Monday, December 20, 2010

Office Move
Please note that the office is moving on 7 January.
We are moving just across the street!
The new address will be:
Memorial City Medical Plaza 1,
902 Frostwood, Suite 210, Houston, Texas 77024
There is covered free parking in garages that connect to the building on the East side and across Frostwood on the Westside.

Tuesday, December 14, 2010

Good news...Reappointed to Courtesy Staff at Texas Children's Hospital

Department of Neurology

Saturday, November 20, 2010

Dr. Rotenberg slected as expert curator for Organized Wisdom

Expert Curator Profile for Joshua Rotenberg MD

Selected by the OrganizedWisdom Medical Review Board as a top expert curator helping people discover the best health information online.
What the 2011 Physician Fee Schedule Final Rule means for your ability to receive quality health care coverage

This issue is relevant to anyone on Medicare or Tricare

OR anyone related to anyone on Medicare/Tricare

OR any one on an insurance indexed to Medicare (everyone with commercial insurance)....

Your access to quality health care may be in jeopardy unless Congress acts to halt cuts in payments for Medicare and TRICARE patients effective Jan. 1. With cuts averaging 30 percent, clinicians will have difficulty covering the costs of medical services. Physicians including your sleep specialist will be forced to cut costs and limit the number of Medicare and TRICARE patients that they see. The AASM needs your help to stop these cuts.

Tuesday, November 02, 2010

November is Epilepsy Awareness Month - Get Seizure Smart

Take the Quiz
Do you know what to do?
Find out How Seizure Smart You Are and Take the Quiz!

This November, for National Epilepsy Awareness Month, the Epilepsy Foundation is asking everyone to Get Seizure Smart about seizure first aid, recognition and types. Epilepsy affects people of all ages and races, and represents one percent of the population in this country—nearly 3 million people...

Friday, October 22, 2010

Botox Shots Approved for Migraine

The Food and Drug Administration on Friday approved Botox, the anti-wrinkle shot from Allergan, as a treatment to prevent chronic migraines.....

The agency’s decision endorses doctors’ use of Botox to treat patients who suffer from a severe form of migraine involving headaches on at least 15 days a month. Britain’sdrug agency approved Botox for the same use this summer.

Botox is already approved by the F.D.A. to treat uncontrolled blinking; crossed eyes; certain neck muscle spasms; excessive underarm sweating; and stiffness associated with muscle spasticity in the elbows and hands. It also is approved for cosmetic purposes — to smooth lines between the eyebrows.

Wednesday, October 13, 2010

Secondary Smoke Linked to ADHD in Children

By Rick Nauert PhD Senior News Editor
Reviewed by John M. Grohol, Psy.D. on October 11, 2010

Secondary Smoke Linked to ADHD in Children

New research suggests children exposed to secondhand smoke are at risk to develop a variety of mental and physical health problems.

Investigators presented findings that show significantly higher rates of attention deficit hyperactivity disorder (ADHD), headaches and stuttering among children exposed to secondhand smoke than those who are not exposed.


Tuesday, September 21, 2010

Rare condition sometimes mistaken for cerebral palsy

An Ontario mother refused to accept her infant had cerebral palsy and fought to get a second opinion. It turns out she was right: he had another, easily treatable disease called dopamine-responsive dystonia.
The condition is part of a group of illnesses that cause repetitive and painful muscle contractions. It can be mistaken for cerebral palsy, but unlike CP, this condition can be treated, if patients get the right diagnosis.
At three months of age, Corinne Fewster-Gagne's son Beckham started showing symptoms of clenched fists, painful stiffness, and uncontrollable crying.
"I was shocked," she told CTV News. "The only question I could think to ask at the time was, 'Is my son ever going to be able to walk?'"
She refused to accept the diagnosis and searched for a second opinion.....

Educational Note - Children can have movement disorders that mimic CP. JR

Another video...!

Monday, September 20, 2010

After this weekend's terrible loss of a young Texan with a history of seizures , many patients and parents will have questions. While no answers are known about this individual, I thought to post two links for educational purposes.

My personal thoughts are for his family, friends and their entire community. Dr R.

