Myofascial Pain Syndrome: A Concise Update on Clinical, Diagnostic and Integrative and Alternative Therapeutic Perspectives

Background: Myofascial pain syndrome is a common multifactorial condition that presents with key manifestations and comorbid with many systemic diseases and regional pain syndromes. Objective:This study aims to concisely review clinical, diagnostic and integrative therapeutic aspects of myofascial pain syndrome. Methods:E-searches (2000-2019) using keywords and Boolean operators were made and using exclusion and inclusion criteria, 50 full articles that focused on myofascial pain syndrome were retained for this review. Results: Myofascial pain syndrome is a multidimensional musculoskeletal disorder with ill-understood etiopathogenesis and pathophysiology and characterized by tender taut muscle with myofascial trigger points, muscle twitch response, specific pattern of referred pain and autonomic symptoms. A variety of pharmacological and nonpharmacological therapies with variable efficacy are used in myofascial pain syndrome, the latter modalities such as education, stretching and exercises, moist hot and cold packs, dry needling and myofascial massage or myofascial trigger point massage are used as first line options. Conclusion:Myofascial pain syndrome and trigger points initiated by repeated strains and injuries co-occur with diverse physical diseases and regional pain syndromes, which need comprehensive diagnostic evaluation using multiple methods. Several interventions are used in patients with myofascial pain syndrome who effectively respond to myofascial massage. This study calls for exploring etiopathogenesis and basic pathophysiological mechanisms underlying myofascial pain syndrome in future.

Detection of interleukins-6 and 8 in saliva as potential biomarkers of oral pre-malignant lesion and oral carcinoma: a breakthrough in salivary diagnostics in Pakistan

Oral cancer is at rise in our population due to increasing use of areca nut [Betel nut] with or without tobacco. It is the second frequent malignant tumour for both the gender in Pakistan. This non-interventional case control study was carried out with the aim to explore saliva as diagnostic medium for detecting interleukins [IL] 6 and 8 as biomarkers of pre-malignant lesions [PML] and oral carcinoma. Total 105 subjects were recruited and were divided into three groups "A", "B" and "C" each comprising of 35 subjects. Group "A" comprised of cases with strong clinical evidence of oral PML. Group "B" constitute clinical and histologically proven OSCC and group "C" include disease free subjects as controls. Saliva from all the recruited subjects was procured by drooling method and stored at-20[degree sign]C before further process. All the collected samples were centrifuged at 4500 rpm for 15 minutes at 4[degree sign]C. Supernatant fluid was used in ELISA for detection and quantification of IL-6 and IL-8. Data was analysed by using Chi-square test and multivariate analysis was done by non-parametric test. P-value of 0.05 was taken as standard reference. Significant co-relation was found for qualitative salivary detection of IL-6 and IL-8 among the groups [P<0.001 and <0.0001 respectively]. Regarding quantitative salivary concentration of leukotrienes, no significant co-relation was found in levels of IL-6 among the groups while there was significant association of IL-8 levels between the groups [P<0.0001].On post Hoc multiple comparison, significant co-relation was found among oral PML group and controls [P=0.001] and OSCC group and control [P=<0.0001]. In conclusion salivary detection of IL-6 and IL-8 could be used as probable biomarker for early detection of oral PML and OSCC in etiologically distinct population of Pakistan

Rauwolfia serpentina improves altered glucose and lipid homeostasis in fructose-induced type 2 diabetic mice

