Effect of Modified Arthroscopic Latarjet on Acromiohumeral Distance at 5-Year Follow-up

Background: It is unclear whether coracoacromial ligament release during the Latarjet procedure will increase superior translation of the shoulder joint. Purpose: To evaluate whether a modified suture button Latarjet procedure can decrease the acromiohumeral distance (AHD). Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis was conducted among 155 patients who underwent a modified suture button Latarjet procedure between 2013 and 2015. AHD was measured on bilateral computed tomography scans taken preoperatively and on scans of the affected shoulder taken on postoperative day 1 and postoperative month (POM) 6, POM 36, and POM 60. At each time point, we recorded pain on a visual analog scale (VAS) and objective shoulder function using the American Shoulder and Elbow Surgeons, Rowe, and Walch-Duplay scores. Preoperative and final follow-up VAS and functional scores were compared using the paired t test. Pairwise comparison of AHD values at each follow-up time point were compared with the preoperative intact side using the paired t test. Intra- and interobserver reproducibility of the AHD measurements was evaluated using the intraclass correlation coefficient. Results: A total of 104 patients who met the criteria completed the final follow-up, which occurred at 62.6 ± 2.4 months (mean ± SD). When compared with presurgery, the VAS and all functional scores improved significantly at the last follow-up ( P < .001 for all). Intra- and interobserver intraclass correlation coefficients indicated good reliability for the ADH measurements. Preoperatively, there were no differences in AHD values between the intact and affected shoulders (7.8 ± 0.8 mm for both; P = .851). The AHD values at postoperative day 1 and POM 6, POM 36, and POM 60 were 9.6 ± 0.7 mm, 8.6 ± 0.9 mm, 8.0 ± 0.8 mm, and 7.9 ± 0.8 mm, respectively, all of which were larger than those of the preoperative intact side ( P < .001 for all). Conclusion: The modified suture button Latarjet procedure not only offered satisfactory therapeutic effects but also did not decrease the AHD at 5-year follow-up.

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Modified Arthroscopic Latarjet Procedure: Suture-button Fixation will not Cause Obvious Increasement of Superior Instability at 5-Year Follow-up

10.21203/rs.3.rs-105908/v1 ◽

2020 ◽

Author(s):

Daqiang Liang ◽

Haifeng Liu ◽

Xinzhi Liang ◽

Qihuang Qin ◽

Lujue Long ◽

...

Keyword(s):

Control Group ◽

Latarjet Procedure ◽

Glenoid Defect ◽

Coracoacromial Ligament ◽

Intact Side ◽

Arthroscopic Latarjet ◽

Arthroscopic Latarjet Procedure ◽

Preoperative Ct ◽

Shoulder Scores

Abstract Background: Whether coracoacromial ligament (CAL) release during Latarjet procedure will increase superior instability of shoulder joint postoperatively remains controversial. This study aims to observe changes in the acromiaohumeral distance (AHD) of patients who underwent modified double-button Latarjet procedure and provide evidence to address the issue.Methods: A retrospective analysis was conducted among 155 patients who underwent modified double-button Latarjet procedure in our department from 2013 to 2015. Preoperative CT scan of bilateral shoulders were used for glenoid defect evaluation. CT scans were performed immediately after operation (PO 0) and during the follow-up at 6, 36, and 60 months postoperatively (POM) to observe the healing and remodeling of the graft, and AHD was measured. The intact sides were set as control group. VAS and objective shoulder scores, including ASES, ROWE, and Walch-Duplay scores, were recorded at each time point.Results: A total of 104 cases who met the criteria completed follow up. The average follow-up time was 62.6 ± 2.4 months. Compared with preoperative conditions, the function scores of the shoulders were significantly improved at the last follow-up. There were no statistical differences of the AHD values between bilateral shoulders preoperatively. The AHD values at PO 0 and POM 6 were significantly higher than those of intact side (p < 0.05). The AHD values at POM 36 and 60 were slightly higher than those of intact side and the differences were statistically significant (p < 0.05).Conclusions: The modified double-button Latarjet procedure not only offers satisfactory therapeutic effect but also will not cause obvious superior instability at the 5-year follow-up.