Unmasking Silent Killer in Epilepsy

On July 9, 2009, Steve Wulchin went to wake his 19-year-old son, Eric, in their home in Boulder, Colo. Eric had been given a diagnosis of epilepsy three years earlier, but other than that, his father said, “there was nothing out of the ordinary.” His seizures had been well controlled; he had not had one in six months.

Yet that morning, Mr. Wulchin found Eric lying on the floor. CPR and paramedics were too late; Eric had died at about 2:30 a.m.

The cause of Eric’s death was ultimately listed as Sudep, for sudden unexplained death in epilepsy. The syndrome accounts for up to 18 percent of all deaths in people with epilepsy, by most estimates; those with poorly controlled seizures have an almost 1 in 10 chance of dying over the course of a decade.

Yet many patients and their families never hear about Sudep until someone dies. Mr. Wulchin said none of Eric’s four neurologists ever mentioned it to the family.

“The message we got back was, ‘There’s no reason why he can’t live a long and normal life,’ ” he said. “It never occurred to me that this was a possibility.”

Now, physicians, researchers, advocates and relatives like Mr. Wulchin, a technology executive, are trying to raise awareness about Sudep. One of their goals is to establish registries of deaths and autopsy results, building databases to support future research.

Sudep most often affects young adults, typically ages 20 to 40, with a history of the convulsive seizures once known as “grand mal.” Others at risk include those with difficult-to-control seizures, or seizures at night; people who take a large number of anti-epileptic medications or take them irregularly; African-Americans with epilepsy; and people with epilepsy whose I.Q. is under 70......more....

What is SUDEP? Sudden Unexplained Death in Epilepsy

In 1868 Bacon, an eminent physician, noted the occurrence of ‘sudden death in a fit’ and almost 40 years later Spratling, one of the earliest American neurologists, recognised epilepsy as ‘a disease which destroys life suddenly and without warning through a single brief attack.’ Despite this, in the 1960’s it was suggested that ‘there is no reason why …someone with epilepsy… should not live as long as he would if he did not have epilepsy’ (Livingstone 1963). SUDEP is sudden unexpected death in someone with epilepsy, who was otherwise well, and in whom no other cause for death can be found, despite thorough post mortem examination and blood tests. The definition excludes people dying in status epilepticus and those who drown.

Awareness of SUDEP has increased over recent years, yet in many countries the medical profession has been reluctant to consider SUDEP. Indeed, there is little information on the number of cases in different countries. It has been estimated that the risk of sudden death is almost 24 times higher than for someone without epilepsy. Most people with newly diagnosed epilepsy will stop having seizures, and SUDEP is very rare amongst them. Searching for risk factors in this group would require meticulous follow up of large numbers of people. Studies of SUDEP have therefore usually been conducted in groups of people with more severe forms of epilepsy, such as specialist clinic populations, hospital inpatients or residential groups. The risk of SUDEP is elevated in these populations. It is estimated as between 1:500 and 1:1000 patient-years in community based populations with epilepsy, and even higher in people considered for surgery.

Sunday, September 19, 2010

Obesity and Disturbed Sleep -Eat less, Move more, SLEEP More - Dr. Josh Rotenberg comments on new research on WABC News

Insufficient sleep increases the risk of obesity.

  • Both body and brain need quality sleep.

Sleep must be of adequate quantity and quality.

Watch for the the vicious circle

  • reduced sleep can increase body weight

  • increased weight can cause sleep apnea

  • sleep apnea fragments and reduces sleep

    Breaking the vicious cycle can help with weight loss. (tie in Denzel?)

If your child has a weight problem

  • Maintain a healthy and firm sleep schedule

  • Turn off video games, computer TV after dark

  • Make behavioral change a family project

  • Keep a sleep diary

  • Watch for a sleep problem

  • Call your physician for further testing

Friday, September 10, 2010

Concussions cause mild traumatic brain injury. Watch this instructional video

Knocks to the head may seem funny in cartoons, sports replays, and YouTube videos, but even minor head injuries often lead to serious concussions. A concussion may leave no trace on a conventional MRI scan yet cause permanent memory loss, attention problems, and depression. NOVA scienceNOW investigates promising new leads in understanding this puzzling condition, which affects millions of people in the U.S., including many high-school and college athletes who suffer concussions yet are encouraged to return to the playing field.

