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Measures and outcomes
In Context
Focal point Measures and outcomes The Lancet Neurology has great pleasure in commemorating 40 years since the development of the Glasgow Coma Scale (GCS).1 Not only has the scale become the standard for the measurement of consciousness level, its has subsequently expanded to provide applications in risk assessment, trend monitoring, classification, and prognosis.2 The GCS was developed to bring clarity to the definition and monitoring of consciousness, and coincided with an uptake in the study of traumatic brain injury (TBI). The natural corollary of the GCS was the development of a companion scale that looked at outcome in patients after TBI; and a year after the publication of the GCS, Jennett and Bond reported the interview-based Glasgow Outcomes Scale (GOS) for just this purpose.3 The original GOS comprised five categories—death, persistent vegetative state, severe disability, moderate disability, or good recovery—and was devised with the notion that a successful outcome should be measured in terms of the quality of survival rather than just a binary distinction between death and survival. To improve sensitivity, the last three categories were later each further divided into two, expanding the total number of outcomes from five to eight, to improve the sensitivity in patients with the best outcomes, in the expanded Glasgow Outcome Scale (GOSE) and a structured interview was included to improve interrater reliability.4 While the GOS and GOSE have stood the test of time, further expansion of knowledge in the spectrum of outcomes and increasing recognition of the multiple domains affected by TBI are likely to necessitate further expansion of the scale, perhaps even leading to a complete overhaul of the way we assess the underlying constructs of brain injury;5 however, for now, we look forward to the 40th anniversary of the GOS in 2015.
Steven Goodrick 1 2
3 4
5
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2: 81–84. Teasdale G, Maas A, Manley G, Stocchetti N, Murray G. The Glasgow Coma Scale at 40 years: standing the test of time. Lancet Neurol 2014; 13: 842–45. Jennett B, Bond M. Assessment of outcome after severe brain damage: a practical scale. Lancet 1975; 305: 480–84. Wilson JL, Pettigrew LE, Teasdale GM. Structured interviews for the Glasgow Outcome Scale: guidelines for their use. J Neurotrauma 1998; 15: 573–85. Kean J, Malec JF. Towards a better measure of brain injury outcome: new measures or a new metric? J Neurotrauma 2014; 95: 1225–28.
www.thelancet.com/neurology Vol 13 August 2014
Lifeline Todd Hardy is a neurologist at Concord Hospital and clinical senior lecturer at the University of Sydney, Australia. He trained in Sydney and at the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK. His main clinical and research interests are in multiple sclerosis and other immune-mediated CNS disorders. He is an associate editor of Advances in Clinical Neuroscience and Rehabilitation. What has been the greatest achievement of your career? The opportunity to have worked briefly as a neurologist at Queen Square—a place steeped in so much history—and to have published in Nature Genetics and The Lancet Neurology.
See Review Lancet Neurol 2014; 7: 740–46
If you had not entered your current profession, what would you have liked to do? I would have liked to become a writer, but I fear a lack of independent wealth and talent would have made this a foolhardy enterprise. What would be your advice to a newly qualified doctor? Follow a path that you are passionate about, and remember that patient care is a privilege. How do you relax? I enjoy reading, music, comedy, art, theatre, watching football, travelling, and eating and drinking well. I love sharing all of these things with my gorgeous partner, Josie. What is your greatest regret? That life is finite. What apart from your family is the passion of your life? If I put aside family (and neurology obviously), then I think my answer would be art. I am passionate about literature, movies, theatre, music, and painting. What is the most memorable comment from your school reports? One of my teachers once criticised me in my school report, aged 8 or 9, for reading “too fluently”. What one discovery or invention would most improve your life? A remedy that would immediately nullify the effects of over-indulgence. What keeps you awake at night? The telephone when I am on-call. Which would you choose, money or power? Money. There is no true power without money. Do you believe there are other life forms in the Universe? I believe there is a strong possibility. If you could have dinner tonight with a famous person of your choice (dead or alive), who would it be? William Shakespeare (alive).
