Year m. Sc nursing rajeev college of nursing k. R. Puram, hassan



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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATON

1.


NAME OF THE CANDIDATE

AND ADDRESS

MR. FARABI IBRAHIM MAKHTHOOM

Ist 1ST YEAR M.SC NURSING



RAJEEV COLLEGE OF NURSING

K.R. PURAM, HASSAN-573201


2.

NAME OF THE INSTITUTION

RAJEEV COLLEGE OF NURSING, HASSAN

K.R. PURAM, HASSAN-573201


3.


COURSE OF STUDY&

SUBJECT

MASTER OF SCIENCE IN NURSING,

MEDCIAL SURGICAL NURSING

4.

DATE OF ADMISSION

13/06/2009

5.

TITLE OF THE STUDY

EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON PREVENTION OF HYPOGLYCEMIA AMONG TYPE 2 DIABETES MELLITUS PATIENTS ADMITTED IN SELECTED HOSPITALS AT HASSAN.

5.1.

PROBLEM STATEMENT

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON PREVENTION OF HYPOGLYCEMIA AMONG TYPE 2 DIABETES MELLITUS PATIENTS ADMITTED IN SELECTED HOSPITALS AT HASSAN”

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

Don’t Let Hypoglycemia Deprive You Of Enjoying



A ‘Normal’ Life- Ever Again! “

-Damian Muirhead

The term diabetes was derived from the Greek verb, diabainein, itself formed from the prefix dia-, “across, apart,” and the verb bainein, “to walk, stand.” hence its derivative diabetes meant “ one that straddles,”. Diabetes is first recorded in English, in the form diabete, in a medical text written around 1425. In 1675, Thomas Willis added the word mellitus, from the Latin meaning “honey”, a reference to the sweet taste of urine. This sweet taste had been noticed in urine by the ancient Greeks, Chinese, Egyptians, Indians, and Persians. In 1776, Mathew Dobson confirmed that the sweet taste was because of an excess of a kind of sugar in the urine and blood of people with diabetes. The ancient Indians tested for diabetes by observing whether ants were attracted to person’s urine and called the ailment “sweet urine disease”. 1

Diabetes mellitus is a chronic systemic disease characterized by either deficiency of insulin or decreased ability of the body to use insulin. Diabetes mellitus is sometimes referred to as “high sugars” by both clients and health care providers.2

The most common type of diabetes mellitus is Type 1 diabetes mellitus, which is characterized by destruction of the insulin-secreting cells (beta cells) of the pancreas and Type 2 diabetes is characterized by insulin resistance and progressively reduced secretion of insulin by beta cells. About 90% of people with diabetes have the type 2 form. Type 2 diabetes occurs most common in people older than 30 years who are obese, although its incidence is increasing in younger adults. If symptoms are experienced, they are frequently mild and may include fatigue, irritability, polyuria, polydipsia, skin wounds that heal properly, vaginal infections or blurred vision. The management of diabetes mellitus includes diet, exercise, self monitoring of blood glucose level, medication, foot care and prevention of complication. The goal for diabetes management is to achieve euglycemia without hypoglycemia and without seriously disrupting the patient’s usual life style and activity.3

Hypoglycemia is an acute complication of Diabetes Mellitus, it is the medical term for a state produced by a lower than normal level of blood glucose. The term literally means “under-sweet blood”. It occurs when the blood glucose falls to less than 40-50 mg/dl. It can be caused by too much insulin intake or oral hypoglycemic agents, too little food or excessive physical activity. Hypoglycemia is also a term in popular culture and alternative medicine for a common, often self-diagnosed, condition characterized by sweating, tremor, tachycardia, palpitation, nervousness, hunger, confusion, slurred speech, emotional changes, double vision, drowsiness, sleeplessness. The individual fails to become aware of hypoglycemia and can result in prolonged hypoglycemia with consequent brain injury, seizure and loss of consciousness. It is treated by changing eating patterns. 3

The patients with diabetes mellitus must carry some form of simple sugar all times. There are many different commercially prepared glucose tablets and gels that patient may find convenient to carry. Patients are advised to refrain from eating high-caloric, high fat dessert foods. Hypoglycemia is prevented by consistent pattern of eating, administering insulin and exercising. Patients and family members must be instructed about the symptoms of hypoglycemia Family members in particular must be made aware that any subtle change in behavior may be an indication of hypoglycemia. It is very important perform blood glucose tests on a frequent and regular basis. Patients who take oral sulfonylurea may also develop hypoglycemia. 3

The over the counter drugs are available to prevent hypoglycemia such as Injection Glucagon 1 mg.



