Use of telemedicine for children with special health care needs.

OBJECTIVE: In 1995, the Children's Medical Services (CMS) of the State of Georgia contracted with the Department of Pediatrics of the Medical College of Georgia (MCG) and the MCG Telemedicine Center to develop telemedicine programs to provide subspecialty care for children with special health care needs. This article presents project statistics and results of client evaluation of services, as well as physician faculty attitudes toward telemedicine. DESIGN: A demonstration project using telemedicine between a tertiary center and a rural clinic serving children with special health care needs was established. Data were collected and analyzed for December 12, 1995 to May 31, 1997, during which 333 CMS telemedicine consultations were performed. RESULTS: Most CMS telemedicine consultations (35%) involved pediatric allergy/immunology. Other subspecialties included pulmonology (29%), neurology (19%), and genetics (16%). Overall, patients were satisfied with the services received. Initially, physician faculty members were generally positive but conservative in their attitudes toward using telemedicine for delivering clinical consultation. After a year's exposure and/or experience with telemedicine, 28% were more positive, 66% were the same, and only 4% were more negative about telemedicine. The more physicians used telemedicine, the more positive they were about it (r =.30). CONCLUSIONS: In terms of family attitudes and individual care, telemedicine is an acceptable means of delivering specific pediatric subspecialty consultation services to children with special health care needs, living in rural areas distant to tertiary centers. Telemedicine is more likely to be successful as part of an integrated health services delivery than when it is the sole mode used for delivery of care.

Cerebrospinal fluid biogenic amines in obsessive compulsive disorder, Tourette's syndrome, and healthy controls.

To examine the role of noradrenergic, dopaminergic, and serotonergic mechanisms in the pathobiology of obsessive compulsive disorder (OCD) and Tourette's syndrome (TS), concentrations of tyrosine (TYR), norepinephrine (NE), 3-methoxy-4-hydroxyphenylethylene glycol (MHPG), homovanillic acid (HVA), tryptophan (TRP), and 5-hydroxyindoleacetic acid (5-HIAA) were measured in the lumbar cerebrospinal fluid (CSF) of 39 medication-free OCD patients, 33 medication-free TS patients, and 44 healthy volunteers. CSF TYR concentrations were reduced (p < .05) in the OCD patients compared to the healthy subjects. CSF NE in TS patients was 55% higher than in healthy controls (p < .001) and 35% higher than in OCD patients (p < .001). After covarying for height, CSF HVA levels were reduced (p < .05) in the OCD group compared to TS patients but not compared to the normal volunteers. No mean differences in CSF MHPG, TRP, and 5-HIAA were observed in this study across the three groups. The CSF NE data support the hypothesis that noradrenergic mechanisms are involved in the pathobiology of TS. Alterations in the balance of noradrenergic, dopaminergic, and serotonergic systems are likely involved in the pathobiology of OCD.

Elevated cerebrospinal fluid levels of oxytocin in obsessive-compulsive disorder. Comparison with Tourette's syndrome and healthy controls.

BACKGROUND: Limited neurobiological data have implicated central arginine vasopressin in the pathobiology of obsessive-compulsive disorder (OCD). Based on twin, family genetic, and pharmacological studies, some forms of OCD are etiologically related to Tourette's syndrome. The role of arginine vasopressin and related compounds such as oxytocin in Tourette's syndrome has not been previously explored. METHODS: To compare cerebrospinal fluid (CSF) levels of arginine vasopressin and oxytocin, we collected CSF at midday in a standardized fashion from a total of 83 individuals (29 patients with OCD, 23 patients with Tourette's syndrome, and 31 normal controls). We also collected family study data on each subject to determine which subjects had a family history positive for Tourette's syndrome, OCD, or related syndromes. RESULTS: In contrast to previous reports, we report similar concentrations of arginine vasopressin for all three groups but increased oxytocin levels in patients with OCD. Remarkably, this increase was observed only in a subset of patients with OCD (n = 22) independently identified as being without a personal or family history of tic disorders (P = .0003). In this subgroup of patients, the CSF oxytocin level was correlated with current severity of OCD (n = 19, r = .47, P < .05). CONCLUSIONS: A possible role for oxytocin in the neurobiology of a subtype of OCD is suggested by the elevated CSF levels of oxytocin and by the correlation between CSF oxytocin levels and OCD severity. These findings reinforce the value of family genetic data in identifying biologically homogeneous (and perhaps more etiologically homogeneous) groups of patients with OCD. Together with emerging pharmacological data showing differential responsiveness to treatment of tic-related OCD vs non-tic-related OCD, these data also argue strongly for the incorporation of tic-relatedness as a variable in biological and behavioral studies of patients with OCD.

Videotape tic counts in the assessment of Tourette's syndrome: stability, reliability, and validity.

OBJECTIVE: We examined the short- and long-term temporal stability of tic counts to estimate the minimum length of videotape needed for a reliable index of overall tic activity and determined the interrater reliability and validity of tic counts based on prolonged videotape segments (> 10 minutes). METHOD: Motor and phonic tic counts and clinician ratings were performed on 43 patients with Tourette's syndrome (TS), aged 7 to 50 years. Short-term stability was estimated by determining the mean interval-to-interval correlation of sequential equal-length segments from 30-minute videotape recordings of 20 subjects. Long-term stability was determined by correlating tic counts at 1-week (N = 14) and 2-week intervals (N = 11). In addition, tic counts were correlated with the most widely used clinical ratings of TS. RESULTS: The short-term stability data indicated that estimates of motor and phonic tic frequencies should be based on videotape counts of at least 5 minutes' duration. Tic counts also were highly reliable and were significantly correlated with clinical ratings with the Yale Global Tic Severity Scale and the Clinical Global Impression Scale for Tourette Syndrome. CONCLUSIONS: Standardized videotape tic counts can provide highly reliable, stable measures of tic frequencies that are moderately correlated with selected global ratings of tic severity.