A 5-month-old child was admitted to the paediatric intensive care unit with status epilepticus and cardio-respiratory arrest. Due to difficulty with obtaining intravenous access, an intraosseous infusion was started in the left proximal tibia. This was discontinued after two days. On examination there was swelling of the left leg with minimal redness. The site of infusion did not show any abnormality. A radiograph of the left leg performed on the ninth day did not reveal any abnormalities. A repeat radiograph performed on the twentieth day is shown above (Panel). What is the diagnosis? Answer: refer to page 237

(Refer to page 209) Answer: Osteomyelitis of the tibia following intraosseous infusion In critically ill or injured paediatric patients, intraosseous infusion (IO) provides rapid access to the systemic venous circulation. This has replaced venous cut-down and central line insertion in emergency situations, being included in standard protocols and training procedures recommended by most specialty associations and societies.

Introduction: Foot infections are one of the major complications of diabetes mellitus and a significant risk factor for lower extremity amputation. Providing effective antimicrobial therapy is an important component in treating these infections. This study assesses the microbial isolates of patients with diabetic foot infections and their antibiotic susceptibility pattern. Materials and Methods: A retrospective study of 75 patients with diabetic foot infections admitted to RIPAS hospital between June 2008 and June 2010 was undertaken. Bacteriological specimens were obtained and processed using standard hospital procedure for microbiological culture and sensitivity testing. Results: Overall, 40 (54%) patients had subcutaneous infections, 22 (29%) had infected superficial ulcers, seven (9%) had infected deep ulcers involving muscle tissues and six (8%) had osteomyelitis. A total of 98 pathogens were isolated. Forty percent of the patients had polymicrobial infection, 39 (52%) had single organism and 6(8%) had no growth. Gram-negative bacteria (67%) were more commonly isolated than gram-positive bacteria (30%). The three most frequently found gram-negative organisms were Pseudomonas aeruginosa (19.4%), Klebsiella pneumoniae (15.3%), and Acinetobacter spp. (10.2%) and gram-positive organisms were Staphylococcus aureus (10.2%), Streptococcus pyogenes (7.1%) and Methicillin resistant Staphylococcus aureus [MRSA] (7.1%). Vancomycin was found to be the most effective against gram-positive bacteria while amikacin was the most effective against gram-negative bacteria based on antibiotic testing. Conclusion: In 40% of diabetic feet infection was polymicrobial. Staphylococcus aureus and Pseudomonas aeruginosa were the most common gram-positive and gram-negative organisms respectively. This study helps us to choose the empirical antibiotics for cases of diabetic foot infections.
Diabetic Complications ; Diabetic Foot ; Microbiology ; Bacteriology

Introduction: Tuberculosis (TB) is a public health problem worldwide including Brunei Darussalam. Osteoarticular involvement is common. The purpose of this study was to review the demographics, clinical features and treatment outcome of patients with osteoarticular tuberculosis (OATB) in Brunei Darussalam. Material and Methods: Patients receiving treatment for OATB between 2003 and 2008 were identified from the National Tuberculosis Coordinating Centre (NTCC) registry. Data was recorded on pre-designed proforma. Results: Twenty-one patients (10 male: 11 female) were identified with a mean age of 49 years (range 19 to 75). Nineteen were Bruneian citizens. The most common presenting symptoms were pain at affected site (n = 15), focal neurological deficit and loss of appetite (n = 7). Two patients gave a positive family history of TB and three had radiological evidence of pulmonary TB. Radiograph of the involved part was positive in nine cases while advanced imaging studies (computed tomography scan and magnetic resonance imaging) were required in 15 instances. The results of positive confirmatory tests were obtained from: smear (n = 10), culture (n = 3) and biopsy (n = 8). In five cases treatment had to be started without any of the confirmatory tests. The spine was the most common site of involvement (n = 12) with five non-spinal and four cases with combined lesions. Surgical intervention was required in six cases. All patients completed the treatment successfully. Conclusions: OATB is not uncommon in Brunei Darussalam and can present diagnostic problems. A high index of suspicion, early confirmation of diagnosis and complete monitored treatment is necessary for successful management of these cases.
Epidemiology ; Tuberculosis, Osteoarticular ; Tuberculosis

It has only been six month since the relaunch of the face lifted Brunei International Medical Journal (BIMJ) together with free open online access platform at www.bimjonline.com, BIMJ has made great strides in its aim of achieving high standards. We would like to share some of these achievements with our contributors and readers.