Case Report Writing

Good afternoon and welcome to today's health professions education series session i'd like to introduce our speaker dr douglas greiter who will be facilitating today's session on case report writing dr greiter is vice chair and assistant professor for the department of basic science education at virginia tech curling school of medicine the topic of case report writing has been popping up a lot recently so we're excited to learn from dr greiter about the essential components and how to guide learners and peers through the process of developing case reports thank you so much again for leading this session today dr greiter and please feel free free to take things away whenever you're ready okay well um make sure can everybody hear me all right we're good yeah so i'm doug greiter and i'm going to basically tell a story about how i started case report writing with medical students residents and fellows here in our environment at curling clinic and virginia tech korean school medicine and along the way if you guys have any questions please feel free to interrupt i'll take them in the middle or at the end the other thing is i only have uh about eight critical slides to go over so i'll be doing a lot of talking so don't expect me to go through a lot of slides so i i began case report writing for two reasons one is we had a dermatology department with a durham residency and it ended up that it was just marianna phillips and i in as faculty in the durham residency and one of the requirements for um a residency is academics including you know writing papers and i thought to myself well this is something i can do marianna's going to take over and she's done a fabulous job of bringing the dermatology residency along and she's actually got it to now where we're going to have two residents a year so we're growing we have more faculty and it's and there's good research going but the part the part i could do was helping the residents that we did have with some some academics and the other reason i started writing case reports is because i was part of the gastroenterology fellowship and some of the gi fellows wanted to do case reports and they would come to me with interesting cases and want to write them up and take them to meetings or they want they wanted to get something published so that when they applied for some some further education they would have something they could rely on and then along the way um a lot of medical students who either rotated in or heard about the process of writing case reports wanted to get involved now and it's it's common for a medical student to come and approach me even without doing a rotation about doing a case report and something they're interested in in an area in which they would like to explore or apply to maybe in the in the future so that's how i got started i have nothing to declare and no relevant uh conflicts of interest and hear the objectives you can you can read them but basically it's about it's about teamwork and being a part of your community so where to start so i gave you the story a little bit how i got started and of course there's a lot of stories to tell with each student or resident or fellow but i had to think back to my own my own residency and um i was a pathology resident obviously because i'm a pathologist and one of my first autopsies um was a young man who who died doing pt so i was in the air force i was at wolford hall medical center in san antonio texas and that that residency is in a big teaching hospital was about a thousand beds at the time uh very complex cases there and across the street um where where airmen basics came in so there was a 17 year old young man who was doing his pt and he was running around the track and all of a sudden he had a heart attack and he collapsed and died and unfortunately you know they rushed him to the er they they couldn't do anything about it and he went to autopsy and i was up for the case so we did this autopsy and what i learned was that he had huge dilated coronary arteries that were totally clotted off he had he had um thrumble emboli he had embolized them or uh they he you know so he and then then we cut the heart and we looked and he had a remote a myocardial infarction as well as the recent myocardial infarction and so the the er staff who was a young captain i was a young captain too but he was a young captain but he was staff wanted to to write it up because he had found um in trying to figure out what was going on and working with me you know we had to go back to the medical records we actually had to go back and talk to the young man's mother and we found out he had kawasaki's disease um before the age of five so he had lymphadenopathy he had a fever he had um um swelling around his lips he had a lot of classic features of that but nobody nobody had thought that maybe they should follow and uh follow him and worry about maybe having heart trouble and kawasaki's disease is known to have give heart people heart problems with dilated coronary arteries so we decided to do a case report and put it in the let me get it we put it in the american uh journal of emergency medicine and in july of 1993 and it took several months to write it up and and get it in so i was thought i thought i thought back about that experience about digging into the patient's history and record involving unfortunately the parents at this time and you know what it meant for my learning in terms of you know why why a young person would have heart trouble and i took that experience and this the success in that experience and thought about how we could do that um here with what i was doing and so that brings us to the point of where do you start when you want to do a case report so you have to have something that's interesting interesting in terms of how the patient presents you have to have an interesting idea you have to have something that would somebody would want to be involved with and then you have to have an interested student a medical student a resident or fellow who wants to pursue it because as busy attendings we probably don't have time