likely yield different results that may change the recommendation. 28

The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach clearly separates the certainty of evidence from the strength of recommendation. This separation allows decision-making based on lower levels of evidence. For example, despite low certainty evidence (derived from case series) regarding the association between aspirin and Reye’s syndrome in febrile children, a strong recommendation for using acetaminophen over aspirin is possible. 29 GRADE literature also describes five paradigmatic situations in which a strong recommendation can be made based on low quality evidence. 30 One of which is when the condition is life threatening. An example of which would be using hyperbaric oxygen therapy for purpura fulminans, which is only based on case reports. 31

Guideline developers and decision-makers often struggle when dealing with case reports/case series. On occasions, they ignore such evidence and focus the scope of guidelines on areas with higher quality evidence. Sometimes they label recommendations based on case reports as expert opinion. 32 We propose an approach to evaluate the methodological quality of case reports/series based on the domains of selection, ascertainment, causality and reporting and provide signalling questions to aid evidence-based practitioners and systematic reviewers in their assessment. We suggest the incorporation of case reports/series in decision-making based on the GRADE approach when no other higher level of evidence is available.

In this guide, we have made the case for publishing case reports/series and proposed synthesis of their results in systematic reviews to facilitate using this evidence in decision-making. We have proposed a tool that can be used to evaluate the methodological quality in systematic reviews that examine case reports and case series.

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Contributors MHM drafted the paper and all coauthors critically revised the manuscript. All the authors contributed to conceive the idea and approved the final submitted version.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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Published: 30 May 2024

Longitudinal qualitative study on the psychological experiences of COVID-19 patients based on timing it right framework

Liangyan Zhang 1 ,
Chen Zhang 2 ,
Kesang Li 1 &
Yan Zhang 3

Scientific Reports volume 14 , Article number: 12409 ( 2024 ) Cite this article

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Health care

Timing it right framework was used as a framework to explore the illness experiences of patients infected with COVID-19 and to analyze the patients' perceptions of the disease and their true inner feelings to provide a reference for the control of infectious diseases. This research adopted a phenomenological research approach to develop a longitudinal qualitative study. A purposive sampling method was used to select participants and 37 patients were recruited. Depending on the principle that participants should have maximum variation and sampling should cease when interviews content saturation is achieved, 16 COVID-19 patients in an isolation ward in Ningbo City, Zhejiang Province were finally included. Data were collected using semi-structured interviews, and the content of the interviews was analyzed by Colaizzi’s 7-step method. The themes of COVID-19 patients’ experiences at various phase were presented as follows: multiple emotions intertwined at the time of diagnosis (anxiety, stressful panic, facing the diagnosis calmly), multiple pressures during the hospitalization period (concerns about the disease, unable to adapt to the ward environment, worrying about future hardship), growth of positive illness experience during the isolation and observation period (sublimated outlook on life, affirmation of the government's anti-epidemic policy, more concerned about their own health), adjustment after returning to society (stigma, loss of previous living environment, problems caused by nucleic acid testing), and adaptation to social life (return to normal life, avoidance of illness experience, post-covid-19 syndrome). The illness experience of COVID-19 patients changed dynamically with time, but a sense of shame and uncertainty about recovery was present throughout the process. Interventions should be developed according to the needs of the patients at different times to inform subsequent optimization of care and management of infectious diseases.

Long COVID: major findings, mechanisms and recommendations

Exploring the reported adverse effects of COVID-19 vaccines among vaccinated Arab populations: a multi-national survey study

Effect of breathwork on stress and mental health: A meta-analysis of randomised-controlled trials

Introduction.

The ongoing global epidemic of coronavirus disease 2019 (COVID-19) has had a significant impact on human society, primarily in terms of public health. As of 2 February 2023, the reported cumulative number of confirmed cases worldwide is approximately 753 million, with approximately 6,814,900 deaths 1 . Importantly, the actual number of infections worldwide may be higher than the reported data due to factors such as limited testing capacity. The Omicron and Delta strains are variants of coronaviruses with high loads, high infectivity, short incubation times, and antigenic escape 2 . Patients experience long viral nucleic acid conversion times and are more likely to develop severe and critical illnesses, with long periods of hospital isolation and medical observation 3 . Studies have shown 4 that patients with COVID-19 who stay in isolation are prone to psychological problems such as anxiety, depression, and fear. The study 5 showed that infected patients had problems such as fatigue, sleep difficulties, and anxiety after discharge from the hospital, and those with severe lung damage during hospitalization were even more likely to be in the target population for long-term rehabilitation interventions after discharge; however, the study was conducted on patients at the beginning of the 2019 outbreak, and the characteristics of the coronavirus variants can cause various psychological experiences in infected patients. There are currently few studies exploring mild COVID-19 patients' experiences during hospitalization and after reintegration into society 6 . The Timing it Right (TIR) framework was proposed by Cameron et al. 7 in the study of stroke care; it divides the process of disease development into five phases: diagnosis, stabilization, preparation, implementation and adaptation. At present, a number of scholars have used different research methods to study the dynamic needs of patients and caregivers with the TIR framework, and have achieved initial results 8 . Based on the TIR framework, it is possible to understand the changes in the experience of COVID-19 patients at different stages of illness, and formulate corresponding support plans, so that the intervention timing and intervention content can match the needs of patients at the current phase of disease 9 , 10 . Therefore, based on the five phases of disease development in the TIR framework, this research explore the illness experiences of COVID-19 patients in a longitudinal study to provide a reference for the subsequent care of patients with infectious diseases and the development of epidemic prevention and control strategies.