763
Focal point Measures and outcomes The Lancet Neurology has great pleasure in commemorating 40 years since the development of the Glasgow Coma Scale (GCS).1 Not only has the scale become the standard for the measurement of consciousness level, its has subsequently expanded to provide applications in risk assessment, trend monitoring, classification, and prognosis.2 The GCS was developed to bring clarity to the definition and monitoring of consciousness, and coincided with an uptake in the study of traumatic brain injury (TBI). The natural corollary of the GCS was the development of a companion scale that looked at outcome in patients after TBI; and a year after the publication of the GCS, Jennett and Bond reported the interview-based Glasgow Outcomes Scale (GOS) for just this purpose.3 The original GOS comprised five categories—death, persistent vegetative state, severe disability, moderate disability, or good recovery—and was devised with the notion that a successful outcome should be measured in terms of the quality of survival rather than just a binary distinction between death and survival. To improve sensitivity, the last three categories were later each further divided into two, expanding the total number of outcomes from five to eight, to improve the sensitivity in patients with the best outcomes, in the expanded Glasgow Outcome Scale (GOSE) and a structured interview was included to improve interrater reliability.4 While the GOS and GOSE have stood the test of time, further expansion of knowledge in the spectrum of outcomes and increasing recognition of the multiple domains affected by TBI are likely to necessitate further expansion of the scale, perhaps even leading to a complete overhaul of the way we assess the underlying constructs of brain injury;5 however, for now, we look forward to the 40th anniversary of the GOS in 2015.
Steven Goodrick 1 2
3 4
5
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2: 81–84. Teasdale G, Maas A, Manley G, Stocchetti N, Murray G. The Glasgow Coma Scale at 40 years: standing the test of time. Lancet Neurol 2014; 13: 842–45. Jennett B, Bond M. Assessment of outcome after severe brain damage: a practical scale. Lancet 1975; 305: 480–84. Wilson JL, Pettigrew LE, Teasdale GM. Structured interviews for the Glasgow Outcome Scale: guidelines for their use. J Neurotrauma 1998; 15: 573–85. Kean J, Malec JF. Towards a better measure of brain injury outcome: new measures or a new metric? J Neurotrauma 2014; 95: 1225–28.
www.thelancet.com/neurology Vol 13 August 2014
Lifeline Todd Hardy is a neurologist at Concord Hospital and clinical senior lecturer at the University of Sydney, Australia. He trained in Sydney and at the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK. His main clinical and research interests are in multiple sclerosis and other immune-mediated CNS disorders. He is an associate editor of Advances in Clinical Neuroscience and Rehabilitation. What has been the greatest achievement of your career? The opportunity to have worked briefly as a neurologist at Queen Square—a place steeped in so much history—and to have published in Nature Genetics and The Lancet Neurology.
See Review Lancet Neurol 2014; 7: 740–46
If you had not entered your current profession, what would you have liked to do? I would have liked to become a writer, but I fear a lack of independent wealth and talent would have made this a foolhardy enterprise. What would be your advice to a newly qualified doctor? Follow a path that you are passionate about, and remember that patient care is a privilege. How do you relax? I enjoy reading, music, comedy, art, theatre, watching football, travelling, and eating and drinking well. I love sharing all of these things with my gorgeous partner, Josie. What is your greatest regret? That life is finite. What apart from your family is the passion of your life? If I put aside family (and neurology obviously), then I think my answer would be art. I am passionate about literature, movies, theatre, music, and painting. What is the most memorable comment from your school reports? One of my teachers once criticised me in my school report, aged 8 or 9, for reading “too fluently”. What one discovery or invention would most improve your life? A remedy that would immediately nullify the effects of over-indulgence. What keeps you awake at night? The telephone when I am on-call. Which would you choose, money or power? Money. There is no true power without money. Do you believe there are other life forms in the Universe? I believe there is a strong possibility. If you could have dinner tonight with a famous person of your choice (dead or alive), who would it be? William Shakespeare (alive).
763