to do a lot of research on everything that's interesting that comes across our desk and i'm sure that's true for most of your clinicians but you know pathology here at curling clinic um most things that are interesting eventually flow through pathology if there's a piece of tissue or blood fill made of it so we we have lots of interesting cases it's it's a wealth of material um so it's nice when you have a student a resident or fellow who thinks something's really neat and they want to dive down and learn more about it so you then you have to think about the angle so something could be well characterized and well described and it still might have teaching value because it's a unique case or there's something really unique about it and the way you might know that is to do a quick literature search so anything that i find interesting where there might be a student resident or fellow who think it's interesting too i probably do a super click literature research myself um but i don't do a full exhaustive literature search i leave that for the the mentee or the student reserve fellow so that brings to another point i want to make and that is that um mentees take time so if you're going to get involved with case report writing in an academic center with other colleagues that cross disciplines and with students um you know if they're gonna put time into it and and do the literature search and they're going to think about what they need to review in the chart and go back in history for example the case i told you about way back when i was a resident you know the kid was 17 years old and we had to go all the way back to records before he was five we had to talk to the parents um [Music] so it can take a lot of time and then if it's something that involves sharing a material with uva or lewisgale or whatever you you know you have to pick up the phone or do other things and then you have to decide um how many people to be involved in the endeavor i i think you need to decide that up front because you don't want any hurt feelings and i know from experience that if you don't um determine how many people are going to be involved and the the uh order of of the number of authors it can it can get messy and i've seen this experience i had this experience in my own time here so i think that's that's really that's really important so so where to start i'm going to give you um an example of a case at the end um to illustrate all this so what's in the big picture what is in this for everybody well one it's fun it's fun to work with medical students residents or fellows and something interesting that's not necessarily a big research project that most of us can do who are in medicine um and can help somebody it can help them produce something that will when they apply to something or just help them learn something in a in a deep way that they wouldn't otherwise if they didn't pursue something at a level where they need to compare pathology or compare radiology or compare clinical presentation with other things and it gives them therefore a peg on which to base all their learning it's just one more thing to tie everything together as they grow so it's fun the other thing is it's about relationships relationships uh with with the people you're mentoring and relationships with other colleagues and relationships are really really important to me and i think to most of us and i know that the mentees really appreciate those of us who take time to help them grow and it's one way to do that without having a big research project and then of course as medical students know they're going from a graded step one to a pass fail step one those relationships and possibly producing a paper um even though it's a case report shows that they can get something done so that they can tackle something and i think that that will um really help them um [Music] so what are the next steps so you have the relationship you have a goal you think about the angle so then you have to decide the venue there are a lot of different venues so in my experience so i'm a skin pathologist and a gi and hepatic pathologist so i look at the number of journals that are out there and um in the durham world there is case reports because of something's exceptional value and clinical path correlation so you take something that's clinically presented and you look at the pathology and you ask the question to an audience what's the answer and then you follow up with the answer and you you go over the differential diagnosis both clinically and pathologically and tie the case together um you could do a letter to the editor sometimes i've done a letter to the editor with somebody and the most recent one was a case of kaposi sarcoma in the mouth and the editor decided that it needed to be an exceptional case report so sometimes it gets changed uh you can do a clinton clinical image so if you have an exceptionally good case it doesn't have to be um it doesn't have to be something that's new it can be something that's classic you can take a clinical image and there's journals including the new england journal of medicine that have a clinical image of the of the issue and it's just a short one page with maybe three references describing what it is we've done that before for something as simple as a skin rash it can be just a teaching case some of some of these journals they want something that's just strictly something you're going to teach so you need to if it's a case report you need to think about the venue and that will determine how you're going to put it together it will determine how many references you need and also determine how many people can be authors for example the new england journal of medicine clinic image page only allows two authors so if you have a mentee it's just the mentee and the attending some clinical pathologic correlation um venues only allow three authors so you have to you have to think about that most of the letters the editor that i've been involved with it doesn't doesn't matter the number of authors same with exceptional case reports doesn't um matter the number of authors so after