Insulin Scheme for Glycemic Control in Non-critical Hospitalized Patients With Type 2 Diabetes in the Context of a Health System in Mexico.
Phase: PHASE4
Conditions: Type 2 Diabetes Mellitus
Sponsor: Universidad de Guanajuato

"Physiological" insulin scheme vs "Traditional" scheme for glycemic control in non-
critical hospitalized patients with Type 2 Diabetes Mellitus: Controlled Clinical Trial 
 
 
Registration number: NCT03350984 
 
Date: 02/08/2019 

MATERIAL AND METHOD 
 
TYPE OF STUDY: 
• 
Clinical controlled trial, randomized, not blinded, comparative between 2 
groups. 
 
WORKING UNIVERSE 
• 
Patients with diabetes mellitus type 2. 
 
SAMPLING FRAME 
• 
Hospitalized patients in the medical and surgical services of the hospital: internal 
medicine, traumatology and orthopedics and general surgery of the General Hospital of 
León not critical with diabetes mellitus type 2. 
 
SAMPLE SIZE 
• 
It was determined a minimal sample size of 33 patients per group plus 7 extra 
patients in each group to compensate possible losses, which gave a total of 40 per 
group. The sample size was determined by the formula: n=(Zα/2+Zβ)2 * (p1(1-p1)+p2(1-
p2)) / (p1-p2)2.(36) It was considered the probability of making a mistake type 1 (α) of 
0.05, a statistical potential (1-β) of 0.80 and a difference of 25% in the rate of 
hypoglycemia in reference with the one reported in the meta-analysis of Christensen 
MB el al(27), for both treatments in a bicaudal way in the distribution curve. 
 
SAMPLING TYPE 
• 
Randomized systematic sampling. The assignment to the treatment schemes was 
made using a randomized numbered table generated by a computer. If more of one 
patient arrived to the hospital at the same time, they were randomized in order of the 
service they arrived: Internal medicine (IM): 1st, Traumatology and orthopedics (TyO): 
2nd and General surgery(GS): 3rd, and in base of the number of bed from lower to 
higher. 
 
INCLUSION CRITERIA 
• 
Patients older than 18 years old, with diagnosis of diabetes type 2 with central 
fasting glucose before randomization between 140mg/dl and 400mg/dl. 
• 
Patients that were diagnosed at admission with DM2 with HBA1>6.5% and fasting 
glucose >126mg/dl (isolated hyperglycemia >200mg/dl was not considered as a 
diagnostic parameter because of the stress conditions, metabolic response to the base 
pathology or steroid exposition that can alter the glycemia values in hospitalized 
patients). 
• 
Patients in not critical state. 
• 
Patients with a diet for diabetic patient per oral administration at least 3 times 

daily. 
 
EXCLUSION CRITERIA 
• 
Parenteral nutrition and continuous enteral nutrition by nasogastric tube. 
• 
Chronic kidney disease with a glomerular filtration rate <15mg/dl or in renal 
replacement therapy. 
• 
Hyperosmolar state or diabetic ketoacidosis. 
• 
Diabetes mellitus type 1 
• 
Hyperglycemia due to stress (negative history of DM2, hyperglycemia and 
HbA1C<6.4) 
• 
- Parenteral nutrition and continuous enteral nutrition by nasogastric tube. 
• 
- Chronic kidney disease with a glomerular filtration rate <15mg / dl or in renal 
replacement therapy. 
• 
- Hyperosmolar state or diabetic ketoacidosis. 
• 
- Diabetes mellitus type 1. 
• 
- Hyperglycemia due to stress (negative history of DM2, hyperglycemia and HbA1 
<6.4) 
• 
- Treatment with any steroid equivalent to more than 10mg of prednisone. 
• 
- Pregnancy. 
• 
- CHILD PUGH C hepatic failure 
• 
- Acute pancreatitis. 
• 
- Sepsis, septic shock or multiple organ failure. 
 
ELIMINATION CRITERIA 
• 
Patient who is discharged by voluntary discharge. 
• 
Patient who, due to their clinical condition that causes aggression (frontal 
syndrome, psychotic state, alcohol withdrawal syndrome, etc.), prevents the 
application of their treatment. 
 
PROCEDURE 
- Patient selection: 
Once the protocol was approved by the HGL committee, the selection of patients was 
initiated; those who met the inclusion and exclusion criteria were invited to participate 
in the study with prior informed consent (Annex 2). Upon entry to the floor of internal 
medicine, general surgery and trauma, a record sheet was filled out with the data, 
which included weight, height, central glucose levels and glycosylated hemoglobin. 
Patients that were not diagnosed but with HbA1> 6.5 were also included in the study. 
 
- Assignment of the groups: 
Patients with diabetes or with HbA1> 6.5% were assigned to the insulin scheme 

according to a systematic randomization which was done by means of a table of random 
numbers generated by a computer, as they were entering the different floors of internal 
medicine, general surgery or traumatology. The assigned scheme was placed in the 
internal part of the folders of indications and vital signs of each patient. The emblem 
of "Patient in protocol" highlighted with a striking color was the identifier of patients in 
protocol. 
 