Rauwolfia serpentina is well-reported in traditional medicines for the treatment of hypertensive and neurological disorders. However, its antidiabetic potential has been currently described in both alloxan-treated and normoglycemic mice. Present effort was carried out to investigate the effect of methanol root extract [MREt] of R.serpentina in fructose-induced type 2 diabetic mice. Experimental mice were grouped into normal control [distilled water 1ml/kg] and fructose-induced type 2 diabetic groups [10% fructose 1 ml/kg].The second group sub-divided into negative [0.05% DMSO 1ml/kg] control, positive [pioglitazone 15mg/kg] control and three test groups [MREt 10, 30 and 60 mg/kg]. Each treatment was given orally for 14 days consecutively then mice were sacrificed in order to collect serum and liver samples to analyze physical, biochemical as well as hematological markers. MREt significantly improved percent body weight and glycemic change along with serum insulin, total cholesterol [TC], triglycerides [TG], lowdensity lipoprotein [LDL-c], very low-density lipoprotein [VLDL-c], high-density lipoprotein-cholesterols [HDL-c], total hemoglobin, glycosylated hemoglobin, hepatic glycogen, coronary risk and fasting insulin resistance indices while suppressed down the activity of 3-hydroxy-3-methylglutaryl Coenzyme A reductase enzyme in test groups when compared with diabetic controls. The present findings conclude that MREt of R. serpentina can effectively betters the carbohydrate and lipid homeostasis by either inhibiting fructose absorption in intestine or decreasing insulin resistance in fructose-induced type 2 diabetic mice

Stress in female medical doctors; a cross-sectional study at tertiary care hospitals of Karachi

In present era stress remains a favorite subject of research especially in medical profession because with high competitive roles and responsibilities, this profession serves the need of mankind. Assessment of professional stress in female medical doctors employed at different tertiary care hospitals of Karachi, Pakistan. The cross-sectional non-experimental survey. Different tertiary care hospitals of Karachi. November, 2012 to July, 2013. Internationally validated and standardized questionnaire was used as survey tool for present research. It was distributed to total two hundred and twenty eight 228 female medical doctors. Total 191 respondents filled the research survey. 64.39% were MBBS, 20.42% were BDS and 15.18% were postgraduate respondents. Cronbach's alpha was 73.60%. Mean age of respondents was 29.32 +/- 6.96 years, average stress score was 12.09 +/- 4.33 with average years of experience were 4.58 +/- 5.57 years. Stress scores on the basis of demographic variables like age groups, experience, qualification and marital status showed average scores in range between10-12 units. However, high frequency of respondents scored moderate to severe stress when probed on the basis of levels of stress they have possess. Categorizing the equation for stress scores observed in the present survey as, MBBS respondents showed more stress units i.e., 12.50, BDS doctors have had 11.50 units stress and postgraduate respondents had 10 units stress scores. Results concluded that stress in female medical professionals is never underestimated as it is clearly indicated through present survey that all female respondents possess average job stress which need to address

Effect of smoking on C-reactive protein levels in chronic periodontitis

The objective of the study was to compare the effect of smoking on the level of C-reactive protein [CRP] in chronic periodontal disease. The response of periodontal treatment and its effect on the level of the CRP was also observed in both groups. Hundred patients with chronic periodontitis were taken. Smoking history of the patients was assessed and accordingly, they were categorized as: Group A [smokers] and Group B [non- smokers]. Periodontal evaluation was done on every patient and blood samples were collected for noting the levels of CRP. All patients were then given treatment of chronic periodontitis by mechanical removal of calculus as well as prescription of antimicrobials and mouth rinses. Periodontal evaluation and blood samples were repeated three months after the given treatment to check the change in CRP levels. At Baseline, CRP levels of smoker group was more than non- smoker group. Three months after the given periodontal treatment, the periodontal health was significantly improved. Mean CRP level in both smoker group and non- smoker group was significantly decreased. Chronic periodontitis has significant effect on CRP levels. Chronic periodontitis may add to the inflammatory burden of an individual and this can be reverted to some extent if appropriate treatment is given. This response will not be affected by adverse effects of smoking

Salivary detection of human Papilloma virus 16 and 18 in pre-malignant and malignant lesions of oral cavity: Is it feasible in Pakistani context of Socio-Cultural Taboos?