you decide what you're going to cover and how you might go about it and what the venue is they based on that the mentee should do an extensive literature search to determine what is what is relevant to the case and what isn't and then the mentee um or mentees some sometimes you know i have a medical student a resident fellow all three working together but but they they make a draft for um the uh the attendings to review and they should they should do it um on their own and do it to the best of their ability and and with the guidelines depending on the journal they they chose and the venue of that journal they should give it to you in a form you you can um you can um you know give your suggestions to them and you have to realize and anytime you have a mentee and you have a process everybody has a different ability and different background so i've actually had medical students um write a case report where i only have to change or make suggestions to one or two things and then i have others where i have to do an extensive editorial um suggests suggestions to make it so we get to where it would be um probably accepted or has a chance of getting accepted for publication and having said that i personally have learned by making mistakes so i told you how i got started i got started because i was in the durham residency and i was doing the the gi fellows teaching and the medical students come around and i hadn't really done very much after my training in my residency so and i had a 24-year air force career and i didn't do very much case report writing so i've only been doing this for about five years so when i first started um i made a lot of mistakes so what i'm telling you is stuff i've learned by by uh just doing it and sometimes when you just do it that that's how you learn so what i've learned is that when when a mentee gives me something you know i probably made the same mistake or i need to learn to write and so it's it's good to think about how to do that as a team and to build the the best product you can but but do it in a way of of helping each other grow so you know one of the things that i did is or i still do is i take a lot of um i take a lot of pictures of the pathology for these case reports and i do it myself instead of having um the medical students residents or fellows do it because it's very hard to take images and i'm sharing that with you because um i actually had a couple case reports rejected because of the the images i took and they they really weren't they really weren't good enough and you know and that's okay because i came in one sunday here at riverside one where i'm where my office is located and sat down for three or four hours and learned how to take pictures of high quality and i i wouldn't i wouldn't have done that if i hadn't got feedback that my images weren't very good and i look back on some of uh the case reports that i got it that we had accepted and there's one particular case report uh on a particular procedure that i had done with dr paul yayton and uh somebody at wake forest and i think one of the one of the gi fellows at the time was involved and i look at the image today and it was a very important case report to communicate something as it's been referred to many times in other publications but i look at my images and i sure wish i sure wish i had taken them um you know with what i know today and so that the what uh what i'm trying to get at is that a mentor's guidance in the process of selecting a journal then the venue the writing um putting the radiology together in the pathology it's this process and i've experienced the process myself and in making mistakes i've learned how to do it better um and quicker and now it's not so hard to do it um which is which is a good thing so once you get a product to look at um you need to select the clinical images any radiology or any pathology images that would go into it and you have to look at you know hopefully they took clinical photos they don't always and hopefully if it's a pertinent you can get a radiologic image and hopefully uh one of the pathologists would be willing to take if it has to do with pathology and a photo micrograph of a blood smear or the tissue or whatever and i've already talked about the journal's criteria and then you look at the references so you have to make sure the references are in the proper format sometimes that can be tricky especially for medical students just starting out you know there's each journal you have to look at what reference what the format is they want the references so actually kick something back if the reference format isn't correct and sometimes that's hard for nutri trainees to understand but um they do do that and then when you when you get it together and you submit it you you have to wait for feedback and reviewers comments and that can be very short it can be a day a couple days or weeks or even months so it depends upon where you submit it typically if you get feedback right away it means it's probably rejected now let's say you get it rejected that's not the end of the world that's not the end of the world because they usually give you feedback and you can look at the feedback they give you and use that to produce a better product to uh submit somewhere else and that that's happened to me uh several times and sometimes i've i've submitted it to a journal that's a mid-tier journal i get the feedback and the mentee and i or whoever's involved we we rework it based on the feedback and we we submitted to a journal that has a higher impact factor and we've had it accepted i've had that happen many times or let's say we submit it to a journal with a high impact factor for what it is and we get feedback and then we redo it and we submit it to some other journal and it and it gets accepted there and and that's a good thing um sometimes they get accepted right away uh and there's minimal changes requested and that's great and but that's not that's not the usual usually somebody has something they want you to look at a little differently or add something and that's common and it's good and it helps you