Thursday, December 15, 2016



HOUSTON (KTRK) -- The mother of a child with special needs is giving his bus driver and aide a huge thanks for helping him when he has seizures.

Duncan is 13 years old and attends Tanglewood Middle School. He can have several seizures per week, and has to wear a helmet to protect him from unexpected falls.

His mom Catherine tells Eyewitness News that his bus driver Miriam Alvarado and aide Julita Rodriguez make all the difference for him, constantly going the extra mile to make sure he gets to and from school safely.

"She came to our home the day before school began last year to meet us, to find out about Duncan's needs, to reassure us about his safety on the bus," Catherine Graham, Duncan's mother, said.

"The other day, he had too much seizure, he did not respond, so I stayed with him, she went inside the school to get the nurse," Rodriguez said.

Graham, however, says that Rodriguez and Alvarado went above and beyond, even after Duncan's seizure.

Saturday, December 10, 2016

Sleep apnea, Sleep Dept, Sleepiness INDEPENDENTLY linked to accidents

Truckers, Drivers ... Its not just the sleep apnea, its the sleepy brain that causes accidents. Compliance and adequate rest are essential to reduce risk. - JR

Sleep Apnea, Sleep Debt and Daytime Sleepiness Are Independently Associated with Road Accidents. A Cross-Sectional Study on Truck Drivers

    • Published: November 30, 2016
  • Background

    Recent research has found evidence of an association between motor vehicle accidents (MVAs) or near miss accidents (NMAs), and excessive daytime sleepiness (EDS) or its main medical cause, Obstructive Sleep Apnea (OSA). However, EDS can also be due to non-medical factors, such as sleep debt (SD), which is common among professional truck drivers. On the opposite side, rest breaks and naps are known to protect against accidents.

    Study Objectives

    To investigate the association of OSA, SD, EDS, rest breaks and naps, with the occurrence of MVAs and NMAs in a large sample of truck drivers.


    949 male truck drivers took part in a cross-sectional medical examination and were asked to complete a questionnaire about sleep and waking habits, risk factors for OSA and EDS.


    MVAs and NMAs were reported by 34.8% and 9.2% of participants, respectively. MVAs were significantly predicted by OSA (OR = 2.32 CI95% = 1.68–3.20), SD (OR = 1.45 CI95% = 1.29–1.63), EDS (OR = 1.73 CI95% = 1.15–2.61) and prevented by naps (OR = 0.59 CI95% = 0.44–0.79) or rest breaks (OR = 0.63 CI95% = 0.45–0.89). NMAs were significantly predicted by OSA (OR = 2.39 CI95% = 1.47–3.87) and SD (OR = 1.49 CI95% = 1.27–1.76) and prevented by naps (OR = 0.52 CI95% = 0.32–0.85) or rest breaks (OR = 0.49 CI95% = 0.29–0.82).


    When OSA, SD or EDS are present, the risk of MVAs or NMAs in truck drivers is severely increased. Taking a rest break or a nap appear to be protective against accidents.

Sleep Apnea and Accidents - New Jersey Train Crash

Sleep apnea is still a major cause of accidents in the work place and in transit.  Investigators need to look at this as a cause of accidents. - JR

Sleep apnea warning issued by regulators after deadly New Jersey train crash

NEW YORK - Federal regulators are urging railroads across the country to test train operators for obstructive sleep apnea after the engineer in September’s deadly New Jersey commuter train crash was found to have the fatigue-inducing disorder.
The Federal Railroad Administration (FRA) will issue a safety advisory, likely this week, stressing the importance of sleep apnea screening and treatment, CBS News correspondent Kris Van Cleave reportsOne railroad that already tests its engineers, Metro-North in the New York City suburbs, found that 1 in 9 suffers from sleep apnea.
Sleep apnea is especially troubling for the transportation industry because sufferers are repeatedly awakened and robbed of rest as their airway closes and their breathing stops, leading to dangerous daytime drowsiness. Studies have long concluded that people with the disorder have diminished performance in multiple areas during the daytime.
“You end up with an engineer who is so fatigued they’re dosing off, they’re falling asleep in these micro bursts and they often have no memory of it, and they’re operating a locomotive at the time, so they’re putting hundreds of people in danger,” Feinberg said.
Airplane pilots with sleep apnea aren’t allowed to fly unless they’ve been successfully treated. Regulators are also pushing for bus and truck drivers to get tested.
NJ Transit engineer Thomas Gallagher, 48, was diagnosed with severe sleep apnea about a month after his train slammed into Hoboken Terminal at double the 10 mph speed limit on Sept. 29, his lawyer said. One woman on a platform was killed by falling debris. More than 100 people were injured.
Gallagher had passed a physical in July and was cleared for duty, lawyer Jack Arsenault said. The engineer told investigators he felt fully rested when he reported to work. He said he had no memory of the crash and only remembered waking up on the floor of the engineer’s cab.

