Thursday, March 19, 2020

Pediatric Neurology Services at Home During Corona / Covid -19

Image result for covid 19 child
Social Distancing Saves Lives in Child Neurology Too
19 March 2020

To: HSC Neurology Patients
Subject: Dr. Rotenberg, Kara Schmidt, Testing and EEG  - Appointments during Coronavirus Emergency 
  • The State of Texas is in the midst of a public health emergency due to coronavirus. 
  • It is imperative to “flatten the curve” of this pandemic by practicing strict social distancing. 
  • Our practice is committed to our patients' needs. 
  • We need to make changes to safely deliver care under these unusual circumstances. 
  • Telemedicine visits are an established part of our practice.  It's business as usual. 
Therefore, effective immediately: 
  1. All appointments will be moved to telemedicine status ONLY. 
  2. New patients will be completed by telemedicine ONLY
  3. Most testing, dietician consults will be completed by telemedicine.  
  4. There will be very few exceptions based on medical need. 
  5. EEG visits will be rescheduled to a different time or place. 
Regarding pulmonary:  Dr. Susarla to release updated guidelines later today. 

This process will stay in place during the course of this emergency. 

Please call your insurance and/or employer to check telemedicine benefits. 

Thank you, 

Dr. Rotenberg 

Information on Covid19

Texas Telemedicine

Governor Abbott Waives Certain Regulations For Telemedicine Care In Texas

March 17, 2020 | Austin, Texas | Press Release
Governor Greg Abbott today waived certain regulations and directed that the Texas Department of Insurance (TDI) issue an emergency rule, all relating to telemedicine care for patients with state-regulated insurance plans to help doctors across Texas continue to treat their patients while mitigating the spread of COVID-19. The suspensions and emergency rule will work together to allow telemedicine visits for patients with state-regulated plans to be paid the same as in-office visits for insurance purposes. These actions build upon waivers the Governor issued last week of portions in the Occupations Code to expand provider flexibility in providing medical services over the phone.
“As the State of Texas responds to COVID-19, we continue to work to maintain regular health care services and operations throughout the state, and telemedicine is one of the most valuable tools we have to ensure Texans continue to receive the health services they need,” said Governor Abbott. “Expanding telemedicine options will help protect the health of patients and health care professionals, and help Texas mitigate the spread of COVID-19.”
Doctors will be eligible for payment from insurance plans regulated by TDI for medical visits they conduct over the phone instead of in-person at the same rate they would receive for in-person visits. 
Medical providers seeking guidance on the impact of the new rule can expect guidance from the Texas Medical Board to be issued in the coming days, including administrative guidance for billing to ensure that claims are processed smoothly.
Insurers seeking guidance on implementation of the emergency rule should contact TDI or visit their webpage for more information.
This coordinated efforts between the Office of the Governor, the Texas Department of Insurance, the Texas Medical Board, and health insurance plans will increase access to health care for all Texans. Today’s action will expand telemedicine options by giving health care providers greater flexibility to perform audio-only telephone consultations with their patients.
As a reminder, Texans covered by CHIP or Medicaid will not be charged copays for test or telemedicine consults. Individuals covered by Medicare or large employer plans should check with their health plan administrator to determine their specific benefits. 

Wednesday, March 18, 2020

Epilepsy & Covid-19 Coronavirus

Epilepsy Coronavirus Covid-19 -  A great site from the Epilepsy Foundation

FB meetup on 18 March

Concerns About COVID-19 (Coronavirus) and Epilepsy

  • Are people with epilepsy at higher risk of developing COVID-19 (coronavirus)?
  • Can COVID-19 increase seizures if a person gets the virus?
  • How can I get more medicine if my health care provider prescribes it?
  • Are there shortages in seizure medicines in the United States?
  • If COVID-19 is in my community, what should I do?
  • How do I protect myself from getting sick?
  • We are Here for You!