grow and it helps you you learn helps me learn not just the process but about disease and how it affects uh patients so the next steps really depend on on feedback and you know what you do with that information so i've been really working on case reports in our community for about five years and um you know now i probably when i work with with the students and the residents i probably get 65 75 percent uh of the things we work on accepted and i think that's i think that's quite high and it's a it's a lot of fun but it's being willing to take the criticism and reformat and and do things a little differently so let's talk about a case how it practically works so um this is a uh this is a clinical photo from uh thigh of a young lady who came into the er so this young lady for four weeks have been complaining of nausea vomiting headache she had a fever of 38 degrees um she was anemic and she has this rash now normally when i look at this rash um i think of urticaria so the thing about this rash is it was greater than 24 hours in duration uh usually were to carry us less than 24 hours and it was not migratory it didn't change so in questioning her she um says the rash began on her right forearm and then stretched spread to the other side of her upper extremities went on her back was was on her abdomen and eventually is on the thighs that you see now and um so a rash that's slightly raised like that that's erythematous that doesn't blanch and doesn't go away and is greater than 24 hours those of us in the dermatology community would think about an erdocarial rash uh that's a vasculitis and that's the reason it doesn't go away in 24 hours usually urticaria if it's true to carry it goes away in 24 hours so we were thinking about her symptoms and she was seen by one of our dermatologists and the circles you see are where the biopsies were done so in this case putting a plug in for proper procedure they should be they should both be punch biopsies now one of them was a shaved biopsy and the shea biopsy was submitted for direct immunofluorescence i'll get back that a little later in the talk and the other was submitted for um histopathology but thinking about the rash and her symptoms uh what she complained about the the part that i didn't tell you is she was um she was covered 19 positive so she came into the er with this rash that she was worried about and not feeling well and so her reverse trans transcript as pcr for stars kobe 2 was positive she actually thought this rash was due to an allergy she thought maybe it was because she changed her soap or you know a mom picked nude laundry detergent or whatever so she tried all kinds of things and it wasn't going away and what she tried didn't work and so the dermatologist and the team thought well this is probably multi-system inflammatory syndrome in a child um which is not that common but does happen in kids so i went and looked at what the cdc recommends and we're going to go over the cdc criteria in a minute for that that diagnosis but they recommend to give you a sense of how common this is they they recommend um that this be reported but it's not mandatory it's voluntary reporting if somebody has multi-system inflammatory disease syndrome of childhood the same for multi-system inflammatory syndrome of adults so it's a voluntary report so in the voluntary reporting system from from february 2020 to january of 2022 uh there have been right around six thousand cases reported so it's about zero point three percent to zero point six percent of kids who have a coveted infection would get this so it's not it's not very common now when you make that diagnosis um it has certain implications but let's talk about the criteria first so multi-system inflammatory syndrome with children you want them to be under underage less than 21. so if they're older than 21 it's multi-system inflammatory syndrome of adults which is slightly different it requires hospitalization so she came this young lady who's 16 came into the er and she was admitted uh they have to have a fever greater than 38 degrees celsius she did and they have to have elevated inflammatory markers meaning crp you know um any inflammatory marker ldh um any inflammatory marker and then involvement at least two organs so this person our patient had skin involvement um but it but it could be uh gastrointestinal could be neural neurologic with a headache could be uh hematologic with anemia thrombocytopenia could be gi because our patient had nausea vomiting neurological headache um problems which you would expect of course cardiac problems so multi-system inflammatory syndrome in children there's there's actually three different classes so class one always has cardiac problems and usually gi class two usually has respiratory problems include including ards or severe respiratory problems and class three usually has skin problems now all of them can have skin problems in fact the skin's involved in 75 of these uh these patients and then the rash can be described variably as morbidiform reticulated scarlet tender form or dicario ours is urticarial in appearance um and of course they have to have a positive uh uh covet 19 test so these are the six criteria that are mandatory and our patient had uh all of them she had elevated she had an elevated crp um she also had an elevated um uh fibrinogen she had an elevated d dimer she had an elevated um her compliment uh levels were normal and i'll i'll come um come back to that so this this um was worrisome and so they they thought about cardiac things because the worst possible thing that could happen to her is to get the dilated coronary arteries like for kawasaki's disease because um sars kobe 2 when it produces multi-system inflammatory syndrome can have a vasculitis that's similar to kawasaki's disease in that and similar to that young man that i described many years ago when i was a resident so this patient actually did get an electrocardiogram and a cardiac workup which was negative and troponin was negative so let's go back let's go back to the rash and let's look at a biopsy so probably um a lot of