Monday, December 05, 2016

CBD / Cannabadiol reduces seizures in Dravet Syndrome

Side effects were frequently seen. Your epilepsy specialist should monitor effects on other anticonvulsants. - JR

Cannabidiol Reduces Seizure Frequency in Refractory Dravet Syndrome

Results of the phase 3, placebo-controlled trial support previous findings from an expanded-access program.
HOUSTON – Adjunctive treatment with cannabidiol reduces convulsive seizure frequency in patients with Dravet syndrome, according to results from a phase 3 study presented at the 2016 American Epilepsy Society Annual Meeting.
While efficacy has previously been demonstrated in this population in data reported from an expanded-access program, this is the first placebo-controlled trial examining the efficacy and safety of cannabidiol in refractory Dravet syndrome.

Sleep helps memory consolidation in children with autism AND neuro-typical controls.

Go to sleep right after reading this. You will remember it better.  - JR
"Sleep Helps Improve Memory Processing in Children with Autism Spectrum Disorders"

Sleep stabilizes the ability to consolidate memory in children with autism spectrum disorder (ASD) as it does with children with typical development, according to a new study presented at the Child Neurology Society annual meeting in National Harbor, MD.

However, when similar information is learned right before bedtime, children show more stable memory processing after a night of sleep. These findings highlight the importance of sleep for cognitive functioning, study author Kiran Maski, MD, a sleep specialist at Boston Children’s Hospital, told the Neurology Today Conference Reporter.

Children with autism forgot about 30 percent of what they had learned across the wake period but forgot only half as much across the sleep period. In contrast, children with typical development forgot 12 percent of what they had learned while awake. Remarkably, these controls improved their memory performance by 5 percent after a night of sleep, suggesting sleep can enhance memory consolidation.

The finding that sleep benefited both groups is surprising, given that children with autism had poorer sleep efficiency than controls (p<0 .001="" font="">

Interestingly, the ability to consolidate memories during sleep was associated with different sleep measures for the controls compared to those with autism. “In the controls, the amount of sleep was positively correlated with memory consolidation,” said Dr. Maski. However, a measure of deeper sleep (slow oscillation power in NREM sleep) was correlated with memory consolidation in the children with autism. “This suggests that sleep duration is more important for memory consolidation in those with typical development, but the quality of sleep may be more important for the children with autism,” she explained.

“The findings suggest a direct relationship between sleep and memory processing in children,” she added. “Our results suggest that improving sleep quality in children with autism could have direct benefits in improving their overall cognitive functioning.”

“We have lots of data telling us that loss of sleep makes people more irritable and less attentive. Brain activity and performance suffer when sleep is not good,” he added. “It is good that clinicians have studied this so people recognize the importance of a good night’s sleep for children, autistic or otherwise.”

  • Maski K, et al. Sleep dependent memory consolidation in children with autism spectrum disorder. Sleep 2015; Epub 2015 Jul 13:

#CBD #Cannabinoids can affect the levels of other anti-convulsants. Hemp Oil / CBD management will NOT be simple!

CBD Cannabinoids can affect the levels of other anti-convulsants. ITs NOT  straightforward.  - JR

Neurology Today Conference Reporter: AES Annual Meeting

Monday, December 5, 2016
Cannabidiol Found to Change Blood Levels of Other Anti-Epileptic Drugs
BY JAMIE TALAN                                    

HOUSTON—Cannabidiol oil can interact with anti-epileptic drugs (AEDs), altering their blood levels and potentially leading to adverse events, scientists at the University of Alabama in Birmingham (UAB) reported here Sunday at the annual meeting of the American Epilepsy Society.

"This is a new potential anti-epileptic drug, and if levels of other anti-epileptic medicines are changing, that is very important information," said Tyler Gaston, MD, an instructor in neurology at UAB who presented the findings. "We just don't know if all of the interactions noted will become clinically significant interactions. A perception exists that CBD is natural and safe, but this is why formal studies need to be done."

........ MORE HERE

The findings are part of a larger open-label treatment study led by UAB's Jerzy Szaflarski, MD, PhD, professor of neurology and director of the epilepsy center, and E. Martina Bebin, MD, professor of neurology.The state provided funding following passage of Carly's Law in 2015 that allowed the university to conduct the study. Parent groups led the way for the passage of the bill.

The scientists enrolled 39 adults and 42 children, all of whom were prescribed Epidiolex, a CBD oil manufactured by GW Pharmaceuticals. These patients continued to have seizures despite trying at least four AEDs. At the time of the study, they were taking an average of two AEDs. They kept daily seizure diaries, and every two weeks they traveled to the hospital for blood tests, including blood counts, liver function tests, and measurements of drug levels for each medication they were taking.