To evaluate salivary detection of HPV-16 and 18 would be feasible and informative biomarker for oral pre-malignant and malignant lesion in our population. This non-interventional, case control study was carried out at department of E.N.T, Head and Neck Surgery, Dow University of Health Sciences, Dow Medical College and Civil Hospital Karachi, Pakistan between July 2011 to December 2012. Total of 105 cases were recruited. These were divided in three groups 'A', 'B' and 'C having 35 subjects each. Group'A' constitutes patients having strong clinical evidence of oral pre-malignant lesions [PML]. Group 'B' includes historically proven oral squamous cell carcinoma [OSCC] and Group 'C' comprised disease free subjects as controls. After taking informed consent, relevant clinical history was recorded on institutional approved performa. Saliva from all subjects was procured by standard 'drooling method'. Samples were stored at +4°C and later transferred to Laboratory to store at-20°C before further process. Samples werKfcentrifuged at 4500 rpm for 15 minutes at 4°C. Cell pellets sediments were used for identification of HPV-16 and 18 by real-time PCR method. Data was entered and analysed using SPSS version 16. P-value of 0.05 was taken as standard. In group 'A', HPV-16 was detected in 3 [8.6%] cases while HPV-18 was not detected in any of the subject. In group 'B', HPV-16 was detected in 07 [20%] while HPV-18 was found in 06 [17.1%] cases. Mixed HPV-16 and HPV-18 were found in 02 [5.7%] cases. In group 'C, HPV-16 was detected in 03 [8.6%] while HPV-18 was not detected in any of the subjects. Significant relationship was observed between the groups for HPV-18 detection [P= 0.002] while for HPV-16, no significant association was found [P= 0.245]. HPV infection for the causation of oral cancer cannot be fully established possibly due to small sample size. More over differences in genetic makeup, environment, indulgence in peculiar risk factor habits, sexual practices and difficult evaluation of the acquisition of viral load due to socio-cultural and religious restrictions could be the reason

Clinical Observations of Unani Kit Medicine "Qurs-e- (Tab) Musaffi and Raughan-e- (Oil) Kamela" on Hypertrophic Lichen Planus A case study

Lichen planus is a chronic, itchy skin disease of unknown cause, characterized by small, purplish bumps or patches of skin having fine, gray lines on the surface. Itching is mild to severe. The lesions are violet coloured, polygonal, flat-topped papules that may coalesce into rough scaly patches it may discrete or in clusters form, sites of involvement are the flexor surfaces of wrists, forearms, ankles, legs, abdomen, and sacrum

A 71 year old female patient of chronic lichen planus was registered with widespread eruption, severe itching with flat topped surface in cluster and discrete form over the lateral and flexor part of both legs since 15 years. The study was carried out in the OPD of Regional Research Institute of Unani Medicine, Mumbai. The duration of treatment was three months. The Unani medicine, Qurs-e- [Tab] Mussaffi was given orally and Raughan-e [Oil] kamela was used as local application over the lesion

A significant relief occured in all features, like itching was almost subsided, surface of lesion and plaques decreased, large compact lesion and wounds gradually minimized, diminish flaking appearances of skin and new eruption almost negative at end of study and other manifestations were also almost subsided

Drinking water quality and public health in southwestern Saudi Arabia: the need for a national monitoring program

The aim was to investigate the bacteriological quality of drinking water, and explore the factors involved in the knowledge of the public about the quality of drinking water in Najran region, Saudi Arabia. A cross-sectional descriptive study. A total of 160 water samples were collected. Total coliforms, fecal coliform, and fecal streptococci were counted using Most Probable Number method. The bacterial genes lacZ and uidA specific to total coliforms and Escherichia coli, respectively, were detected using multiplex polymerase chain reaction. An interview was conducted with 1200 residents using a questionnaire. Total coliforms were detected in 8 [20%] of 40 samples from wells, 13 [32.5%] of 40 samples from tankers, and 55 [68.8%] of 80 samples from roof tanks. Twenty [25%] and 8 [10%] samples from roof tanks were positive for E. coli and Streptococcus faecalis, respectively. Of the 1200 residents participating in the study, 10%, 45.5%, and 44.5% claimed that they depended on municipal water, bottled water, and well water, respectively. The majority [95.5%] reported the use of roof water tanks as a source of water supply in their homes. Most people [80%] believed that drinking water transmitted diseases. However, only 25% of them participated in educational programs on the effect of polluted water on health. Our results could help health authorities consider a proper regular monitoring program and a sustainable continuous assessment of the quality of well water. In addition, this study highlights the importance of the awareness and educational programs for residents on the effect of polluted water on public health