you need to be oriented i would too um so here's the epidermis up here there's a basilar layer and these are blood vessels right here and what i want to show you is there's a nuclear fragment there and there's a nuclear fragment there and there's a nucleus so that those are neutrophils that are breaking apart so we call that carorectic debris so this is um and there's an intact neutrophil right here this is an intact neutrophil so this is a blood vessel with a vasculitis so it's a acute neutrophilic vasculitis that's low grade because there's not a lot of it and some of it's over here and this is deeper in the dermis of this patient so what you see here is fibrin and eosinophils and neutrophils that's loose in the dermis and right below this is this blood vessel here with the same neutrophils and kerosene debris and here's a vessel right here that's full of fibrin [Music] so she does have urticarial vasculitis with a proven vasculitis on biopsy and so the concern for her heart um and other vessels being inflamed is real which goes back to um an angle so the dermatologist did a biopsy and submitted for a direct immunofluorescence the direct immunofluorescence we're looking for immunoglobulin deposition or complement deposition or fibrinogen around the blood vessels but uh this person did a shave biopsy so it didn't go deep the real the most the mostly the the vessels that were involved the most were in the mid dermis and deeper in this particular case so a shape biopsy didn't get it so thinking about the type of biopsy to do is really important so just because the dif was negative for immunoglobulins or fibrinogen or c3 or complement doesn't mean it's truly truly negative the other thing is her complement levels were normal i told you guys that earlier and um it's not uncommon for erdocardial vasculitis not to have deposition on diff if you have normal complement if she had a low complement which does happen in some cases or to carol vasculitis i would expect to find deposition of something in those vessels so she has two reasons not not to have a positive dif one is the type of biopsy that was done it was it was a shave not a punch and the other the other reason is is because she had a normal she had normal compliments it was not um it was not hypo compliment he made so what's the angle the angle is that people who have multi-system inflammatory syndrome both children adults in this case we're talking about adults they have rashes and this disease is new and the correlation between the histopathology and the clinical presentation is lacking in the literature so i knew that when i saw this case under my microscope i had erdocariovasculitis i had epic open i went into epic saw the rash i saw the positive uh a cova test i saw that she had more than one organ involved because she presented with nausea vomiting diarrhea headache and a fever i put it all together and then i looked in the literature and saw that oh people have described urticaria morbiliform rash garlic uniform rash etc but nobody had really done a biopsy and described the pathology so i knew that if we took that angle of describing the pathology it would probably get ex except accepted because it's a new it's a new it's a new entity that we're looking at so whenever you think about a case report if you think about an angle it can actually be something that helps all of us in medicine across across not just the united states but canada and the world and we can see what it is so this this patient probably needs to be followed to make sure that the vasculitis i saw in the deep dermis and subcutaneous tissue isn't involving her coronary artery she probably should be followed periodically by looking at that so that she won't end up like that young airman basic i had um who was 17 when i was a young resident who died from a heart attack because people didn't didn't follow up on kawasaki's disease and i know they follow up on kawasaki's disease today um but you know there's all these things we can learn so you know you could say well what's your next angle for um for somebody with um a coven 19 infection well we have lots of things to talk about here at corellian clinic so we actually have um i actually have a medical student who's a fourth year who's accepted into dermatology here at curling clinic and we have a patient who has a vaccine-related eruption of papules and plaques and it's um it's been recently well described and it's in the literature but what we're going to do is use it to show you a different venue we're going to use a clinical path correlation we're going to take the clinical photos that we have in the pathology and pose it as a question in a journal as a teaching case and and then answer it in a separate uh in a separate uh question section which is actually printed so the particular journal we're going to submit it to um submits the has has people look at the questions on on an online version and then they answer it in a printed version um and but there's there's a lot of different ways to um to do things and i think i think a medical student soon to be derm resident thinking about vaccine related rashes and uh the gamut of all the things that can occur is is a good thing and it's it's fun to be a part of that so i think i've been talking for 35 minutes and i haven't seen any questions but but that's my story my story is i started doing uh case reports to be a part of the community because a lot of the young people um who are medical students or residents and fellows wanted wanted help with putting things together and it was a way to dive deep into something and get a breath of understanding and to do it in a fun way and to build relationships so i probably went too fast but does anybody have any questions or anything they want to know and feel free to unmute and ask a question if you'd like there's a couple in the chat but i can hold those and if there is somebody that wants to go ahead and ask a question now and if you think of something as we continue our discussion feel free to chime in but um uh a question uh how how do we promote our learners students and