The CBD dose was titrated, starting at 5 mg/kg per day and increased to tolerability and seizure control every two weeks by 5 mg/kg per day up to a maximum of 50 mg/kg per day. The researchers had baseline data of blood levels for the AEDs the participants were taking; throughout the study the investigators adjusted the doses if they thought that there were drug-drug interactions.

Dr. Gaston said clobazam and valproate doses were frequently adjusted because of increasing sedation and/or alterations in liver function tests. The scientists looked for changes in serum levels of 19 AEDs as the dose of CBD was increased.

Serum levels of topiramate (p< 0.01), rufinamide (p< 0.01), and desmethyclobazam (p< 0.01), an active metabolite of clobazam, were increased. The researchers also found decreased levels of clobazam (p< 0.01) as the dose of CBD increased in children and adults. They also observed a significant increase in serum levels of zonisamide (p=0.02) and eslicarbazepine (p=0.04) as the CBD dose was increased in the adults only. In addition, increased reports of sedation were seen in adults with higher desmethylclobazam levels.



AES Abstract 2.208: Gaston T, Liu Y, Cutter G, et al. Drug interactions between pharmaceutical grade cannabidiol (CBD) oil and commonly used anti-epileptic drugs (AEDs).

Monday, November 28, 2016

BIG News: Dr. Rotenberg achieves Board Certification in Brain Injury Medicine

 I am very gratified to fill a void in pediatric neurology subspecialty care for Houston, Katy, Sugar Land, San Antonio, Seguin and surrounding areas.  - JR

Dr. Joshua Rotenberg achieved Board Certification in Brain Injury Medicine! 

"The subspecialty of BIM will focus on the prevention of brain injury and the evaluation, treatment, and rehabilitation of individuals with acquired brain injury.

BIM physicians provide a high level of care for patients with brain injury and their families in the hospital, postacute setting, and over the continuum of care to facilitate the process of recovery and improve medical and functional outcomes."

Joint administration by American Boards of Physical Medicine and Rehabilitation AND American Board of Psychiatry and Neurology.

Saturday, October 01, 2016

Constraint Induced Therapy improved function for up to 6 months in a randomized trial!



To investigate the long-term effects of home-based constraint induced therapy (CIT) on motor control underlying functional change in children with unilateral cerebral palsy (CP).


Randomized controlled trial.


Home based.


Children with unilateral CP (N=45; aged 6–12y) were randomly assigned to receive home-based CIT (n=23) or traditional rehabilitation (TR) (n=22).


Both groups received a 4-week therapist-based intervention at home. The home-based CIT involved intensive functional training of the more affected upper extremity during which the less affected one was restrained. The TR involved functional unimanual and bimanual training.

Main Outcome Measures

All children underwent kinematic and clinical assessments at baseline, 4 weeks (posttreatment), and 3 and 6 months (follow-up). The reach-to-grasp kinematics were reaction time (RT), normalized movement time, normalized movement unit, peak velocity (PV), maximum grip aperture (MGA), and percentage of movement where MGA occurs. The clinical measures were the Peabody Developmental Motor Scales, Second Edition (PDMS-2), Bruininks-Oseretsky Test of Motor Proficiency (BOTMP), and Functional Independence Measure for children (WeeFIM).


The home-based CIT group showed a shorter RT (P<.05) and normalized movement time (P<.01), smaller MGA (P=.006), and fewer normalized movement units (P=.014) in the reach-to-grasp movements at posttreatment and follow-up than the TR group. The home-based CIT group improved more on the PDMS-2 (P<.001) and WeeFIM (P<.01) in all posttreatment tests and on the BOTMP (P<.01) at follow-up than the TR group.


The home-based CIT induced better spatial and temporal efficiency (smoother movement, more efficient grasping, better movement preplanning and execution) for functional improvement up to 6 months after treatment than TR.

Friday, September 16, 2016

Houston Practice Pediatric Neurology/Sleep NP or PA - Make a Difference Every Day!

Nurse Practitioner (PNP, FNP) 
Physician Assistant


Houston Specialty Clinic - Neurology and Sleep Specialists, a regional leader in specialty care has experienced great demand. We offer academic quality care and personal access. We take care of people experiencing illness or seeking answers to specialty level concerns.

 Our practice is seeking an extender to offer an enhanced scale advanced specialty care in neurologic illness in children.

Job Summary: Under general direction, provides care in collaboration with the neurologist in the evaluation and treatment of pediatric neurologic illness and sleep disorders; serves as a resource person for staff; presents lectures, seminars, programs, or conferences; responsible for collaboration, facilitation, and implementation of research projects; provides direct clinical service to patients and families including psychosocial assessment, crisis intervention, counseling, supportive therapy, behavior modification, care management, and patient education.

