Children experience feelings of nervousness, fear, or worry from time to time; these feelings are part of a normal response to a stressful situation, but when they occur to such an extent that they interfere with normal life, children anxiety disorder may be the underlying cause.
Children anxiety disorder may be manifested by symptoms such as extreme nervousness, inability to concentrate, poor school performance, and physical symptoms like nausea, heart palpitations, headache, shortness of breath, and sweating. Children anxiety disorder can be the result of a recent traumatic or high-stress event such as a move to a new home and school, divorce of the parents, death of a pet or a loved one, or it can have no obvious environmental or emotional basis at all.
Anxiety disorder in children is treated most successfully the earlier treatment begins; treating anxiety may include a combination of talk therapy, positive reinforcement, and in some cases medications.
Symptoms of children anxiety disorder:
Anxiety disorder can be difficult to recognize, because symptoms are often attributed to other factors (like Social anxiety). Signs of extreme nervousness and restlessness, an inability to concentrate, poor school performance, difficulty relating to peers, irritability, and physical complaints such as nausea, upset stomach and frequent headaches may indicate an anxiety disorder.
Causes of children anxiety disorder:
Medical researchers have not yet fully uncovered the causes behind anxiety disorder. There is some suggestion of a hereditary link, as anxiety and other mental disorders tend to run in families, and studies have located small differences in areas of the brain that influence anxiety.
How to diagnose children anxiety disorder?
Anxiety diagnosis is based mainly on the observations by the doctor and parents of a child's behavior. While there are no laboratory tests that can pinpoint anxiety disorder, certain tests may be conducted to rule out another underlying medical cause for the symptoms.
Common categories of children anxiety disorder:
Some of the most common types of childhood anxiety disorders include obsessive-compulsive disorder, phobias (irrational and overwhelming fears), separation anxiety disorder, post traumatic stress disorder, and panic disorder,. These conditions usually affect children between the ages of 6 and 11.
Treatment: Treatment of anxiety in children is more effective the sooner it is addressed after the appearance of symptoms. The most common form of treatment for children anxiety disorder is psychotherapy and teaching positive reinforcement techniques; medicines may also be prescribed for children with anxiety.

A Case of separation anxiety:
Master Rahul, aged 9 yrs, studies in 3rd standard.
The child was apparently normal before he was brought for the consultation. He started developing the following symptoms when the school reopened after vacations.
Fear of being alone.
Difficulty in sleeping & he gets up frightened from sleep after which he is unable to sleep.
Frequently complaints of headache & stomach ache.
He refuses to go to school without the mother. Earlier he used to go in an auto with his friends.
Throws tantrum when mother returns home after dropping him at school.
Complaints of loose stools & attacks of breathlessness accompanied by anxiety.
Moves anxiously from place to place. Restless.
A recent traumatic event had occurred in the family where mother was hospitalized for a week.
The following line of treatment was adopted:
• Psychotherapy: This helped the child learn to understand his feelings and tolerate the separation to a more natural degree.
• Cognitive Behavioral Therapy: This taught the child to change the way he thinks about separation, allowing him to respond more appropriately to natural separation from the mother.
• Medication: Homoeopathic medicine (Ars Alb 200) was given. He recovered well with treatment. There were some brief recurrences of the anxiety, but the coping skills learned through treatment were effective at dealing with the problem when it came up the next time, making each instance shorter and more manageable until the anxiety disappeared completely. Child’s self esteem was strengthened through positive reinforcement. The whole family supported and helped the child as he is undergoing treatment.
Dr. Nahida M.Mulla.M.D (Hom) MACH
PRINCIPAL.
Professor of Repertory & PG Guide.
HOD Paediatric OPD.
Child Counsellor.
A.M.Shaikh Homoeopathic Medical College, Hospital & PG Research Centre, Nehru Nagar, Belgaum - 590010
E-Mail: drnahida_mulla@yahoo.com
Mobile: 09448814660.

MULJIBHAI PATEL UROLOGICAL HOSPITAL, NADIAD

St. Paul’s Medal Awarded to Dr. Mahesh Desai of MPUH Nadiad

Dr. Mahesh Desai, Medical Director and Managing Trustee of MPUH, Nadiad was yesterday awarded the prestigious 'St.Paul's Medal 2012' by the British Association of Urological Surgeons (BAUS) during its Annual Scientific Meeting held in the Scottish Exhibition and Conference Centre (SECC) in Glasgow. The Medal is awarded to distinguished colleagues from overseas whose contributions to the Association in particular, or to Urology in general, BAUS Council particularly wishes to appreciate and honour. Since the inception of this Medal in 1989, Dr Mahesh Desai is only the second Indian honoured with this international recognition.

