An Indonesian adult with obesity hypoventilation syndrome: a case report

Obesity hypoventilation syndrome (OHS) is an often overlooked and limited case with other conditions that can cause hypoventilation.

Case presentation

An Indonesian female, 22 years old, always feels sleepy, has difficulty concentrating and controlling her appetite. The patient had a fever, respiratory rate of 32 ×/min, pulse rate of 115 ×/min, apathy, obesity (BMI =46.6 kg/m²), and she used oxygen therapy with a non-rebreathing mask of 10 l/min (SO₂ of 89%). The patients had daytime hypercapnia & alveolar hypoventilation without other causes of hypoventilation. She was likely to have a chronic condition with relatively stable symptoms that had fallen into a state of acute on chronic hypercapnic respiratory failure. The patient used mechanical ventilation and received supportive management. After 19 days of treatment, the patient's condition improved, and it was recommended to lose weight gradually. In 1-week post hospitalization, the patient experienced a weight loss of 5 kg.

Discussion

Mechanical ventilation, supportive management, and decreased body weight of 25-30% gradually have improved prognosis in OHS patients. Bariatric surgery is carried out when the patient cannot lose weight with diet and exercise.

Conclusion

OHS management includes oxygen therapy and gradually decreased body weight.

Factors associated with disease severity of COVID‑19 in patients with type 2 diabetes mellitus

Diabetes mellitus causes a decline in immunological function, an increase in proinflammatory cytokines, and a prothrombotic state, thus providing risk factors for the severity of coronavirus disease 2019 (COVID-19) in patients with type 2 diabetes mellitus (T2DM). The aim of the present study was to analyze the risk factors associated with the severity of COVID-19 in patients with T2DM. A cross-sectional observational study was performed on 201 patients with T2DM from May 1 to August 31, 2020 and admitted to the isolation ward of Dr Soetomo General Hospital (Surabaya, Indonesia). The patients were divided into severe (108 cases; 53.7%) and non-severe (93 cases; 46.3%) groups, which were considered the dependent variables. Univariate and multivariate analysis was performed. The independent variables were age, sex, diabetes onset, chronic complications, presence of hypertension, randomized blood glucose, HbA1c, albumin, and neutrophil-lymphocyte ratio (NLR). A P-value <0.05 was considered to be statistically significant. The median age of the 201 subjects was 56 years, with 70.1% <60 years old, 52.7% male, 76.1% with diabetes onset <10 years, and 108 patients (53.7%) in severe condition. The results of the bivariate analysis revealed that diabetes onset >10 years (OR 2.5; P=0.011) was associated with severity of COVID-19 in patients with T2DM, however hypoalbumin (OR 1.93; P=0.054) was not associated with disease severity. Furthermore, multivariate analysis revealed that male sex (OR 2.07; P=0.042), age (≥60 years) (OR 2.92; P=0.008), HbA1c (≥8%) (OR 3.55; P=0.001), hypertension (OR 4.07; P=0.001), and an NLR ≥7.36 (OR 6.39; P=0.001) were associated with severe COVID-19. Collectively, it was revealed that increased NLR, hypertension, poor glycemic control, older age, and male sex were risk factors associated with the severity of COVID-19 among diabetic patients.

Dynamic balance in obese subjects: before and after telerehabilitation weight-bearing exercise for better balance

Background: People with obesity tend to have balance disturbance and a higher fall risk than those with normal BMI. The Weight-bearing Exercise for Better Balance (WEBB) is an exercise program that could improve balance in the elderly population, but no study implementing the WEBB program on obese subjects. This study aims to analyze the effects of the telerehabilitation WEBB program on dynamic balance in obese subjects, measured by Maximized Reach Distance (%MAXD) and a composite score of the Modified Star Excursion Balance Test (mSEBT). Methods: Ten male participants aged 18-30 were recruited. Participants underwent the WEBB program 3 times a week for 8 weeks in their own homes under the supervision of the researchers. The intensity of the exercise was increased every 2 weeks. For the analysis, %MAXD and composite score mSEBT were used to assess the dynamic balance before and after the WEBB program. Results: There was a significant increase (p < 0.05) in %MAXD of both sides and all directions. The mSEBT composite score of both sides also significantly increased (p < 0.05). All the statistical results showed large effect sizes. Conclusion: The WEBB program through telerehabilitation is proven to significantly improve dynamic balance, as indicated by an increase in %MAXD and mSEBT composite scores in obese subjects.