Monday, September 06, 2010

Does your child have a weight problem? Make sure they have sufficient sleep.
Children who sleep less than 8 hours, snack more and take in more fat and carbohydrates.
Actigraphy is a procedure performed in my office every day. JR

The Association of Sleep Duration with Adolescents’ Fat and Carbohydrate Consumption

Allison Weiss1; Fang Xu, MS1; Amy Storfer-Isser, MS1; Alicia Thomas, MS, RD, LD1; Carolyn E. Ievers-Landis, PhD2; Susan Redline, MD, MPH1

Study Objectives: To investigate the relation between sleep duration and energy consumption in an adolescent cohort.
Design: Cross-sectional.
Setting: Free-living environment.
Participants: Two hundred forty adolescents (mean age 17.7 ± 0.4 years).
Measurements and Results: Daily 24-hour food-recall questionnaires and wrist-actigraphy measurements of sleep duration were employed to test the hypothesis that shorter weekday sleep duration (< p =" 0.004)" p =" 0.001).">Conclusion: Quantitative measures of macronutrient intake in adolescents were associated with objectively measured sleep duration. Short sleep duration may increase obesity risk by causing small changes in eating patterns that cumulatively alter energy balance.
Keywords: Sleep duration, diet, obesity, adolescents, 24-hour food recall

Citation: Weiss A; Xu F; Storfer-Isser A; Thomas A; Ievers-Landis CE; Redline S. The association of sleep duration with adolescents’ fat and carbohydrate consumption. SLEEP 2010;33(9):1201-1209.

Temple Grandin - Conversations from Penn State

Temple Grandin, one of the most internationally recognized autistics and a renowned expert in animal science talks about her life with autism and its influence on her work. She also discusses the new HBO movie based on her autobiography

This is a fantastic interview that covers many areas of Dr. Grandin's expertise in autism and animal behavior.

For parents of children with autism, I highly recommend her books and interviews. As an auditory learner, I am fascinated by how she thinks.

Saturday, September 04, 2010

Comorbidity between epilepsy and sleep disorders.

This article reminds me to think about the broader illness experience in people with epilepsy. JR

Comorbidity between epilepsy and sleep disorders.

Manni R, Terzaghi M.

Epilepsy Res. 2010 Aug;90(3):171-7. Epub 2010 May 31.

Sleep Medicine and Epilepsy Unit, IRCCS C. Mondino National Institute of Neurology Foundation, Via Mondino 2, Pavia, Italy.


Despite being relatively common and potentially able to have clinical and pathophysiological consequences, the comorbidity between epilepsy and sleep disorders is poorly investigated in the literature and rarely taken into consideration by clinicians in general practice. There is increasing evidence that obstructive sleep apnoea (OSA) coexists in epilepsy (in 10% of unselected adult epilepsy patients, 20% of children with epilepsy and up to 30% of drug-resistant epilepsy patients). A few lines of evidence suggest that continuous positive airway pressure treatment of OSA in epilepsy patients improves seizure control, cognitive performance and quality of life. Parasomnias and epileptic seizures can coexist in the same subject making the differential diagnosis of these conditions particularly challenging. In childhood, a frequent association between epilepsy and NREM arousal parasomnias, enuresis and rhythmic movement disorder has been documented. A particular pattern of association has been found between nocturnal frontal lobe epilepsy (NFLE) and NREM arousal parasomnias, the latter being found in the personal or family history of up to one third of NFLE patients. As far as REM parasomnias are concerned, REM sleep behaviour disorder, unrecognised or misdiagnosed, has been found to co-occur in 12% of elderly epilepsy patients. Patients with epilepsy often complain of poor, non-restorative sleep; however, insomnia in epilepsy is poorly investigated, with the literature giving conflicting prevalence data and no information on the impact of this disorder on seizure control, or on the best therapeutic approach to insomnia in this particular group of patients. A greater awareness, among clinicians, of the comorbidities between sleep disorders and epilepsy may help to prevent misdiagnosis and mistreatment. Sleep hygiene measures in epilepsy need to be more comprehensive, taking into account the various pathologies that may underlie disordered sleep in epilepsy patients.

