About The Practice

Serving Texas Children's Concerns about Neurology, Epilepsy Developmental & Sleep Disorders. Advanced spasticity management.

The Houston Area ( Bellaire Katy Sugar Land Richmond Missouri City Cypress The Woodlands Lake Jackson)

The Greater San Antonio Area ( New Braunfels Seguin Central Texas)

Dr Joshua Rotenberg. Board Certified in Neurology with Special Qualifications in Child Neurology.

Dr. Rotenberg has added subspecialty board certification in epilepsy AND sleep disorders (American Board of Psychiatry & Neurology-Child Neurology).

Member - American Epilepsy Society

Member - American Academy of Cerebral Palsy & Developmental Medicine

Texas Medical & Sleep Specialists - Children & Adults Welcome. WWW.TXMSS.COM 713-464-4107

Thursday, July 17, 2014

Study: Sleep disordered breathing can change pregnancy outcomes

According to a study, sleep disordered breathing during pregnancy can influence pregnancy outcomes, such as gestational diabetes.

Humans spend around 30 percent of their lives sleeping. Unfortunately, this time to re-energize and recharge our batteries may not always be so "restful" for everyone. Now, a recent study published in the American Journal of Obstetrics & Gynecology found that women dealing with this health issue may endure more problems throughout their pregnancy.
For the study, researchers examined 188 women and assessed the prevalence and trend of sleep-disorder breathing (SDB) and its effect on pregnancy outcomes.
Researchers discovered a dose-dependent relationship between the severity of SDB throughout early pregnancy and the risk of developing gestational diabetes. They also found that those with more moderate or severe SDB throughout early pregnancy were at an increased risk of developing gestational diabetes.
"This study suggests a dose-dependent relationship between SDB exposure in early pregnancy and the subsequent development of gestational diabetes," the authors noted in the study. 
However, researchers note that there was no association between SDB exposure in early or late pregnancy, as well as any of the other adverse pregnancy outcomes.
Read more here

Do doctors have an obligation to protect athletes from concussions?

This article discusses if doctors have an ethical obligation to teach and protect athletes from concussions.

The American Academy of Neurology (AAN), the largest professional association of neurologists and a leading authority on sports concussion, is releasing a new position paper that states doctors have an ethical obligation to educate and protect athletes from sports concussion and clear them to play only when the athlete is medically ready, standing firm against objections from players, parents or coaches. The statement is published in the July 9, 2014, online issue of Neurology®, the medical journal of the AAN, and is being released ahead of The Sports Concussion Conference, July 11-13, 2014, in Chicago, where the AAN will share the latest scientific advances in diagnosing and treating sports concussion.
The AAN position statement calls for doctors to safeguard the future mental and physical health of athletes as a top priority, especially regarding return-to-play decision-making. Physicians also must educate patients and their families about the dangers of concussion in all relevant sports, according to the statement.
The Academy has spent several years analyzing all of the available research and ethical issues to develop this official position paper, which corresponds with the AAN's guideline on sports concussion.
"With nearly four million sports-related concussions in the US each year, it is imperative doctors are educated and protect these athletes who may have sustained a concussion," said lead author Matthew P. Kirschen, MD, PhD, a neurologist with The Children's Hospital of Philadelphia and a member of the American Academy of Neurology. "Concussions can have devastating effects such as short-term impairments in athletes' cognitive and athletic performance. Repeat concussions have been linked to long-term impairments in brain function, such as problems with learning, memory and behavior."
The statement also:
• Supports wider use of baseline cognitive testing
• Recommends that concussion evaluation and management training be added to neurology residency programs
• Suggests the development of a national concussion registry with mandatory reporting, which may help to document more rigorously the incidence and recurrence of concussion at all levels of play
Ethically, the statement concludes that physicians caring for athletes during and after a sports-related concussion should have adequate training and experience in the recognition and evaluation of both the existence and severity of potential brain injury.
"These strategies could help identify the threshold at which the number and severity of head injuries leads to irreversible brain injury. They may also help to clarify how concussion risk varies with factors like age, gender, puberty stage and ethnicity so athletes and parents can make informed decisions about playing contact sports," said Kirschen.
Read more here

Tuesday, July 15, 2014

Study claims that ADHD medication can increase risk of heart issues

A study claims that medication used to treat ADHD might increase the risk of heart complications in children.

