Objective-To identify the number of patients who were misdiagnosed as being in the vegetative state and their characteristics.Design-Retrospective study of the clinical records of the medical, occupational therapy, and clinical psychology departments.Setting-20 bed unit specialising in the rehabilitation of patients with profound brain damage, including the vegetative state.Subjects-40 patients admitted between 1992 and 1995 with a referral diagnosis of vegetative state.Outcome measures-Patients who showed an ability to communicate consistently using eye pointing or a touch sensitive single switch buzzer.Results-Of the 40 patients referred as being in the vegetative state, 17 (43%) were considered as having been misdiagnosed; seven of these had been presumed to be vegetative for longer than one year, including three for over four years. Most of the misdiagnosed patients were blind or severely visually impaired. All patients remained severely physically disabled, but nearly all were able to communicate their preference in quality of life issues-some to a high level.Conclusions-The vegetative state needs considerable skill to diagnose, requiring assessment over a period of time; diagnosis cannot be made, even by the most experienced clinician, from a bedside assessment. Accurate diagnosis is possible but requires the skills of a multidisciplinary team experienced in the management of people with complex disabilities. Recognition of awareness is essential if an optimal quality oflife is to be achieved and to avoid inappropriate approaches to the courts for a declaration for withdrawal of tube feeding. IntroductionThe vegetative state is a rare disorder which is diagnosed

BackgroundThe Rare and Undiagnosed Diseases Diagnostic Service (RUDDS) refers to a genomic diagnostic platform operating within the Western Australian Government clinical services delivered through Genetic Services of Western Australia (GSWA). GSWA has provided a state-wide service for clinical genetic care for 28 years and it serves a population of 2.5 million people across a geographical area of 2.5milion Km2. Within this context, GSWA has established a clinically integrated genomic diagnostic platform in partnership with other public health system managers and service providers, including but not limited to the Office of Population Health Genomics, Diagnostic Genomics (PathWest Laboratories) and with executive level support from the Department of Health. Herein we describe report presents the components of this service that are most relevant to the heterogeneity of paediatric clinical genetic care.ResultsBriefly the platform : i) offers multiple options including non-genetic testing; monogenic and genomic (targeted in silico filtered and whole exome) analysis; and matchmaking; ii) is delivered in a patient-centric manner that is resonant with the patient journey, it has multiple points for entry, exit and re-entry to allow people access to information they can use, when they want to receive it; iii) is synchronous with precision phenotyping methods; iv) captures new knowledge, including multiple expert review; v) is integrated with current translational genomic research activities and best practice; and vi) is designed for flexibility for interactive generation of, and integration with, clinical research for diagnostics, community engagement, policy and models of care.ConclusionThe RUDDS has been established as part of routine clinical genetic services and is thus sustainable, equitably managed and seeks to translate new knowledge into efficient diagnostics and improved health for the whole community.

Acquired brain injury (ABI) can lead to a constellation of higher-order executive problems, which can impact significantly on everyday behaviour. While some neuropsychological assessments are able to measure these impairments objectively, increasingly, clinicians are finding that a subset of their patients passes these tests while still exhibiting difficulties in day-to-day living. Calls have therefore been made to develop assessments that are more sensitive and that are more ecologically valid. In this study, in Experiment 1, a multiple errands task (MET) based around a business office was created to assess concurrently nine aspects of executive functioning (planning, prioritisation, selective-thinking, creative-thinking, adaptive-thinking, multi-tasking, action-based prospective memory (PM), eventbased PM and time-based PM). This new paradigm, the Jansari assessment of Executive Functions (JEF C ) showed a significant difference between six individuals with ABI and matched healthy controls; further, it showed that across the nine constructs there was a range of performance. In Experiment 2, JEF C was recreated in a virtual environment resembling a computer game, and it was found that this version significantly differentiated between 17 individuals with ABI and 30 healthy controls. These results suggest that the virtual version of JEF C could be used as a new assessment of executive function. The profile of performance across the nine constructs for each individual provides a wealth of objective information that could potentially inform targeted rehabilitation.

Widespread introduction of early case management of patients after severe head injury is not supported, and early case management is not a substitute for improvement in provision of skilled and specialist rehabilitation for patients.

Vocational rehabilitation offering educational and experiential learning opportunities is effective in enabling participants with severe acquired brain injuries to return to paid employment.

Background. There have been a number of developments in the assessment of dynamic risk in the criminological literature. The dynamic risk assessment and management system (DRAMS) has been developed to facilitate the measurement of dynamic factors of risk for offenders with intellectual disability. Method. The study was designed to assess the construct validity, reliability and predictive utility of the DRAMS in 23 male forensic patients in a high secure setting. Predictions were made against independently collected incident data. Concurrent validity was assessed against the Ward Anger Rating Scale (WARS). Results. A reformulation of the individual section variables according to convergent and discriminant correlational analysis revealed Cronbach's alpha levels of >.8 for all sections apart from mood (alpha .750) and items retained to facilitate clinical information (alpha −.017). Two hundred pairs of WARS and DRAMS assessments revealed orderly sectional correlations. The sections of mood, antisocial behaviour, and intolerance/agreeableness predicted incidents with a medium effect size as did total DRAMS score. There were highly significant differences between assessments taken 1 or 2 days prior to an incident and control assessments conducted at least 7 days from an incident. Conclusions. The reformulated DRAMS has good construct and concurrent validity. It appears to be a reliable assessment tool and informs on risk levels relating to stable and acute proximal factors. It appears as an important addition to the utility of risk assessments for this population.

Purpose Research on dynamic risk assessment has developed over the last 10 years and a number of variables have emerged as being possible predictors of future sexual and violent offences. These variables include hostile attitude/anger and compliance with routine. In 2002, Thornton (Sexual Abuse: A Journal of Research & Treatment 14, 139) developed a framework for dynamic risk assessment which also includes distorted and dysfunctional attitudes, socio-affective functioning, self-management and, for sex offenders, sexual interests. In 2000, Hanson & Harris (Criminal Justice & Behaviour 27, 6) provided empirical support for the predictive power of a number of dynamic factors which they split into stable and acute variables. In their research they found poor social supports, antisocial lifestyle, and poor self-management strategies to be important in addition to cooperation with supervision and hostile attitude. The present report describes the development of the Dynamic Risk Assessment and Management System (DRAMS) -an assessment for dynamic/proximal risk factors in people with intellectual disabilities. Method In a field trial, the DRAMS was administered by staff unfamiliar with the formal requirements of the assessment. They were familiar with other ward-based assessments. Ten subjects were assessed for reliability purposes (total of 45 assessments) and five subjects were assessed consistently over a 3-month period. Eighteen aggressive incidents were recorded in these five subjects and the relationship between DRAMS assessments and the incidents was calculated. Assessments were recorded on the day of the incident, the day before the incident and on a control day, which was at least 7 days before or after an incident. Results Four items achieved high reliability -mood, psychotic symptoms, self-regulation, compliance with routine -in addition to total score. Two items achieved intermediate reliability -antisocial behaviour and problems with thinking/attitudes, and three items were not applicable to this client group in that none of the participants was ever rated on them -substance abuse, renewal of emotional relationships and victim access. One item had poor reliability -therapeutic alliance. There were significant differences between the DRAMS assessment on the control day and assessments both on the day prior to the incident and the day of the incident for three of the six subscales and total score. Conclusion Initial results would suggest that the DRAMS is a reliable instrument apart from the therapeutic alliance category. Initial signs suggest that it may be predictive of aggressive incidents in residential settings. Several developments to other settings and the client groups are discussed.

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