residents to start looking at cases through the lens of this could be a case report um like you mentioned so identifying that angle yeah that's a great question i think sometimes they need to be guided because it's hard to know what is important and what isn't right because i remember when i was a resident well when i was a medical student my job was to look at all the information and then eventually i got to be a resident my job was to sort through the information and know what's important and then as attending you know what's important and try to build on what's important right so i think it's hard for learners to to know i actually think that's our job in this particular case um this this multi-system inflammatory syndrome and children rash i actually had a um i actually had a a medical student who was who is very interested and she she and i um we realized together that it was potentially important because i was looking under the microscope and i could have just said oh it's just erdocardial vasculitis next case i've seen this before which i have i have several cases of vertical vasculitis every year no big deal but this was different because um the dermatologist put pictures in epoch so i looked at the picture and then i read the clinical history so if i hadn't read the clinical history in epic and i'm a pathologist so i need to go to epic and look that and i need to put it together so i think at least medical students need to be guided when to realize something is important i think the gi fellows i work with and the durham residents particularly after they've been doing it for a year they they know when something's got some angle that's unusual um i'll give you i'll give you an example so another example that's a gi related uh i have a miracle cell carcinoma and a small bowel so merkel cell carcinomas are under con erner can cell carcinomas primary to the skin usually and it's like well it's in the small bowel must be metastatic well i don't know that it's metastatic but the person got a pet a pet scan and we can't find it anywhere else and they they had a skin exam they can't find it anywhere else but i took i took the merkle cell or the small cell carcinoma and i tested it for a a specific virus for merkel cell and it's positive um so when i present that at when i presented that to a gi fellow they knew right away that that would be something interesting and they want to take it they want to take it as an abstract to the next meeting of the american college of gastroenterology for example but so it depends upon where their learner is whether or not they're going to recognize it it's being unusual or have an angle that you could present great thank you um so someone answered this question in the chat but i wanted to give you the opportunity to to get your thoughts so what are the rules or procedures around using photos of actual patients informed can is informed consent required it depends upon the journal all journals require informed consent if you use identifiable anything on the body tattoo anything that's identifiable that can be traced to a person you have to have informed consent all journals require informed consent if you take a picture of the face even if you block the eyes they all do but um if you're doing a simple um you know challenge with answer most journals don't require informed consent um it's just it just it just depends upon the journal you know most paid journals um require informed consent no matter what you have to get the parent's consent no matter what um but there are some journals that require informed consent regardless if there's identifiable or non-identifiable so it just depends the journal i look up the required criteria i have the mentee look up their criteria and we follow them um you know have i ever had a patient turn me down yeah of course um but you know that's okay i've actually had them change their mind too um this this is a neat story it's it's fun it goes to show you what medicine's like so i had a case that we wrote up and um i had it accepted and i had the patient agree to let us publish it and they signed off on it because it involved the face then he went for a second opinion somewhere and that the person who had a second opinion disagreed with my diagnosis but i already had it accepted and peer reviewed and the person who wanted to change the diagnosis actually was a was an editor on this journal so i sent him all the paperwork and all the information i had and he actually changed his mind and back down and he had to go talk to the patient and say hey you know it really was worthy of publication because of course the patient gets in the middle of that and says hey you know what's going on here and i don't want it to happen and so you never know what's going to happen so you know in all that you build relationships right i have a good relationship with this clinician at this other institution but you you just never know what's going to happen awesome thanks for that um how do you get past some learners bias about just doing a case report just doing a case report um well you know yeah i got it um you know they have to want to do it so if it's just a case report i would say don't do it um but most the students i work with um when they actually start doing it and they find out what they're learning they love it so it's different than research right i know that this school really the the school we're associated with the virginia tech curling school of medicine and i'm in the department of basic science education and i do basic science research and i i work really hard and i believe in it this is something totally different right the purpose of a case report in my mind is to help somebody dig deep into something they wouldn't otherwise do look at a differential diagnosis clinical and pathology pathologically and put it together in a way that they can get it across the finish line for something that will help others and it will help them to show that they can complete something it isn't to do research but if somebody thought of it as just a case report i i don't want i don't want them on