Wednesday, September 11, 2019

An open letter to DSHS regarding tcup program.


Dear Governor Abbot and Dr. Hellerstedt,

I am a pediatric neurologist and epilepsy specialist practicing in Houston. I have experience with the TCUP for over 1 year and manage over 80 patients on cannabanoids (including Epidiolex). I am also a parent of a child with a neurogenetic disorder.

Today the DSHS will take public comment on a puzzling list of selected conditions where medical cannabis may be allowed in Texas.

While well-intentioned, the "list" appears to be far from ready to deploy. 
  •  Many illnesses are inexplicably omitted. One glaring omission in my 1 minute review is  ataxias. What is the evidentiary basis for inclusion the list?
  • Pediatric illnesses such as SMA and muscular dystrophies are listed under "Incurable Neurodegenerative Diseases with Adult Onset". Does the adult-pediatric division on the list imply that people with SMA (a pediatric illness) cannot get CBD until they are adults?  The distinction makes no biologic sense.
  • The specificity of this list is problematic. The era of genetic sequencing has opened our eyes to thousands of low denominator disorders that are progressive and incurable.  New conditions are genetically defined rapidly with daily changes. How often will DSHS update this list to keep pace? 
  • Many progressive degenerative disorders are still NOT diagnosed at a level of specificity demanded here.  For instance, people can have a leukodystrophy without a specific diagnosis.   There is no test for these conditions that, in sum, are not rare. If doctors cannot come to a genetic diagnosis, are patients not allowed to seek relief ? Do you really want to commit staff to review charts or trust the doctors?
  • The decision to treat should be one between a doctor and patient.  Conceptually, one wonders why DSHS is deciding that a person with Refsum disease is meritorious but not one with Rett Syndrome? 
Ultimately,  from a policy perspective the list will usher a blizzard of “what about me” requests and an understandable outpouring of accusations of arbitrary insensitivity.

Further, the list is an assault on the practice of medicine. Physicians can prescribe narcotics, chemotherapy and many other toxic agent. But, it seems odd that government will decide who has an incurable neurodegenerative disorder?

Perhaps the list should include a general statement allowing a physician to decide e.g. “All Other neurologic disorders of  genetic, inflammatory, oncologic, metabolic, vascular and/ or idiopathic etiology”? 

Dr. Rotenberg 

Tuesday, September 10, 2019

Texas Medical Cannabis - Does Your illness Qualify? The DSHS will decide.

What are Incurable Neurodegenerative Diseases? 


The DSHS will decide if you or your loved one's illness is important enough to qualify for medical cannabis. DSHS will decide if the condition incurable enough or degenerative enough.  Wow. 

Contact your legislator and governor. JR


Here is a link to the proposed rule 

https://www.dshs.state.tx.us/features/HB3703/proposed-rule.pdf



Notice of Public Hearing - Implementation of House Bill 3703

Proposed New Rule Relating to Designating Incurable Neurodegenerative Diseases

The Department of State Health Services (DSHS) will hold a public hearing to accept public comments on the proposed new rules to implement House Bill 3703, relating to designating incurable neurodegenerative diseases.
The public hearing will be from 1:00 p.m. to 3:00 p.m. on September 11, 2019, in the Moreton Building, Room M-100, Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756. If the time allotted does not accommodate the number of persons who register to speak on or before 3:00 p.m., DSHS will extend the public hearing to accommodate those registrants, however, that extension will only be until 5:00 p.m. on that date. 
The public hearing will be structured for the receipt of oral or written comments by interested persons. Individuals may present oral statements when called upon in order of registration. There will be no open discussion during the public hearing. Comment time for each individual will be determined by the total number of persons registered to speak in the time allotted.  If time permits, comments will be limited to 3 minutes per speaker but may be further limited by DSHS if more registrants need to be accommodated.

Saturday, September 07, 2019

Trans Cranial Electric Stimulation Tdcs Literature Library

Tdcs  involves the cortex and subcortical networks 

TDCS Article Library

 Often, patients ask me for the latest literature on transcranial direct stimulation.

 Here are links to my library of abstracts from PUBMED at the National Library of Medicine

 I update the site from time to time so please check back.

Dr Josh

Basics - https://en.wikipedia.org/wiki/Transcranial_direct-current_stimulation


Ataxia - LINK to articles on TDCS and ataxia

Autism - LINK to articles on autism and TDCS TES

Brain Injury - LINK to Brain Injury

Cerebral Palsy - LINK to CP Articles

Monday, August 19, 2019

TransCranial Electrical Stimulation - tDCS tACS - What is it?

What is Transcranial Direct Current Stimulation (tDCS)?

Transcranial direct current stimulation (tDCS), is a non-invasive, painless brain stimulation treatment that uses direct electrical currents to stimulate specific parts of the brain.

The therapy works by delivering a low intensity electrical current to part of the brain responsible for abnormal pain sensation. This constant, low intensity current is passed through two electrodes placed over the head which modulates neuronal activity.
The treatment is not surgical and drug free. 
There are two types of stimulation with tDCS: anodal and cathodal stimulation. Anodal stimulation acts to excite neuronal activity while cathodal stimulation inhibits or reduces neuronal activity.