Design and participants

This study utilized a phenomenological research approach to develop a longitudinal qualitative study using the TIR framework. To conduct a longitudinal qualitative study, it is necessary to select specific time points for data collection, and the chosen time frame should be adequate for observing changes in the phenomenon under investigation 11 . In this study, the time frame for data collection was established through two interviews. The first interview (T1) took place during the period when the infected individuals were isolated, and the second interview (T2) occurred 6 months after their reintegration into society. The study employed a purposive sampling method to select patients who had been diagnosed with COVID-19 and were admitted to an isolation ward in Ningbo City, Zhejiang Province, between January and October 2022. The inclusion criteria were as follows: (1) confirmed COVID-19 infection; (2) age above 18 years; and (3) voluntary participation in this study and providing informed consent. The exclusion criteria were as follows: (1) those who were seriously ill and unable to communicate and (2) those with serious psychological or cognitive dysfunction. Those who automatically withdrew or were lost to follow-up during the interview were dropped from the study. A total of 37 patients were recruited for the study, and the sample size of the study was determined based on information saturation of the interviewees 12 . The specificity of the sampling was measured by demographic characteristics and the Self-Rating Depression Scale (SDS) 13 . Sampling ceased when interviews content saturation was achieved. Finally, 16 cases of representative infected patients were included in the study, including patients with no depression (9 cases, 56%), suspected mild depression (1 case, 6%), and suspected moderate depression (6 cases, 37.5%), numbered "N1" to "N16". In this study, two in-depth interviews were conducted with the infected patients, one during their isolation period and another after 6 months of reintegrating into society. Notably, during the second interview, two of the participants exhibited evasive behavior. For example, one participant was very talkative in the first interview, and he was able to talk more about his true feelings and describe them in more details based on the experience of the illness. However, in the second interview, he spoke less and only answered yes, no or fine, showing an evasive attitude. In order to fully understand the thoughts of the participants and enhance the integrity and continuity of the study, after obtaining informed consent, the interviewer supplemented the interview content by contacting their relatives, and returned the transcript of the interview content to the participants for confirmation, so as to ensure the authenticity of the content. The basic information of the study participants is shown in Table 1 .

Data collection

The participants provided informed consent and completed the demographic scale and SDS scale assessment before the interview. The interview outline was designed according to the five phases of diagnosis, stabilization, preparation, implementation and adaptation in the TIR framework. Longitudinal qualitative studies require researchers to use the insights gained from previous interviews to inform the focus of subsequent data collection 14 . The researcher preinterviewed two infected individuals prior to the formal interview and amended the interview outline. The interview outline was as follows. During Phase 1 (T1), the following questions were asked: ① How did you feel when you were diagnosed with COVID-19? ② What was your initial feeling after arriving at the isolation ward? ③ What are your needs and feelings during hospitalization? ④ How do you feel when you go to the quarantine point for medical observation? ⑤ How will the Spring Festival affect you? ⑥ If you are cured and returned to society, what expectations or concerns do you have? During Phase 2 (T2), the following questions were asked: ① What was your mood at the beginning of reintegration? Give an example of 1–2 things that were particularly impressive at that time. ② How do you feel now? How has your life changed? ③ Is there anything particularly troubling you at present? How do you solve these troubles? Do you have any hopes or suggestions? Due to the requirements of epidemic prevention and control, the interview was conducted by telephone, and the interview time was 15–60 min.

Data analysis

The interview content was analyzed by Colaizzi’s 7-step method. The steps are as follows: (1) two researchers carefully read all the original data; (2) they independently identify significant statements that were repeated by multiple participants and were important and meaningful to the research question; (3) they code repetitive and meaningful views by temporarily "suspending" their assumptions and value judgments; (4) they gather ideas after coding to form the prototype of the theme; (5) they write a detailed typical original description; (6) they identify similar ideas and condense them into themes; and (7) they return the topic structure to the participants for verification. The results of the SDS questionnaire were descriptive statistical analyzed by SPSS 25.0.

Quality control

SDS questionnaire collection: during hospitalization, a researcher issued and collected the questionnaire, explained the questions appropriately, and checked the completeness of the answers on the spot. (2) Interview data collection: all researchers in the study received professional training in qualitative research, and all interview data collection was completed by the first author (isolation ward nurse). The researcher kept in touch with the participants during the follow-up period to establish trust and friendly relationships. The researcher used the daily chat information as supplementary information. At the end of each interview, the researcher transcribed the audio-recorded information within 24 h and recorded the tone of voice, pitch change and other information of the participants. (3) Data analysis: data collection and analysis were carried out in parallel, with each of the 2 researchers listening to the audio-recordings and reading the textual information repeatedly, independently summarizing statements of significance, and summarizing the text of the statements. And the themes and subthemes extracted from the collected data were repeated to the participants by instant messaging software to further confirm whether they had the same feeling or experience and record any possible supplemental information. It was explained to the participants at the first interview that the preliminary results would be reported back to them for verification.