Viral etiology of respiratory infections in children in southwestern Saudi Arabia using multiplex reverse-transcriptase polymerase chain reaction

To investigate 15 respiratory viruses in children with acute respiratory tract infections [ARTIs] using multiplex reverse-transcriptase polymerase chain reaction [RT-PCR], and to analyze the clinical and epidemiological features of these viruses. In a cross-sectional study, 135 children,

relationship between sleep and cognitive functioning in adult people

The purpose of the current study is to find out if subjective sleep complaints will have less cognitive functioning in older people [50 years and above]. Sleep was assessed with the subscale Sleep Problems of the Symptoms Checklist-90 [Arrendell and Ettema 1986]. Cognitive performance was measured with the Mini Mental Status Examination [Folstein, et al 1975] which is used as a dependent variable. Subjective complaints would be negatively associated with cognitive performance, since in elder people biological sleep is likely to be related with cognitive changes. A group of 12 people were given the task of collecting data through purposeful sampling techniques. Sample size of 120 participants was assessed. Each member of the group collected data from 10 subjects. Pearson Correlation Moment was applied for data analysis. In older persons the coefficient of falling asleep difficulty was -0.05 [p=0.33] and for waking up too early the coefficient was -0.13 [p=0.012] while for restless sleep coefficient was calculated as -0.09 [p=0.094]. The assumption was verified that sleep problems negatively associated with cognitive functioning

Effect of exercise training program in post-CRET post-CABG patients with normal and subnormal ejection fraction [EF > 50% or < 50%] after coronary artery bypass grafting surgery

The aim of the present study is to compare the effect of exercise training program in post-Cardiac Rehabilitation Exercise Training [CRET], post-CABG patients with normal and subnormal ejection fraction [EF >50% or <50%] who have undergoing coronary artery bypass grafting [CABG] surgery. The study was conducted on 100 cardiac patients of both sexes [age: 57-65 years] who after CABG surgery, were referred to the department of Physiotherapy and Rehabilitation between 2008 and 2010 at Liaquat National Hospital and Medical College, Karachi. The patients undertook exercise training program [using treadmill, Recumbent Bike], keeping in view the Borg's scale of perceived exertion, for 6 weeks. Heart Rate [HR] and Blood Pressure [BP] were measured and compared in post CABG Patients with EF [>50% or <50%] at the start and end of the exercise training program. Statistical formulae were applied to analyze the improvement in cardiac functional indicators. Exercise significantly restores the values of HR and BP [systolic] in post CABGT Patients with EF [>50% or <50%] from the baseline to the last session of the training program. There appeared significant improvement in cardiac function four to six weeks of treadmill exercise training program. After CABG all patients showed similar improvement in cardiac function with exercise training program. The exercise training program is beneficial for improving exercise capacity linked with recovery cardiac function in Pakistani CABG patients

Influence of anthropometric measurements on abnormal gonadotropin secretion in women with polycystic ovary syndrome

To evaluate the influence of anthropometric measurements on abnormal gonadotropin secretion in patients with polycystic ovary syndrome [PCOS]. Cross-sectional study. The Institute of Basic Medical Sciences [IBMS], DUHS in collaboration with Gynae/infertility clinics of the Civil Hospital and Lady Dufferin Hospital, Karachi, from October 2010 to February 2011. One hundred and sixty three oligomenorrhic PCOS women of reproductive age [18 - 40 years] fulfilling the revised Rotterdam 2003 criteria were studied. The data recorded on a prescribed proforma included current age, age at menarche, menstrual irregularities, presence of hirsuitism, acne, infertility, familial nature, blood pressure, BMI and waisthip ratio. Blood samples for gonadotropin assay were taken randomly on day 6th to 30th of menstrual cycle, in a gel tube. Hormonal assay was performed using chemiluminescent immunoassay. Kruskul Wallis test was used to assess the influence of BMI levels on LH:FSH values. The mean weight was 66.14 +/- 11.02 kg and mean BMI was 27.03 +/- 4.42 kg/m2. There was no significant difference in mean LH/FSH ratio [p=.575] among BMI groups. However, there was a positive correlation between BMI and LH:FSH ratio [p=0.04, r=0.155]. There was high frequency of obesity [69%] in women with PCOS. Although no significant difference was found between mean LH:FSH ratio among different BMI groups levels but significant correlation between BMI levels and LH: FSH suggested that there was positive relation between BMI and LH: FSH