6.2 NEED FOR THE STUDY

Diabetes mellitus is one of the most common disease with which mankind throughout the world is affected today is primarily due to his luxurious life style and unhealthy food habits is of great concern. So as many people are suffering from diabetes mellitus and are taking intensive treatment. The major adverse effect of intensive therapy is increase incidence of hypoglycemia.

According to the World Health Organization, approximately 180 million people worldwide suffer from diabetes. Its incidence is increasing rapidly, and it is estimated that by the year 2030, this number will almost double. Diabetes mellitus occurs throughout the world, but is more common (especially type 2) in the more developed countries. With prevalence rates doubling between 1990 and 2005, The Centers for Disease Control has characterized the increase as an epidemic. 4

According to WHO reports, India has nearly 44 million diabetic subjects today, which is chiefly contributed by the urban population. The scenario is changing rapidly due to socio-economic transition occurring in the rural areas also. Availability of improved modes of transport, and less strenuous jobs as in the vicinity have resulted in decreased physical activities. Better economic conditions have produced changes in diet habits. The conditions are more favorable for expression of diabetes in the population, which already has a racial and genetic susceptibility for the disease. Recent epidemiological data show that the situations are similar throughout the country. 5

A study conducted on Control diabetes on your own assesses the importance of self monitoring blood glucose by diabetic patients. According to studies, 25% of the patients develop diabetes-related complications, which are mostly due to poor diabetes control. Monitoring blood sugar levels at home is an essential component of diabetes management. Self-Monitoring Blood glucose helps evaluate the effectiveness of pharmacological therapy and the impact of dietary factors on glycemic control. It could help patients interpret and respond to blood glucose patterns, identify acute complication such as low blood glucose reactions-hypoglycemia (“unawareness”). 6

The threat and incidence of hypoglycemia is the major limiting factor in intensive glycemic control for both type 1 and type 2 diabetes. Unfortunately, the threat and incidence of iatrogenic hypoglycemia is increased in attempts to achieve euglycemia as recommended by current treatment guidelines. Surveys investigating the prevalence of hypoglycemia have provided some alarming results. The Diabetes Control and Complications Trial (DCCT) reported a threefold increase in severe hypoglycemia and coma in intensively treated patients versus conventionally treated patients. Hypoglycemia is relatively common in type 2 diabetes, with prevalence rates of 70-80%. 7

A study conducted on Hypoglycemia associated hospitalizations in a population with a high prevalence of non-insulin dependent diabetes mellitus (NIDDM) in Seattle, Washington. During an estimated 26,125 person-years of observation among diabetic patients, there were 126 hypoglycemia-associated admissions related to diabetes among 109 diabetic patients, yielding a hospitalization rate of 4.7 per 1000 person-years. 8

The investigator felt in India, the number of diabetes patients is increasing and the disease is now prevalent in all age groups. It is seen that patients with diabetes mellitus lack knowledge about the disease condition and its management, all involved with diabetes care agree that patients play a major role in successful management of diabetes mellitus. So all aspects of diabetic care should be taught to the patients who are suffering from diabetes mellitus for remission of disease and improving quality of life. So the investigator felt it necessary to conduct a study regarding hypoglycemia in diabetes patients.



6.3 STATEMENT OF THE PROBLEM

“A study to assess the effectiveness of structured teaching programme on prevention of hypoglycemia among type 2 diabetes mellitus patients admitted in selected hospitals at Hassan.”



6.4 OBJECTIVES OF THE STUDY

  • To assess the knowledge regarding prevention of hypoglycemia among Type 2 Diabetes Mellitus patients before and after structured teaching programme.

  • To administer structured teaching programme on prevention of hypoglycemia among Type 2 Diabetes Mellitus patients.

  • To evaluate the effectiveness of structured teaching programme on prevention of hypoglycemia among Type 2 Diabetes Mellitus patients by comparing pre test and post test knowledge scores.

  • To associate between the post test knowledge scores with the selected socio demographic variable.