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“JUMPing into Diabetes Control”: A Group-Setting Self-Empowerment Lifestyle Intervention among Diabetes Patients

Healthcare ◽

10.3390/healthcare8020090 ◽

2020 ◽

Vol 8 (2) ◽

pp. 90

Author(s):

Sheena Henry ◽

Lu Shi ◽

Virginia Alexander ◽

Richard O’Neal ◽

Stephen Carey ◽

...

Keyword(s):

Group Intervention ◽

Internal Medicine Resident ◽

Mean Value ◽

T Test ◽

Post Intervention ◽

Medicine Resident ◽

Significant Difference ◽

One Year ◽

Paired T Test

We examined the impact of a group-based self-empowerment intervention among diabetes patients, which uses multidisciplinary education, collaborative learning, peer support, and development of diabetes-specific social capital to improve glycemic control and weight management. Thirty-five patients who had primary care established at the Prisma Health Upstate, Internal Medicine Resident clinic and held the diagnosis of diabetes for longer than one year were recruited for our single-arm pilot intervention. Each group intervention session involved one to two internal medicine resident physician facilitators, a clinical diabetic educator, and 5–10 patients. Each session had a framework facilitated by the resident, with most of the discussion being patient-led, aiming to provide a collaborative learning environment and create a support group atmosphere to encourage self-empowerment. Patients’ hemoglobin A1c level and body mass index (BMI) before the intervention and 3 to 6 months after completion were collected from the laboratory results obtained in the participants’ routine clinic visits. All graduates from this three-week intervention were invited to attend monthly maintenance sessions, and we tracked the HgbA1c measures of 29 JUMP graduates one year after the intervention, even though 13 of the 29 chose not to participate in the monthly maintenance sessions. The pre-intervention HgbA1c level averaged 8.84%, whereas the post-intervention HgbA1c level averaged 7.81%. A paired t test showed that this pre–post difference of 1.03 percentage points was statistically significant (p = 0.0007). For BMI, there was an average decline of 0.78 from the pre-intervention mean value of 40.56 to the post-intervention mean value of 39.78 (p = 0.03). Among the 29 participants who agreed to participate in our follow-up measure of their HgbA1c status one year after the intervention, a paired t test showed that there was no significant difference between the post-JUMP measure and the follow-up measure (p = 0.808). There was no statistically significant difference between the HgbA1c level of those participating in the maintenance program and that of those not participating (post-intervention t test of between-group difference: p = 0.271; follow-up t test of between-group difference: p = 0.457). Our single-arm, pilot study of the three-week group intervention of self-empowerment shows promising results in glycemic control and weight loss. The short duration and small number of sessions expected could make it more feasible for implementation and dissemination as compared with popular intervention protocols that require much longer periods of attendance, if the effectiveness of this patient group-based self-empowerment approach can be further established by randomized controlled studies in the future.

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Modified Arthroscopic Latarjet Procedure: Suture-Button Fixation Achieves Excellent Remodeling at 3-Year Follow-up

The American Journal of Sports Medicine ◽

10.1177/0363546519887959 ◽

2019 ◽

Vol 48 (1) ◽

pp. 39-47 ◽

Cited By ~ 3

Author(s):

Jian Xu ◽

Haifeng Liu ◽

Wei Lu ◽

Zhenhan Deng ◽

Weimin Zhu ◽

...

Keyword(s):