Impact of untreated high blood pressure on renal function tests at initial diagnosis of hypertension

Pakistani population is at higher risk of developing hypertensive complications at a younger age, resulting from undiagnosed and untreated hypertension [HTN]. High cost of medical care is a barrier to early detection and assessment of end organ damage as well as physicians are disinclined to adopt more aggressive therapeutic management to improve blood pressure control. A cross sectional study was planned to determine the effect of high blood pressure on renal function tests in a random population aged 25-50 year, at initial diagnosis of hypertension. The study was conducted on total 276 subjects; 201selected from five general practitioners clinics in Karachi and were classified into pre hypertensive, and hypertensive stages I and II on the basis of 7th JNC report. Two BP readings were taken half an hour apart. A blood sample was drawn for measurement of serum urea, creatinine and a dipstick test was done to check protein in urine. The results were compared with 75 control, normotensive subjects. The percentage, mean and Standard deviation were computed. ANOVA was performed to compare four study groups and LSD test was applied to compare pair-wise group. Pearson's correlation was applied to find out association of renal function with stages of hypertension. The mean urea and creatinine levels were on higher normal side in HTN stages-I and II [39.91 +/- 8.51 and 1.72 +/- 0.54 in stage-I and 44.51 +/- 9.93 and 1.91 +/- 0.88 in stage-II respectively]. The frequency of proteinuria was also more in these groups, indicating declining renal function in these patients as compared to control and prehypertension groups. Subjects diagnosed with stage I and II HTN showed evidence of subclinical renal damage, along with the presence of proteinuria at the time of diagnosis

Molecular diagnosis of oral pre-malignant lesions and oral squamous cell carcinoma in saliva-a breakthrough in Pakistan

To evaluate salivary detection of interleukin 6 and 8 and high risk HPV-16 and 18 are informative biomarkers of Oral Pre-malignant Lesion [PML] and Oral Squamous Cell Carcinoma [OSCC] in our population. July 2011 to December 2012. Total 105 cases were included. The subjects were divided in three groups 'A', 'B' and 'C' having 35 participants each. Group 'A' comprised of patients having strong clinical evidence of oral PML. Group 'B' constitutes histologically proven OSCC and Group 'C' includes disease free subjects as controls. Relevant clinical history was recorded after informed consent on institutional approved performa. Saliva was collected as per standard drooling method'. Samples were stored at +4oC and later transferred to Dow Diagnostic, Research and Reference Laboratory to store it at -20oC before further process. Samples were subjected to centrifugation at 4500 rpm for 15 minutes at 4oC. Supernatant fluid phase was used in ELISA for detection and quantification of IL6 and IL8. . Cell pellets were used for identification of high risk HPV-16 and 18 by real-time PCR. Data was entered and analyzed on SPSS version 16. P-value of 0.05 was taken as standard reference. In group 'A', IL6 was not detected in almost all the subjects except one case. IL8 was detected in 26/35 [74.3%] subjects and not detected in 09 [25.7%] cases. In group 'B', IL6 was detected in 13 [37.1%] cases and in 22 [62.9%] cases, it cannot be detected. IL8 was detected in 33 [94.3%] and it was not detected in 02 [5.7%] subjects. It is observed that IL8 is consistently found raised in group 'A' and 'B'. In group 'C', IL6 was not detected in any of the subject while IL8 was detected in 10[28.6%] cases. Significant association was found for qualitative salivary detection of IL6 and IL8 between the groups [P= < 0.0001 and < 0.0001 respectively]. Regarding quantitative salivary concentration of IL6 and IL8, no significant co-relation was found in salivary levels of IL6 between the groups while there was significant association of salivary IL8 levels between the groups [P= <0.0001]. On post Hoc multiple comparison, significant co-relation was found in IL8 levels between oral PML group and controls [P=0.001] and OSCC group and controls [P= <0.0001]. In group 'A', HPV-16 was detected in salivary samples of 3 [8.6%] cases while HPV-18 was not detected. In group 'B', HPV-16 was detected in the salivary samples of 07 [20%] cases while HPV-18 was detected in 06 [17.1%] cases. Mixed HPV-16 and HPV-18 were found in 02 [5.7%] cases. In group 'C', HPV-16 was detected in 03[8.6%] cases while HPV-18 was not detected in any of the subjects. Significant relationship was observed between the groups for salivary HPV-18 detection [P= 0.002] while for detection of HPV-16, no significant association was found [P= 0.245]. Salivary concentration of IL6 and IL8 in oral PML and oral cancer are useful biomarkers in our population. Detection of HPV infection for the causation of oral cancer cannot be fully established possibly due to small sample size. More over different genetic makeup, environmental and geographic differences, indulgence in peculiar risk factor habits and different sexual practices compared to west due to socio-cultural and religious restrictions could be the reason

