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

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Presentation on theme: "AFP Journal Review January 1, 2009 Cindi Hurley, MD MBA February 12, 2009."— Presentation transcript:

1 AFP Journal Review January 1, 2009 Cindi Hurley, MD MBA February 12, 2009

2 Topics 1. Principles of Casting & Splinting 2. 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: FractureInflammatory conditions SprainsDeep lac repairs across joints Tendon lacerationSevere 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 es/cast/ es/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 6 th 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 Glucose Oral 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 Incretin Mimetics 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 1. Lispro (Humalog), Aspart (Novolog) onset: 5-15 minutes peak: 1-2 hours duration: 4-5 hours 2. 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.

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