6.5 HYPOTHESIS

H1: There will be significant difference between pre-test and post test knowledge scores regarding hypoglycemia and its prevention among Type 2 Diabetes Mellitus patients.

H2: There will be significant association between post test knowledge scores with selected demographic variables.

6.6 ASSUMPTIONS


  • The Diabetic patients may have less knowledge regarding hypoglycemia and its prevention.

  • The structured teaching programme will enhance the knowledge level of type 2 diabetes mellitus patients regarding prevention of hypoglycemia.

6.7 OPERATIONAL DEFINITIONS

  • Assess: It refers to statistical estimation of knowledge regarding prevention of hypoglycemia among type 2 diabetes mellitus patients.

  • Effectiveness: It refers to change in the level of knowledge after administering structured teaching programme regarding prevention of hypoglycemia among type 2 diabetes mellitus patients.

  • Structured teaching programme: It refers to a systematically organized instruction on knowledge regarding hypoglycemia and its prevention among type 2 diabetes mellitus patients admitted in hospital.

  • Prevention: It refers to action which halts before occurrence of hypoglycemia.

  • Hypoglycemia: It refers to condition which occurs when one’s blood glucose level is lower than normal, usually less than 40-50mg/dl.

  • Type 2 Diabetes Mellitus: It refers to the condition which is characterized by insulin resistance and progressively reduced secretion of insulin beta cells.

  • Patients: It refers to the persons with Type 2 Diabetes Mellitus those who are admitted in selected hospitals at Hassan.

6.8 SAMPLING CRITERIA

Inclusion criteria

  • Diabetic patients who are admitted in selected hospitals at Hassan.

  • Diabetic patients those who are willing to participate in the teaching programme.

  • Diabetic patients who can read or write either Kannada or English.

Exclusion criteria

  • Diabetic patients who are not willing to participate in the teaching programme.

  • Diabetic patients who cannot read or write either Kannada or English.

  • Diabetic patients who are critically ill.

6.9 DELIMITATIONS OF THE STUDY

  • The study is limited to the diabetic patients admitted in selected hospitals at Hassan.

  • The study period is limited to 4-6 weeks of duration.

  • The sample size is limited to 60 patients.

6.10 SIGNIFICANCE OF THE STUDY

The study signifies the importance of structured teaching programme to enhance the knowledge of diabetic patients regarding prevention of hypoglycemia.



6.11 CONCEPTUAL FRAME WORK

The conceptual framework for this study is planned based on General systems theory.



6.12 REVIEW OF LITERATURE

Review of literature is a key step in the research process. It refers to an extensive, exhaustive and systematic examination of publications relevant to the research. A literature review helps to lay the foundation for a study and can also improve new research ideas. It can help with orientation to what is known and not known about an area of inquiry, to ascertain what research can best make a contribution to the existing base of evidence.

A study conducted on Exploration and documentation of indigenous hypoglycemic substances of North Karnataka to document indigenous hypoglycemic substances by diabetics of North Karnataka region. The present study was conducted in North Karnataka region was selected for conducting the documentation study. Five zones of North Karnataka with varied ecological diversity were chosen randomly, one or two places were selected from each zone for data collection on hypoglycemic foods. About 30 urban diabetic subjects were randomly selected from each of the five zones with a total of 150 subjects. A detailed pretested questionnaire including questions on basal data and the use of hypoglycemic substances, consumption pattern and side effects was used to collect the information from diabetics. About 20 indigenous hypoglycemic substances were documented in North Karnataka region. All the substances were of plant origin. 9

A study conducted on Drug management of type 2 diabetes mellitus-clinical experience at a diabetes center in South India to determine minimum and maximum drug regimens for tight glycemic control. The study was conducted on 3207 type 2 diabetic subjects attending a diabetes centre in South India over a period of ten years (1992-2002). The meta analysis of the study shows that optimal anti-diabetic measures can arrest the further progression of the disease and intensive therapy could help in achieving tight glycemic control. The study concludes that whatever regimens are followed, unless the subject follows a strict diet and exercise pattern, diabetes control would remain elusive. 10

A study conducted on Diabetes care in India-Patient’s perceptions, attitude and practices to understanding their perceptions, attitude, and practices in relation to their disease and its management. The study concludes that with limited support from the health care system, the person with diabetes mellitus is fairly ignorant about their disease. 11

