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Welcome to A & A Case Reports

Saidman, Lawrence J. MD

doi: 10.1097/ACC.0b013e31829c6877
Editorial: Editorial

From the Department of Anesthesiology, Stanford University, Stanford, California.

Accepted for publication May 16, 2013.

Funding: None.

The author declares no conflicts of interest.

Address correspondence to Lawrence J. Saidman, MD, Department of Anesthesiology, Stanford University, Stanford, CA 94305. Address e-mail to

I am pleased to welcome readers to the first issue of A & A Case Reports, our new online journal publishing Case Reports, related Editorial Commentary, and Correspondence. Anesthesia & Analgesia1 and Anesthesiology2 recently announced that they were suspending publication of Case Reports. One reason is that Case Reports typically reduce the Impact Factor of a journal because they are rarely cited. Regardless of the merits of Impact Factor as a metric of journal worth, journals and their editors necessarily consider Impact Factor in strategic planning.

At the same time, Case Reports are appreciated by readers for describing “real life” management of difficult or unusual cases not often encountered by practitioners. In a recent issue of Anesthesia & Analgesia, Steven Shafer1 identified many Case Reports whose publication launched productive careers dedicated to solving the puzzle posed by an unusual observation in a single patient.

I know this from personal experience. While attempting to quantify the minimum alveolar concentration of halothane,3 a patient anesthetized with halothane and receiving a succinylcholine infusion became hyperthermic (38.5 C), hypercarbic, and acidotic (combined metabolic and respiratory). Serendipitously, an early version of the blood gas analyzer invented by Severinghaus and Bradley4 was available, enabling the metabolic derangement to be rapidly quantified and treated. Over the next several decades, others created a diagnostic test (muscle biopsy calcium contracture test),5 identified dantrolene as an effective treatment,6 and eventually identified the genetic lesion (ryanodine receptor).7

Another striking example was the report by Crandell et al.8 describing a series of patients developing renal failure following methoxyflurane anesthesia. While initially somewhat controversial,9 this report led to a series of studies characterizing the nature of the renal injury (renal tubular),10 the precipitating cause (serum fluoride concentration >50 ppm),11 an animal model mimicking the human injury (Fisher 344 rats),12 and the recognition that the duration and depth of anesthesia and the extreme lipid solubility set the stage for the development of this problem. Ultimately, this series of reports representing the best in translational science resulted in the disappearance of methoxyflurane as a clinically useful anesthetic in humans.

Few Case Reports will be as dramatic as the first report characterizing the metabolic lesion of malignant hyperthermia or Crandell et al.’s case series8 demonstrating renal toxicity following methoxyflurane. However, our objective is to publish Case Reports that are educational and relatively unusual. Case Reports do not however have to be the first example of what is being reported. Indeed, important observations bear repeating! However, they must be observations that will help anesthesiologists with the management of unusual patients or clinical situations.

In the 4 months since announcing the creation of A & A Case Reports, our acceptance rate for Case Reports has doubled to slightly greater than 10% of submitted Case Reports. The bar to acceptance remains high, which is as it should be. Readers don’t have time for Case Reports that fail to teach something interesting.

A & A Case Reports will publish accepted articles online rapidly and on a continuous schedule, with new articles posted as soon they are ready. In addition, easily digestible issues of A & A Case Reports, compiling articles from the Web site, will be available on the iPad, via the widely accessed Anesthesia & Analgesia app. The only downside to authors publishing in A & A Case Reports is the delay in MEDLINE–PubMed indexing, which will not occur until 2014.

Management strategies described in our Case Reports will not be universally agreed upon. Of course, that is how clinical practice evolves. Evidence-based medicine requires lengthy systematic study of a clinical problem. However, the germ of the solution often begins with a Case Report. The case report examples in Shafer’s editorial1 all demonstrated evolution from an interesting observation to careful assessment characterizing the mechanism, and finally to treatment of the condition or prevention of the cause. Disagreement will occur, which is why I expect an active Correspondence section regarding alternative diagnoses and treatments to those described in the Case Report. Occasionally a Case Report needs to be placed in clinical context, particularly when an innovative solution is described. These will be discussed in invited “Editorial Commentary,” appended to the Case Report.

I hope to receive comments, and, yes, complaints, as we launch A & A Case Reports. It is only through an active dialog with you, our reader, that we can learn from this experiment and continually improve our new journal. Please read the journal. Please share your thoughts. Please participate in active discussions about cases that interest you. Please be an active participant as a reader, reviewer, Case Report author, and correspondent, to ensure the success of A & A Case Reports.

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1. Shafer SL. Anesthesia & Analgesia Case Reports. Anesth Analg. 2013;116:513–4
2. Eisenach JC. Case reports are leaving Anesthesiology, but not the specialty. Anesthesiology. 2013;118:479–80
3. Saidman LJ, Havard ES, Eger EI 2nd. Hyperthermia during anesthesia. JAMA. 1964;190:1029–32
4. Severinghaus JW, Bradley AF. Electrodes for blood pO2 and pCO2 determination. J Appl Physiol. 1958;13:515–20
5. Nelson TE, Bedell DM, Jones EW. Porcine malignant hyperthermia: effects of temperature and extracellular calcium concentration on halothane-induced contracture of susceptible skeletal muscle. Anesthesiology. 1975;42:301–6
6. Harrison GG. Control of the malignant hyperpyrexic syndrome in MHS swine by dantrolene sodium. Br J Anaesth. 1975;47:62–5
7. Fairhurst AS, Hamamoto V, Macri J. Modification of ryanodine toxicity by dantrolene and halothane in a model of malignant hyperthermia. Anesthesiology. 1980;53:199–204
8. Crandell WB, Pappas SG, Macdonald A. Nephrotoxicity associated with methoxyflurane anesthesia. Anesthesiology. 1966;27:591–607
9. Urgena RB, Gergis SD. Nephrotoxicity from methoxyflurane anaesthesia: a 6-year retrospective study. Br J Anaesth. 1973;45:358–62
10. Mazze RI. Methoxyflurane revisited: tale of an anesthetic from cradle to grave. Anesthesiology. 2006;105:843–6
11. Plummer JL, Hall PD, Jenner MA, Ilsley AH, Cousins MJ. Hepatic and renal effects of prolonged exposure of rats to 50 p.p.m. methoxyflurane. Acta Pharmacol Toxicol (Copenh). 1985;57:176–83
12. Bell LE, Hitt BA, Mazze RI. The influence of age on the distribution, metabolism and excretion of methoxyflurane in Fischer 344 rats: a possible relationship to nephrotoxicity. J Pharmacol Exp Ther. 1975;195:34–40
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