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 http://intermed.med.uottawa.ca/procedur es/cast/ http://intermed.med.uottawa.ca/procedur 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.