Wednesday, March 04, 2020

Magnesium, tics, Tourette syndrome

Magnesium Tourette Syndrome and Tics

I often have questions about magnesium for tics and Tourette’s syndrome.

 One open label study showed benefit using IV magnesium with B6. It appears that a double blind placebo controlled trial was planned but results have not been published.

One must keep in mind that the potential side-effects of high doses of magnesium are probably unsafe and that magnesium itself can have side effects.

So, is the Research promising? Yes.
Do I recommend IV magnesium for tics? Normally, no. There are too many risks.
Screen for magnesium or zinc deficiency in at-risk children? I think so.

Articles on pubmed are here often have questions about magnesium for ticks and Tourette’s syndrome.

Saturday, February 29, 2020

Monday, February 10, 2020

A book for Siblings of Kids with Special Needs - "I am Special Too"

Image result for i am special too noah rubinson
I just got my copies. Wow!

Picture the life of a child with special needs. What do you see? Frequent trips to the doctor? Simple everyday activities made significantly more difficult by irreversible developmental delays? A young boy or girl struggling to navigate the world, weighed down by a disability over which they have no control?
Now visualize the daily struggles of that child's family members. Is the child's mother or father forced to leave the workforce to raise their son or daughter? 

Dr Josh Rotenberg Houston Top Child Neurologist - 6 Years in a Row

Gratified to be chosen as a Top Doctor for the Houston Texas Region. 
Dr. Rotenberg selected by peers for top pediatric neurology in Houston Texas
2020 Top Pediatric Neurology Houston TX

2018 Top Child Neurology - Houston

2019 Top Child Neurologist - Houston Texas

Tuesday, February 04, 2020

Autism, Cognitive Impairment Genetics - ZNF292 Variants in NeuroDevelopmental Disorders

This disorder has incomplete penetrance and a
MRI findings 

Features of ZNF292 neurodevelopmental disorder
very broad spectrum of presentation from ADD/ADHD to autism and cognitive impairment. The gene can be medically relevant. - JR

P.s. Thankful that I could contribute

De Novo and Inherited Variants in ZNF292 Underlie a Neurodevelopmental Disorder With Features of Autism Spectrum Disorder

Article here


Purpose: Intellectual disability (ID) and autism spectrum disorder (ASD) are genetically heterogeneous neurodevelopmental disorders. We sought to delineate the clinical, molecular, and neuroimaging spectrum of a novel neurodevelopmental disorder caused by variants in the zinc finger protein 292 gene (ZNF292).
Methods: We ascertained a cohort of 28 families with ID due to putatively pathogenic ZNF292 variants that were identified via targeted and exome sequencing. Available data were analyzed to characterize the canonical phenotype and examine genotype-phenotype relationships.
Results: Probands presented with ID as well as a spectrum of neurodevelopmental features including ASD, among others. All ZNF292 variants were de novo, except in one family with dominant inheritance. ZNF292 encodes a highly conserved zinc finger protein that acts as a transcription factor and is highly expressed in the developing human brain supporting its critical role in neurodevelopment.
Conclusion: De novo and dominantly inherited variants in ZNF292 are associated with a range of neurodevelopmental features including ID and ASD. The clinical spectrum is broad, and most individuals present with mild to moderate ID with or without other syndromic features. Our results suggest that variants in ZNF292 are likely a recurrent cause of a neurodevelopmental disorder manifesting as ID with or without ASD.
Keywords: ZNF292; autism spectrum disorders; exome sequencing; intellectual disability; next-generation sequencing.
“ZNF292 encodes a highly conserved zinc finger protein that acts as a transcription factor. ZNF292 is composed of eight exons, the last of which is the largest and encodes all 16 highly conserved zinc fingers of the predicted 2723-residue protein (canonical transcript in GenBank: NM_015021.2). Three of these zinc fingers (10–12) bind DNA at the promoter of growth hormone where it cooperates with POU1F1, a member of the POU family of transcription factors known to activate transcription in somatotrophs.5 Accordingly, the ZNF292 protein was originally described as an enhancer of growth hormone (GH) expression in the pituitary gland of a rat animal model.5 Its role was further delineated as a tumor suppressor with critical roles in tumor development and progression.6 However, the role of ZNF292 in neurodevelopment is virtually unknown.”