This study was reviewed and approved by the Ethics Committee of Ningbo No.2 Hospital (YJ-NBEY-KY-2022-102-01). All methods were performed in accordance with the relevant guidelines and regulations such as ethical standards of the institutional ethics committee and with the Declaration of Helsinki. All participants signed informed consent forms.

An interpretive understanding of the illness experiences of patients infected with COVID-19 was constructed in this study. The analysis yielded five categories and fifteen sub-categories (Table 2 ).

Theme 1: multiple emotions intertwined at the time of diagnosis

Due to different personality characteristics and understanding of the disease, infected patients showed the following emotional changes in the early stage of diagnosis.

Anxiety: since most infected patients learned about their infection suddenly, most of them had significant fidgeting, irritability, insomnia, and felt inexplicably nervous and worried when they were diagnosed or preparing for medical isolation. N5-T1: "I was so anxious when I was diagnosed that I felt like the sky was falling." N9-T1: "Since that time I have not been able to sleep well at night, I wake up after an hour of sleep." N2-T1: "I felt like it was going by so slowly and every day felt like years. Before the quarantine, I was worried that I wouldn't eat or sleep well, and that was true." Some of the infected patients felt upset when they were first diagnosed, as they received many calls for epidemiological investigations from various departments and organizations. N6-T1: "The initial phase has been very busy. I was the first to be infected, and there was a particular focus on me. At that time, my sleep was disturbed."

Stressful panic: the knowledge that there was no effective treatment, the uncertainty of the sequelae and the possibility of recurrence all put the infected patients in fear of the disease at the time of diagnosis, with three infected patients displaying more pronounced despair. N12-T1: "At that time, I was lying in bed for two days feeling like I was going to die. It was bad anyway. I was scared, scared of the after-effects, scared for my life (emotional)." N9-T1: "[Messages on my mobile phone] made me think nonsense. If the virus in my body had stayed, I would have been locked up forever. It gave me a feeling of panic."

Facing the diagnosis calmly: some of the infected patients were not so afraid of the diagnosis because people around them had already been infected. N1-T1: "The mood was a bit panicky, not particularly panicky. Because my in-laws have already been diagnosed, I already have a general idea in my mind." Some infected patients had a more comprehensive understanding of the corresponding symptoms of infection and were more receptive. N11-T1: "Not afraid of the disease. I have read the news that most of the foreign countries are infected, so I am calm." N3-T1: "It was mild… and curable, so I just didn't have much stress anyway."

Theme 2: multiple pressures during the hospitalization period

When patients were hospitalized, the disease itself, positivity for 2019-nCoV nucleic acid, and the specificity of the isolation environment made them feel deeply stressed.

Concerns about the disease: the threat to COVID-19 patients' lives and safety during hospitalization was stressful for those infected, either because of their own experiences of repositivity or because they witnessed others experiencing repositivity. N11-T1: "The biggest concern was that I didn't know how long it would take to be discharged from the hospital, how long it would take to recover … I didn't know if there were any after effects and whether there would be a relapse." N5-T1: "(After being repositive for the third time) I cried all the time during those 2 days when I was isolated again. The last 2 days were fine, (my mood) calmed down, and today I'm a little bit annoyed again, my wife and my youngest daughter they don't seem to have a good nucleic acid result. That aspect is affecting me a lot, a lot of stress (speaking faster)." N14-T1: "There is a feeling of fear in my heart. This is the first time I've had a repositive, and I've heard that there are a lot of repositive people, and I'm scared in my heart." Due to the special nature of COVID-19 patients, the vast majority of them chose to conceal their condition to avoid worrying about their families. N3-T1: "I didn't dare to make a video call to my mother. I was afraid that if my mother knew I was inside the hospital, she would have to worry about me."

Unable to adapt to the ward environment: most infected patients were transferred to isolation wards for medical observation and treatment, and the unfamiliar and confined environment often made them feel uncomfortable. N4-T1: "It feels unreal to be here, the air is treated and the rooms are airtight." Meanwhile, due to the shortage of beds, most isolation wards housed many people, to which some infected patients are not accustomed, and some infected patients were deeply stressed about secondary infections. N2-T2: "I don't like to sleep with other people in the same room. But, since I was a child, I have been timid and I am afraid to sleep alone. I am not used to sleeping in the hospital." N12-T1: "I was worried about my problems and whether sleeping in the same ward would spread the virus to each other, so I never took off my mask." Isolation also prevents infected patients from spending time with their families. During the festive season, which symbolizes reunion, they had to spend time alone. N10-T1: "The arrival of Chinese New Year had an impact on me. There are so many things I can't do because (I can't) be reunited with my family."