Humeral Head ◽

Case Series ◽

Concentric Circle ◽

Vertical Position ◽

Latarjet Procedure ◽

Level Of Evidence ◽

Suture Button ◽

The Mean ◽

Best Fit

Background: Some studies have advocated the use of suture-button fixation during the Latarjet procedure to reduce complications associated with screw fixation. However, the sample size of these studies is relatively small, and their follow-up period is short. Purpose: To investigate the efficacy of the suture-button Latarjet procedure with at least 3 years of follow-up and remodeling of the coracoid graft. Study Design: Case series; Level of evidence, 4. Methods: A total of 152 patients who underwent the suture-button Latarjet procedure between February 2013 and February 2016 were selected, and 128 patients who met the inclusion criteria were enrolled in this study. Preoperative and postoperative clinical results were assessed. The position and healing condition of the coracoid graft and arthropathy of the glenoid and humeral head were also assessed using radiography and 3-dimensional computed tomography (CT). Results: The mean follow-up time was 40.3 ± 5.8 months. There were 102 patients included in this study. The mean visual analog scale score for pain during motion, the American Shoulder and Elbow Surgeons score, the Rowe score, and the Walch-Duplay score were improved considerably. A total of 100 grafts achieved bone union. The overall absorption rate was 12.6% ± 4.3%. Graft absorption mostly occurred on the edge and outside the “best-fit” circle of the glenoid. A vertical position was achieved in 98 grafts (96% of all cases) immediately postoperatively, with the mean graft midline center at the 4 o’clock position. In the axial view, CT showed that 89 grafts were flush to the glenoid, whereas 2 and 11 grafts were fixed medially and laterally, respectively. In all cases, the bone graft and glenoid tended to extend toward each other to form concentric circles during the remodeling process. During follow-up observations, the height of the 11 grafts that were positioned laterally (ie, above the glenoid level) exhibited a wave-curved change. No arthropathy was observed in any patient. Conclusion: Patient outcomes were satisfactory after the modified arthroscopic suture-button Latarjet technique. Graft absorption mostly occurred on the edge and outside the “best-fit” circle of the glenoid. The graft exhibited the phenomenon of ectatic growing when it fused with the glenoid and finally remodeled to a new concentric circle with the humeral head analogous to the original glenoid. Grafts positioned laterally did not cause arthropathy of the joints within the period of the study.

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Follow-Up of Advanced Parkinson’s Disease Patients after Clinical or Surgical Emergencies: A Practical Approach

Parkinson s Disease ◽

10.1155/2020/8860785 ◽

2020 ◽

Vol 2020 ◽

pp. 1-7

Author(s):

Hélio A. G. Teive ◽

Matheus Gomes Ferreira ◽

Carlos Henrique F. Camargo ◽

Renato P. Munhoz

Keyword(s):

Parkinson’S Disease ◽

Parkinson's Disease ◽

T Test ◽

Advanced Parkinson’S Disease ◽

Surgical Emergencies ◽

Advanced Stages ◽

Wheel Chair ◽

Drug Interventions ◽

Paired T Test

Background. Patients with advanced stage Parkinson’s disease (PD) typically present with a myriad of motor and nonmotor symptoms in addition to comorbidities and, as a consequence, polypharmacy. Objective. To analyze a series of cases of advanced PD in which a clinical or surgical emergency played a trigger role in the irreversible progression of landmarks of the course of the disease. Methods. Data were collected during a 13-month observational period of a cohort of 230 PD patients, in 751 medical appointments. We included a total of 13 (5.65% of the total number) patients with advanced PD defined by Hoehn & Yahr (H&Y) stage ≥3 who presented with various clinical and surgical complications which, with the contribution of drug interventions, led to significant worsening of patients’ overall clinical condition. Results. Hip fractures and infections were the most common complications identified. As part of this scenario, most patients presented with delirium, often requiring treatment with dopamine receptor blocking agents and/or had dopaminergic treatment withdrawn. Upon reassessment after 3 months, all patients remained bed or wheel chair bound (H&Y 5) and presented significant worsening of their UPDRS part III score of at least 10 points (mean 51.5 ± 3.3; paired t-test two-tailed p < 0.0001 compared to baseline). The mean dose of levodopa at baseline was 907.7 ± 149.8 mg (600–1200) and significantly higher (paired t-test two-tailed p < 0.0001 ) on follow-up, 1061.5 ± 175.8 mg (700–1300). Conclusion. Clinical and surgical emergencies are major determinants for a progression of PD to more advanced stages.

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Improving the care of people with dementia in general hospitals: evaluation of a whole-system train-the-trainer model

International Psychogeriatrics ◽

10.1017/s1041610216002222 ◽

2016 ◽

Vol 29 (4) ◽

pp. 605-614 ◽

Cited By ~ 12

Author(s):

Elizabeth L. Sampson ◽

Victoria Vickerstaff ◽

Stephanie Lietz ◽

Martin Orrell

Keyword(s):