Emergency thrombectomy in acute upper limb ischemia patient with diabetes mellitus

Background: Acute limb ischemia is a sudden decrease in limb blood perfusion with an onset of less than 14 days, most commonly occurs in lower extremities. Diabetes mellitus, one of diseases underlying peripheral artery disease, complicates the pathophysiology of acute limb ischemia. In this case report we present a patient with type 2 diabetes mellitus and acute limb ischemia in the left upper extremity that had successful thrombectomy treatment. Case presentation: A 58-year-old female patient came to the Emergency Care Unit of Dr. Soetomo General Hospital with the continuous pain in the five fingers to the palm of the left hand for the past two days. The numbness spread from the elbow to the left fingers, making them weak and difficult to grip. Those five fingers were pale and cold as well. The left hand had no pulsated radialis and ulnar artery, weak brachial pulse and undetected pulse oximetry result. The patient was diagnosed with type 2 diabetes mellitus since 2005 and has a controlled treatment. On the first day of hospitalization, the patient was scheduled for emergency thrombectomy at Dr. Soetomo General Hospital. Follow-up on the seventh-day post-surgery, the patient had no complaints of pain and pale in the left hand and the brachial, ulnar and radial arteries were palpable. Conclusion: Acute limb ischemia is uncommon in the upper extremities but we found that it has an excellent prognosis with early revascularization, even in a patient with diabetes mellitus. The treatment must be in conjunction with aggressive diabetes mellitus treatment to avoid acute limb ischemia worsening

The role of serum ferritin level and disease severity in COVID-19 with type 2 diabetes mellitus patients

Introduction: The disease progression of coronavirus disease 2019 (COVID-19) in individuals with comorbidities, such as type 2 diabetes mellitus (T2DM) in particular, has been associated with the occurrence of the cytokine storm. Ferritin, an acute-phase protein indicating inflammation, has been linked to T2DM and the severity of COVID-19. Our study aimed to investigate the association between the level of ferritin and the severity of COVID-19 in T2DM patients. Methods: A cross-sectional study was conducted among COVID-19 patients admitted at Dr. Soetomo General Hospital, Surabaya, from April to September 2020. The patients who met the inclusion criteria were enrolled in the study. The data used in this study was secondary data obtained from the medical records at Dr. Soetomo General Hospital, which consisted of serum ferritin levels, the severity of COVID-19, the results of blood analysis, and other demographic and clinical characteristics (age, gender, hypertension, the number of complaints, and vital signs). Data analysis was performed using SPSS software and presented in percentage (%), mean ± standard deviation (SD), or median (min-max). A chi-square test was carried out to identify the association between serum ferritin level and the severity of COVID-19 in T2DM patients at α=0.05. Results: Of the total 159 patients were included and 80.8% of them had moderate severity of COVID-19, whereas the rest (19.5%) had severe COVID-19. Out of total patients, 78.6% had ferritin levels of ≥400 mg/dL, suggesting hyperferritinemia syndrome (mean ± SD: 1177.21 ± 1275.90 mg/dL). The Chi-squared analysis revealed a significant association between serum ferritin levels with the severity of COVID-19 in T2DM patients (p=0.024). Conclusion: There was a significant relationship between serum ferritin levels and the severity of COVID-19 in T2DM patients and further study with a bigger sample size is needed to confirm this finding.

Recurrent seizures as manifestation of hypoparathyroidism-related hypocalcemia in a patient with post-subtotal thyroidectomy

Background: Hypocalcemia, a condition where the serum calcium concentration or total serum calcium is below normal, could be associated with various manifestations including severe symptoms requiring immediate hospitalization. The condition can cause by several causes including iatrogenic thyroidectomy. Here, we report a patient of hypocalcemia associated with hypoparathyroidism due to post-thyroidectomy. Case presentation: A 32-year-old woman admitted to the hospital complained of stiffness and tingling in the extremities accompanied by recurrent seizures. The serum calcium level was low and this hypocalcemia condition was associated with low parathyroid hormone levels after subtotal thyroidectomy surgery. Laboratory examination indicated calcium 4.8 mg/dL and parathyroid hormone 2.21 pg/ml. The patient had bradycardia with prolonged QT on electrocardiography (ECG) and developed cataracts in both eyes which could be associated with chronic hypocalcemia. The patient's condition improved after correction of hypocalcemia. After discharge, the patient was given calcium and levothyroxine supplementation due to hypothyroid conditions. Conclusion: The hypocalcemia condition in the patient was associated with low parathyroid hormone level post-subtotal thyroidectomy surgery. This case highlights the impotence of detailed analyses of hormonal, radiological and histological investigations of patients with thyroid gland diseases to diagnose such conditions early and to ensure timely management.