Worrying about future hardship: because the whole family was quarantined or because they themselves were the main laborer in the family, most infected patients reported that the long period of isolation had affected their financial income and were worried about the future. N5-T1: "There has been no income for a few months now, which means that life may be hard in the future." Due to the release of information from epidemiological surveys, infected patients are often worried about having the disease known to their acquaintances. N5-T2: "[The flow survey information] would be better to change that column where the surname is written to a number. Because we are the only ones infected in the factory, it is easy for others to guess." Infectious patients worry about social discrimination brought about by the disease and about whether they will still be able to have a suitable learning environment, job, and residence in the future. N5-T1: "I worry about whether it will affect my youngest daughter's ability to go to a better kindergarten." N10-T1: "I feel that I will not be able to find a job if people know about my disease. … I am sure I will be treated differently." "N2-T1: "We are renting a house outside, the landlord knows about it and may not let us stay in this place. What should we do?"

Theme 3: growth of positive illness experience during the isolation and observation period

Patients were under medical isolation and observation during this period. There is deeper thinking after enduring pressure from all sides, and some patients gain growth.

Sublimated outlook on life. Some infected patients were grateful for the dedication of healthcare workers. N1-T1: "Really, I feel that you are all very good. Doctors have it so hard. I didn't feel it before." Some patients thanked the teachers for caring for their children during the infection. N1-T2: "The teachers and classmates are very caring for my daughter. In particular, her class teacher was really nice. There was no one to look after her when she first came out (family members were quarantined for infection). My daughter was alone at home, and I was worried. Her teacher let my daughter go to her house. The teacher said I am not afraid." Some infected patients also said that during the isolation period, they had time to calm down and question their souls and thought more about life. N6-T1: "Actually, when I was in the isolation ward, I had more time and space to think, and then I might think more deeply about something, like the meaning of life. I would find so many things that I just naturally realized."

Affirmation of the government's anti-epidemic policy. N6-T1: "I think our government departments are very committed because our national situation is different from that of foreign countries, with a large population. If our country really doesn't care about controlling the epidemic at all, the medical resources can't keep up." N9-T1: "I fully comply with the rules and regulations of the isolation ward. The country invests a lot of resources. We eat and live medically for free."

More concerned about their own health. The experience of falling ill has made more patients pay more attention to their own health, and they actively participate in sports and pay attention to physical checkups and rest. N11-T1: "It's better to have a medical checkup to see if this virus has any other effects on your body. In the future, I will have regular medical check-ups once every six months or a year. Now, I also started to run (during the quarantine phase), I didn't run much before."

Theme 4: adjustment after returning to society

The infected often return to society in a state of fear and with a deep sense of stigma. Some infected patients have lost their former jobs and living environments, and their finances and lives have been greatly affected. At the same time, the nucleic acid test also brought troubles to their lives after returning to society.

Stigma: infected patients often have a heavy self-psychological burden when they return to society. They are afraid of being rejected and treated differently. The main manifestations are fear of stigma and concealment of medical history. N1-T2: "We definitely have to report to the community when we go back. We have to explain the situation. After explaining the situation, the people in the village will be scared to death, they will ostracize them (brother, parents), and then it will definitely have an impact on my parents and my brother's lives, so we didn't dare to go back." Some infected patients were worried that they would cause others to become infected, causing them to be quarantined as well. N16-T1: "I'm worried that if I go back to being positive in the future, I will infect others, even if it doesn't hurt, will I have to quarantine people for so many days?" With the shame of the disease, many infected patients were unable to go home to their families. N1-T2: "I would love to go back to my hometown. Because my parents are also 70 years old, and I can't take care of them when I'm out of town. But, now I can't go back to my hometown."

Loss of previous living environment. Some infected patients lost their original living and working environments after returning to society. Some COVID-19 patients moved away from their original environments of their own initiative because they were afraid that others would know that they had been infected by COVID-19. N1-T2: "We moved home. But, we are still afraid of bumping into people we know: "Some infected patients were asked not to go to work or to change their working environments for fear of mutual infection in their workplaces. N2-T2: "We were not allowed to go to work in the factory at that time because the other employees didn't agree to let us go to work." N9-T2: "She used to work in Department 5, but the original department didn't want her anymore." A new environment means a new start, which leads to greater pressure on the lives of infected patients. N1-T2: The pressure on my husband's life is too great. I also went to look for a job. After looking for a few days, I felt very sad and found that I could only do more flexible work like takeaway. Life is difficult, we've borrowed a lot of money now, and there's a lot of financial pressure and mental stress."

Problems caused by nucleic acid testing. Because of previous infections, policies require infected patients to have a separate nucleic acid test. This often meant that they had to spend time and effort looking for a separate site where they could do a separate nucleic acid test. N1-T2: "My child can't do a separate nucleic acid test at school anyway, so we have to find a nucleic acid test site by ourselves." When doing the nucleic acid test alone, they were split into two teams, separate from the people doing the mixed nucleic acid test, and the people in their team were faced with more inquiries about infection, which put more pressure on them." N1-T2: "When we went to do the nucleic acid test, the security guard at the door asked once, then the person who checked the identity after the questioning asked again, and the sampler asked again. I had nightmares every day." In addition, they were concerned that doing the nucleic acid test alone would increase the risk of reinfection. N5-T2: "When we do the nucleic acid test alone, we are with people who are at high risk. The book they have registered in we touch it again, register it again and go with them. If I get infected again, I reckon I'm going to go mad." Because of the fear of repositivity, infected patients are extremely concerned about the results of their own and their family's nucleic acid tests." N3-T2: "To be honest, some people, like my wife, have repeated repositive and go to quarantine sites over and over again. Very upset and depressed. I'm worried about my own and my wife's nucleic acid test results."