Dementia Care ◽

T Test ◽

Organizational Level ◽

Train The Trainer ◽

Sense Of Competence ◽

Information Leaflets ◽

People With Dementia ◽

Paired T Test

ABSTRACTBackground:There are concerns about the quality of care that people with dementia receive in the general hospital. Staff report a lack of confidence and inadequate training in dementia care.Methods:A train-the-trainer model was implemented across eight acute hospital trusts in London via a large academic health and science network. Impact was evaluated using mixed methods. Data were collected at (a) individual level: “Sense of Competence in Dementia Care” (SCID), (b) ward level: Person Interaction and Environment (PIE) observations, (c) organization level: use of specific tools, i.e. “This Is Me,” (d) systems level: numbers and types of staff trained per trust. Results were analyzed with descriptive statistics and paired t-test with thematic framework analysis for PIE observations.Results:The number of staff trained per trust ranged from 67 to 650 (total 2,020). A total of 1,688 (85%) baseline questionnaires and 456 (27%) three month follow-up questionnaires were completed. Mean SCID score was 43.2 at baseline and 50.7 at follow-up (paired t-test, p < 0.001). All sub-scales showed a small increase in competence, the largest being for “building relationships.” Organizational level data suggested increased use of carer's passport, “This Is Me” documentation, dementia information leaflets, delirium screening scales, and pathways. PIE observations demonstrated improved staff–patient interactions but little change in hospital environments.Conclusions:There was a significant improvement in staffs’ sense of competence in dementia care and the quality of interactions with patients. More hospitals adopted person-centered tools and pathways. Work is required to investigate if these changes improve hospital outcomes for people with dementia.

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Skeletal Stability after Bilateral Sagittal Split Advancement and Setback Osteotomy of the Mandible with Miniplate Fixation

Craniomaxillofacial Trauma & Reconstruction ◽

10.1055/s-0033-1356763 ◽

2014 ◽

Vol 7 (1) ◽

pp. 9-15 ◽

Cited By ~ 3

Author(s):

SrinivasanHanumantha Rao ◽

Loganathan Selvaraj ◽

Arathy S. Lankupalli

Keyword(s):

Postoperative Period ◽

T Test ◽

Mandibular Incisor ◽

Facial Height ◽

Group I ◽

Mandibular Plane ◽

Change Position ◽

Skeletal Stability ◽

Paired T Test

The purpose of this study was to evaluate intraorally placed mini plates and monocortical screws in terms of postoperative skeletal stability after bilateral sagittal split advancement and setback osteotomy of the mandible. Ten patients were included in this study with five requiring advancement (group I) and five requiring setback of the mandible (group II). Bell and Epker modified surgical technique was followed for all the patients. All the patients underwent pre- and postsurgical orthodontics. Cephalometric radiographs were taken preoperatively, immediate, 3, 6, and 12 months postoperatively. Cephalometric tracings were performed by one individual examiner using a modified burstone analysis. Statistical analysis was performed using the student paired t-test. In advancement patients, SNB (sella, Nasion, B point) angle showed relapse at 12th month postoperative period which was statistically significant (2.4 degrees). No changes were observed in anterior facial height, posterior facial height, Frankfort-mandibular incisor angle (FmiA), and overjet during the follow-up period. In setback patients, posterior facial height ( p < 0.05), angles between the lower incisors and mandibular plane and pogonion had a statistically significant change position of 1.4 mm (paired t-test, p = 0.03). The SNB angle, anterior facial height, interincisal angle, and FmiA remained constant (0.8–1.2 degrees) during the follow-up period. In advancement cases, the relapse was seen from the third month postoperative period but in setback cases, the relapse was noted from the sixth month onward and the skeletal relapse in these cases were noticed cephalometrically.

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Puppet Show Tokoh Superhero Indonesia untuk Mengurangi Persepsi Negatif Pada Anak Berkebutuhan Khusus

Psikostudia : Jurnal Psikologi ◽

10.30872/psikostudia.v9i2.3912 ◽

2020 ◽

Vol 9 (2) ◽

pp. 143

Author(s):

Riska Sari ◽

Putri Hanifah ◽

Rahma Wati ◽

Miranti R Asyid

Keyword(s):

Social Sciences ◽

T Test ◽

Purposive Sampling ◽

Post Test ◽

Puppet Show ◽

Paired T Test

Penelitian ini bertujuan untuk melihat efektivitas metode puppet show tokoh superhero Indonesia untuk mengurangi persepsi negatif pada anak berkebutuhan khusus. Subjek dalam penelitian ini dipilih menggunakan teknik purposive sampling yaitu siswa kelas tiga SD yang berjumlah 30 orang dan memiliki persepsi negatif terhadap anak berkebutuhan khusus. Data yang dianalisis dengan bantuan program Statistical Package for Social Sciences (SPSS) 21.0 foe Windows. Hasil penelitian menunjukkan bahwa uji sample paired t-test menghasilkan nilai p = 0,000 (< 0,050) pada pre-test ̶ dan post-test, post-test follow-up didapatkan hasil nilai p = 0,001 (< 0,050), sehingga dapat disimpulkan subjek yang mengikuti puppet show tokoh superhero Indonesia mengalami penurunan persepsi negatif terhadap anak berkebutuhan khusus.

