Оформление отчета о клиническом случае на основе международных рекомендаций

Ежегодно в мировой медицинской литературе публикуются десятки тысяч статей, посвященных описанию клинических наблюдений или серии случаев. Однако отсутствие единых требований подготовки публикаций, разные правила для авторов в медицинских журналах могут приводить к неполному представлению медицинской информации, снижению прозрачности отчетности и  затруднять критическую оценку представленных наблюдений.

Цель обзора: анализ требований основных международных руководств, регламентирующих подготовку клинических случаев в медицинских научных журналах.

Материалы и  методы. Проведен структурированный поиск статей, представленных на сайте EQUATOR и в PubMed, посвященных рекомендациям по представлению клинических случаев.

Результаты. Проанализированы актуальные рекомендации по отчетности о клинических случаях в  клинической медицине (CARE), хирургии (SCARE) и радиологии (CARE-radiology). Рассмотрены структура и содержание контрольных перечней, особенности оформления основных разделов публикации, требования к документированию медицинских данных. Представлены примеры обработки изображений пациентов и методы достижения анонимности, продемонстрирована возможность графической визуализации течения заболевания с  использованием хронологической шкалы.

Заключение. Таким образом, следование требованиям CARE и другим производным рекомендациям будет способствовать стандартизации подготовки отчетов о  клинических наблюдениях, улучшению качества описания клинических случаев, повышению полноты и  прозрачности публикации, их воспроизводимости. Представленный обзор может служить практическим руководством для авторов, рецензентов и редакторов медицинских журналов при подготовке, экспертной оценке и  публикации клинических случаев.

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