Theme 5: adaptation to social life

Six months after returning to society, most of the infected patients returned to normal life with the support and tolerance of society, but some of them still avoided infection and concealed their status as recovered persons. Some of the infected patients developed post-COVID-19 syndrome.

Return to normal life. Some infected patients integrated into society with the tolerance of colleagues and friends around them. N2-T2: "Still working as normal. My friends and I still play well and sit together for meals." N8-T2: "I was a bit afraid that my colleagues would laugh at me in various ways before I came to work. But, none of them did." Nucleic acid testing is also gradually becoming less frequent. N7-T2: "In the beginning, it was a single test, now it's all mixed." Some infected patients said that they no longer avoided the fact that they were infected under self-regulation and gradually returned to normal life. T12-N2: "When I first came out of quarantine, whenever people talked about this stuff, I wanted to avoid it and didn't want to hear about it. Now, when people talk about doing nucleic acids, I seem to slowly be able to accept it."

Avoidance of illness experience. Some infected patients still avoided infection and concealed their identities as a recovered person. N16-T2 Husband added: "Whoever mentions this, she is anxious about it. Some old folks called me and asked about this, and she was also a little anxious in her heart. There is nervousness in her heart, and she doesn't want to talk about it anymore." During the interview with N5-T2, the infected patient herself said, "I don't feel anything, it doesn't affect me at the moment. Everything is fine. Don't want to think about it." However, interviewing his lover, he said, "He used to look like a child, he used to laugh and joke around, but now he looks sad every day. He doesn't talk much in his free time." This experience has changed his personality.

Post-COVID-19 syndrome. Some infected patients still have residual weakness, chest tightness, loss of smell, sleep disorders, etc. N14-T2: "The body is a bit different anyway. I'm more tired than I used to be at work, and I'm not as fit as I used to be. Sleep has been bad, easy to wake up. I have no sense of smell." N15-T2: "I feel a bit breathless sometimes when I walk a few steps. I feel tired."

This study conducted a longitudinal exploration of COVID-19 patients' experience based on the TIR framework. In general, the TIR framework has played a good guiding role in the exploration of COVID-19 patients' illness experience. During the diagnosis phase, COVID-19 patients were usually very concerned about their own health problems, and due to great pressure caused by isolation, they were prone to psychological problems. The stabilization and preparation phase of COVID-19 patients were in the long isolation treatment. Patients gradually adapted to isolation treatment and started to plan their life after discharge. They were worried about discrimination and worried that they would never go back to the original life. In addition, because COVID-19 patients were kept in isolation for a long time, some patients began to reflect on the experience of the disease and the past life status, and thus gained growth. The stigma of COVID-19 patients was felt throughout the course of the illness, but it was particularly evident during the implementation and adaptation phase. Due to the stigma and discrimination, some patients actually made great changes to their work and life during this two phase. At this time, social support was particularly important for patients to reintegrate into society. The following discussion provides detailed analysis of the above phenomena.

The results of this study showed that all infected patients diagnosed for the first time had psychological problems such as anxiety, fear, and sleep disorders, and seven patients (43.75%) were suspected of having mild to moderate depression according to the SDS scores, which is similar to the results of the study by Deng et al. 15 . This may be due to the highly contagious nature of COVID-19 and the lack of specific treatment, resulting in infected patients being prone to excessive stress, panic, and even psychological stress disorder at the early stage of diagnosis 16 . At the same time, 14 cases (87.5%) of the infected patients expressed concern about the possibility of "repositivity" after recovery and the existence of sequelae. A related study found that noninfectious viral RNA persisted in most of the "repositive" cases, which may be due to slow disease regression 17 . A positive test does not always mean that the patient is infectious, as it may detect fragments of viral nucleic acid 18 . However, most patients know little about this and develop more anxiety and fear. In contrast, those patients who have knowledge of the new coronavirus tend to have less fear and worry. Cheng Hualing et al. 19 meta-integrated the psychological experience of COVID-19 patients in China and found that more information provided by medical personnel to infected patients about the treatment and prognosis of the disease could eliminate the anxiety caused by the patients' lack of knowledge. Therefore, health promotion should be strengthened, and patients should be encouraged to acquire knowledge of the disease in various aspects, including transmission channels, protective measures, symptom classification, prognosis, etc. Patients’ questions should be patiently answered based on their own conditions, and they should be encouraged to obtain correct information through official authoritative channels to avoid "information panic" 20 .