It may be recalled, last year, Dr. Mahesh Desai had become the first Indian to assume the Office of the President of Societe Internationale d’Urologie (SIU), and the President-elect of the Endourological Society Inc.

SPONTANEITY AND NAMASMARAN: DR. SHRINIWAS KASHALIKAR

NAMASMARAN is admired, appreciated and advised by hundreds of saints.
But apparently; few fortunate are haunted by the mystery of NAMA, fewer pursue it and still fewer persist on it! Amongst these; very few are convinced of its cosmic benevolence and take it upon them to spread the glory of NAMA.
But there is nothing to despair; as the experience, conviction and joy of NAMA; go on multiplying and deepening endlessly. The beginners as well as the veterans; all; have a spontaneous spring of ambrosia to manifest and nurture the mankind and the universe; at appropriate time.
Practitioners of NAMASMARAN actually go on “digging within them”; and in the course of time (and at appropriate time); the spontaneous spring of ambrosia begins to break open into a fountain. This gives indescribable, innate and yet universally benevolent ecstasy!
One may not believe in all this; but verify; if one wishes; the power of NAMASMARAN; by practice!

ऐसे माझेनि नामघोशे
नाही करिती विश्वाची दु:ख्खे

अवघे जगचि महासुखे
दुमदुमित भरले (200)

कही एकाधेनि वैकुंठा जावे
ते तिही वैकुंठचि केले आघवे
ऐसे नामघोष गौरवे
धवळले विश्व (203)