Ghayda M. Mirzaa, MD 1,2,3, Jessica X. Chong, PhD2,3, Amélie Piton, MD4,5, Bernt Popp, MD6, Kimberly Foss, MS1, Hui Guo, PhD7, Ricardo Harripaul, MSc8,9, Kun Xia, PhD7, Joshua Scheck, BS1, Kimberly A. Aldinger, PhD1, Samin A. Sajan, PhD10, Sha Tang, PhD11, Dominique Bonneau, MD, PhD12,13, Anita Beck, MD, PhD2, Janson White, PhD14, Sonal Mahida, MGC, CGC15, Jacqueline Harris, MD15, Constance Smith-Hicks, MD, PhD15, Juliane Hoyer, MD6, Christiane Zweier, MD, PhD6, André Reis, MD6, Christian T. Thiel, MD6, Rami Abou Jamra, MD16, Natasha Zeid, MS, CGC17, Amy Yang, MD18,
Laura S. Farach, MD19, Laurence Walsh, MD20, Katelyn Payne, MS, CGC20, Luis Rohena, MD21,22,
Milen Velinov, MD, PhD23, Alban Ziegler, MD12,24, Elise Schaefer, MD, PhD25,
Vincent Gatinois, MD, PhD26,27,28, David Geneviève, MD, PhD26,27,28, Marleen E. H. Simon, MD29, Jennefer Kohler, MS30, Joshua Rotenberg, MD31, Patricia Wheeler, MD32, Austin Larson, MD33, Michelle E. Ernst, MS, CGC34, Cigdem I. Akman, MD34,35, Rachel Westman, MS, CGC36,
Patricia Blanchet, MD27, Lori-Anne Schillaci, MD37, Catherine Vincent-Delorme, MD38,
Karen W. Gripp, MD39, Francesca Mattioli, PhD40, Gwenaël Le Guyader, MD, PhD41,
Bénédicte Gerard, MD4, Michèle Mathieu-Dramard, MD42, Gilles Morin, MD43, Roksana Sasanfar, MD43, Muhammad Ayub, MD44, Nasim Vasli, PhD45, Sandra Yang, MS, CGC46, Rick Person, PhD46,
Kristin G. Monaghan, PhD46, Deborah A. Nickerson, PhD14, Ellen van Binsbergen, M Gregory M. Enns, MBChB30,47, Annika M. Dries, BS30, Leah J. Rowe, MS, CGC33, Anne C. H. Tsai, MD33, Shayna Svihovec, MS, CGC33, Jennifer Friedman, MD48,49, Zehra Agha, MD50, Raheel Qamar, MD50, Lance H. Rodan, MD51,52, Julian Martinez-Agosto, MD, PhD53, Charlotte W. Ockeloen, MD54,
Marie Vincent, MD55, William James Sunderland, PhD56, Jonathan A. Bernstein, MD, PhD30,47, Undiagnosed Diseases Network, Evan E. Eichler, PhD14,58, John B. Vincent, PhD8,9,
University of Washington Center for Mendelian Genomics (UW-CMG), Michael J. Bamshad, MD2,3
1Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, WA, USA; 2Division of Genetic Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA; 3Brotman Baty Institute for Precision Medicine, Seattle, Washington, USA; 4Molecular Genetic Unit, Strasbourg University Hospital, Strasbourg, France; 5Institute of Genetics and Molecular and Cellular Biology, Université de Strasbourg, Illkirch, France; 6Institute of Human Genetics, University Hospital Elrangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany; 7Center for Medical Genetics & Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, Hunan, China; 8The Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health (CAMH), Toronto, ON, Canada; 9Institute of Medical Science, University of Toronto, Toronto, ON, Canada; 10Department of Clinical Genomics, Ambry Genetics, Aliso Viejo, CA, USA; 11WuXi NextCODE, Cambridge, MA, USA; 12Département de Biochimie et de Génétique, CHU d’Angers, Angers, France; 13UMR INSERM 1083 CNRS 6015, Angers, France; 14Department of Genome Sciences, University of Washington School of Medicine, Seattle, WA, USA; 15Department of Neurogenetics, Kennedy Krieger Institute, Baltimore, MD, USA; 16Institute of Human Genetics, University Medical Center Leipzig, Leipzig, Germany; 17Yale New Haven Health, New Haven, CT, USA; 18Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR, USA; 19Department of Pediatrics, McGovern Medical School at the University of Texas Health Sciences Center, Houston, TX, USA; 20Indiana