Four infected patients (25%) in this study indicated that the relatively confined environment and instruments in the isolation area caused feelings of loneliness and helplessness. The isolation treatment measures separated the patients from the outside world, as they left their familiar working and living environments to enter a state of isolation, confinement and monotony. The patients' original lifestyles were completely disrupted, and certain financial losses were incurred. The unfamiliar environment and medical equipment increased the patients' fear and loneliness while also hindering the discharge of their negative emotions. This is consistent with the findings of Wang et al. 20 and Shaban et al. 21 . A retrospective study 22 found that isolation may cause unexpected mental trauma for patients and may even lead to self-injurious behaviors such as suicide. These effects persisted 3 years after desegregation. Psychological disorders can lead to low immunity and reduced motivation for treatment, thus negatively affecting disease recovery 23 . Currently, the treatment and care of patients in isolation wards are mainly focused on the disease itself, with relatively little attention given to the physical and psychological effects of isolation. Improving the treatment environment in isolation areas, providing as much stimulation as possible during the normal routine of work and rest, establishing a good lifestyle, and diversifying hospital activities are of great significance in relieving emotional tension, breaking psychological barriers, and promoting disease recovery 24 . Studies have shown that having sufficient sunlight is particularly effective for psychological relief 25 . Isolation areas should be set up to face south, and lighting measures should be strengthened. Public corridors can be set up in the isolation area so that infected patients can stagger their activities appropriately. Healthcare workers who are fully "armed" can paste their names on their protective clothing to improve communication between doctors and patients and reduce patients' sense of isolation. There are also studies 26 suggesting the use of the Rosenthal effect, that is, using praise, trust and expectation, and other psychological hints to help patients regain confidence and obtain positive motivation to change their own behaviors. By communicating with patients to understand their psychological needs, sources of negative emotions and specific factors affecting their emotions, healthcare professionals, in collaboration with teams from various disciplines, can encourage infected patients to cope positively and provide social support and psychological guidance to improve their quality of life 27 . The patients in this study were often in a state of confusion and worry before discharge and were also often unable to adjust to a good rhythm of life within a short period after discharge. Healthcare professionals can help patients develop a postdischarge transition plan during inpatient isolation so that they can quickly return to their original lives. At the same time, a scale of social reintegration behavior of infected patients with infectious diseases that is suitable for our country should be developed to prospectively investigate the current status of social reintegration of infected patients and to understand the changes in social reintegration behaviors in different periods to take corresponding measures to help such people adapt to their situations as soon as possible.

As a contagious disease, COVID-19 can lead to fear among the population as well as stigma and discrimination against specific groups of people 28 , and patients develop a sense of shame about their illness as a result. The results of this study show that patients often want to keep their experience of the disease confidential. The vast majority of infected patients in this study chose to conceal their illness from their family members. Due to the existence of a sense of shame, patients not only kept their disease experience secret but also often consciously reduced their mobility after discharge from the hospital to avoid infecting others. Patients may actively distance themselves from their friends and relatives, resulting in the loss of an important source of social support and a sense of isolation 29 . There were also patients who did not actively conceal their condition, but friends and colleagues of the infected patients intentionally chose to distance themselves from the infected patients out of fear and rejection after learning of their condition. Six patients (37.5%) in this study were thus forced to leave their original places of residence or work, causing them to develop more negative emotions. On the other hand, the infected patients who indicated that their colleagues and friends treated them no differently than before reported that they resumed normal life more quickly after returning to society. Yuan et al. 19 showed that the social support system of infected patients is an important factor in their posttraumatic growth. Social support based on kinship is the main way for most Chinese people to obtain social support. If this basic relationship is damaged, it prevents infected patients from obtaining the understanding and support of others, which can have a great impact on their physical and mental health 30 . The establishment of a good social support system will enhance psychological health; in contrast, the accumulation of negative emotions will lead to a variety of psychological problems 31 . Healthcare workers in the diagnosis and treatment of COVID-19 patients not only need to give the necessary treatment measures but also need to comprehensively assess the degree of understanding of the disease and social support system of infected patients. Healthcare workers should encourage infected patients to inform their families of their illnesses through daily communication, collaborate with their families to provide relevant psychological care, and improve the level of posttraumatic growth of patients 32 . In addition, the limitations of the public's knowledge of the disease will increase the individual's self-psychological burden, which will deepen the self-perception and experience of public stigma, resulting in the internalization of stigma 33 . Therefore, it is necessary to strengthen the information dissemination of infectious diseases, set up relevant policies for social groups such as communities and companies to avoid the public's rough treatment of infected patients returning to society, to protect the normal work and lives of infected patients and to reduce economic losses. This study shows that the policy benefits given by the government make infected patients believe in the national epidemic prevention policy and thus have confidence in the diagnosis and treatment of the disease. Therefore, state policy supports the reintegration of COVID-19 patients into society through macrocontrol.

Six months after returning to the community, some of the patients in this study still had sequelae of COVID-19, such as malaise, insomnia, chest tightness, and loss of smell. A recent study published in The Lancet 34 also confirmed this phenomenon. Similar studies have shown that the acute phase of COVID-19 and subsequent health damage involves multiple systems, such as the respiratory, neurological, and cardiovascular systems 18 . Given that infected patients at this stage need professional guidance to avoid delaying their illness, we call for greater collaboration among scholars from different countries to share experiences in the treatment of the disease to improve the physical and mental health of the population in the face of the postinfection syndrome caused by the global pandemic of COVID-19 patients.