PMID: 20570109

Tuesday, August 31, 2010

Family sleep center order form

  • Pediatric outpatient sleep study request
  • Home sleep testing for adults
  • After hours EEG request

Pediatric Sleep Diary

Please print and fill out to bring to your physician

What is a Seizure Diary?

A seizure diary is a record of when seizures occur, and what happened during the attack. These can be recorded on any diary, spreadsheet or calendar (e.g. Google or a free "Gus' Pet Wash" promotional calendar). I have offered some basic requirements for a diary and links to sites with ready-made templates for seizure diaries. I welcome recommendatons and reviews! Dr. Rotenberg, Houston TX

What to record

In their simplest form, they consist of a "count" of seizures within a day, week, or month, which will let your doctor calculate the seizure frequency. More sophisticated diaries, however, can include information about other factors as well: - links to a FREE iphone app for a seizure diary - Many types of diaries in pdf form. Includes forms for infantile spasms. From the UK a pdf formdiary - A basic diary in excel form.

Nice sites sponsored by the makers of anticonvulsants -

From UCB there is a site on preparing for a physician visit. There is a detailed history form with a short diary -

From Eisai - From Lundbeck

Monday, August 30, 2010

What is Cerebral palsy

Central nervous system


Cerebral palsy is condition, sometimes thought of as a group of disorders that can involve brain and nervous system functions such as movement, learning, hearing, seeing, and thinking.

Ther are several different types of cerebral palsy, including spastic, dyskinetic, ataxic, hypotonic, and mixed.

Alternative Names

Spastic paralysis; Paralysis - spastic; Spastic hemiplegia; Spastic diplegia; Spastic quadriplegia


Cerebral palsy is caused by injuries or abnormalities of the brain. Most of these problems occur as the baby grows in the womb, but they can happen at any time during the first 2 years of life, while the baby's brain is still developing.

In some people with cerebral palsy, parts of the brain are injured due to low levels of oxygen (hypoxia) in the area. It is not known why this occurs.

Premature infants have a slightly higher risk of developing cerebral palsy. Cerebral palsy may also occur during early infancy as a result of several conditions, including:

  • Bleeding in the brain

  • Brain infections (encephalitis, meningitis, herpes simplex infections)

  • Head injury

  • Infections in the mother during pregnancy (rubella)

  • Severe jaundice

In some cases the cause of cerebral palsy is never determined.


Symptoms of cerebral palsy can be very different between people with this group of disorders. Symptoms may:

  • Be very mild or very severe

  • Only involve one side of the body or both sides

  • Be more pronounced in either the arms or legs, or involve both the arms and legs

Symptoms are usually seen before a child is 2 years old, and sometimes begin as early as 3 months. Parents may notice that their child is delayed in reaching, and in developmental stages such as sitting, rolling, crawling, or walking.

There are several different types of cerebral palsy. Some people have a mixture of symptoms.

Symptoms of spastic cerebral palsy, the most common type, include:

  • Muscles that are very tight and do not stretch. They may tighten up even more over time.

  • Abnormal walk (gait): arms tucked in toward the sides, knees crossed or touching, legs make "scissors" movements, walk on the toes

  • Joints are tight and do not open up all the way (called joint contracture)

  • Muscle weakness or loss of movement in a group of muscles (paralysis)

  • The symptoms may affect one arm or leg, one side of the body, both legs, or both arms and legs

The following symptoms may occur in other types of cerebral palsy:

  • Abnormal movements (twisting, jerking, or writhing) of the hands, feet, arms, or legs while awake, which gets worse during periods of stress

  • Tremors

  • Unsteady gait

  • Loss of coordination

  • Floppy muscles, especially at rest, and joints that move around too much

Other brain and nervous system symptoms:

  • Decreased intelligence or learning disabilities are common, but intelligence can be normal

  • Speech problems (dysarthria)

  • Hearing or vision problems

  • Seizures

  • Pain, especially in adults (can be difficult to manage)

Eating and digestive symptoms

  • Difficulty sucking or feeding in infants, or chewing and swallowing in older children and adults

  • Problems swallowing (at all ages)

  • Vomiting or constipation

Other symptoms:

  • Increased drooling

  • Slower than normal growth

  • Irregular breathing

  • Urinary incontinence

Exams and Tests

A full neurological exam is critical. In older people, testing cognitive function is also important.