ज्ञानेश्वरी 9 वा अध्याय

Hyaluronic acid in osteoarthritis
Osteoarthritis(OA) is a degenerative joint disease and is thought to be wear and tear of joint as part of an aging process.There are 2 types of OA,primary and secondary.Primary OA occurs in a joint de novo.It occurs in elderly and mostly in weight-bearing joints such as knee and hip.This is more common.Secondary OA occurs due to an underlying primary disease of the joint which leads to the degeneration of the joint.It can occur at any age and occurs commonly at the hip. Osteoarthritis is characterized by a loss of articular cartilage, which has a highly limited capacity to heal itself. Along with these cartilage changes, a reduction in the elastic and viscous properties of the synovial fluid occurs. The molecular weight and concentration of the naturally occurring hyaluronic acid decreases. Theoretically, this loss of elastoviscosity decreases the lubrication and protection of the joint tissues and is one postulated mechanism of pain production in osteoarthritis.1,2 Pharmacologic treatment generally consists of analgesics and/or nonsteroidal anti-inflammatory drugs (NSAIDs). Physical therapy can be used, with exercises to maintain range of motion and strength. Intra-articular corticosteroid injections are often used for transient symptom relief. When conservative measures fail, surgical treatments limited to arthroscopic debridement, osteotomies to redistribute load and total joint replacements have been the only options until recently.
Intraarticular injections of hyaluronic acid is a viscosupplementation that is newly available options for patients with symptomatic knee osteoarthritis.The increase in viscoelasticity of the synovial fluid seems to play a role.The indications for viscosupplementation can be considered for use in patients who have significant residual symptoms despite traditional nonpharmacologic and pharmacologic treatments.Patients who are intolerant of traditional treatments can be considered these injections.
Viscosupplementation
The concept of viscosupplementation is based on pathologic changes of synovial fluid hyaluronic acid with its decrease molecular weight and supplementation.Two hyaluronic acid products are currently available in the United States: naturally occurring hyaluronan (Hyalgan) and synthetic hylan G-F 20 (Synvisc). Hylans are cross-linked hyaluronic acids, which gives them a higher molecular weight and increased elastoviscous properties. The higher molecular weight of hylan may make it more efficacious than hyaluronic acid because of its enhanced elastoviscous properties and its longer period of residence in the joint space (i.e., slower resorption)3. The exact mechanism of action of viscosupplementation is not well known. Although restoration of the elastoviscous properties of synovial fluid seems to be the most logical explanation, other mechanisms must exist. The actual period that the injected hyaluronic acid product stays within the joint space is on the order of hours to days, but the time of clinical efficacy is often on the order of months.4 Other possible mechanisms to explain the long-lasting effect of viscosupplementation include anti-inflammatory and antinociceptive properties, or stimulation of in vivo hyaluronic acid synthesis by the exogenously injected hyaluronic acid.5
Clinical studies of hyaluronan
Multiple studies have been conducted to assess the efficacy of intra-articular hyaluronan injections. Initial studies6-8 in the 1970s and 1980s demonstrated benefits for hyaluronan-injected knees. More recently, Dahlberg and colleagues,9 and Henderson and coworkers,10 in randomized, double-blind placebo-controlled trials found no benefit from intra-articular hyaluronan over placebo. Lohmander and associates11 similarly found no significant differences between overall treatment and placebo groups; however, a subgroup analysis of patients more than 60 years of age with more severe symptoms revealed beneficial effects from the hyaluronan injections. In contrast to these recent trials, which demonstrated no or minimal beneficial effects from intra-articular hyaluronan, other randomized controlled studies12-14 suggest overall beneficial effects of hyaluronan over placebo. Another study15 demonstrated efficacy of hyaluronan in a randomized blinded trial, with the treatment group showing more improvement than the placebo group and a group taking oral naproxen.
Clinical studies of cross-linked hylan
A summary of four clinical trials performed in Germany using cross-linked hylan16 demonstrated excellent results in 71 percent of hylan-treated patients, compared with 29 percent of placebo-treated patients. After six months, 53 percent of hylan-treated patients still reported excellent pain relief, compared with 22 percent of the placebo-treated patients. In a double-blind, randomized placebo-controlled trial using hylan,17 it was found that 39 to 71 percent of hylan-treated patients were symptom free at 26 weeks compared with 13 to 45 percent of placebo-treated patients. Another study18 compared intra-articular hylan with NSAID therapy in a randomized blinded trial. Hylan was found to be as effective as NSAID therapy at 12 weeks and was superior to NSAID therapy at 26 weeks. In addition, findings from a clinical practice19 showed that 80 percent of 458 knees injected with hylan had a positive response, and the average duration of efficacy was 8.2 months.
Adverse effects of intraarticular hyaluronic acid
Rates of adverse reaction has been low.The most frequent adverse reaction to this treatment is transient localised pain or effusion which is resolved within one to three days.There were no systemic effects attributed to hyaluronic acid.There are also reports on cases of induced pseudogout20.No long term side effects have been reported21.
Indications
Intra-articular hyaluronic acid injections should be considered in patients with significantly symptomatic osteoarthritis who have not responded adequately to standard nonpharmacologic and pharmacologic treatments or are intolerant of these therapies (e.g., gastrointestinal problems related to anti-inflammatory medications).2,14,15 Patients who are not candidates for total knee replacement or who have failed previous knee surgery for their arthritis, such as arthroscopic debridement, may also be candidates for viscosupplementation. Total knee replacement in younger patients may be delayed with the use of hyaluronic acid22.
Injection technique
Hyalgan is supplied in 2-mL vials (one injection per vial) or prefilled syringes, and Synvisc is supplied in 2-mL prefilled syringes. The recommended injection schedule is one injection per week for five weeks for Hyalgan, and one injection per week for three weeks for Synvisc. Repeat courses of viscosupplementation can be performed after six months. A knee joint can be injected several ways. One approach is to have the patient lie supine on the examination table with the knee flexed 90 degrees. In this position, the anterior portions of the medial and lateral joint lines can easily be palpated as dimples just medial or lateral to the inferior pole of the patella. Often, the medial joint line is easier to palpate and define and can be chosen as the site of injection. Alternatively, the knee joint can be approached with the knee extended, again with the patient lying supin. Most commonly the superolateral edge of the patella is the site of injection, but other quadrants of the knee near the patellar edges can also be chosen. With this approach (knee in extended position), the needle is generally aimed under the patella.
Actual injection site can be marked with a fingernail imprint or the barrel of a pen. Next, sterile preparation with a povidone iodine preparation (Betadine) and alcohol can be performed. A 22- to 25-gauge needle can be used for the injection. Local anesthesia with lidocaine before the injection can be used, but with a small gauge needle this is not always necessary. Alternatively, an ethyl chloride spray can be used for local anesthesia. Following puncture through the skin and into the joint space, the injection is accomplished. If resistance is encountered, redirection of the needle may be necessary.
If effusion is present, aspiration of the joint is recommended before the injection to prevent dilution of the injected hyaluronic acid. The aspiration can be performed at the same site as the injection, as previously described. The same needle can be left in place and used for the aspiration and the injection. Aspiration may require a larger bore needle, such as an 18- or 20-gauge needle. Following local anesthesia with intradermal lidocaine or ethyl chloride spray, the needle can be placed into the joint for aspiration. When aspiration is completed, hemostat clamps can be used to grasp and stabilize the needle, while the aspiration syringe is detached from the needle. The syringe containing hyaluronic acid can then be attached to the same stabilized needle followed by injection. No excessive weight-bearing physical activity should take place for one to two days following injection.