An Indonesian adolescent with Turner syndrome and β-thalassemia in low-resource setting: A case report and literature review article

Background

Turner syndrome and β-thalassemia very rarely occur together in an individual.

Case presentation

An Indonesian adolescent, 18 years old, complained is fatigue a week ago. She has a medical history of β-thalassemia for age 6 months and Turner syndrome identification for age 16 years. Meanwhile, she regular consumes deferasirox 500 mg every day. Physical examination showed pale conjunctiva and pale face. Body view similar children aged 13 years old. Laboratories investigation values included Hb of 7.7 gr/dL, MCV of 79.5 fL, MCH of 25.9 pg, MCHC of 28.6%, WBC of 6780/mm³, PLT of 242,000/mm³, AST of 15 U/L, ALT of 20 U/L, Ferritin of 1692.32 ng/mL, growth hormone of 0.468 ng/mL, Estradiol of <11.80 pg/mL, luteinizing hormone of 53.50 mIU/mL, and follicle-stimulating hormone of 115.19 mIU/mL. Chromosomal analysis showed Turner syndrome. The patient received a packed red cell transfusion of up Hb of 10 gr/dL, deferasirox 500 mg daily, and a contraceptive tablet. Due to financial issue in Indonesia, patient with Turner syndrome does not get proper hormonal therapy such as growth hormone, vitamin D supplementation, and other hormone replacement therapy.

Discussion

Turner syndrome and thalassemia in low-resource settings are challenges in themselves, so in their implementation, only thalassemia can be controlled, but for therapy, it does not show an improvement in prognosis.

Conclusion

Turner syndrome and thalassemia both worsen the patient's condition.

An Indonesian male with congenital hypogonadotropic hypogonadism: A case report and literature review

Introduction

Congenital hypogonadotropic hypogonadism (CHH) is a rare disorder caused by insufficient gonadotropin-releasing hormone (GnRH) production.

Case presentation

An Indonesian adolescent, 22 years old, Javanese ethnic, complained of a small penis, low sexual desire, fatigue, and anosmia since childhood. Medical history stated that the patient had low testosterone levels 7 years ago and received testosterone once. Testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were decreased. The testicular ultrasound result was bilateral microtestis, suspicious of bilateral hypoplasia of the epididymis. Brain MRI also supports the diagnosis of hypogonadotropic hypogonadism, and the patient received Sustanon of 250 mg/2 weeks. The patient showed a good prognosis after 1 month of therapy.

Discussion

The success of CHH therapy must be explored to improve its management.

Conclusion

CHH in an Indonesian male shows a good prognosis with testosterone injection.

•

CHH diagnosis is difficult to confirm in low-resource settings.

•

Testosterone induction is a classic CHH therapy.

•

CHH has a poor prognosis.

The effectiveness of topical hyaluronic acid on decreasing Interleukin-6 and acceleration of wound healing (Push Score) in Wagner II-III diabetic foot ulcer in Dr. Soetomo Hospital Surabaya

Background: A diabetic foot ulcer is a complication that often occurs in patients with diabetes mellitus. The healing process of a chronic wound is more complicated and requires more complex treatment. There is an increase in IL-1, IL6, and TNF-α pro-inflammatory cytokines in a chronic wound. Hyaluronic acid (HA) is a component that has been used for a long time and is known to help the wound healing process. This study was at a time to determine the effectiveness of hyaluronic acid on the reduction of interleukin-6 in accelerating the healing of Wagner II-III diabetic foot ulcers. Methods: This study is an experimental, randomized study of pre and post-test design on diabetic foot ulcer patients with the Wagner II-III classification who were controlled at the thoracic, cardiac, and vascular surgery polyclinic at Dr. Soetomo Hospital Surabaya. Data were analyzed using SPSS version 20 for Windows. Result: About 39 samples are willing to participate in the study, divided into 20 samples in the treatment group and 19 in the control group. The mean concentrations of IL-6 in the treatment group before and after the intervention were 280.70±155.50 ng/ml and 126.60±145.60 ng/ml. There was a significant decrease in IL-6 levels (p<0.05) before and after the intervention. The mean concentrations of IL-6 in the control group pre and post were 315.20±127.40 ng/ml and 136.30±134.60 (p<0.05). The decrease in the control and treatment groups was no statistically significant difference (p>0.05). There was no significant difference in the PUSH Score (p>0.05) in the two groups before intervention/treatment. The decrease of wound area in the control and treatment groups were -4.80 ((-0.40)-(-24.50)) and -4.8 ((-0.70)-(-30.90)) (p>0.05). Conclusion: Topical hyaluronic acid and wound care using 0.9% NaCl reduced interleukin-6 levels, PUSH scores, and wound area in Wagner II-III diabetic foot ulcers.