This study found that there is a lack of clarity in the division of labor between departments and duplication of investigations by various departments in the process of epidemiological investigation.. It is recommended that the relevant departments should strengthen the integration and sharing of information by using big data and increase training in epidemiological investigation to improve efficiency 26 . Knowing the benefits of epidemiological investigation and personal information protection can reduce the uneasiness of infected patients, it is recommended that the media increase the scientific knowledge of epidemiological investigations and, at the same time, hide patients’ last names in the publication of epidemiological investigation information to protect the privacy of infected patients, and prohibit malicious human searches and other behaviors.

Limitations

While the study has its merits, it also has its limitations. First, this study interviewed COVID-19 patients only in Ningbo and did not include patients from multiple regions and centers. Second, this study was conducted during the control phase of the epidemic in China, and except for filling out the SDS scale, which was face-to-face, both interviews were conducted over the phone, and preventing the use of visual aids.

Conclusions

The objective of this study was to explore the perceptions and comprehension of patients infected with COVID-19 during the Chinese new coronavirus epidemic. COVID-19 patients encounter numerous psychological challenges while simultaneously experiencing physical discomfort, isolation, a sense of shame, and uncertainty regarding recovery. While some patients eventually adapt to their circumstances, not all are able to do so. Therefore, it is crucial for healthcare providers and families to provide support in order to facilitate patient adjustment to normal life. Interventions should be tailored according to the specific needs of patients at different stages, informing subsequent optimization of care and management strategies for infectious diseases.

Data availability

The datasets generated and analysed during the current study are not publicly available due privacy protection but are available from the corresponding author on reasonable request.

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This research was supported by Medical Scientific Research Foundation of Zhejiang Province under Grant No. 2023KY1091; Zhejiang Provincial Natural Science Foundation of China under Grant No. LY22H160006.

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Liangyan Zhang organized interviews and collected the data. Liangyan Zhang and Chen Zhang analyzed the data and wrote the main manuscript text. All authors reviewed the manuscript.

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Zhang, L., Zhang, C., Li, K. et al. Longitudinal qualitative study on the psychological experiences of COVID-19 patients based on timing it right framework. Sci Rep 14 , 12409 (2024). https://doi.org/10.1038/s41598-024-63215-4

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10 Examples of Qualitative Research

1. in-depth interviews - one-on-one conversations to explore participants' thoughts and experiences., 2. focus groups - group discussions to gather diverse perspectives on a topic., 3. ethnographic studies - immersive observation to understand cultural practices and behaviors., 4. case studies - detailed examination of a single subject or group to uncover insights., 5. narrative analysis - studying personal stories to understand how people make sense of their experiences., 6. content analysis - analyzing text, images, or media to identify themes and patterns., 7. phenomenological research - exploring lived experiences to understand the essence of a phenomenon., 8. grounded theory - developing theories based on data collected from participants., 9. participatory action research - collaborating with participants to address community issues and create change., 10. discourse analysis - examining language use in communication to understand social and cultural contexts., more stories.