Whether drugs used to treat attention deficit hyperactivity disorder boost the risk of heart conditions in children remains a subject of concern. Now, research from Denmark suggests medications such as Ritalin and Concerta make rare cardiac problems twice as likely, although still uncommon.
"The risk of adverse cardiac effects of ADHD medication is real and should not be forgotten," said study lead author Dr. Soren Dalsgaard, an associate professor at Aarhus University.
However, doctors and parents should not be alarmed and take kids off stimulant medication if they have benefits from it and no cardiac symptoms, he said. "But we should continue to monitor cardiovascular status," he added.
The findings aren't definitive because they don't prove cause-and-effect and they seem to conflict with some previous research that looked at fewer heart conditions over shorter periods of time.
The inattention, hyperactivity and impulsivity associated with ADHD can make it hard for children with the disorder to learn and socialize. Stimulant drugs taken on a daily basis can help control these behaviors.
Worldwide, the number of children and teens with ADHD who take stimulant medications is increasing, according to background research in the study. Experts say these drugs can boost heart rate and blood pressure.
"The most common cardiac effects are benign -- very small, clinically insignificant increases in heart rate or blood pressure," said Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at Cohen Children's Medical Center of New York in New Hyde Park.
Alarms sounded because of reports of sudden deaths, heart attack and stroke related to ADHD drugs, which has led some physicians to assess heart health before starting young people on the drugs.
But a 2011 study of U.S. children and young adults published in the New England Journal of Medicine found no link between ADHD drugs and heart attacks, sudden death and stroke. And in 2012, a study in the Journal of the American Medical Association found no sign of a link in young and middle-aged adults either.
The new study, published online recently in the Journal of Child and Adolescent Psychopharmacology, followed 714,000 children in Denmark, born from 1990 to 1999, for an average of 9.5 years. Of those, 8,300 were diagnosed with ADHD after age 5.
Of the total with ADHD, 111 kids -- or a little more than 1 percent -- had a heart problem such as high blood pressure, cardiac arrest, irregular heartbeat or general cardiovascular disease.
When the researchers adjusted their statistics to take into account certain differences, they found those who took methylphenidates such as Ritalin or Concerta -- whether diagnosed with ADHD or not -- were about twice as likely to suffer from heart problems.
The researchers didn't examine whether ADHD itself could be linked to heart problems.
In a news release, journal editor Dr. Harold Koplewicz said the study "confirms the small but real risk we have understood for some time through prior reports and clinical experience." Koplewicz is president of the Child Mind Institute in New York City.
The findings raise the question of whether the benefits of the drugs outweigh the possible harms. In the big picture, few children who took the drugs actually developed heart problems, study lead author Dalsgaard said.
"Indeed, the benefits from ADHD medication can be worth the risk of adverse effects, but we should not underestimate the risk of cardiac effects," he said.
Adesman emphasized the rarity of heart problems in ADHD patients. Parents may wish to talk to a pediatric cardiologist if their child has an existing heart problem and they wish to put them on a stimulant for ADHD, he said.
"In my experience, most cardiologists will support treatment with stimulant medication for most children with congenital heart disease -- even for kids who have had open heart surgery to repair a malformed heart," he said.
More research is planned, Dalsgaard said, especially to unravel an unusual finding in the study. Children seemed at higher risk of heart problems if their doctors had lowered their drug dosage. It's not clear if the change in dose contributed to the heart issues or whether there's another explanation.
Read more here

iPad access could help children with autism speak

A study shows that iPad access may help speaking skills for children with autism.