University Health at Riley Hospital for Children, Indianapolis, IN, USA; 21Division of Genetics, Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX, USA; 22Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; 23New York State Institute for Basic Research in Developmental Disability, NY, Staten Island, USA; 24Service de Génétique Médicale, Centre hospitalier, Le Mans, France; 25Service de Génétique Médicale, Hôpitaux Universitaires de Strasbourg, Institut de Génétique Médicale d’Alsace, Strasbourg, France; 26Service de génétique clinique, Département de Génétique Médicale, Maladies Rares et Médecine Personnalisée, Strasbourg, France; 27Centre de Référence Maladies Rares Anomalies du Développement et Syndromes Malformatifs Sud-Ouest Occitanie Réunion, Hôpital Arnaud de Villeneuve, Montpellier, France; 28Université Montpellier, Unité Inserm U1183, Montpellier, France; 29Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands; 30Stanford Center for Undiagnosed Diseases, Stanford University, Stanford, CA, USA; 31Memorial Hermann Memorial City Medical Center, Houston, TX, USA; Arnold Palmer Hospital for Children, Orlando, FL, USA; 33Section of Genetics, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA; 34Institute for Genomic Medicine, Columbia University Irving Medical Center, New York, NY, USA; 35Division of Pediatric Neurology, Columbia University Irving Medical Center, New York, NY, USA; 36Division of Genetics, St. Luke’s Clinic, Boise, ID, USA; 37Department of Genetics and Genome Sciences, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; 38Service de Génétique Clinique Guy Fontaine Centre de référence maladies rares Anomalies du dévelopement, Hôpital Jeanne de Flandre Lille, Lille, France; 39Department of Pediatrics, AI duPont Hospital, DE, Wilmington, USA; 40Institut de Genetique et de Biologie Moleculaire et Cellulaire, Illkirch-Graffenstaden, Lille, France; 41Service de Génétique Clinique, Centre de compétence Maladies rares Anomalies du dévelopement, CHU de Poitiers, Poitiers, France; 42Service de Génétique Clinique Centre de référence maladies rares Anomalies du dévelopement, CHU Amiens-Picardie, Amiens, France; 43Children’s Medical Center, UMass Memorial Medical Center, Worcester, MA, USA; 44Department of Psychiatry, Queen’s University, Kingston, ON, Canada; 45Division of Clinical & Metabolic Genetics, Hospital for Sick Children, Toronto, ON, Canada; 46GeneDx, Gaithersburg, MD, USA; Division of Medical Genetics, Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford University, Stanford, CA, USA; 48Departments of Neurosciences and Pediatrics, University of California San Diego and Division of Neurology, Rady Children’s Hospital, San Diego, CA, USA;  Rady Children’s Institute for Genomic Medicine, San Diego, CA, USA; 50Department of Biosciences, COMSATS University, Islamabad, Pakistan; 51Division of Genetics and Genomics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA; 52Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA; 53David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; 54Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands; 55CHU de Nantes, Service de génétique médicale, Nantes, France; 56University of Washington Foundation Board, University of Washington, Seattle, WA, USA; 57NIH Undiagnosed Diseases Network, Office of the Director and the National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA; 58Howard Hughes Medical Institute, University of Washington, Seattle, WA, USA.

