An older man with memory impairment and convulsionsBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j2824 (Published 05 July 2017) Cite this as: BMJ 2017;358:j2824
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I was pleased to see that neurosyphilis was on the list of differential diagnoses, particularly in light of increasing national incidence of syphilis. It is very likely we will be seeing more manifestations of syphilis in the coming years and therefore we should be encouraged to think of syphilis in any differential.
I was curious to know which ‘infectious screen’ tests were done and their significant negative results. I would hope HIV was one of them as symptoms described could be attributable to conditions presenting in patients living with HIV/ AIDS (such as HIV encephalopathy or progressive multifocal leukoencephalopathy). HIV testing is no longer a test for ‘specialist medicine’, and in fact is heavily encouraged by NICE , PHE  and BHIVA  to be screened for by any clinician who believes that HIV could be in the list of differential diagnoses (without the need for ‘pre-test counselling’!). It would be useful to see a negative HIV test as a significant negative in any case write up as routine, thus hopefully not only enabling us the make an informed list of possible diagnoses, but also to reduce institutional stigma for the condition.
1) ‘HIV testing: increasing uptake among people who may have undiagnosed HIV’ NICE guideline [NG60] Published date: December 2016
2) Public Health England, ‘HIV testing in England: 2016 report https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
3) British HIV Association: UK national guidelines for HIV testing 2008 http://www.bhiva.org/HIV-testing-guidelines.aspx
Competing interests: No competing interests
Although the Glasgow Coma Scale (GCS) has been used for the purpose of quantification of altered level of consciousness both in patients with traumatic brain injury (1) and in those with non traumatic brain injury (1) (2), its continuing use has been questioned on the grounds of its undue complexity (3) (4) and its poor interrater reliability (1) (5).
One consequence of the undue complexity of the GCS is that it is not consistently remembered (3). In one study only 15% of military physicians calculated the GCS correctly in spite of the fact that all of them were were familiar with the scale and most had completed the advanced trauma life support course (3). In another study only 48% of clinicians correctly scored the GCS in a written clinical scenario, with neurosurgeons correct in only 56% of the time (4).
Poor interrater reliability is exemplified by a study in which independent paired assessments by attending emergency physicians showed that GCS scores were the same in only 38% of instances, and were 2 or more points apart in 33% (1). A prospective observational study examined the interrator reliability of the GCS and three other scales including the Simplified Motor Scale, when measured by 2 physicians within 5 minutes, in 120 adults presenting in the Emergency Department with altered levels of consciousness (5). Percentage agreement was 83% for the Simplified Motor Scale and only 42% for the GCS. The kappa statistic was 0.70 for the former, and 0.32 for the latter (5).
The GCS is also only grossly predictive of outcomes in patients with traumatic brain injury (6), and might, arguably, be even less predictive of outcomes in non-traumatic head injury patients such as the one in the vignette (2). "Indeed", to quote one authority, "it remains unstudied whether the GCS yields any independent contribution above and beyond unstructured clinical judgment alone" (6). Perhaps it is time we said "Cheerio, Laddie", and bade farewell to the GCS (6).
(1) Gill MR., Reiley DG., Green SM. Interrater Reliability of Glasgow Coma Scale Scores in the Emergency Department. Ann Emerg Med 2004;43:215-223
(2) Zhao X-h., Liu Y-m., Yang X., Wang S-z., Wang S-j. An older amn with memory impiarment an convulsions. BMJ 2017;358:j2824
(3) Riechers RG., Ramage A., Brown W et al. Physici8an knowledge of the Glagow Coma Scale. J Neurotrauma 2005;22:1327-1334
(4) Bassi S., Buxton N., Punt JA et al. Glasgow Coma Scale: a help or a hinderance? Nr J Neurosurg 1999;13:526-539
(5) Gill M., Martens K., Lynch EL., Salih A., Green SM. Interrater reliability of 3 simplified neurologic scales applied to adults presenting to the Emergency department with altered levels of consciousness. Ann Emerg Med 2007;49:403-407
(6) Green SM. Cheerio, Laddie! Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med 2011;58:427-430
Competing interests: No competing interests