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A Multicenter Retrospective Study With a Minimum 5-Year Follow-up Comparing Arthroscopic Bankart Repair and the Latarjet Procedure

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120941366 ◽

2020 ◽

Vol 8 (8) ◽

pp. 232596712094136

Author(s):

Eran Maman ◽

Oleg Dolkart ◽

Rafael Krespi ◽

Assaf Kadar ◽

Gabriel Mozes ◽

...

Keyword(s):

Shoulder Instability ◽

Bankart Repair ◽

Anterior Shoulder Instability ◽

Published Data ◽

Return To Sports ◽

Latarjet Procedure ◽

Recurrent Instability ◽

Arthroscopic Bankart Repair ◽

Functional Scores

Background: Arthroscopic Bankart repair (ABR) and the Latarjet procedure are surgical techniques commonly used to treat anterior shoulder instability. There is no consensus among shoulder surgeons regarding the indications for choosing one over the other. Purpose: To compare the results of the Latarjet procedure with those of ABR for the treatment of anterior shoulder instability. Study Design: Cohort study; Level of evidence, 3. Methods: Data on all patients who were treated surgically for recurrent anterior shoulder instability between 2006 and 2011 were retrospectively collected at 4 medical centers. The minimum follow-up was 5 years. Data were retrieved from medical charts, and patients were interviewed to assess their level of satisfaction (range, 0-100), functional outcomes (using the American Shoulder and Elbow Surgeons shoulder score; the Subjective Shoulder Value; and the Disabilities of the Arm, Shoulder and Hand score), and quality of life (using the 12-Item Short Form Health Survey [SF-12]). Information on return to sports activities and postoperative level of activity compared with that of the preinjury state, complications, reoperations, and recurrent instability were recorded and evaluated. Results: A total of 242 patients were included. The Latarjet procedure was performed in 27 shoulders, and ABR was performed in 215 shoulders. Patients in the ABR group had significantly higher rates of redislocation (18.5%; P = .05) and subluxation (21.4%; P = .43) but a lower rate of self-reported apprehension (43.0%; P = .05) compared with patients in the Latarjet group (3.7%, 14.8%, and 63.0%, respectively). There were 5 patients in the ABR group who underwent reoperation with the Latarjet procedure because of recurrent instability. The functional scores in the Latarjet group were better than those in the ABR group. The SF-12 physical score was significantly better in the Latarjet group than in the ABR group (98.1 vs 93.9, respectively; P = .01). Patient satisfaction and subjective scores were similar in both groups. Conclusion: These results support recently published data on the Latarjet procedure that showed its superiority over ABR in midterm stability (dislocations or subluxations). The contribution of self-reported apprehension to the broad definition of stability is not clear, and apprehension rates were not correlated with satisfaction scores or the recurrence of dislocation or subluxation.

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Outcomes of the Latarjet procedure for the treatment of chronic anterior shoulder instability: patients with prior arthroscopic Bankart repair versus primary cases

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00204 ◽

2019 ◽

Vol 7 (5_suppl3) ◽

pp. 2325967119S0020

Author(s):

Jean-David Werthel ◽

Vincent Sabatier ◽

Lior Amsallem ◽

Marie Vigan ◽

Alexandre Hardy

Keyword(s):

