AFP Journal Review January 1, 2009

1. AFP Journal ReviewJanuary 1, 2009 Cindi Hurley, MD MBA February 12, 2009

2. Topics • Principles of Casting & Splinting • Mgmt of Blood Sugar in Type 2 Diabetes

3. Casting & Splinting Review

4. Assess Need for Immobilization • Casts & Splints serve to promote healing, maintain bone alignment, decrease pain, protect the injury and compensate for weakness • Conditions that benefit from immobilization: Fracture Inflammatory conditions Sprains Deep lac repairs across joints Tendon laceration Severe soft tissue injury Reduced joint dislocations

5. What’s the Difference? • Both start with application of a stockinette & padding • Splinting involves non–circumferential application of a plaster or fiberglass support held in place by an elastic bandage • Casting involves circumferential application of plaster or fiberglass

6. Splint or Cast? • Must assess the stage & severity of the injury, potential for instability, risk of complications, and patient’s functional requirements • Splints used more often for simple or stable fractures, sprains, tendon injuries & other soft tissue injuries • Casting used for definitive and/or complex fractures

7. Advantages of Splinting • Faster & Easier to Apply • May be static & prevent motion or dynamic & allow controlled motion • Allows for natural swelling • Easily removed to allow for regular inspection

8. Disadvantages of Splinting • Allow excessive motion at injury site • Inappropriate for definitive treatment of unstable or potentially unstable fractures such as those requiring reduction, spiral fractures and dislocation fractures

9. Advantages of Casting • More effective immobilization

10. Disadvantages of Casting • Takes more time & skill to apply • Higher risk of complications

11. Complications of Splinting & Casting • Compartment Syndrome • Most serious complication • Increased pressure within a closed space, compromises blood flow & tissue perfusion • If pt experiences severe swelling, worsening pain, numbness or tingling , or dusky appearance  ER • Heat Injury • Pressure Sores and Skin Breakdown • often caused by pressure from a wrinkled, unpadded or underpadded area over a bony prominence

12. Complications, continued • Infection • Common with open wound • Moist, warm environment is ideal for infection • Ischemia • Dermatitis • Joint Stiffness • Neurological Injury

13. Guidelines • Inspect the involved extremity and document skin lesions, soft-tissue injuries, and neurovascular status beforehand • Protect the patient’s clothing • Properly position the extremity before, during & after application of materials • Properly pad bony prominences and high-pressure areas

14. Guidelines, continued • Avoid tension and wrinkles on materials • Use the right temperature of water – the hotter the water the faster the material sets and the greater the risk for heat injuries – use tepid water for plaster and room temp water for fiberglass • Do not dump water used on plaster down the sink – it will clog!

15. Videos • http://intermed.med.uottawa.ca/procedures/cast/

16. Follow-Up • Elevate the injured extremity to decrease pain & swelling • Refrain from getting the material wet • Educate pt re: compartment syndrome • Avoid strong opioids so pain is not masked that should prompt a doctor’s visit • Most require initial follow-up within 1 -2 weeks

17. Management of Blood Glucose in Type 2 Diabetes Mellitus

18. Statistics on Type 2 Diabetes • 6th cause of death in US • Leading cause of kidney failure • Leading cause of new blindness in adults • More than 20 million Americans have T2DM, however 30% are undiagnosed

19. We Need to Focus On • Lifestyle Changes • Management of Cardiovascular Risk Factors • Management of Blood Glucose Levels

20. Lifestyle Modifications • Weight loss goal of 7% • Reduces incidence of T2DM by 58% !!! • Exercise goal of 150 minutes per week • (30 mins/day x 5 days/week) • TLC much more effective than Metformin in reducing blood glucose & HbA1C

21. Mgmt of Cardiovascular Disease Risk Factors • Interventions to manage blood pressure, cholesterol and microalbuminuria have been shown to decrease mortality • Use ASA if T2DM and • Have existing CAD • Have RFs for CAD • Are over 40 yo

22. Mgmt of Cardiovascular RF’s • Use Statins if T2DM and - have existing CAD - they are older than 40 with at least one CAD RF • Use ACE or ARBs if T2DM and • Micro- or macroalbuminuria