Clinical characteristics and outcomes of hospitalized COVID-19 patients with diabetes mellitus in East Java, Indonesia: A cross-sectional study

Introduction: Diabetes mellitus has been perceived as the worsening factor for coronavirus disease 2019 (COVID-19), where diabetes mellitus patients with pre-existing inflammatory condition could develop acute respiratory disease syndrome as well as multi-organ dysfunction. Managing diabetes mellitus amidst severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is also a matter of concern as several antidiabetic therapies could affect the progression of COVID-19. This study aimed to provide the clinical characteristics and outcomes of patients with both COVID-19 and diabetes mellitus receiving blood glucose lowering therapies and COVID-19 symptomatic treatments.

Methods: This retrospective study was performed on 260 medical records of patients hospitalized between May 2020 to February 2021 in East Java, Indonesia. Patients were confirmed COVID-19 positive based on the results from real time polymerase chain reaction (RT-PCR) using nasal swab samples collected on hospital admission. Data included were demographic characteristics, COVID-19 symptoms, severity of COVID-19, comorbidities (other than diabetes mellitus), fasting blood glucose (FBG), and 2-hours post-prandial blood glucose (2hPBG), and outcomes.

Results: Most of the patients had age range of 41–60 years old (76.1%) with more than a half of the subjects (60%) were obese. Patients with uncontrolled diabetes were distributed evenly among the COVID-19 severities (74.3% in asymptomatic group, 73.6% in mild group, and 74.1% in moderate group). There were reductions in FBG and 2hPBG levels measured before (210.75±81.38 and 271.19±100.7 mg/dL, respectively) and after the treatment (181.03±68.9 and 222.01±86.96 mg/dL, respectively). All patients received multivitamin and symptomatic treatment for COVID-19. Oral antidiabetic drug (57.6%) and insulin (28.8%) were administered to lower the blood glucose level of the patients. As many as 96.9% patients survived, while 3.1% died.

Conclusion: COVID-19 could affect the blood glucose level, suggesting the importance of antihyperglycemic therapies among patients with both COVID-19 and diabetes mellitus.

Impact of COVID-19 Lockdown on the Metabolic Control Parameters in Patients with Diabetes Mellitus: A Systematic Review and Meta-Analysis

BACKGROUND

Abrupt implementation of lockdowns during the coronavirus disease 2019 (COVID-19) pandemic affected the management of diabetes mellitus in patients worldwide. Limited access to health facilities and lifestyle changes potentially affected metabolic parameters in patients at risk. We conducted a meta-analysis to determine any differences in the control of metabolic parameters in patients with diabetes, before and during lockdown.

METHODS

We performed searches of five databases. Meta-analyses were carried out using random- or fixed-effect approaches to glycaemic control parameters as the primary outcome: glycosylated hemoglobin (HbA1c), random blood glucose (RBG), fasting blood glucose (FBG), time-in-range (TIR), time-above-range (TAR), time-below-range (TBR). Mean difference (MD), confidence interval (CI), and P value were calculated. Lipid profile was a secondary outcome and is presented as a descriptive analysis.

RESULTS

Twenty-one studies enrolling a total of 3,992 patients with type 1 or type 2 diabetes mellitus (T1DM or T2DM) were included in the study. Patients with T1DM showed a significant improvement of TIR and TAR (MD=3.52% [95% CI, 0.29 to 6.74], I2=76%, P=0.03; MD=-3.36% [95% CI, -6.48 to -0.25], I2=75%, P=0.03), while FBG among patients with T2DM significantly worsened (MD=3.47 mg/dL [95% CI, 1.22 to 5.73], I2=0%, P<0.01). No significant difference was found in HbA1c, RBG, and TBR. Use of continuous glucose monitoring in T1DM facilitated good glycaemic control. Significant deterioration of lipid parameters during lockdown, particularly triglyceride, was observed.

