Vinegar for Pseudomonas infections

Over the last few years of clinical practice I've come across the use of acetic acid, i.e. vinegar, for pseudomonas wound infections. When I was in the developing world, and our dressing choice consisted of iodine, hydrogen peroxide, potassium permanganate and gauze, it was one thing that we could use when the telltale bright green with its accompanying odour reared its head.

So I wondered what the evidence was, and came up with this lovely, albeit underpowered, study:

Nagoba, B., Wadher, B., Kulkarni, P. and Kolhe, S. Acetic Acid Treatment of Pseudomonal Wound Infections: Eur J Gen Med 2008;5(2):104-106

accessed at http://www.bioline.org.br/pdf?gm08019

Basically they confirmed what I had picked up in clinical practice, in quite a nice way. They used irrigation and soaked gauze to administer 3% acetic acid in a variety of wounds including 2 foot wounds which had positive cultures for Pseudomonas aeruginosa with varying antibiotic sensitivities and which had failed to respond to usual treatment.

This has since been repeated in different circumstances including in prospective RCTs such as that published by Madhusudhan in 2015 (Int Wound J. 2015 Apr 8. doi: 10.1111/iwj.12428)

So in terms of a low cost treatment for what can be a difficult infection to treat, there is some evidence behind use of vinegar for Pseudomonas.

Forefoot ultrasounds

Today's little pile of reference links comes from an apparently normal ultrasound in the context of dodgy clinical presentation with a funny black area between the metatarsal heads (?neurovascular bundle? but it seems too big).

So apparently the interwebs are full of people also wanting to know about forefoot sonography.

Here are some places to start looking:

http://www.driainduncan.com.au/sonographers-stuff/a-sonographers-guide-to-imaging-the-forefoot/

Our little case was a little less homogenous than this neuroma
http://www.ajronline.org/doi/full/10.2214/ajr.180.4.1801121

http://www.ultrasoundpaedia.com/pathology-foot/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4033725/


I'm still lost as to why what I see in the pictures isn't a neuroma or bursa, but at least these few resources are a good place to start in terms of looking at forefoot sonography.

CKD Staging: A Reminder...

I spent a little bit of time working in renal but it's been a few years since then, and my brain failed on telling me to eGFR cutoffs for staging of CKD, so here they are. Thanks Kidney Health Australia!

>60 not CKD if no microalbuminuria, haematuria or structural kidney disease
Stage 1 >/= 90
Stage 2 60-89
Stage 3a 45-59
Stage 3b 30-44
Stage 4 15-29
Stage 5 <15 or on dialysis


(source: http://www.kidney.org.au/cms_uploads/docs/02_algorithm-for-inital-detection-of-ckd.pdf)

Anticoagulants and dry needling/acupuncture

So, I had a patient come in on Xarelto (rivaroxaban) requesting acupuncture. And my gut instinct said, "Hell no", but I thought I'd check the literature first.

And it turns out, anticoagulants aren't an absolute contraindication to dry needling. There are a couple of clinical guidelines for physiotherapists using acupuncture that talk about avoiding joints and using finer gauge needles (e.g. Australian Society of Acupuncture Physiotherapists - www.acupuncturephysio.org)

But there's an interesting paper where they compared patients on warfarin, patients on antiplatelet therapy and patients on nothing interesting and they didn't seem to have many more complications:

Young-Jee Kim, Soo-Kyung Kim, Seung-Yeon Cho, Seong-Uk Park, Woo-Sang Jung, Sang-Kwan Moon, Chang-Nam Ko, Ki-Ho Cho, Sang-Beom Kim, Won-Chul Shin, Jung-Mi Park. Safety of acupuncture treatments for patients taking warfarin or antiplatelet medications: Retrospective chart review study. Eur J Integr Med 2014;6:492–496.

Here's a commentary:
http://www.sciencedirect.com/science/article/pii/S2213422015000256

PTTD: handy reference graph awaits:

http://www.orthobullets.com/foot-and-ankle/7020/posterior-tibial-tendon-insufficiency-ptti

There's a great table in this article on staging. Thanks Orthobullets!

A lovely little overview on managing diabetic foot infections...

A lovely little overview on managing diabetic foot infections...

http://www.australianprescriber.com/magazine/30/1/21/4

I really liked the "if it smells add metronidazole" option: nice clinical tip on helping to recognise coliform/gram negative involvement in terms of empiric therapy prior to getting swab results back. Not sure about it being evidence based but it sounds like a nice idea in theory - any thoughts?

How feet grow: a selection of abstracts

So I thought I was going to get to see a little tacker with a 2-size difference in foot length. Turns out they saw someone else, but in the process I came across these few interesting articles:

Foot Growth in Children Age One to Five Years

Foot & Ankle International February 1990 vol. 10 no. 4 211-213 by Gould et al.

The Lowdown: 

Kids feet grew: 1/2 a size in less than 2 months up till 15 months old

1/2 size in 2-3 months from 15-24 months

1/2 size every 3-4 months from 2-3 years

1/2 size every 4 months from 3-5 years

Boys feet were on average 1 size longer and wider than girls. Width and length growth were proportional.

Next:

Foot Growth Rate in Children Age One to Six Years*

Foot & Ankle International January 1983 vol. 3 no. 4 207-210  By Wenger et al.

They used to think shoe size changed every 1-2 months from 2-6 years:

Their study showed a size change (I assume a half size?) every 2-3 months from 12-30 months then 4 months 30-48 months then 6 months 4-6 years.

Intro

So I keep coming across all these articles that I lose track of when I'm looking into stuff for clinical cases and things, and I thought, hey, there aren't enough blogs in the world, especially not enough blogs about foot stuff, and looking at foot stuff counts as CPD in the foot land that I live in at the moment.

So I thought I'd start a blog. All the cool kids are doing it. Read along if you want, but please don't take it as gospel.

E.