23. Management of Blood GlucoseOral Agents • Biguanides • Sulfonylureas • Non-Sulfonylureas • Alpha Glucosidase Inhibitors • Amylin Analogues • Incretin Enhancers • Incretin Mimetics • Thiazolidinediones (TZDs)

24. Biguanides • Examples: Metformin (Glucophage) • Mechanism: decreases hepatic glucose production and intestinal glucose absorption; and to a lesser extent, increases insulin sensitivity of peripheral cells • SA’s: nausea, diarrhea, flatulence • Caution: RI (d/c if Cr > 1.4), using IV dye • Cost: $20-30/month if generic • Note: 1) only hypoglycemic agent shown to reduce mortality 2) approved for children > 10 yo

25. Insulin Secretatogues: Sulfonylureas • Examples: Glyburide, Glipizide, Amaryl • Mechanism: incease insulin secretion from the pancreatic islet beta cell by closing K+ channels • SA’s: hypoglycemia, wt gain • Cost: $50/month

26. Insulin Secretatogues: Non-sulfonylureas • Examples: Starlix, Prandin • Mechanism: stimulates pancreatic islet beta cell insulin release • SA’s: hypoglycemia • Cost: $175/month

27. Alpha Glucosidase Inhibitors • Examples: Acarbose (Precose), Miglitol (Glyset) • Mechanism: acts at the brush border in the small intestine to delay glucose absorption • SA’s: flatulence, abdominal pain, diarrhea • Cost: $80-$90/month • Note: Shown to decrease CV events

28. Amylin Analogues • Examples: Pramlintide (Symlin) • Mechanism: exact mechanism of action unknown; decreases postprandial plasma glucose rise, suppresses glucagon secretion, slows gastric emptying • SA’s: nausea, vomiting, anorexia, headache, diarrhea • Caution: Severe hypoglycemia can occur, especially with co-administration of insulin • Cost: $150-$250/month

29. Incretin Enhancers • Examples: Januvia, Onglyza • Mechanism: slows incretin metabolism, increasing insulin synthesis/release, decreasing glucagon levels • SA’s: nausea & vomiting • Caution: adjust dosage in pts with RI • Cost: $180/month

30. IncretinMimetics • Examples: Byetta • Mechanism: enhances insulin secretion in response to elevated plasma glucose levels • SA’s: nausea & vomiting, diarrhea, dizziness • Caution: not recommended in pts with Cr Cl < 30 • Cost: $250/month • Tidbit: derived from a compound found in the saliva of the Gila monster, a large lizard native to the southwestern US

31. Thiazolidinediones (TZDs) • Examples: Actos & Avandia • Mechanism: increases insulin sensitivity in peripheral tissue, and to a lesser extent, decreases hepatic glucose production • SA’s: wt gain, fluid retention • Caution: liver dz, pregnancy, HF, association between Avandia and CV events • Cost: $150/month

32. Goal for Blood Glucose • Maintain as close to normal as possible without causing hypoglycemia • ADA recommends A1C < 7% • In relatively well-controlled DM, home monitoring has not been associated with significant improvement in A1C levels

34. Rapid Acting Insulin • Lispro (Humalog), Aspart (Novolog) onset: 5-15 minutes peak: 1-2 hours duration: 4-5 hours • Regular (Humulin R) onset: 30-60 minutes peak : 2-4 hours duration: 8-10 hours note: inject 30 minutes before meal

35. Intermediate-Acting Insulin • NPH (Humulin N) onset: 1-2 hours peak: 4-8 hours duration: 10-20 hours

36. Long-Acting Insulin • Glargine (Lantus) onset: 1-2 hours peak: relatively flat duration: 20-24 hours dosing: start at 10 units per day, titrate at 2 units per day q 3 days

37. References • Boyd A, Benjamin H, Chad A. Principles of Casting and Splinting. American Family Physician. Jan 1, 2009. • Ripsin C, Randall U. Management of Blood Glucose in Type 2 Diabetes Mellitus. American Family Physician. Jan 1, 2009.