Shoulder Instability ◽

Bankart Repair ◽

Anterior Shoulder Instability ◽

Latarjet Procedure ◽

Sports Activity ◽

Simple Shoulder Test ◽

Arthroscopic Bankart Repair ◽

Functional Scores ◽

The Mean

Objectives The two most common surgical interventions for recurrent anterior shoulder instability include arthroscopic Bankart repair and the Latarjet procedure. However, indications for each procedure remain debated between surgeons with 90% of surgeons (except French surgeons) preferring soft tissue Bankart repair initially. It remains unclear whether the results of a Latarjet procedure performed after a failed arthroscopic Bankart repair differ from those performed for primary cases. The purpose of our study was to compare the postoperative outcomes of patients who had undergone a Latarjet as a primary surgery versus those who had had a Latarjet as revision surgery for a failed arthroscopic Bankart repair Methods Patients who had undergone open or arthroscopic Latarjet procedure between 2003 and 2015 in 5 fellowship-trained surgical practices were included. Charts were retrospectively reviewed to identify patients who had undergone a primary Latarjet or those who had had a Bankart repair prior to the Latarjet. Age, ISIS score, BMI, sports activity, hyperlaxity and delay before surgery were retrospectively collected. Outcome measures were prospectively collected, including range of motion, SSV, Walch-Duplay, scores, recurrence of instability, apprehension or new surgery. Results A total of 311 patients were included. 28% of the patients were lost to follow-up and the mean follow-up was 3.4 years +/-0.8. There were 21 patients who had had a Bankart repair prior to the Latarjet procedure. Both populations were comparable regarding preoperative data. The postoperative instability rate was 3% in the overall population; 4.8% in the “primary Latarjet” group and 2.3% in the ”Latarjet for failed Bankart” group. This difference was not significant (p=0.50). However, the mean Walch-Duplay score was significantly lower and the pain scores significantly higher in patients who had had a prior Bankart repair: 51.9 +/- 25 versus 72.1 +/- 25.2 and 2.5/10 versus 1.2/10 respectively. The Simple Shoulder Test was comparable in both groups. Conclusion The study confirms that the Latarjet is an effective procedure to treat primary chronic anterior instability and also to stabilize a shoulder after a failed Bankart repair. However, the thought that a Bankart repair does not “burn any bridges” appears to be incorrect relative to postoperative pain and functional scores in the setting of future Latarjet procedure.

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Pengaruh Diskusi grup dan Brief Telephone Counseling Terhadap Peningkatan Sikap Pasien Diabetes Mellitus (DM) Terkait Pencegahan Komplikasi di PROLANIS Puskesmas Bojonegoro dan Puskesmas Wisma Indah

Jurnal Ilmu Kesehatan MAKIA ◽

10.37413/jmakia.v11i1.151 ◽

2021 ◽

Vol 11 (1) ◽

pp. 59-64

Author(s):

Angger Anugerah Hadi H.S ◽

Bayu Khayudin

Keyword(s):

Diabetes Mellitus ◽

Telephone Counseling ◽

T Test ◽

P Value ◽

Test Design ◽

Post Test ◽

Paired T Test ◽

Diabetes Melitus

ABSTRAK Diabetes Melitus merupakan salah satu penyakit kronis yang banyak dialami oleh masyarakt Indonesia. Semakin lama durasi pada penderita DM, maka semakin besar kemungkinan munculnya penyakit-penyakit komplikasi. Penyakit stroke, jantung coroner, luka DM dan gagal ginjal merupakan contoh penyakit yang dapat timbul akibat DM Tujuan dari penelitian ini adalah untuk meningkatan sikap pasien DM terkait pencegahan komplikasi dengan metode yang efektif dan efisien. Penelitian ini menggunakan pendekatan pra-eksperimental dengan rancangan one group pre-post test design. Sampel dalam penelitian ini adalah pasien DM yang mengikuti prolanis di puskesmas Wisma indah, dan puskesmas Bojonegoro sebanyak 32 responden. Diskusi grup dan Brief Telephone Counseling dilakukan dengan 2 tahapan yaitu pendidikan kesehatan terkait pencegahan komplikasi dan follow-up melalui telepon. Berdasarkan hasil uji paired T-test didapati hasil p-value 0,000. Dengan demikian disimpulkan hasil terdapat peningkatan sikap responden setelah dilakukan intervensi yang dilakukan oleh peneliti. Penelitian ini diharapkan dapat menghasilkan artikel ilmiah yang terbit dalam jurnal nasional. Selain itu, luaran lain yang diharapkan adalah buku saku terkait pencegahan komplikasi DM Kata Kunci : Diabetes Mellitus, Komplikasi Diabetes Mellitus, Diskusi Grup, Brief telephone Counseling, Sikap

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