Background: Deep brain stimulation (DBS) in patients with severe, refractory Tourette syndrome (TS) has demonstrated promising but variable results thus far. The thalamus and anteromedial globus pallidus internus (amGPi) have been the most commonly stimulated sites within the cortico-striato thalamic circuit, but an optimal target is yet to be elucidated. Objectives: This study of 15 patients with long-term amGPi DBS for severe TS investigated whether a specific anatomical site within the amGPi correlated with optimal clinical outcome for the measures of tics, obsessive compulsive behaviour (OCB), and mood. Methods: Validated clinical assessments were used to measure tics, OCB, quality of life, anxiety, and depression before DBS and at the latest follow-up (17-82 months). Electric field simulations were created for each patient using information on electrode location and individual stimulation parameters. A subsequent regression analysis correlated these patient-specific simulations to percentage changes in outcome measures in order to identify any significant voxels related to clinical improvement. Results: A region within the ventral limbic GPi, specifically on the medial medullary lamina in the pallidum at the level of the AC-PC, was significantly associated with improved tics but not mood or OCB outcome. Conclusions: This study adds further support to the application of DBS in a tic-related network, though factors such as patient sample size and clinical heterogeneity remain as limitations and replication is required.

Tourette syndrome (TS) is a childhood neurobehavioural disorder, characterised by the presence of motor and vocal tics, typically starting in childhood but persisting in around 20% of patients into adulthood. In those patients who do not respond to pharmacological or behavioural therapy, deep brain stimulation (DBS) may be a suitable option for potential symptom improvement. This manuscript attempts to summarise the outcomes of DBS at different targets, explore the possible mechanisms of action of DBS in TS, as well as the potential of adaptive DBS. There will also be a focus on the future challenges faced in designing optimized trials.

Context: Measuring testicular volume (TV) by orchidometer is the standard method of male pubertal staging. A paucity of evidence exists as to its inter-and intra-observer reliability and the impact of clinicians' gender, training and experience on accuracy.Objective: Prosthetic testicular models were engineered to investigate accuracy and reliability of TV estimation. Design: Simulation study.Setting: Conducted over three-day 2015 British Society for Paediatric Endocrinology and Diabetes (BSPED) meeting.Participants: Two hundred fifteen meeting delegates (161F, 54M): 50% consultants, 30% trainees, 9% clinical nurse specialists, 11% other professionals.Intervention: Three child-sized mannequins displayed latex scrotum containing prosthetic testicles of 3, 4, 5, 10 and 20 mL. Demographic data, paediatric endocrinology experience, TV examination training, examination technique and TV estimations were collected. Delegates were asked to repeat their measurements later during the meeting. Scrotum order was changed daily.Main outcome measures: Accuracy by variance from the simulated TV. Inter-and intra-observer variability.Results: One thousand two hundred eighty four individual estimations were obtained.Eighty-five participants repeated measurements. Delegates measured TV accurately on 33.4% (±2.6) of occasions: overestimations 37% (±2.3), underestimations 28% (±1.8) (Fleiss' Kappa score 0.04). The accuracy of assessing a 4 mL testis was 36%-39%.Observers underestimated the volume when paired with a 3 mL testis and overestimated when paired with a 5 mL testis demonstrating a tendency impose biological symmetry. Intra-observer reliability was lacking; individuals giving different estimations for the same size testicle on 61% (±4.2) of occasions, 20% (±3.5) of estimations were more than 1 size outside the previous measurement. On only 39% (±4.2) of occasions did individuals agree with their previous estimation (irrespective of whether or not it was initially accurate). Training did not impact on results but experience did improve accuracy. Conclusions:Overall TV estimation accuracy was poor. Considerable variation exists between and within subjects. Seniority slightly improved measurement estimation.

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AimsTo assess neurological admissions to the critical care unit in our centre according to published prioritisation criteria and evaluate predictors of outcome.MethodsWe reviewed 39 patient records between November 2012-April 2015, and ranked from 1 to 4 according to prioritisation criteria. We evaluated predictors of outcome, including length of stay, using regression modelling.Results18 females and 21 males were assessed with a mean age of 41 years (range 23–83). Twelve patients had strokes, 6 status epilepticus, 16 neuromuscular disorders, 1 post-arrest hypoxia-ischaemia, 3 metabolic problems and 1 meningitis. Six patients had serious co-morbidities. Mean time from ward to critical care was 5 days (range 0–39), time on critical care was 10 days (0–45), and time from critical care to home 23 days (2–84). Sixty-six percent received non-invasive ventilation, 51% intubation and ventilation, 27% tracheostomy and 8% inotropes. 23 patients were classed priority 1, 9 priority 2 and 7 priority 3. Seventy-four percent survived to discharge to the ward and of these 93% went home. Of survivors, 62% had a Rankin score 1–2. All the priority 3 patients died. There was no association between length of stay and outcome.ConclusionsNeurological patients in critical care generally have good outcomes, even with prolonged stays. Meeting priority 3 criteria was associated with poor prognosis.

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