References:

1. Marshall KW. Viscosupplementation for osteoarthritis: current status, unresolved issues and future directions. J Rheumatol 1998;25:2056-8.
2. George E. Intra-articular hyaluronan treatment for osteoarthritis. Ann Rheum Dis 1998;57:637-40.
3. Wobig M, Bach G, Beks P, Dickhut A, Runzheimer J, Schwieger G, et al. The role of elastoviscosity in the efficacy of viscosupplementation for osteoarthritis of the knee: a comparison of hylan G-F 20 and a lower-molecular-weight hyaluronan. Clin Ther 1999;21:1549-62.
4. Cohen MD. Hyaluronic acid treatment (viscosupplementation) for OA of the knee. Bull Rheum Dis 1998;47:4-7.
5. Balazs EA, Denlinger JL. Viscosupplementation: a new concept in the treatment of osteoarthritis. J Rheumatol 1993;20(suppl 39):3-9.
6. Peyron JG, Balazs EA. Preliminary clinical assessment of Na-hyaluronate injection into human arthritic joints. Pathol Biol [Paris] 1974;22:731-6.
7. Weiss C, Balazs EA, St. Onge R, Denlinger JL. Clinical studies of the intraarticular injection of HealonR (sodium hyaluronate) in the treatment of osteoarthritis of human knees. Osteoarthritis symposium. Palm Aire, Fla., October 20-22, 1980. Semin Arthritis Rheum. 1981;11(suppl 1):143-4.
8. Peyron JG. Intraarticular hyaluronan injections in the treatment of osteoarthritis: state-of-the-art review. J Rheumatol 1993;39(suppl):10-5.
9. Dahlberg L, Lohmander LS, Ryd L. Intraarticular injections of hyaluronan in patients with cartilage abnormalities and knee pain. A one-year double-blind, placebo-controlled study. Arthritis Rheum 1994;37:521-8.
10. Henderson EB, Smith EC, Pegley F, Blake DR. Intra-articular injections of 750 kD hyaluronan in the treatment of osteoarthritis: a randomised single centre double-blind placebo-controlled trial of 91 patients demonstrating lack of efficacy. Ann Rheum Dis 1994;53:529-34.
11. Lohmander LS, Dalen N, Englund G, Hamalainen M, Jensen EM, Karlsson K, et al. Intra-articular hyaluronan injections in the treatment of osteoarthritis of the knee: a randomised, double blind, placebo controlled multicentre trial. Hyaluronan Mulicentre Trial Group. Ann Rheum Dis 1996;55:424-31.
12. Dougados M, Nguyen M, Listrat V, Amor B. High molecular weight sodium hyaluronate (hyalectin) in osteoarthritis of the knee: a 1 year placebo-controlled trial. Osteoarthritis Cart 1993;1:97-103.
13. Puhl W, Bernau A, Greiling H, Kopcke W, Pforringer W, Steck KJ, et al. Intraarticular sodium hyaluronate in osteoarthritis of the knee: a multicentre double-blind study. Osteoarthritis Cart 1993;1:233-41.
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16. Adams ME. An analysis of clinical studies of the use of crosslinked hyaluronan, hylan, in the treatment of osteoarthritis. J Rheumatol (suppl) 1993;39:16-8.
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18. Adams ME, Atkinson MH, Lussier AJ, Schulz JI, Siminovitch KA, Wade JP, et al. The role of viscosupplementation with hylan G-F 20 (Synvisc) in the treatment of osteoarthritis of the knee: a Canadian multicenter trial comparing hylan G-F 20 alone, hylan G-F 20 with non-steroidal anti-inflammatory drugs (NSAIDs) and NSAIDs alone. Osteoarthritis Cart 1995;3:213-25.
19. Lussier A, Cividino AA, McFarlane CA, Olszynski WP, Potashner WJ, De Medicis R. Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol 1996;23:1579-85.
20. Disla E, Infante R, Fahmy A, Karten I, Cuppari GG. Recurrent acute calcium pyrophosphate dihydrate arthritis following intraarticular hyaluronate injection. Arthritis Rheum 1999;42:1302-3.
21. Maheu E. Hyaluronan in knee osteoarthritis: a review of the clinical trials with hyalgan. Eur J Rheumatol Inflamm 1995;15:17-24.
22. Red book. Montvale, N.J.: Medical Economics Data, 1999.