The following other tests may be performed:

  • Blood tests

  • CT scan of the head

  • Electroencephalogram (EEG)

  • Hearing screen

  • MRI of the head

  • Vision testing


There is no cure for cerebral palsy. The goal of treatment is to help the person be as independent as possible.

Treatment requires a team approach, including:

  • Primary care doctor

  • Dentist (dental check-ups are recommended around every 6 months)

  • Social worker

  • Nurses

  • Occupational, physical, and speech therapists

  • Other specialists, including a neurologist, rehabilitation physician, pulmonologist, and gastroenterologist

Treatment is based on the person's symptoms and the need to prevent complications.

Self and home care include:

  • Getting enough food and nutrition

  • Keeping the home safe

  • Performing exercises recommended by the health care providers

  • Practicing proper bowel care (stool softeners, fluids, fiber, laxatives, regular bowel habits)

  • Protecting the joints from injury

Putting the child in regular schools is recommended, unless physical disabilities or mental development makes this impossible. Special education or schooling may help.

The following may help with communication and learning:

  • Glasses

  • Hearing aids

  • Muscle and bone braces

  • Walking aids

  • Wheelchairs

Physical therapy, occupational therapy, orthopedic help, or other treatments may also be needed to help with daily activities and care.

Medications may include:

  • Anticonvulsants to prevent or reduce the frequency of seizures

  • Botulinum toxin to help with spasticity and drooling

  • Muscle relaxants (baclofen) to reduce tremors and spasticity

Surgery may be needed in some cases to:

  • Control gastroesophageal reflux

  • Cut certain nerves from the spinal cord to help with pain and spasticity

  • Place feeding tubes

  • Release joint contractures

Stress and burnout among parents and other caregivers of cerebral palsy patients is common, and should be monitored.

Support Groups

For organizations that provide support and additional information, see cerebral palsy resources.

Outlook (Prognosis)

Cerebral palsy is a lifelong disorder. Long-term care may be required. The disorder does not affect expected length of life. The amount of disability varies.

Many adults are able to live in the community, either independently or with different levels of help. In severe cases, the person may need to be placed in an institution.

Possible Complications

  • Bone thinning or osteoporosis

  • Bowel obstruction

  • Hip dislocation and arthritis in the hip joint

  • Injuries from falls

  • Joint contractures

  • Pneumonia caused by choking

  • Poor nutrition

  • Reduced communication skills (sometimes)

  • Reduced intellect (sometimes)

  • Scoliosis

  • Seizures (in about half of patients)

  • Social stigma

When to Contact a Medical Professional

Call your health care provider if symptoms of cerebral palsy develop, especially if you know that an injury occurred during birth or early infancy.


Getting the proper prenatal care may reduce the risk of some rare causes of cerebral palsy. However, dramatic improvements in care over the last 15 years have not reduced the rate of cerebral palsy. In most cases, the injury causing the disorder may not be preventable.

Pregnant mothers with certain medical conditions may need to be followed in a high-risk prenatal clinic.


Johnston MV. Encephalopathies. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 598.

Whelan MA. Practice parameter: diagnostic assessment of the child with cerebral palsy: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2004;63:1985-1986.

Reid SM, Johnstone BR, Westbury C, Rawicki B, Reddihough DS. Randomized trial of botulinum toxin injections into the salivary glands to reduce drooling in children with neurological disorders. Dev Med Child Neurol. 2008;50:123-126.

Sakzewski L, Ziviani J, Boyd R. Systematic review and meta-analysis of therapeutic management of upper-limb dysfunction in children with congenital hemiplegia. Pediatrics. 2009;123:e1111-1122.

Review Date: 9/16/2009
Reviewed By: Daniel B. Hoch, PhD, MD, Assistant Professor of Neurology, Harvard Medical School, Department of Neurology, Massachusetts General Hospital; and Neil K. Kaneshiro, MD, MHA, Clinical Assistant Professor of Pediatrics, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

EEG (Electroencephalogram)

What It Is

An electroencephalogram (EEG) is a non-painful monitoring test used to detect abnormalities related to electrical activity of the brain. This procedure tracks and records brain wave patterns. Small metal discs with thin wires (electrodes) are placed on the scalp, and then send signals to a computer to record the results. Normal electrical activity in the brain makes a recognizable pattern. Through an EEG, doctors can look for abnormal patterns that indicate seizures and other problems.