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Case Reports, Case Series
Editorial. Introduction. Case reports and case series or case study research are descriptive studies to present patients in their natural clinical setting. Case reports, which generally consist of three or fewer patients, are prepared to illustrate features in the practice of medicine and potentially create new research questions that may contribute to the acquisition of additional knowledge ...
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Case Studies/ Case Report/ Case Series
A case study, also known as a case report, is an in depth or intensive study of a single individual or specific group, while a case series is a grouping of similar case studies / case reports together. A case study / case report can be used in the following instances: where there is atypical or abnormal behaviour or development.
Case Study Methodology of Qualitative Research: Key Attributes and
A case study is one of the most commonly used methodologies of social research. This article attempts to look into the various dimensions of a case study research strategy, the different epistemological strands which determine the particular case study type and approach adopted in the field, discusses the factors which can enhance the effectiveness of a case study research, and the debate ...
Case series: Design, measures, and classic example
Case series is one of the most common studies performed in medical research and provides the foundation for many more rigorous research studies. The primary outcome of a case series is a testable hypothesis that may be further evaluated with a more rigorous study design. Benefits of case series include their relative inexpensive nature, smaller ...
Case series: design, measures, and classic example
Case series are observational reports without analysis. They are uncontrolled, anecdotal reports of uncommon or novel cases in individuals or groups of patients. ... 2020 by Zhan et al. from the China Novel Coronavirus Investigating and Research Team. 4 This article shone a spotlight on COVID-19, warned the medical community of its existence ...
Methodology: How to develop a case report or case series report
Abstract. Case reports or case series reports are descriptive studies, although their results are not used to make inferences, they are the first line of evidence for new therapies and a preamble to research with a stronger methodological design. This type of study is essential to describe new or unusual diseases, adverse events, or ...
Methodological quality of case series studies: an introduction to the
Results: The JBI critical appraisal tool for case series studies includes 10 questions addressing the internal validity and risk of bias of case series designs, particularly confounding, selection, and information bias, in addition to the importance of clear reporting. Conclusion: In certain situations, case series designs may represent the ...
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Series. Oxford Library of Psychology. Collection: ... a program, or a policy. Below I identify different ways in which case study is used before focusing on qualitative case study research in particular. However, first I wish to indicate how I came to advocate and practice this form of research. Origins, context, and opportunity often shape the ...
Case Study Methods and Examples
The purpose of case study research is twofold: (1) to provide descriptive information and (2) to suggest theoretical relevance. Rich description enables an in-depth or sharpened understanding of the case. It is unique given one characteristic: case studies draw from more than one data source. Case studies are inherently multimodal or mixed ...
JBI Critical Appraisal Tools
Methodological quality of case series studies: an introduction to the JBI critical appraisal tool ... Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evid Based Healthc. 2015;13(3):179-187.
Case series research: a case for qualitative method in assembling
This article acknowledges the value of qualitative method used in this manner and argues further that there is a particular instance where this method can do more, in that it can stand alone in the gathering of evidence. This instance comes under the banner of case series research.
UCSF Guides: Qualitative Research Guide: Case Studies
According to the book Understanding Case Study Research, case studies are "small scale research with meaning" that generally involve the following: The study of a particular case, or a number of cases. That the case will be complex and bounded. That it will be studied in its context. That the analysis undertaken will seek to be holistic.
The clinical case report: a review of its merits and limitations
Throughout history the clinical case report and case report series have been integral components of medical literature[].The case report genre held a strong position until it was sidelined in the second half of the 20 th century[2, 3].New methodologies for research articles paved the way for evidence-based medicine.
Case series: design, measures, and classic example
Handbook for Designing and Conducting Clinical and Translational Research. 2023, Pages 207-209. Chapter 34 - Case ... They are uncontrolled, anecdotal reports of uncommon or novel cases in individuals or groups of patients. Although case series fall low on the hierarchy ... Qualitative methods and mixed methods. Translational Surgery, 2023, pp ...
Case series research: A case for qualitative method in assembling
Full-text available. Jan 2010. Anne H. Watson. Max Ito. Roger O Smith. Lori Andersen. Request PDF | Case series research: A case for qualitative method in assembling evidence | Evidence-based ...
PDF for use in JBI Systematic Reviews Checklist for Case Series
JBI guidance for conducting reviews of effectiveness research, qualitative research, prevalence/incidence, etiology/risk, economic evaluations, text/opinion, diagnostic test accuracy, ... case series that states we included all patients (24) with osteosarcoma who presented to our clinic
Methodological quality and synthesis of case series and case reports
Evaluating methodological quality. Pierson7 provided an approach to evaluate the validity of a case report based on five components: documentation, uniqueness, objectivity, interpretation and educational value, resulting in a score with a maximum of 10 (a score above 5 was suggested indicate a valid case report). This approach, however, was rarely used in subsequent work and seems to conflate ...
Case series
A case series (also known as a clinical series) is a type of medical research study that tracks subjects with a known exposure, such as patients who have received a similar treatment, [1] or examines their medical records for exposure and outcome. Case series may be consecutive [2] or non-consecutive, [3] depending on whether all cases ...
Longitudinal qualitative study on the psychological ...
This research adopted a phenomenological research approach to develop a longitudinal qualitative study. A purposive sampling method was used to select participants and 37 patients were recruited.
10 Examples of Qualitative Research
10 Examples of Qualitative Research. 1. In-depth Interviews - One-on-one conversations to explore participants' thoughts and experiences. 2. Focus Groups - Group discussions to gather diverse perspectives on a topic. 3. Ethnographic Studies - Immersive observation to understand cultural practices and behaviors. Explore 10 examples of ...
Qualitative Research
Qualitative research is a complex and cluttered area of scholarship. This is not because there is an inherent confusion about it. Rather, it is because 'qualitative' research is a cover-all term for a wide range of research strategies, paradigms, parent disciplines, sources of data, and methods of analysis for them.

Case series: an essential study design to build knowledge and pose hypotheses for rare and new diseases

Cecilia Maria Patino

Juliana Carvalho Ferreira

PRACTICAL SCENARIO

CONCEPTS AND APPLICATION

METHODOLOGY AND QUALITY OF CASE SERIES STUDIES

Quantitative study designs: Case Studies/ Case Report/ Case Series

Case Study / Case Report / Case Series

The stages of a Case Study / Case Report / Case Series

Which clinical questions does Case Study / Case Report / Case Series best answer?

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The clinical case report: a review of its merits and limitations

Conclusions

New observations

Generating hypotheses

Researching rare disorders

Solving ethical constraints

In-depth narrative case studies

Educational value

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Flexible structure

Clinical practice can be changed

Exercise for novice researchers

Communication between the clinical and academic fields

Entertainment

Studying the history of medicine

No epidemiological quantities

Causal inference not possible

Generalization not possible

Overinterpretation

Emphasis on the rare

Confidentiality

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Narrative synthesis

Quantitative synthesis

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Theme 1: multiple emotions intertwined at the time of diagnosis

Theme 2: multiple pressures during the hospitalization period

Theme 3: growth of positive illness experience during the isolation and observation period

Theme 4: adjustment after returning to society

Theme 5: adaptation to social life

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