9. Therapeutic Intervention

What to write

9a – Types of intervention (e.g., pharmacologic, surgical, preventive, self-care)

9b – Administration (e.g., dosage, strength, duration)

9c – Changes in intervention (with rationale)

Explanation

Therapeutic interventions are often the focus of case reports or they may provide key diagnostic information. In either case, we recommend reporting them in enough detail to facilitate replication. Complex or poorly defined interventions may benefit from use of the TIDieR guideline (a CONSORT extension) to enhance the accuracy, transparency, and reproducibility of an intervention¹.

A brief explanation of why the patient received a particular intervention (such as the target condition, the preexposure clinical course, etc.) should be provided in this section; however, we suggest reserving a more detailed rationale for the discussion section. The general format for reporting interventions is outlined below (see Table 1). Case reports focusing on harms should include the manufacturer and brand of the products in question. Explain changes made to an intervention and describe care received from other providers.

Therapeutic intervention descriptions

All interventions:

• Specify type of intervention, indicated condition, and intervention¹

Pharmaceuticals (over-the-counter and prescription drugs):

• International nonproprietary name (INN), dosing regimen, and length of intervention
• For formulations that are administered as volumes of a fluid (e.g., intravenous infusions or oral liquid formulations) state the concentration of the formulation
• Provide manufacturer and brand names if relevant

Dietary supplements and botanical medicines:

• Ingredients and dosing regimen (e.g., EPA [eicosapentaenoic acid] 750 mg plus DHA [docosahexaenoic acid] 250 mg, 1 capsule orally once daily for 6 months)
• If medicinal plants are used, indicate plant species using the Latin binomial name, the quantity of herbal substance or constituents, and the parts of the plant
• Provide manufacturer and brand names if relevant

Lifestyle recommendations (e.g., physical activity or exercise):

• Frequency, intensity, timing, and type

Examples

9a—Types of intervention (e.g., pharmacologic, surgical, preventive, self-care)

“Surgery

Under general anesthesia in the prone position, the C1–C7 laminae were exposed. Twenty millimeters of the width of the C2–C7 laminae were removed using a high-speed drill. Adhesions between the calcification and dura mater were gently stripped off, and the laminae were resected en block with the calcification. Fifteen millimeters of the width of the C1 posterior arch was removed using a high-speed drill. Pulsating dura mater was observed after laminectomy, but the pulse was weak. The dura mater appeared hypertrophic; however, we did not incise the dura mater.”

From Eight years of follow-up after laminectomy of calcium pyrophosphate crystal deposition in the cervical yellow ligament of patient with Coffin–Lowry syndrome: a case report².

9b—Administration (e.g., dosage, strength, duration)

“The patient was started on induction eculizumab at 900 mg IV weekly for 4 weeks and responded well with improvement in platelet count and renal function. He was transitioned to every-other-week maintenance eculizumab, and hemodialysis was discontinued.”

From Maintenance eculizumab dose adjustment in the treatment of atypical hemolytic uremic syndrome: a case report and review of the literature³.

“Rapid sedation was commenced with ziprasidone, lorazepam, droperidol, and zuclopenthixol acetate (Table 4). Benztropine was administered for prophylaxis against extrapyramidal side effects of the antipsychotic medications. The level of sedation attained was unsatisfactory as he remained severely agitated and combative interspersed with only brief periods of drowsiness. He could not follow direction or adhere to boundaries established by staff. All attempts at de-escalation and distraction were met with aggression.

Table 1: Medications administered to the patient in our emergency department and selected behavioral observations

Time	Medication name, dose, and route	Behavioral observations
17:20	Approximate time of presentation to our emergency department	Extremely aggressive, threatening, and offensive behavior and language
17:26	Ziprasidone 20 mg IM, lorazepam 2 mg IM	nbsp;
17:30	Lorazepam 2 mg IM	nbsp;
17:40	Zuclopenthixol acetate 150 mg IM, benztropine 2 mg IM	nbsp;
18:05	Lorazepam 2 mg IV	Vital signs and IV access obtained, blood sampled
18:30	Droperidol 10 mg IM	Verbally abusive, threatening, aggressive
22:30	Ziprasidone 20 mg IM	nbsp;
23:00	Lorazepam 2 mg IV	nbsp;
01:00		Sedated and quiet
04:00	Droperidol 10 mg IM, Lorazepam 2 mg IV	Yelling, abusive, shaking bed, threatening staff
06:00		Sedated but intermittent abuse and threats
11:20	Ziprasidone 20 mg IM	nbsp;
13:00	Droperidol 25 mg IM	Acute arousal, combative during transport to psychiatric ward”

From Polysubstance-induced relapse of schizoaffective disorder refractory to high-dose antipsychotic medications: a case report⁴.

9c—Changes in intervention (with rationale)

“Partial resolution of the hemolytic process was observed while the patient was treated with daily plasmapheresis with 5% albumin, at a volume of 3L–4L. A total of seven daily plasmapheresis treatments were performed, which resulted in a gradual decrease of the patient’s LDH and bilirubin and a rise in his level of haptoglobin. However, the patient still required almost daily blood transfusions. On the basis of earlier reports indicating an anecdotal benefit of rituximab treatment for immune cytopenias, plasmapheresis was discontinued and our patient was placed on rituximab therapy at a dose of 375 mg/m2 every week. A total of four doses were administered over a period of 4 weeks. Although an initial increase in LDH level after the initiation of rituximab treatment was noted, there was no evidence of worsening hemolysis. After the first two courses of rituximab therapy, the patient showed a marked clinical improvement. His hemoglobin level stabilized… and he no longer required blood transfusions.”

From Severe refractory autoimmune hemolytic anemia with both warm and cold autoantibodies that responded completely to a single cycle of rituximab: a case report⁵.

Training

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References

1.

Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of interventions: Template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348(mar07 3):g1687-g1687. doi:10.1136/bmj.g1687

2.

Morino T, Ogata T, Horiuchi H, Yamaoka S, Fukuda M, Miura H. Eight years of follow-up after laminectomy of calcium pyrophosphate crystal deposition in the cervical yellow ligament of patient with coffin–lowry syndrome: A case report. Medicine. 2016;95(31):e4468. doi:10.1097/md.0000000000004468

3.

Thomson N, Ulrickson M. Maintenance eculizumab dose adjustment in the treatment of atypical hemolytic uremic syndrome: A case report and review of the literature. Clinical Case Reports. 2016;4(8):773-776. doi:10.1002/ccr3.628

4.

Tucker MG, Kekulawala S, Kent M, Mostafa S, Harvey R. Polysubstance-induced relapse of schizoaffective disorder refractory to high-dose antipsychotic medications: A case report. Journal of Medical Case Reports. 2016;10(1). doi:10.1186/s13256-016-1031-3

5.

Gupta S, Szerszen A, Nakhl F, et al. Severe refractory autoimmune hemolytic anemia with both warm and cold autoantibodies that responded completely to a single cycle of rituximab: A case report. Journal of Medical Case Reports. 2011;5(1). doi:10.1186/1752-1947-5-156