Sunday, February 02, 2020

Concussion in HS football - 1/14 per team in every practice or game?

Here is my math.:

If the risk of brain injury is one in 1000 per athletic exposure in high school football, and

there are approximately 70 players per team,

then the risk is about 1 in 14 per team per practice or game.

So, every 14 games or practices, one student will suffer a brain injury.

Girls soccer and boys ice hockey are not much better. But look at the, incidence of concussions in hockey GAMES vs practice.

Concussion in high school sports

Concussion Incidence and Trends in 20 High School Sports

Zachary Y. KerrAvinash ChandranAliza K. NedimyerAlan ArakkalLauren A. Pierpoint and Scott L. Zuckerman


BACKGROUND: Ongoing monitoring of concussion rates and distributions is important in assessing temporal patterns. Examinations of high school sport-related concussions need to be updated. This study describes the epidemiology of concussions in 20 high school sports during the 2013–2014 to 2017–2018 school years.
METHODS: In this descriptive epidemiology study, a convenience sample of high school athletic trainers provided injury and athlete exposure (AE) data to the National High School Sports-Related Injury Surveillance Study (High School Reporting Information Online). Concussion rates per 10 000 AEs with 95% confidence intervals (CIs) and distributions were calculated. Injury rate ratios and injury proportion ratios examined sex differences in sex-comparable sports (soccer, basketball, baseball and softball, cross country, track, and swimming). We also assessed temporal trends across the study period.
RESULTS: Overall, 9542 concussions were reported for an overall rate of 4.17 per 10 000 AEs (95% CI: 4.09 to 4.26). Football had the highest concussion rate (10.40 per 10 000 AEs). Across the study period, football competition-related concussion rates increased (33.19 to 39.07 per 10 000 AEs); practice-related concussion rates decreased (5.47 to 4.44 per 10 000 AEs). In all sports, recurrent concussion rates decreased (0.47 to 0.28 per 10 000 AEs). Among sex-comparable sports, concussion rates were higher in girls than in boys (3.35 vs 1.51 per 10 000 AEs; injury rate ratio = 2.22; 95% CI: 2.07 to 2.39). Also, among sex-comparable sports, girls had larger proportions of concussions that were recurrent than boys did (9.3% vs 6.4%; injury proportion ratio = 1.44; 95% CI: 1.11 to 1.88).
CONCLUSIONS: Rates of football practice-related concussions and recurrent concussions across all sports decreased. Changes in concussion rates may be associated with changes in concussion incidence, diagnosis, and management. Future research should continue to monitor trends and examine the effect of prevention strategies.
  • Accepted August 7, 2019.

Sunday, January 26, 2020

Ricky Gervais - Its a Sneezing Tic

Dear 60 Minutes Australia, Mr. Woolley and Mr. Gervais, 

Its an instructive video for people suffering, and though unintended,  please don't needlessly add to stigma. #Tourette syndrome is not funny!

Most Respectfully, 

Dr Josh


Yes. Mr Gervais, neurologic problems are not funny. 

Sneezing Tics are uncommon

Asperger was a Nazi who killed children.

How about we stop honoring this Nazi collaborator and murderer? The Holocaust could not have happened without the collaboration of physicians who believed in  lebensunwertes Leben or “ life unworthy of life,”

University of Vienna’s Children’s Hospital
where Asperger worked 
 ”...protected children he deemed intelligent. But he also referred several children to Vienna’s Am Spiegelgrund clinic, which he undoubtedly knew was a centre of ‘child euthanasia’, part of what was later called Aktion T4. “