While focusing on outpatient care, duties may include any and/or all of the following:

  1. Participates in delivering direct patient care; provides instructions and teaching to patients and families; assists in outpatient clinics with examinations and assessments; follows up on lab, test, and procedure results and prescriptions; informs patients of medication changes; informs physicians of patients' questions; evaluates patients' qualifications for clinical research studies; provides initial contact with patients' primary physician; establishes referral database; communicates with referring physicians for follow-up care and referrals.
  2. Collaborates with health care team members in planning, implementing, and evaluating comprehensive patient care; provides direct clinical service to patients and families including psychosocial assessment, crisis intervention, counseling, supportive therapy, behavior modification, care management, and patient education; develops patient programs for consumer relations and patient satisfaction issues; provides conflict resolution; May attend rounds in the hospital; consults and implements in-service programs and research protocols; researches improvements in patient management, including coordination between services and conservation of resources; facilitates and participates in meetings and projects.
  3. Serves as a resource person and a nurse consultant for staff; presents lectures, seminars, or conferences; collaborates, facilitates, and implements research projects; develops an annual plan for professional development; attends conferences; maintains and improves current knowledge and competency in advanced practice nursing;.
  4. Perform other duties as assigned.


  • Knowledge of clinical practice nursing
  • Verbal/written communication skills
  • Interpersonal/human relations skills
  • Patient assessment skills
  • Public speaking skills
  • Research skills
  • Ability to respond to questions in a tactful and professional manner
  • Ability to instruct/teach/tutor
  • Ability to maintain confidentiality


Education and experience equivalent to:

Masters degree in nursing and certification in specialty area of a Clinical Nurse Specialist or Nurse Practitioner; supplemented with two (2) years related experience. Texas RN License and certification as an Advanced Practice Nurse required.


TX PA licensure supplemented with two (2) years related experience

Physical Requirements – Typical for an outpatient clinic. May require some driving to satellite clinics.
Competitive Salary & Productivity Bonus Commensurate with Experience
HSC offers eligible employees a broad package of benefits such as health care, dental plan, vision plan, 401K.

Contact Dr Joshua Rotenberg
Fax 713-465-4522

Sunday, September 04, 2016

Hickey Causes Fatal Stroke in teen

Teenager dies from stroke 'caused by love bite from his girlfriend'


The hickey — or love bite — caused a blood clot, which traveled to his brain

Family blame older girlfriend, who has disappeared
A teenage boy has died from a stroke that is understood to have been caused by a love bite from his girlfriend
Julio Macias Gonzalez, 17, had convulsions while eating dinner with his family in Mexico City, after spending the evening with his 24-year-old girlfriend, local media reported.
Emergency services were called, but the boy died at the scene. 
According to Mexican media reports, doctors believe the suction of the love bite resulted in a blood clot, which travelled to Mr Gonzalez’s brain and caused the stroke.
The boy’s parents blamed his girlfriend for the death, and she is thought to be in hiding.

Saturday, September 03, 2016

What is an LP or a lumbar puncture? What is a spinal tap?

This is an excellent instructive video on what is an LP? What is a spinal tap?

What is a Lumbar Puncture

Watch this video to understand a lumbar puncture  Video here

Wednesday, August 31, 2016

Autism? Developmental Delay? Epilepsy? When to use Exome Sequencing - Now Official AAN Policy

Emerging in my practice in 2013, exome has now become an everyday child neurology practice tool like MRI.  - JR

Clinical Exome sequencing in neurologic disease

  1. Bruce H. Cohen, MD
  1. Correspondence to:
  1. Neurol Clin Practvol. 6 no. 2 164-176


Purpose of review: The landscape of genetic diagnostic testing has changed dramatically with the introduction of next-generation clinical exome sequencing (CES), which provides an unbiased analysis of all protein-coding sequences in the roughly 21,000 genes in the human genome. Use of this testing, however, is currently limited in clinical neurologic practice by the lack of a framework for appropriate use and payer coverage.
Recent findings: CES can be cost-effective due to its high diagnostic yield in comparison to other genetic tests in current use and should be utilized as a routine diagnostic test in patients with heterogeneous neurologic phenotypes facing a broad genetic differential diagnosis. CES can eliminate the need for escalating sequences of conventional neurodiagnostic tests.
Summary: This review discusses the role of clinical exome sequencing in neurologic disease, including its benefits to patients, limitations, appropriate use, and billing. We also provide a reference template policy for payer use when considering testing requests.
Clinical exome sequencing (CES) is a new state-of-the-art molecular diagnostic genetic test. It has the potential to rapidly and efficiently detect disease-causing genetic mutations within any gene in the human genome and is therefore becoming widely used in clinical practice. This template policy addresses the health benefits, limitations, and appropriate use of this type of testing in patients with neurologic disease.