Integration of Hybrid Model Diabetes Self-Management Education and Support at Primary Health Care During COVID-19 Pandemic: Protocol Paper of DIAJAPRI Health Coaching Study

IntroductionCOVID -19 pandemic has threatened the optimal achievement on type-2 diabetes mellitus (T2DM) target in primary health care (PHC), due to our priority in COVID-19 management, limited access of patients to PHC and their lifestyle changes as the impact of social restrictions. Therefore, the empowerment of capability of patients on diabetes self-care is required through optimal education and support. The use of telehealth in T2DM management has benefits on improving outcomes of patients. We aim to assess the role of telehealth diabetes self-management education (DSME) versus hybrid (telehealth and face-to-face method) diabetes self-management education and support (DSMES) to improve T2DM outcomes in PHC during COVID-19 pandemic. Methods and analysisThis study is an open label randomized-controlled trial that will be conducted in 10 PHCs in Jakarta, Indonesia, involving patients with T2DM. Subjects are classified into 2 groups: DSME group and DSMES group. Intervention will be given every 2 weeks. DSME group will receive 1 educational video every 2 weeks discussing topics about diabetes self-management, while DSMES group will receive 1 educational video and undergo 1 coaching session every 2 weeks. All interventions will be conducted by trained health workers of PHC, who are physicians, nurses, and nutritionists. Our primary outcome is the change of HbA1C level and our secondary outcomes are the changes of nutritional intake, physical activity, quality of life, anthropometric parameter, fasting blood glucose, lipid profile, inflammatory markers, and progression of diabetes complications at 3 and 6 months after intervention compare to the baseline. Ethics and disseminationThis study protocol has been approved by the Health Research Ethics Committee University of Indonesia. Subjects agree to participate will be given written informed consent prior to data collection. Findings from this study will be published in peer-reviewed journals and presented at conferences. Trial Registrationhttp://www.clinicalstrials.gov with identifier number NCT05090488. SummaryO_ST_ABSStrengths and limitations of the studyC_ST_ABSO_LIThis study evaluates the role of hybrid DSMES, which is useful in areas with limited access or on lockdowns. C_LIO_LIThis study will evaluates the implementation of hybrid DSMES, its benefits, difficulties, and obstacles. C_LIO_LIWe uses validated questionnaire instruments and routinely collected clinical data. C_LIO_LIBecause all of our interventions will be conducted by PHCs health workers, our results depend on the ability and adherence of PHCs health workers. C_LI

Risk factors for inpatient Hypoglycemia in a tertiary care hospital in Indonesia / Journal of the ASEAN Federation of Endocrine Societies

Introduction@#Hypoglycemia is an important and harmful complication that often occurs in inpatient and outpatient settings. This study aims to assess the incidence of inpatient hypoglycemia and its related factors. We also assessed mortality and length of hospital stay.@*Methodology@#We performed a retrospective cohort study among patients with type 2 diabetes mellitus admitted to a tertiary hospital in Indonesia. Using multivariate regression, we analyzed age, sex, body mass index, comorbidities, history of hypoglycemia, hyperglycemia treatment administered, nutritional intake, and medical instruction as the related risk factors for inpatient hypoglycemia.@*Results@#From 475 subjects, 80 (16.8%) had inpatient hypoglycemia, of which, 7.4% experienced severe hypoglycemia. We found that patients with a history of hypoglycemia (RR: 4.6; 95% CI: 2.8-7.6), insulin and/or sulfonylurea treatment (RR 6.4; 95% CI: 1.6-26.5), and inadequate nutritional intake (RR 2.6; 95% CI: 1.5-4.3) were more likely to have hypoglycemic events compared to those who did not. The length of hospital stay for patients in the hypoglycemic group is significantly longer than those in the non-hypoglycemic group (13 vs 7 days, p<0.001), but their mortality rates did not differ (16% vs 10.9%, p=0.18).@*Conclusion@#Inpatient hypoglycemia may be affected by a history of hypoglycemia and inadequate nutritional intake. Patients who had inpatient hypoglycemia tend to have a longer median length of hospital stay.

Autologous Bone-Marrow vs.Peripheral Blood Mononuclear Cells Therapy for Peripheral Artery Disease in Diabetic Patients

Diabetes mellitus (DM) remains one of the most important risk factors for peripheral artery disease (PAD), with approximately 20% of DM patients older than 40 years old are affected with PAD. The current standard management for severe PAD is endovascular intervention with or without surgical bypass. Unfortunately, up to 40% of patients are unable to undergo these revascularization therapies due to excessive surgical risk or adverse vascular side effects.Stem cell therapy has emerged as a novel therapeutic strategy for these ‘no-option’ patients. Several types of stem cells are utilized for PAD therapy, including bone marrow mononuclear cells (BMMNC) and peripheral blood mononuclear cells (PBMNC). Many studies have reported the safety of BMMNC and PBMNC, as well as its efficacy in reducing ischemic pain, ulcer size, pain-free walking distance, ankle-brachial index (ABI), and transcutaneous oxygen pressure (TcPO2). However, the capacity to establish the efficacy of reducing major amputation rates, amputation free survival, and all-cause mortality is limited, as shown by several randomized placebo-controlled trials. The present literature review will focus on comparing safety and efficacy between BMMNC and PBMNC as cell-based management in diabetic patients with PAD who are not suitable for revascularization therapy.