CONCLUSION

Implementation of lockdowns during the COVID-19 pandemic did not worsen glycaemic control in patients with diabetes. Other metabolic parameters improved during lockdown, though lipid parameters, particularly triglyceride, worsened.

Profile of Diabetic Foot Ulcer Patients at Tertiary Care Hospital in Surabaya, Indonesia

Background: Diabetic Foot Ulcer (DFU) has been associated with a high mortality rate of Diabetes Mellitus (DM) patients. Both behavioral and biological factors cause predisposition to DFU. Purpose: This research describes the profile of hospitalized DFU patients at a tertiary care hospital in Surabaya. Methods: A retrospective descriptive study that analyzed medical records of hospitalized T2DM patients with DFU in Dr. Soetomo General Hospital. Sampled respondents were patients ≥ 21 years old who were hospitalized between 2016–2018. Demographic data, clinical characteristics, medical histories, length of hospital stay, laboratory results, precipitating factors, microorganism culture results, treatment, and outcome were analyzed. Descriptive analysis is presented in the form of narratives, tables, and diagrams. Results: 9.08% of hospitalized Type 2 DM (T2DM) cases were related to foot ulcers. The average patient age was 57.00 ± 9.83 years with no gender predominance. DM was poorly controlled (Mean HbA1C 9.78±2.83%; RBG 251.83 ± 158.15 mg/dL). The majority of patients had sepsis (68.26%) and renal function impairment (62.72%). Ulcers with Wagner grades of 4–5 were frequent (41.31%). The highest percentage of sepsis (80.49%) and the average leukocyte level (22.60±11.95 x109/L) were found in gangrenous feet. Anemia was more predominant and severe in ulcers with higher Wagner grades. Trauma and Escherichia coli were the most common precipitating factors and microorganisms isolated, respectively. Amputation was performed for 82.36% of patients who were admitted to hospital with gangrene. The Lower Extremity Amputation (LEA) and mortality rates were 14.11% and 40.93%, respectively. Conclusion: DFUs were found to have a relatively high prevalence among T2DM patients, and must never be neglected due to the high associated mortality rate.

Effect of High Fat Diet on Weight Loss Through the Expression of Uncouple Protein 1 in Mice Visceral Fat

Obesity has become an epidemic around the world. High fat diet (HFD) have been implemented as one of intervention to battle obesity. Uncouple protein 1 (UCP1) is one of the key factor on energy expenditure. The aim of this experiment is to see the macronutrients composition on weight loss and UCP1 expression in the visceral fat. Fifty male mice, 2-3 months old, 18-30 grams, were put in five different groups. K1 were fed (20% protein, 62.0% carbohydrate, 12% fat), K2 (60% protein, 0% carbohydrate, 30% fat), K3 (45% protein, 0% carbohydrate, 45% fat), K4 (30% protein, 0% carbohydrate, 60% fat), K5 (15% protein, 0% carbohydrate, 75% fat). The experiment was done in four weeks, mice body weight was measured every week. UCP1 expression seen using immunohistochemistry staining was measured at the end of the fourth week. Significant weight loss was achieved by K4 (-9.60±3.81) gram by the end of week four (p<0.05). K4 had the least amount of visceral fat. The result was that K4 achieved a significant visceral fat mass (0.02±0.06) gram compared to K1 (0.53±0.08) gram. Compared to other groups K5 expressed UCP1 more than the others (3.78±3.72) cphfp. HFD fed groups produced significant weight loss, group that had the greatest weight loss is K4. Meanwhile, each group had a variety of UCP1 expression.