Adding access to a computer tablet to traditional therapy may help children with autism talk and interact more, new research suggests.
The study compared language and social communication treatment -- with or without access to an iPad computer tablet -- in 61 young children with an autism spectrum disorder (ASD) and found that the device helped boost the effect of the treatment.
"All the children improved, but they improved more if they had access to the iPad," said Connie Kasari, professor of human development and psychology and psychiatry at the University of California, Los Angeles' Semel Institute for Neuroscience and Human Behavior.
The children used the iPad when they were engaged in play, she said. "It focused on helping them initiate conversation, using the iPad to comment on what they were doing. The iPad worked because it is a visual stimulant with auditory feedback," she explained. For instance, children would mispronounce a word, hear it pronounced correctly on the iPad, and then learn to say it correctly, she said.
But, Kasari emphasized, "The iPad is just a tool." It worked because it was used within a treatment aimed at helping improve the children's communication skills, she noted.
The study was published in the June issue of the Journal of the American Academy of Child & Adolescent Psychiatry. Autism Speaks, a research and advocacy organization, funded the study.
Autism spectrum disorders are a group of developmental disorders. Communication and social problems are hallmarks of ASDs. As many as one in 68 U.S. children has an autism spectrum disorder, according to estimates from the U.S. Centers for Disease Control and Prevention.
Children in the study were between the ages of 5 and 8. All were considered "minimally verbal," which experts define as speaking fewer than 20 functional words, Kasari said. "The majority had far fewer." About 30 percent of children with an autism spectrum disorder are minimally verbal, she said, sometimes even after years of treatment.
For the first three months, all of the children received two sessions a week, totaling two to three hours a week. At the three-month mark, nearly 78 percent of children in the iPad-added group had an early response, but just 62 percent of those in the group without it did, the investigators found.
An early response was defined as an improvement of 25 percent or more in half of the 14 measures, such as the number of spoken words and the use of new words, Kasari said.
If a child was not progressing at the three-month mark, the researchers added the tablet. But adding it later was not as effective as using it from the start, Kasari's team found. The researchers followed the children for three years.
"The idea of using an iPad is a novel approach," said Dr. Ruth Milanaik, an attending physician at the Cohen Children's Medical Center in New Hyde Park, N.Y. Milanaik treats children with autism and reviewed the study's findings.
"The idea of technology being used to help children who really need different approaches is so important," she said. It's crucial, however, she agreed, to understand that the iPad "was simply a tool" and that it was an adjunct to the traditional interventions that aimed to improve communication and other developmental advances.
While a 25 percent improvement -- the measure used to define response -- may not seem like much to some, Milanaik said that "every small step, for the parents of an autistic child, is monumental."
Kasari and her team are continuing to study the iPad, planning to enroll about 200 children in four cities during a planned five-year study.
If the research continues to bear out, the hope would be to use the iPads in school programs and to train parents in its use at home, both experts agreed.
Read more here

Sleep deprivation can lead to symptoms of schizophrenia

Research shows that sleep deprivation for 24 hours can lead to a person developing symptoms of schizophrenia.

Twenty-four hours of sleep deprivation can lead to conditions in healthy persons similar to the symptoms of schizophrenia. This discovery was made by an international team of researchers under the guidance of the University of Bonn and King's College London. The scientists point out that this effect should be investigated more closely in persons who have to work at night. In addition, sleep deprivation may serve as a model system for the development of drugs to treat psychosis. The results have now been published in The Journal of Neuroscience.
In psychosis, there is a loss of contact with reality and this is associated with hallucinations and delusions. The chronic form is referred to as schizophrenia, which likewise involves thought disorders and misperceptions. Affected persons report that they hear voices, for example. Psychoses rank among the most severe mental illnesses. An international team of researchers under the guidance of the University of Bonn has now found out that after 24 hours of sleep deprivation in healthy patients, numerous symptoms were noted which are otherwise typically attributed to psychosis or schizophrenia. "It was clear to us that a sleepless night leads to impairment in the ability to concentrate," says Prof. Dr. Ulrich Ettinger of the Cognitive Psychology Unit in the Department of Psychology at the University of Bonn. "But we were surprised at how pronounced and how wide the spectrum of schizophrenia-like symptoms was."
The scientists from the University of Bonn, King's College London (England) as well as the Department of Psychiatry and Psychotherapy of the University of Bonn Hospital examined a total of 24 healthy subjects of both genders aged 18 to 40 in the sleep laboratory of the Department of Psychology. In an initial run, the test subjects were to sleep normally in the laboratory. About one week later, they were kept awake all night with movies, conversation, games and brief walks. On the following morning, subjects were each asked about their thoughts and feelings. In addition, subjects underwent a measurement known as prepulse inhibition.
Unselected information leads to chaos in the brain
"Prepulse inhibition is a standard test to measure the filtering function of the brain," explains lead author Dr. Nadine Petrovsky from Prof. Ettinger's team. In the experiment, a loud noise is heard via headphones. As a result, the test subjects experience a startle response, which is recorded with electrodes through the contraction of facial muscles. If a weaker stimulus is emitted beforehand as a "prepulse," the startle response is lower. "The prepulse inhibition demonstrates an important function of the brain: Filters separate what is important from what is not important and prevent sensory overload," says Dr. Petrovsky.
In our subjects, this filtering function of the brain was significantly reduced following a sleepless night. "There were pronounced attention deficits, such as what typically occurs in the case of schizophrenia," reports Prof. Ettinger. "The unselected flood of information led to chaos in the brain." Following sleep deprivation, the subjects also indicated in questionnaires that they were somewhat more sensitive to light, color or brightness. Accordingly, their sense of time and sense of smell were altered and mental leaps were reported. Many of those who spent the night even had the impression of being able to read thoughts or notice altered body perception. "We did not expect that the symptoms could be so pronounced after one night spent awake," says the psychologist from the University of Bonn.
Sleep deprivation as a model system for mental illnesses
The scientists see an important potential application for their results in research for drugs to treat psychoses. "In drug development, mental disorders like these have been simulated to date in experiments using certain active substances. However, these convey the symptoms of psychoses in only a very limited manner," says Prof. Ettinger. Sleep deprivation may be a much better model system because the subjective symptoms and the objectively measured filter disorder are far more akin to mental illnesses. Of course, the sleep deprivation model is not harmful: After a good night's recovery sleep, the symptoms disappear. There is also a need for research with regard to persons who regularly have to work at night. "Whether the symptoms of sleep deprivation gradually become weaker due to acclimatization has yet to be investigated," says the psychologist from the University of Bonn.
Read more here