Effects of Allium sativum [Garlic] on systolic and diastolic blood pressure in patients with essential hypertension

The present study evaluated the effects of garlic on blood pressure in patients with essential hypertension Patients [n=210] with stage 1 essential hypertension were divided into 7 groups named as A, B, C, D, E, F and G. Each group comprised of 30 patients. Each patient in group A, B, C, D and E has received garlic tablets at the dose of 300/mg. 600/mg, 900/mg, 1200/mg and 1500/mg in divided doses per day respectively for 24 weeks while Group F and group G were given tablet atenolol and placebo respectively. Blood pressure readings were recorded at weeks 0, 12 and 24. Present study showed significant decrease in both Systolic and Diastolic blood pressure in both dose and duration dependent manner. In each garlic treated group, significant reduction in SBP and DBP [p<0.005] were observed when compared with atenolol [P<0.005] and placebo

Assessment of suicidal and self-injurious behaviours among patients with depression

The aim of this cross-sectional 1-year study was to estimate the prevalence and to identify the risk factors for suicidal and self-injurious behaviours among patients with depression. A convenience sample of 557 out- and inpatients diagnosed with mood disorders was selected from 3 treatment settings in Riyadh, Saudi Arabia. Eligible patients completed data on sociodemographic variables and the Columbia suicide severity rating scale risk assessment version. The reported prevalence of attempted suicide in the previous week was 36.6%, interrupted suicide attempt 29.8%, aborted suicide attempt 34.6% and self-injurious behaviour without suicide intent 7.7%. Concerning suicide ideation, 47.2% reported suicidal thoughts, 36.6% suicidal thoughts with methods but without a specific plan and 35.4% suicidal intent without a specific plan. Male sex, joint family type, literate education, being in employment, smoking and physical co-morbidities were significantly associated with all types of suicide behavior

Studies on the anti-bacterial, anti-fungal and anti-microbial activities of unani drug mastagi [pistacia lentiscus linn.] a review

The Unani drug Mastagi [Mastic] is used in Unani System of Medicine since very long. It is a resin or more correctly an oleoresin containing little oil, obtained from a cultivated variety of Pistascia lentiscus. The plant is an evergreen dioecious shrub and native to the Mediterranean region [France, Spain, Portugal, Greece, Turkey] and also found in North Africa. Mostly mastic is produced on the Greek Island of Chios, some is also produced in Algeria, Morocco and the Canary Island. Mastic is used in the Unani System of Medicine since long and its actions are mentioned in Unani classical literature as: attenuant, resolvent, tonic for vital organ, liver tonic, internal body tonic and appetizer etc. Recently some studies have shown its activities as anti-bacterial, anti-fungal and anti microbial