Effect of High Fat Diet on Weight Loss Through the Expression of Uncouple Protein 1 in Mice Visceral Fat

Obesity has become an epidemic around the world. High fat diet (HFD) have been implemented as one of intervention to battle obesity. Uncouple protein 1 (UCP1) is one of the key factor on energy expenditure. The aim of this experiment is to see the macronutrients composition on weight loss and UCP1 expression in the visceral fat. Fifty male mice, 2-3 months old, 18-30 grams, were put in five different groups. K1 (20% protein, 62.0% carbohydrate, 12% fat), K2 (60% protein, 0% carbohydrate, 30% fat), K3 (45% protein, 0% carbohydrate, 45% fat), K4 (30% protein, 0% carbohydrate, 60% fat), K5 (15% protein, 0% carbohydrate, 75% fat). The experiment was done in four weeks, mice body weight was measured every week. UCP1 expression seen using immunohistochemistry staining was measured at the end of the fourth week. Significant weight loss was achieved by K4 (-9.60±3.81) gram by the end of week four (p<0.05). K4 had the least amount of visceral fat. The result was that K4 achieved a significant visceral fat mass (0.02±0.06) gram compared to K1 (0.53±0.08) gram. Compared to other groups K5 expressed UCP1 more than the others (3.78±3.72) cphfp. HFD fed groups produced significant weight loss, group that had the greatest weight loss is K4. Meanwhile, each group had a variety of UCP1 expression.

PROFILE OF DIABETIC KETOACIDOSIS PATIENTS AT REGIONAL PUBLIC HOSPITAL DR. SOETOMO IN 2017

Background: Diabetic ketoacidosis (DKA) is one of many life-threatening complications of diabetes mellitus (DM), which is characterized by severe hyperglycemia, metabolic acidosis and ketonemia. This complication can eventually lead to coma and death if not treated properly. Purpose: The aim of this study is to describe the profile of the DKA patients who were at Regional Public Hospital (RSUD) Dr. Soetomo in 2017. Methods: This study was a descriptive study that used the medical record data of DKA patients who were at RSUD Dr. Soetomo in 2017. The study’s total sample size was 63 patients. The study’s variables were gender, age, type of DM, severity of DKA, precipitating factors, main complaints, vital signs, random plasma glucose level, electrolyte level, and blood gas analysis. The frequency, mean, and standard deviation were analyzed. Results: Most of the 63 DKA patients were female (66.67%), aged from 50–59 years (38.10%). The DKA cases being handled by the Dr. Soetomo Hospital were overwhelmingly of type 2 DM patients (88.89%). More than half the patients (58.73%) experienced severe DKA. Altered states of consciousness (46.03%) and shortness of breath (26.98%) were the most common main complains made by the DKA patients. Almost all patients experienced infection (88.89%) as the precipitating factor; the most common infections were sepsis (92.86%), pneumonia (30.36%), and urinary tract infections (23.21%). Two thirds of the patients (66.67%) had a length of stay of 0–7 days. About 57.14% of the DKA patients died while undergoing treatment. Conclusion: The number of severe DKA patients and the mortality rate in our study were higher than in other studies. Females and the elderly were more prone to DKA, and the most common precipitating factor was infection.

Safety and efficacy in early insulin initiation as comprehensive therapy for patients with type 2 diabetes in primary health care centers

AIM

to analyze the safety and efficacy of early insulin initiation therapy for patients with type 2 diabetes mellitus (T2DM) in primary health care provided by general practitioners (GPs) in Surabaya, East Java, Indonesia.

METHODS

pre-post study of ninety nine diabetic patients without previous insulin treatment with HbA1c levels >8% were involved in this study. The study was conducted in 10 primary health care centers in Surabaya between October 2011 to June 2012. Each patient received insulin therapy for 12 weeks. Laboratory examination was performed for each patient including fasting plasma glucose (FPG), 2 hours post-prandial plasma glucose (2hPPG) and HbA1c examination before and after the study. Self monitoring blood glucose (SMBG) examination was conducted in order to adjust the insulin dose and prevent the incidence of hypoglycemia. Data was statistically analyzed using paired-T test.

RESULTS

FPG level was decreased from baseline data (209 mg/dL) to 152.07 mg/dL at the end of the study (56.93 mg/dl; p=0.0001). The average of 2hPPG level was also decreased from 313.00 mg/dl to 220.72 mg/dL ( 92.28 mg/dL; p=0.0001). HbA1c was reduced from 11.60% at baseline to 8.95% at the end of study ( 2.65%; p=0.0001). Hypoglycemia was found in 6 patients (6.06%) in this study, but all events were mild and did not need to be admitted to hospital.

CONCLUSION

the safety of insulin therapy iniatiation might be provided by GPs at primary health centers with significant efficacy and minimal side effects.