Common issues that hurt your sleep

This article discusses common issues that hurt people's sleep, and tells you what to do about them.

You might remember a time when you could drift off to sleep in an instant and remain in a state of blissful slumber well past lunchtime the next day. Now your sleep is more likely to be lighter and more fitful, and when you wake up in the morning you don't always feel refreshed.

A lack of good-quality sleep could be a natural consequence of changing sleep-wake patterns after menopause. It's also likely that the issue is physical--and fixable. Many conditions can disrupt your rest, and they can be treated. It's important to address these issues. Lack of sleep does more than make you drowsy. Chronic insomnia has been linked to a variety of health problems, including obesity, high blood pressure, heart disease, diabetes and depression.

Go through this list to see whether you might have one of these sleep-stealing conditions. Also check your medicine cabinet. Some medications, including corticosteroids, beta blockers, cold and flu remedies, and certain antidepressants also can interfere with sleep.
1. Sleep apnea
The conventional image of sleep apnea is of the overweight man who snores, but women of any size can also develop these repeated pauses in breathing while they sleep.
"A woman who has a narrow jaw or a change in muscle tone can get apnea," says Dr. Julia Schlam Edelman, clinical instructor in obstetrics and reproductive biology at Harvard Medical School and author of "Successful Sleep Strategies for Women and Menopause Matters: Your Guide to a Long and Healthy Life." Either of these anatomical issues can block oxygen from reaching your lungs (and subsequently the rest of your body) while you sleep. Snoring might not be your main symptom if you do have sleep apnea, but you will notice that you're especially sleepy during the day.
Solution: See a specialist for a sleep study. You may be able to relieve apnea with a few lifestyle adjustments, such as sleeping on your side or losing weight. Your doctor might also suggest an oral appliance or a CPAP machine that blows air into your airways to keep them open at night.
2. Diet
What you eat can affect your sleep. Spicy foods can contribute to painful heartburn. Big meals leave you uncomfortably full, and over time can contribute to obesity--a well-known risk factor for sleep apnea. Too much caffeine could keep you wide awake, even if you finish your coffee in the morning.
"It takes six hours to clear half of the caffeine from your body. If you have enough caffeine, it's still in your body at 4 in the morning," says Dr. Edelman. And though a glass of wine or two with dinner will make you feel relaxed or even sleepy, it won't help you sleep. "You can fall asleep, but once you're asleep you can't sleep deeply," she says.
Solution: Eat dinner at least a couple of hours before bedtime, and keep the meal light. Avoid spicy, fatty foods, as well as alcohol and caffeine. Also, don't drink too many fluids before bed. Having to constantly get up to go to the bathroom can disrupt your sleep, too.
3. Lack of exercise
Sleep and exercise complement each other. Working out regularly can help you sleep better, and conversely, you're more likely to exercise if you get a good night's rest.
Solution: Exercise every day if you can, ideally in the morning. Doing a high-energy aerobic routine too close to bedtime can have the opposite of the intended effect, making you too energized to sleep. A gentle yoga stretch before bed probably won't hurt, though. It might even help you relax.
4. Pain
Arthritis aches or any other kinds of pain don't make for restful slumber. Conversely, a lack of sleep can increase your pain. Researchers believe that a lack of sleep may activate inflammatory pathways that exacerbate arthritis pain. Poor sleep can also make you more sensitive to the feeling of pain.
Solution: In addition to the pain remedies your doctor recommends, try using a heating pad or taking a warm bath before bed to soothe achy joints or muscles. Lying against a body pillow can put you in a more comfortable position while you sleep.
5. Restless legs syndrome
Women are twice as likely as men to have restless legs syndrome (RLS)--a condition that causes a creepy, crawly feeling and uncontrollable movements in the legs at night. It's often linked to hormonal changes early in life and during pregnancy, but RLS can continue as you get older. RLS isn't just miserably uncomfortable--researchers at Harvard have linked this condition to an increased risk for heart disease and depression in women.
Solution: Try simple interventions first. Exercise every day, take a hot bath before bed, massage your legs, and cut back on things that can make you jittery--like caffeine and tobacco. If these measures don't work, your doctor may recommend one of several medicines that reduce RLS symptoms--including ropinirole (Requip), pramipexole (Mirapex), rotigotine (Neupro), or gabapentin enacarbil (Horizant).
6. Depression
"Depression is a common compromiser of sleep, and it's much more common in women than in men," Dr. Edelman says. Women who are depressed may sleep more than usual, but their sleep isn't restful. Some of the antidepressants meant to counteract depression, particularly SSRIs, can also interfere with sleep.
Solution: See your primary care doctor, psychologist, psychiatrist, or therapist for help, which may include medications, talk therapy, or both. If your antidepressant seems to be keeping you awake, ask your doctor to switch you to another drug.
7. Stress
It's impossible to sleep when the weight of the day is pressing on you. Finding a sense of calm before bed isn't easy, especially when you can't unplug from the demands of your day.
Solution: Establish wind-down time. Do a quiet, relaxing activity before bed that doesn't involve a screen. Talk to a friend or family member, sew, or read a real book--not one on a backlit tablet device.
"Just allow yourself to have quiet time," Dr. Edelman adds. And don't sleep with your smartphone on your bedside table.
8. Poor sleep habits
Sometimes insomnia stems from long-ingrained behaviors, like staying up too late or engaging in stimulating activities before bed.
Solution: Follow a few basic sleep hygiene strategies. Go to bed and wake up at the same times each day. Keep your bedroom cool, dark, and comfortable. Use your bed for sleep and sex only. If you can't fall asleep within 15 minutes, get up and leave the bedroom. Read or do another quiet activity for 15 to 20 minutes until you get sleepy.
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Sunday, July 13, 2014