A study conducted on Prevalence and extent of glycemic excursions in well-controlled patients with type 2 diabetes mellitus using continuous glucose-monitoring system (CGMS) in Iran to evaluate the extent of glycemic excursions in well-controlled type 2 diabetic patients. The study was carried out in 21 diabetic patients on oral agents. Patients underwent continuous glucose monitoring by CGMS for 3 days. Number and duration of glycemic excursions, correlation coefficient (%) between CGMS and self monitoring blood glucose (SMGB), mean absolute difference (%MAD) and complications of CGMS were analyzed. Disconnection of device was the most common complication (3 patients). This study concludes that well controlled type 2 diabetic patients have a considerable number of hypoglycemia and hyperglycemia events that may be missed by SMGB. 12

A study conducted on Minimizing the risk of hypoglycemia in older adults: a focus on long-term care in Texas, USA to consider the risk and impact of hypoglycemia in older adults with type 2 diabetes, to describe how to interpret blood glucose readings in an older patient's medical record, and to discuss strategies for avoiding hypoglycemia in this patient population. A literature search was performed. Pharmacists working in long-term care settings can take several steps to help their older patients avoid hypoglycemia, including recommending the use of insulin regimens with more physiologic time-action profiles, such as insulin analogs. They also can help facilities develop protocols for treating hyperglycemia and hypoglycemia, offer insulin pattern management services, and help educate the staff about the optimal use of insulin therapies. 13

A study conducted on Hypoglycemia and strict glycemic control in critically ill patients in Netherlands to summarize available data on prevalence of hypoglycemia, risk factors, and possible consequences of hypoglycemia in critically ill patients. There is strong evidence that strict glycemic control is beneficial for critically ill patients. Recent attempts to confirm these findings have not succeeded. Instead, they have increased the fear for negative consequences of hypoglycemia. Hypoglycemia is four to seven times more frequent in patients treated with strict glycemic control. Risk factors for hypoglycemia are a change in nutrition without adjustment of insulin treatment, diabetes mellitus, sepsis, shock, liver failure, and the need for renal replacement therapy. Consequences of hypoglycemia in critically ill patients are not well defined, but overall current evidence suggests that beneficial effects of strict glycemic control outweigh possible negative effects of hypoglycemia. The study concludes that hypoglycemia should be avoided in critically ill patients, but not at the cost of less stringent glycemic control. Strict glycemic control with a low incidence of hypoglycemia can be achieved with a validated (computerized) algorithm and increased surveillance in patients with an increased risk for hypoglycemia. 14

A study conducted on Hypoglycemia in hospitalized patients treated with anti hyperglycemic agents in Philadelphia. The aim of the study was to determine the incidence and manifestations of hypoglycemia among those who are receiving ant hyperglycemic therapy. A 3-month prospective study was done on hypoglycemia in hospitalized patients. Out of 2174 subjects, 206 (9.5%) experienced 484 hypoglycemic episodes. Of these episodes 72% were in patients receiving only insulin for hyperglycemia. The study concludes that hypoglycemia in hospitalized patients taking anti hyperglycemic agents are common. 15

A study conducted on Hypoglycemia in stable insulin treated veterans with type 2 diabetes: a prospective study of 1662 episodes. A study was conducted among 344 patients with type 2 diabetes mellitus on risk factors for hypoglycemic episodes. Electronically recorded self-monitored blood glucose results were collected during 12 months of routine monitoring. Subjects graded the severity of hypoglycemic episodes as 0 (asymptomatic), 1 (moderate symptoms), and 2 (severe symptoms). The study revealed that among 344 patients, 176 (51.2%) documented at least one hypoglycemic reading for a total of 1662 episodes; 53.34% attributed that hypoglycemia occurred due to missing a meal, 23.8% due to exercise. The study concludes that a high proportion of stable, insulin-treated subjects developed hypoglycemic episodes. 16

