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246 Complex Regional Pain Syndrome in a Child: First Case Report from Kuwait... September 2011 important role in diagnosis of this syndrome because there are often few, if any other radiologic modalities that show an abnormality [9] . Our patient’s diagnosis was made by performing a bone scan that showed the classical appearance of intense periarticular activity in the involved extremity on the delayed phase of the scan preceded by hyperemia in a similar distribution on the immediate postinjection blood flow and blood pool phases of the scan [10] . The best prediction of success in the management of CRPS is early treatment. Therefore, prompt diagnosis and treatment of CRPS provide palliation and allow recovery [11] . The treatment goal in CRPS is pain relief, functional recovery, and psychological improvement. This often requires a multidisciplinary approach [4] . The most important part of treatment is an appropriate and intensive physical therapy program that should be initiated early. Medications such as tricyclic antidepressant and anticonvulsants are frequently used and are typically prescribed by pain clinics. Calcium channel blockers have also shown some benefit. Sympathetic blocks may be used and have been beneficial [2] . One therapeutic intervention is transcutaneous nerve stimulator (TENS). It decreases symptoms by increasing nutritional flow [11] . The recurrence risk in CRPS is 25%. The prognosis is generally good in contrast to adults who have a poorer prognosis [11] . Frustration during treatment is common because the pathophysiology of CRPS is not completely understood and the therapeutic efforts may fail. A trialand-error approach to treatment is often mandatory. Early recognition of CRPS and prompt intervention, however, provide the best opportunity for clinical improvement [11] . CONCLUSION It should be emphasized that CRPS is a chronic, painful disease associated with significant morbidity in children and adolescents and may cause temporary or permanent functional incapacitation. Pediatricians should be alert, since the diagnosis is made on clinical suspicion and when made early the prognosis improves. ACKNOWLEDGMENT We would like to thank Dr. Khalda Al-Zaabi from the Department of Nuclear Medicine for her valuable contribution in the diagnosis of our patient. REFERENCES 1. Veldman PH, Reynen HM, Arntz IE, Goris RJ. Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients. Lancet 1993; 342:1012-1016. 2. Wilder RT, Berde CB, Wolohan M, Vieyra MA, Masek BJ, Micheli LJ. Reflex sympathetic dystrophy in children. Clinical characteristics and follow-up of seventy patients. J Bone Joint Surg Am 1992; 74:910- 919. 3. Small E. Reflex sympathetic dystrophy in pediatric patients: Reflection from clinician, In Greydanus D, Patel D, editors. Adolescent Medicine: State of the art reviews. NY: American Academy of Pediatrics; 2007. p221-225. 4. Raja SN, Grabow TS. Complex regional pain syndrome I (reflex sympathetic dystrophy). Anesthesiology 2002; 96:1254-1260. 5. Stanton RP, Malcolm JR, Wesdock KA, Singsen BH. Reflex sympathetic dystrophy in children: an orthopedic perspective. Orthopedics 1993; 16:773- 779. 6. Sherry DD, Wallace CA, Kelley C, Kidder M, Sapp L. Short and long-term outcomes of children with complex regional pain syndrome type I treated with exercise therapy. Clin J Pain 1999; 15:218-223. 7. Small E. Chronic musculoskeletal pain in young athletes. Pediatr Clin North Am 2002; 49: 655-662. 8. Graif M, Schweitzer ME, Marks B, Matteucci T, Mandel S. Synovial effusion in reflex sympathetic dystrophy: an additional sign for diagnosis and staging. Skeletal Radiol 1998; 27:262-265. 9. Nadel HR, Stilwell ME. Nuclear medicine topics in pediatric musculoskeletal disease: techniques and applications. Radiol Clin North Am 2001; 39:619-651. 10. Kozin F, Soin JS, Ryan LM, Carrera GF, Wortmann RL. Bone scintigraphy in the reflex sympathetic dystrophy syndrome. Radiology 1981; 138:437-443. 11. Teasdall RD, Smith BP, Koman LA. Complex regional pain syndrome (reflex sympathetic dystrophy). Clin Sports Med 2004; 23:145-155.
September 2011 KUWAIT MEDICAL JOURNAL 247 Selected Abstracts of Articles Published Elsewhere by Authors in Kuwait Kuwait Medical Journal 2011, 43 (3): 247-250 Chewing Areca Nut, Betel Quid, Oral Snuff, Cigarette Smoking And the Risk of Oesophageal Squamous-Cell Carcinoma in South Asians: A Multicentre Case-Control Study Akhtar S, Sheikh AA, Qureshi HU Faculty of Medicine, Kuwait University, Jabriya, Kuwait Faculty of Health Sciences, Aga Khan University, Karachi, Pakistan Eur J Cancer 2011 Jul 4 [Epub ahead of print] Oesophageal cancer remains an important public health problem worldwide. This multicentre matched case-control study examined the chewing areca nut alone, betel quid with tobacco, oral snuff (snuff dipping) and cigarette smoking as the risk factors for oesophageal squamous-cell carcinoma. We enrolled 91 cases of oesophageal squamous-cell carcinoma and 364 matched controls from three tertiary-care hospitals in Karachi, Pakistan. A structured questionnaire was used to collect the data through face-to-face interview of the participants. Multivariable conditional logistic regression model showed that after adjusting for the effect of ethnicity, ever chewed areca nut alone (adjusted matched odds ratio (mOR(adj)) = 3.7; 95% confidence interval (CI): 1.6 - 8.5), ever chewed betel quid with tobacco (mOR(adj) = 12.8; 95% CI: 6.3-26.2), ever practiced snuff dipping (mOR(adj) = 4.3; 95% CI: 1.6 - 11.7) and ever smoked cigarettes (mOR(adj) = 2.9; 95% CI: 1.4 - 5.9) were significantly and independently associated with oesophageal squamous-cell carcinoma status. The adjusted summary population attributable risk (PAR) percent for all four substances together was 67.0. Furthermore, despite incomplete synergy, there was manifold increase in the risk of oesophageal squamous-cell carcinoma, if the respondents ever smoked cigarettes and ever chewed betel quid with tobacco (mOR(adj) = 21.4; 95% CI: 6.3 - 72.4) or if they ever smoked cigarettes and ever practiced snuff dipping (mOR(adj) = 14.4; 95% CI: 2.3 - 91.1). The adjusted PAR (%) was higher for the dual practice of smoking cigarettes and chewing betel quid with tobacco (64.3) than dual practice of smoking cigarettes and snuff dipping (32.2). Public awareness to curtail the addiction to these substances may result in a substantial reduction in the incidence of oesophageal squamous-cell carcinoma and related mortality in this and similar settings. Pattern and Etiology of Culture-Proven Early-Onset Neonatal Sepsis: A Five-Year Prospective Study Al-Taiar A, Hammoud MS, Thalib L, Isaacs D Department of Community Medicine and Behavioral Sciences, Faculty of Medicine, Kuwait University, Kuwait Int J Infect Dis 2011 Jun 27 [Epub ahead of print] Objectives: To investigate the incidence of early-onset neonatal sepsis and identify the main pathogens over a 5-year period in Kuwait. Methods: Blood samples were collected from all infants with any clinical or laboratory feature suggestive of sepsis, at the main maternity hospital in Kuwait. Cases of early-onset neonatal infection were defined as culture of a single potentially pathogenic organism from blood or cerebrospinal fluid from infants younger
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