Is Transcranial Direct Current Stimulation (tDCS) Effective?

Recent studies support a therapeutic potential of tDCS in patients with:
  • Ataxia
  • Fibomyalgia
  • Dysautonomia
  • Brain injury
  • Disorders of Consciousness
  • Migraine
  • Dyslexia
  • Spasticity
  • Cerebral Palsy

Chronic neuropathic pain, Parkinson, stroke recovery, tinnitus (ringing in the ears), traumatic spinal cord injury, depression and other illnesses.
TES treatments are complementary - that is they are used after standard therapies have failed.
 tDCS devices have not been approved by the FDA for this application.
Although tDCS is still an evolving form of brain stimulation, it potentially has several advantages over other brain stimulation techniques. It is cheap, non-invasive, painless and safe. It is also easy to administer and the equipment is easily portable.


Thursday, August 15, 2019

Low THC CBD now available in Texas for more conditions.

Low-THC CBD has arrived for more conditions. 

Important news for people and families living with: 
  • Autism
  • Spasticity
  • Epilepsy
  • ALS
  • MS 
The Texas Legislature recently enacted HB 3703  providing additional medical conditions for which low-THC cannabis may be prescribed and increasing the respective specialties in which prescribing physicians may practice.

The Compassionate Use Registry of Texas (CURT) has undergone the modifications necessary to allow prescriptions for the additional medical conditions. 

Autism and spasticity are among these indications.  ANY patient with epilepsy or seizures may be considered.

Dr. Rotenberg is registered with TCUP and I have extensive experience with these agents in children with epilepsy.

If you are interested in learning more. Please speak to Kara Schmidt PA or to me at the next visit.

Dr. Rotenberg

Board Certified in Epilepsy, Brain Injury and Sleep Medicine

Tuesday, May 07, 2019

Medical Cannabis - CBD in Texas goes to the Senate After HB 1365 Passes House

Might Low THC cannabis help someone you love with  medical conditions like cancer, autism, PTSD, Alzheimer’s, Parkinson’s, Huntington’s, Tourettes, Crohn’s, multiple sclerosis and muscular dystrophy? 

Call your Texas senator, LtGovernor, Governor to express your opinion. - JR


By Natalie Hee, FOX 26 News
Posted May 07 2019 11:17AM CDTVideo Posted May 06 2019 10:23PM CDT Updated May 07 2019 11:28AM CDT

HOUSTON (FOX 26) - A rare type of epilepsy is the only way medical cannabis is prescribed in the state. One Houston family says it saved their daughter’s life and now they’re pushing for a bill to help people with other types of conditions.

Lora Taylor says her 37-year-old daughter, Julie, has intractable epilepsy and used to have an average of up to 95 seizures a month. Julie has tried 26 of the 28 medications suitable for her condition. Her options seemed to be running thin until she was prescribed CBD oil by her pediatric neurologist in September.

“I had never seen anything work that well, that effectively in really in 36 years. Most of her seizures were anywhere from 3 to 25 minutes. But after the first 30 days using the CBD oil, that was reduced to two 10-second seizures,” Taylor said.

Over the last eight months, Taylor said there's been dramatic improvement in the frequency and severity of Julie's seizures. She says not only has her mobility improved, Julie’s now able to sleep through the night.

“She used to not be able to move her arms or put her arms down at all,” Taylor said.

Julie's rare form of epilepsy is currently one of the only qualifying types of debilitating medical conditions eligible for medical cannabis under state law.

House Bill 1365, authored by Representative Eddie Lucio, would expand eligibility to include patients with other debilitating medical conditions like cancer, autism, PTSD, Alzheimer’s, Parkinson’s, Huntington’s, Tourettes, Crohn’s, multiple sclerosis and muscular dystrophy. The bill would also establish a Cannabis research program and review board.

Dr Joshua Rotenberg, a pediatric neurologist who specializes in epilepsy, said the low-THC cannabis isn't a one-size-fits-all answer for these conditions. He said the success rate can vary from patient to patient but rather, it's having the option available for families like the Taylors who feel like they're running out of time.

“Instead of being hung up about the diagnoses, it opens it up for discussion and application,” Dr. Rotenberg said.

HB 1365 was voted and approved by the House Monday. The bill will head to the Senate next for consideration.



VIDEO HERE

Saturday, April 06, 2019

Treatment for Ataxia - TDCS

A treatment where there are none. JR


Cerebello-spinal tDCS in ataxia

A randomized, double-blind, sham-controlled, crossover trial

https://n.neurology.org/content/91/12/e1090

Conclusions A 2-week treatment with cerebello-spinal tDCS reduces symptoms in patients with ataxia and restores motor cortex inhibition exerted by cerebellar structures. Cerebello-spinal tDCS might represent a promising future therapeutic and rehabilitative approach in patients with neurodegenerative ataxia, still an orphan disorder of any pharmacologic intervention.

https://n.neurology.org/content/91/12/e1090