A systematic review on the association between Lipid Accumulation Product Index and Type 2 Diabetes Mellitus / Journal of the ASEAN Federation of Endocrine Societies

Introduction@#Excess fat accumulation contributes to the development of type 2 diabetes mellitus (T2DM). Lipid accumulation product (LAP) is an index computed from waist circumference and triglycerides, which represents increased lipotoxicity. We aim to study the relationship of LAP index and T2DM and its utility as a predictor for T2DM development.@*Methodology@#A literature search in PubMed and Cochrane database was performed to retrieve and review studies reporting the association between LAP and T2DM@*Results@#Two cross-sectional studies from Japan and the United States, and one cohort study from Iran were obtained. A high LAP was associated with a higher risk of T2DM [odds ratio (OR) 19.1, 95% confidence interval (CI) (6.6-55.5) for women; and OR 7.4, 95% CI (5.1-10.8) for men].@*Conclusion@#LAP was strongly associated with T2DM. Its utility in predicting the development of T2DM needs to be confirmed.

Seventy-two hour mortality prediction model in patients with Diabetic Ketoacidosis: A retrospective cohort study / Journal of the ASEAN Federation of Endocrine Societies

Objective@#This study aims to identify predictors of 72-hour mortality in patients with diabetic ketoacidosis (DKA).@*Methodology@#In this retrospective cohort study, data were obtained from medical records of adult patients with DKA in Cipto Mangunkusumo General Hospital from January 2011 to June 2017. Associations of predictors (age, type of diabetes, history of DKA, comorbidities, level of consciousness, renal function, bicarbonate, potassium, lactate, betahydroxybutyrate levels, and anion gap status) and 72-hour mortality were analyzed. The mortality prediction model was formulated by dividing the coefficient B by the standard error for all variables with p<0.05 in the multivariate analysis.@*Results@#Eighty-six of 301 patients did not survive 72 hours after hospital admission. Comorbidities (HR 2.407; 95% CI 1.181–4.907), level of consciousness (HR 10.345; 95% CI 4.860–22.019), history of DKA (HR 2.126; 95% CI 1.308–3.457), and lactate level (HR 5.585; 95% CI 2.966–10.519) were significant predictors from multivariate analysis and were submitted to the prediction model. The prediction model had good performance. Patients with total score less than 3 points were at 15.41 % risk of mortality, 3 – 4 points were 78.01% and 5 – 6 points were 98.22% risk of mortality. @*Conclusion@#The 72-hour mortality rate in Cipto Mangunkusumo General Hospital was 28.57%. The mortality prediction model had a good performance and consisted of comorbidities, history of DKA, level of consciousness and lactate level.

The adaptive immune response in Graves’ Disease: Does Vitamin D have a role? / Journal of the ASEAN Federation of Endocrine Societies

@#Graves' disease (GD) is an autoimmune disease characterized by excessive autoantibody formation by the lymphocyte B cells (B cells). The autoantibodies will bind to Thyroid Stimulating Hormone receptors (TSHR) and enhance the production of thyroid hormone. Previous studies indicate that the impairment of immune response in GD happens in several points in the adaptive immune response, particularly the profile of the intrathyroidal dendritic cells (tDC), the imbalance of T helper-1 (Th1) and T helper-2 (Th2), the Th17 cells that act as pro-inflammatory cells and the dysfunction of immune modulating T regulator (Treg) cells.6-11 Vitamin D is a steroid hormone which has pleiotropic effects. The role of vitamin D in bone and calcium metabolism is already established. The discovery of vitamin D receptor (VDR) in immune cells such as monocytes/macrophages, T cells and B cells, demonstrates that vitamin D may influence innate and adaptive immune process. Recent studies try to explore the relationship between vitamin D and autoimmune disease, furthermore they consider vitamin D as a modifiable environmental factor in autoimmune diseases.13,40 Most people with autoimmune diseases have lower vitamin D level than that of healthy subjects. Vitamin D level also has been associated with disease activity of Systemic Lupus Erythematosus (SLE) and Rheumatoid Arthritis (RA). Vitamin D influences adaptive immune response through its ability to modulate dendritic Cells (DC), T cells, B cells and Treg cells. Although previous studies reported the immune response disturbance in GD include the tDC, Thelper and Treg cells,6-11 little is known whether the immunoregulatory effect of vitamin D can interfere with the natural history of GD. The effect of vitamin D in GD remains to be explored.