The CHD8 mutation was found to be a genetic link to Autism

A study found that the CHD8 mutation is a genetic link to autism.

In a collaboration involving 13 institutions around the world, researchers have broken new ground in understanding what causes autism. The results are being published in Cell magazine July 3, 2014: "Disruptive CHD8 Mutations Define a Subtype of Autism in Early Development."
"We finally got a clear cut case of an autism specific gene," said Raphael Bernier, the lead author, and UW associate professor in the Department of Psychiatry and Behavioral Sciences and the clinical director of the Autism Center at Seattle Children's.
Bernier said people with a mutation in the CHD8 gene have a very "strong likelihood" that they will have autism marked by gastrointestinal disorders, a larger head and wide set eyes.
In their study of 6,176 children with autism spectrum disorder, researchers found 15 had a CHD8 mutation and all these cases had similar characteristics in appearance and issues with sleep disturbance and gastrointestinal problems.
Bernier and his team interviewed all 15 cases with CHD8 mutations.
To confirm the findings, researchers worked with scientists at Duke University who do zebra fish modeling. The researchers disrupted the CHD8 gene in the fish and the fish developed large heads and wide set eyes. They then fed the fish fluorescent pellets and found that the fish had problems discarding food waste and were constipated.
Bernier said this is the first time researchers have shown a definitive cause of autism to a genetic mutation. Previously identified genetic events like Fragile X, which account for a greater number of autism cases, are associated with other impairments, such as intellectual disability, more than autism. Although less than half a percent of all kids will have this kind of autism related to the CHD8 mutation, Bernier said there are lots of implications from this study.
"This will be a game changer in the way scientists are researching autism," he said.
The results could lead the way to a "genetics-first approach" that could uncover hundreds more genetic mutations and lead to genetic testing. Genetic testing could be offered to families as a way of guiding them on what to expect and how to care for their child. Currently, autism is diagnosed based on behavior, said Bernier.
In the short term, Bernier said, clinicians can pay attention to the small population with this CHD8 mutation and provide targeted treatment.
Researchers say autism has currently been linked to different types of genetic events. The most commonly researched genetic events associated with autism are chromosomal re-arrangements, called "copy number variations," in which a chunk of chromosome is copied or deleted. But no one rearrangement affects more than 1 percent of all autism cases. While these copy number events are associated with autism, they do not have a definitive link, or as they say among researchers, a "strong penetrance."
Then there are genetic mutations in which a gene has been disrupted and is not creating the kind of protein it should create. The CHD8 gene mutation is the first gene mutation to show a very strong penetrance linked to a certain subtype of autism.
Read more here