SUMMARY The nature of the neurological and mental disabilities resulting from severe head injuries are analysed in 150 patients. Mental handicap contributed more significantly to overall social disability than did neurological deficits. This social handicap is readily described by the Glasgow Outcome Scale, an extended version of which is described and compared with alternatives. Comments are made about the quality oflife in disabled survivors.

SUMMARY A close relative of each of 42 severely head injured patients was interviewed at 5 years after injury, following initial study at 3, 6, and 12 months. Persisting severe deficits, in some cases worse than at 1 year, were primarily psychological and behavioural, although minor physical deficits, for example in vision, were also common. Relatives were under great strain; significantly more so than at 1 year. The best predictor of strain in the relative was the magnitude of behavioural and personality change in the patient.The purely physical sequelae of severe head injury (sensorimotor disturbance, gait disturbance, cranial nerve lesions, etc) are well documented,1 2 but it is becoming increasingly recognised that often the most serious long term morbidity after head injury is psychological; involving cognitive, behavioural, and social and family disturbance.Research into psychological sequelae has produced reports of both short term (1-2 years),3 9 and long terml0o 17 outcome. The reports are based on widely varying samples of patients ranging from those admitted to one neurosurgical unit,3 to those admitted to a variety of hospital units,7 and those in a rehabilitation unit. those with the most severe brain damage.17 Thomsen's 10-15 year follow-up of cases initially examined within 2 years of injury, disclosed a high incidence of divorce, continuing dependency, communication disturbance, and psychosocial sequelae including personality change and emotional disturbance. These late sequelae related to the presence and degree of brain stem damage (presumably reflecting the severity of damage throughout the cerebrum).The present authors reported a detailed study of psychosocial outcome 1 year after injury,3 in which attempts were made to describe the natural history of psychosocial disturbance in patient and family, and to relate changes in the patient to distress in the family. By one year after injury emotional and behavioural disturbances in the patient were frequently described by a relative, and these rather than continuing physical or communication disturbances were the best predictors of stress in the relative who had the main responsibility for caring for the patient. The present study reports the 5 year outcome of a sample of these patients. The aims were firstly to identify the patterns of change in behavioural disturbance in the patient and distress in the family during the first 5 years after injury; and secondly, to identify predictors of behavioural disturbance in the patient and continuing distress in the caring relative.

It is the aim of these revised guidelines to reflect what the committee has identified as the most important changes to be made in thinking about patients with AMI. Many therapies and procedures in current use are not based on sound scientific evidence. The committee proposes the abandonment of such therapies and procedures that can be identified with confidence. On the other hand, new information suggests that a practical division of all patients with AMI is to classify them as those with ST-segment elevation and those without it. Evidence now shows a distinction in pathoanatomy between the two that demands different therapeutic approaches. Ample evidence exists that persons with suspected MI and ST-segment elevation or bundlebranch block (BBB) should undergo immediate reperfusion, and those without these findings should not. Committee members were selected from cardiovascular specialists with broad geographical representation and combined involvement in academic medicine and primary practice. The Committee on Management of Acute Myocardial Infarction was also broadened by members of the American Academy of Family Physicians, the American College of Emergency Physicians, the AHA Council on Cardiovascular Nursing, and the American Association of Critical-Care Nurses.

The rate and prediction of return to work was examined in 98 severely head injured patients during the first seven years after injury. The employment rate dropped from 86% before injury to 29% after. Younger patients, and those with technical/managerial jobs before injury were more likely to return to work than those over 45 years of age, or in unskilled occupations. Physical deficits were not related to return to work, but the presence of cognitive, behavioural, and personality changes was significantly related to a failure to return to work.

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