A study conducted on the Risk factors for severe hypoglycemia in type 2 diabetic patients admitted to hospital in Piraeus, Greece to assess the prevalence and causes of severe treatment related hypoglycemia in type 2 diabetes mellitus patients. Out of the 2858 patients admitted, 207 had severe hypoglycemia. 72 were being managed with insulin, 132 oral hypoglycemic drugs and 3 combined insulin/oral drugs. Only 28.5% of patients were attending a diabetes clinic. The cause of the hypoglycemic attack could be determined for 86.1% of cases; 30.8% were due to missed meal. The study concludes that education and level knowledge about diabetes mellitus, and particularly hypoglycemia symptoms was inadequate. Logistic regression analysis showed that knowledge about diabetes mellitus correlated with educational status and with follow-up in a diabetes clinic. 17

A study conducted on Hypoglycemia in patients with type 2 diabetes mellitus in Atlanta, USA to determine the predisposing factors for hypoglycemia in patients with type 2 diabetes. Retrospective, cross-sectional analysis set in an outpatient specialty diabetes clinic. A total of 1055 patients were included. Prevalence of hypoglycemia symptoms was 12% for patients treated with diet alone, 16% for those using oral agents alone, and 30% for those using any insulin. Severe hypoglycemia occurred only in 5 patients, all using insulin. Multiple regression analysis demonstrated that insulin therapy, lower HbA (1c) level at follow-up, younger age, and report of hypoglycemia at the baseline visit were independently associated with increased prevalence of hypoglycemia. There were no significant predictors of severe hypoglycemia. The study concludes that mild hypoglycemia is common in patients with type 2 diabetes undergoing aggressive diabetes management, but severe hypoglycemia is rare. 18



7 MATERIALS AND METHODS

7.1 SOURCE OF DATA COLLECTION

The data will be collected from Type 2 diabetes mellitus patients admitted in selected hospitals at Hassan.



7.2.1 RESEARCH APPROACH

The pre experimental approach will be used to conduct the study.



7.2.2 RESEARCH DESIGN

A pre experimental study with one group pre test and post test.



Group

Pre test

Intervention

Post test

S

O1

X

O2

S- Study group

O1- Pre test

X-Intervention

O2- Post test



7.2.3 SETTING OF THE STUDY

The study will be conducted in selected hospitals at Hassan.



7.2.4 POPULATION

The population of the present study comprises of type 2 diabetes mellitus patients admitted in selected hospitals at Hassan.



7.2.5 SAMPLE SIZE

The sample of the study consists of 60 diabetic patients.



7.2.6 SAMPLE TECHNIQUE

Non probability convenience sampling technique will be adopted to select the sample.



7.2.7 PILOT STUDY

Pilot study is planned with 10% population.



7.2.8 DATA COLLECTION TOOL

It comprises of self-administered questionnaire, which consists of two sections.



Section A: Deals with patients background data that includes age, sex, religion,

educational qualification, income etc.



Section B: Deals with structured questionnaire seeks information regarding knowledge on

hypoglycemia and its prevention.



7.2.9 DATA ANALYSIS METHOD

It includes descriptive and inferential statistics.



Descriptive statistics:

To describe the demographic variables and level of knowledge, number, frequency,

percentage, mean and standard deviation will be used.

Inferential statistics:


  • ‘t’ test will be used to compare pre test and post test knowledge scores.

  • The chi square test will be used to find the association between the demographic variables with knowledge scores.

  • Paired’t’ test value will be calculated to assess the effectiveness of structured teaching programme.

7.3 VARIABLES

Independent variable

Structured teaching programme on hypoglycemia and its prevention.



Dependent variable

Knowledge on hypoglycemia and its prevention.



7.4 ETHICAL CONSIDERATION

  • Does the study require any investigation or intervention to be conducted on patients or

oth.er humans or animals?

Yes, study requires structured teaching programme to be conducted on diabetic patients.



  • Has ethical clearance being obtained from the institutions?

Yes, ethical clearance has been obtained from principal of Rajeev College of Nursing as

as well as from the authorities of the hospitals.



8. REFERENCES

  1. Diabetes Mellitus. Available from: URL: http://en.wikipedia.org/wiki/diabetes-mellitus

  2. Joyce M. Black, Jane Hokanson Hawks. Medical-Surgical Nursing Clinical Management for Positive Outcomes. 7th ed. Elsevier Publications: St.Louis; 2005. Volume 1:1243-75

  3. Suzanne C. Smeltzer, Brenda Bare. Brunner & Suddarth’s Text book of Medical-Surgical Nursing.10th ed. Lippincott Williams & Wilkins: Philadelphia; 2004. 1150-80

  4. Michael Jay Katz. Diabetes, Type 2. Wild Iris Medical Education: Available from: URL: http://www.nursingceu.com/courses/208/index_nceu.html

  5. Ramachandran A. Rising Prevalence of Diabetes in India and the Implications of ADA-EASD Consensus on the Management. Epidemiology of Diabetes in India: Available from: URL: http://www.apiindia.org/medicine update 2007/ 31.pdf.