my team because i want them to be excited about what they're doing all right um another comment it seems as though it's a great opportunity for department collaboration um the case report i am writing up was initiated by pathology and it was a great experience is there a process or framework for interesting cases in an easy pathway for case reports uh well you know i said at the beginning that most the great cases come through pathology if there's a piece of tissue associated and so i have case i have things that could be written up as a case report every week because we have great pathology here you know we're curling clinics really the only game in town i know there's some there's some things going over at lewisgale they have great material too but we we have great material we have the appalachian area it's as good as anywhere i've been in the world right and i've lived all over the world and i've done consult only pathology before so um you know if you if you have a particular area and you want us to keep our eyes out you know it would be you know thought we pathologists are broken down into organ systems so we have breast pathology gym pathology we're broken into teams because we're academic and it's impossible to keep up with everything so if you have a particular area you're interested in you should ask the pathologist in that area of expertise to keep their eyes out for cases that might be interesting and i do that anyway even for stuff i'm not that interested in we're working on uh i'm always saying i'm always saving things for medical students in case somebody's interest like i'm not i'm not very good at orthopedic pathology but it's hard to get into orthopedic residency it's super hard and so i'm always if i come across something and i don't very often because that's not what i look at but if i come across something i actually set it aside thinking that someday somebody's going to want to apply to orthopedics and they might they might need something to help them stand out but i would recommend talking to a pathologist in the area of interest to say to to save or let you know when something interesting comes by yeah um and then there's a follow-up con uh comment to that that says um perhaps we can create like a repository of those cases and that the students are very excited about engaging in case report opportunities so maybe that's a good you know connection that they can make um uh to engage in case reports uh the last question i have is do you have any advice for preparing folks for reviewer feedback particularly those who are new to submitting to journals yeah have thick skin and don't take it personally i mean you know the the truth is uh when i first started i i got a lot of rejection but i took i personally took what i was given and ran with it and the students and the residents of the fellows i worked with we took it in stride and tried to make it better um but but you know the hardest i gave you the one that was hardest for me to take which is that you know some i didn't take very good micro photographs so that means through my microscope with the camera set up having the lighting just right in this net and i got it down now i could take really great photos publication quality but um you know sometimes reviewers are wrong i told you about the reviewer who who said i was wrong on something and i had to change it but um and and we've had review i've had you know this case here this erdocardial vasculitis case um i had one reviewer say they couldn't see the vasculitis and another reviewer say it was a case of great vasculitis so you know which is it i like i let the editor-in-chief make the the uh you know the call and of course he decided it was great vasculitis but you never know what a reviewer is going to say you have to you have to have thick skin and take it with a grain of salt but but realize if they say something and you and you use it and you change it and it gets accepted somewhere else because you took their advice it's a good thing are there any other questions for dr greiter i think we've learned a lot i think there's a lot of opportunity for collaboration and for potential cases that can be used for case reports it sounds like we have learners at different levels that are very excited to engage in case reports so i'm hopeful that some folks here can encourage them to to get involved with case report writing um so if there's no other questions i think we can be done a little early for today um but i'll give folks the opportunity to to chime in if there's anything else i want to ask one more question if you don't mind of course so i was engaged in a little dialogue on the side here via the chat but i see a lot of cvs come through where people list case reports in the section entitled peer-reviewed and it it leads me to wonder whether most case reports are in fact peer-reviewed would you say that they're peer-reviewed all of my case reports are peer-reviewed okay so then the how people perceive them as compared to a journal article may be different but but they are at least in the category in other words it's not incorrect in general to list them in the section of your cv where you list peer-reviewed things as long as you identify them as case reports yeah that's right okay oh david they could have a separate section um case reports like i do right or you can have the um journal articles listed as referenced articles um and i've seen some people listen as refereed articles um yeah you have the same thing with abstract sometimes they're peer reviewed sometimes they're not so you know it just depends but having them in different categories is good but yeah thank you that that's that's a helpful clarification anything else any other questions all right well thank you dr greiter we really appreciate your time um if i'm i'm going to say if if anyone has any further questions i'm sure that you're open to them reaching out individually via email so um uh if that's all for today we thank you guys for your time and um we will see you at an upcoming session thank you so much dr greiter have a wonderful day everyone.