Antihyperlipidemic effect of Adonis vernalis

To study the effect of Adonis vernalis on triton-induced hyperlipidemic rabbits. Hyperlipidemia has become a major risk factor for a large variety of diseases including coronary artery disease and thus increasing mortality ratio globally. A. vernalis [AV] commonly called as Pheasant's eye is a Homoeopathic remedy and considered as cardiotonic due to presence of cardiac gylcosides with strong diuretic action. The present study investigates the hyperlipidemic effects of Adonis vernalis in chemically [triton; 400 mg/kg intraperitoneally] induced hyperlipidemic rabbits. Its effects on lipid profile, glucose, total protein, serum uric acid and liver specific enzyme alanine aminotransferase [ALT] were determined by administering alcoholic extract of A. vernalis [5 mg/kg] orally and compared against respective control groups. AV [5 mg/kg] had shown a significant decrease in serum cholesterol and triglycerides when compared with control, triton-induced hyperlipidemic control [TIC] and triton-induced positive control [TIPC] [p<0.05]. It slightly increased HDL, clear decrease in LDL and total protein while no effect was found on ALT, uric acid and glucose. According to the experimental findings the alcoholic extract of A. vernalis found to be a potent antihyperlipidemic agent and also showed hepatoprotective property

Pattern of child and adolescent psychiatric disorders among patients consulting publicly-funded child psychiatric clinics in Saudi Arabia

Data about psychiatric problems among young people are scarce in the Gulf countries. This retrospective review of records describes the pattern of child and adolescent psychiatric disorders among patients consulting 3 child psychiatric clinics in Saudi Arabia during the year 2008. Most patients were referred from the public health sector [92.8%]. Psychotropic drugs were prescribed for 86.2% of patients and psychotherapy for 55.2%. Maternal perinatal complications and other psychosocial stressors were noted in almost 45.8% of cases. Family history of psychiatric disorder was reported in 31.5% of patients. Psychiatric comorbidity was noted in 40.5% of cases while physical diseases were noted in 29.9%. The outcome was classified as unstable at the last consultation in 17.9% of cases. In a linear regression analysis the only factors significantly associated with unstable outcome were a higher load of symptoms [OR 2.64] and perinatal complications [OR 2.84]

Patients preference in the management of urinary stone disease

To assess patients' preference in choosing modality of treatment for the urinary stone disease. 100 consecutive patients with urinary stone disease were interviewed through self designed questionnaire. Following parameters were evaluated: presentation, biochemical and radiological investigations, previous treatment, patient's preference in choosing modality of treatment [hakeem, homeopathy, allopathy and spiritual treatment], duration of treatment and cost. Ultimate management of patients was also assessed. Mean age of the patients were 38.43 years. There were 61 males and 39 females. Mean duration of illness was 4.3 years. Mean stone size was 3.83 cm. Seventy six patients had kidney stones, four patients were with ureteric stones, eleven patients had bladder stones and twelve patients had bilateral renal stones. Seven patients were in renal failure due to stones. First priority was hakeem/ quacks in 45%, allopathic in 39%, homeopathic in 17% and spiritual treatment in 03% patients. Mean cost of treatment of different modalities was as follows: Allopathic Rs 4,530/-, Homeopathic Rs 2,747/-, Hakeem Rs 2,427- and Spiritual Rs 907/-. Fifty five patients underwent pyelolithotomy, 10 patients percutaneous nephrolithitomy [PNL], eleven patients Nephrectomy, 4 patients ureteroscopic removal of stone [URS], 11 patients Vesicolithotmy/Litholapaxy and 4 patients extracorporeal shock wave lithotripsy [ESWL]. Mean post-op stay was 10.5 days. In spite of recent advances in medical science, allopathy is not the first choice for vast majority of the patients in the management of urinary calculi. Our population is still under the influence of hakeems, quacks and homeopaths. Reasons are illiteracy, poverty, fear of surgery and negative propaganda through media. Patients with small stones requiring ESWL end up with major surgical procedures, like pyelolithotmies and nephrectomies. Some of them develop renal failure because of inappropriate management