  6. Mohan V. Control diabetes on your own. The Hindu: 2004. Available from: URL: http://www.hindu.com/thehindu/mag/2004/07/11/stories/2004071100480600.htm

  7. Vanessa J. Briscoe, Stephen N. Davis. Hypoglycemia in Type 1 and Type 2 Diabetes: Physiology, Pathophysiology, and Management. Clinical Diabetes: 2006. July; 24(3): 115-21. Available from: URL: http://clinical diabetesjournals.org/content/24/3/115.full

  8. Sugaraman JR. Hypoglycemia associated hospitalizations in a population with a high prevalence of non-insulin-dependent diabetes mellitus. Diabetes.Res Clin Pract: 1991. November; 14(2): 139-47. Available from: URL: http://www.ncbi.nlm.nih.gov/pubmed/1756685

  9. Vijaya Banakar, Usha Malagi, Rama K. Naik. Exploration and Documentation of Indigenous Hypoglycemic Substances of North Karnataka. Karnataka Journal of Agricultural Sciences: Karnataka; 2007. 20(2): 350-52

  10. Paneerselvam A. Drug management of type 2 Diabetes mellitus -Clinical experience at a Diabetes center in South India. International Journal of diabetes in developing countries: 2004. 24(2):40-6. Available from: URL: http://www.ijddc.com/text.asp?2004/24/2/40/26772

  11. Kapoor A, Shishoo S, Ahuja MMS, Vidyasen, Mankame K. Diabetes Care in India-Patient’s perceptions, Attitudes and Practices. International Journal of diabetes in developing countries: 1997. Volume 17: Available from: URL:http://www.rssdi.org/1997_jan-mar/original_article2.pdf

  12. Shokoufeh Bonakdaran, Reza Rajabian. Prevalence and extent of glycemic excursions in well-controlled patients with type 2 diabetes mellitus using continuous glucose-monitoring system. 2009. 63 (2): 66-71. Available from: URL: http://www.indianjmedsci.org/article.asp?issn=0019-5359

  13. Garza H. Minimizing the risk of hypoglycemia in older adults: a focus on long-term care. Consult Pharm: 2009. Volume 24: 18-24. Available from: URL: http://www.ncbi.nih.gov/pubmed/19555132?itool=EntrezSystem2...

  14. Vriesendorp TM, Devries JH, Hoekstra JB. Hypoglycemia and strict glycemic control in critically ill patients. Curr Opin Crit Care: 2008. August; 14(4): 397-402. Available from: URL: http://www.ncbi.nlm.gov/pubmed/18614902

  15. Varghese P, Gleason V, Sorokin R. Hypoglycemia in hospitalized patients treated with anti hyperglycemic agents. J Hosp Med: 2007. July; 2(4): 234-40. Available from: URL: http://www.ncbi.nlm.gov/pubmed

  16. Murata GH, Duckworth WC, Shah JH. Hypoglycemia in stable insulin treated veterans with type 2 diabetes: a prospective study of 1662 episodes. Journal of Diabetes and Its Complications: 2005. January 1; 19(1): 10-7

  17. Sotiropoulos A, Skliros EA, Tountas C, Apostolou U, Peppas TA, Pappas SI. Risk factors for severe hypoglycemia in type 2 diabetic patients admitted to hospital in Piraeus, Greece. East Mediterr Health J: 2005. May; 11(3): 485-9. Available from: URL: http://www.ncbi.nlm.gov/pubmed/16602470

  18. Miller CD, Phillips LS, Ziemer DC, Gallina DL, Cook CB, El-Kebbi IM. Hypoglycemia in patients with type 2 diabetes mellitus. Arch Intern Med: 2001. July 9; 161(13): 1653-9. Available from: URL: http://www.ncbi.nlm.gov/pubmed/11434798




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