Why It's Done

The most common reason an EEG is performed is to diagnose and monitor seizure disorders. EEGs can also help to identify causes of other problems such as sleep disorders and changes in behavior. EEGs are sometimes used to evaluate brain activity after a severe head injury or before heart or liver transplantation.


If your child is having an EEG, preparation is minimal. Your child's hair should be clean and free of oils, sprays, and conditioner to help the electrodes stick to the scalp.

Your doctor may recommend that your child stop taking certain medications before the test that can alter results.

It's often recommended that kids avoid caffeine up to 8 hours before the test. If it's necessary for your child to sleep during the EEG, the doctor will suggest ways to help make this easier including sleep deprivation.

The Procedure

An EEG can either be performed in an area near the doctor's office or at a hospital. Your child will be asked to lie on a bed or sit in a chair. The EEG technician will attach electrodes to different locations on the scalp using adhesive paste. Each electrode is connected to an amplifier and EEG recording machine.

The electrical signals from the brain are converted into wavy lines on a computer screen. Your child will be asked to lie still because movement can alter the results.

If the goal of the EEG is to mimic or produce the problem your child is experiencing, he or she may be asked to look at a bright flickering light or breathe a certain way. The health care provider performing the EEG will know your child's medical history and will be prepared for any issues that may arise during the test.

Most EEGs take about an hour to perform. If your child is required to sleep during it, the test will take longer. You might be able to stay in the room with your child, or you can step outside to a waiting area

What to Expect – No Pain, No Pain

An EEG isn't uncomfortable and patients do not feel any shocks on the scalp or elsewhere; however, having electrodes pasted to the scalp can be a little stressful for kids, as can lying still during the test.

Getting the Results

A neurologist (a doctor trained in nervous system disorders) will read and interpret the results. Though EEGs vary in complexity and duration, results are typically available in several days.


EEGs are very safe. If your child has a seizure disorder, your doctor might want to stimulate and record a seizure during the EEG. A seizure can be triggered by flashing lights or a change in breathing pattern.

Helping Your Child – Tap into their imagination

You can best ease your child through this procedure by “joining them” on an adventure of their choice. Perhaps they are going to the moon? The hair salon?

You can also help prepare your child for an EEG by explaining that the test won't be uncomfortable. You can describe the room and the equipment that will be used, and reassure your child that you'll be right there for support. Bring their favorite books or toys.

For older kids, be sure to explain the importance of keeping still while the EEG is done so it won't have to be repeated.

If You Have Questions

If you have questions about the EEG procedure, speak with your doctor. You can also talk to the EEG technician before the exam.

Sunday, August 29, 2010

J Child Neurol. 2010 Jul 20. [Epub ahead of print]

Do Patients With Absence Epilepsy Respond to Ketogenic Diets?

Groomes LB, Pyzik PL, Turner Z, Dorward JL, Goode VH, Kossoff EH.

The John M. Freeman Pediatric Epilepsy Center, The Johns Hopkins Hospital, Baltimore, MD, USA.


Dietary therapies are established as beneficial for symptomatic generalized epilepsies such as Lennox-Gastaut syndrome; however, the outcome for idiopathic generalized epilepsy has never been specifically reported. The efficacy of the ketogenic and modified Atkins diet for childhood and juvenile absence epilepsy was evaluated from both historical literature review and patients treated at Johns Hopkins Hospital. Upon review of 17 published studies in which absence epilepsy was included as a patient subpopulation, approximately 69% of 133 with clear outcomes patients who received the ketogenic diet had a >50% seizure reduction, and 34% of these patients became seizure free. At Johns Hopkins Hospital, the ketogenic diet (n = 8) and modified Atkins diet (n = 13) led to similar outcomes, with 18 (82%) having a >50% seizure reduction, of which 10 (48%) had a >90% seizure reduction and 4 (19%) were seizure free. Neither age at diet onset, number of anticonvulsants used previously, particular diet used, nor gender correlated with success.

PMID: 20647578 [PubMed - as supplied by publisher]