-Patient monitorization 
At least one sample of central glucose and one HbA1c determination were taken at the 
time of admission to the protocol. A fasting blood glucose was taken every day, 2 hours 
after breakfast, before lunch, before dinner and 2 hours after dinner, as well as 
capillary blood glucose at midnight at 3 am. The data obtained were recorded on the 
nursing working sheet. 
 
- About the control of diet and calories for patients 
Upon entering the protocol, a standardized diet for patient with diabetes was assigned 
to each patient with a caloric intake of 1600 to 2000 kcal depending on the 
requirements for body weight, calculated by the nutrition staff. The distribution was 
50% of carbohydrates, 30% of lipids and 20% of proteins. In those patients who continued 
with hyperglycemia and didn't have control with a standardized diabetic diet, an 
individualized diet was performed, for which an energy requirement calculation was 
made 25-30 kcal/kg and in patients with obesity 20 kcal/kg. The distribution of 
carbohydrates 45-55% and lipids 25-35%, proteins 15-25%. 
A food ration was provided at breakfast between 8 - 9hr, another at 14 - 15hr and 
another at approximately 20-21hr. 
For patients who showed a tendency to hypoglycemia, in addition to the insulin 
adjustment, snack foods were indicated by the nutrition service. The assistance of 
family members and nurses was requested to ensure that the ration of their food was 
finished. In those patients who presented episodes of hypoglycemia associated with not 
finishing their food, designated insulin scheme was suspended. 
 
-Protocol of insulin treatment and management of hypoglycemia: 
 
1. Schematic "Physiological" 
 
A. Patients previously treated with insulin or patients who were not treated on an 
outpatient basis with insulin (oral diet or hypoglycemic agents) or first diagnosis of 
DM2: Suspend the dose of insulin applied and stop the oral antidiabetic drugs on 
admission and replace them with insulin, Initiating the total daily dose: When the 
basal glucose is between 140 and 200 mg / dl: 0.4 IU/kg/day and between 201 and 

400 mg/dl: 0.5 IU/kg/day. When the patient is susceptible to hypoglycemia events 
(localized infection, glomerular filtration rate of 16-30 ml/min/m2, age greater than 
70 years), the dose of 0.35 IU/kg/day may be initiated at the endocrinologist's 
consideration. 
- 50% of the total insulin dose with Glargine and the other 50% with Lispro insulin 
fractionated according to the number of foods. 
- Glargine is administered once a day, at 8 pm. 
- Lispro is administered in three divided doses proportionally immediately before each 
meal. 
- To prevent hypoglycemia, if a subject cannot eat, skip the Lispro insulin dose of that 
food. 
 
B. Insulin adjustment: 
- If fasting capillary glucose is <140 mg/dl in the absence of hypoglycemia: no change. 
- If fasting capillary glucose is between 140 and 180 mg/dl: the total insulin dose 
increases by 10%. 
- If fasting capillary glucose is>180 mg/dl: increase the total insulin dose by 20%. 
- If fasting capillary glucose is <70mg/dl, decrease the daily dose of total insulin by 
20%. 
 
C. Supplemental Insulin: Administer insulin Lispro according to the protocol 
"Complementary scheme". The scheduled insulin dose during the meal hour was 
supplemented with insulin lispro if basal glucose was higher than 180mg/dl by the 
"complementary scheme" protocol (Annex 1). If fasting or postprandial capillary 
glucose persists >180mg/day despite the previously assigned scheme: 
- If a patient can eat all or most of their meals, administer supplemental insulin Lispro 
following the "usual" column. 
- If a patient cannot eat, has a soft tissue infection, is >70 years old or has a 
glomerular filtration rate of 15-30ml/min, administer supplemental insulin Lispro 
following the "insulin-sensitive" column. 
- If the capillary glucose is persistently >180 mg/dl in the absence of hypoglycemia, 
increase the insulin scale from the "sensitive" to "usual" column or from the "usual" 
column to the "resistant" column. 
 
2. Traditional Scheme: 
 
A. Patients previously treated with insulin or patients who were not treated on an 
outpatient basis with insulin (oral diet or hypoglycemic agents) or first diagnosis of 
DM2: Suspend the insulin dose applied and stop the oral antidiabetic drugs on 
admission and replace them with insulin, initiating Total daily dose: If basal glucose 

is between 140 and 200 mg/dl: 0.4 IU/kg/day. If basal glucose is between 201 and 
400 mg/dl: 0.5 IU/kg/day. When the patient is susceptible to hypoglycemia (localized 
infection, glomerular filtration rate of 16-30 ml/min/m2, age greater than 70 years), 
the dose of 0.35 IU/kg/day may be initiated at the endocrinologist's discretion. 
- 2/3 parts of the calculated dose with NPH Insulin at 8 a.m. and 1/3 part of the dose 
at 8 p.m., is always administered at the same time. 
- In order to prevent hypoglycemia, if a subject cannot eat, suspend the dose of NPH 
insulin. 
 
B. Insulin adjustment: 
- If fasting capillary glucose is <140 mg/dl in the absence of hypoglycemia: no change. 
- If fasting capillary glucose is between 140 and 180 mg/dl: the total insulin dose 
increases by 10%. 
- If fasting capillary glucose is>180 mg/dl: increase the total insulin dose by 20%. 
- If fasting capillary glucose is <70mg/dl, decrease the daily dose of total insulin by 
20%. 
C. Supplemental Insulin: Administer supplemental insulin lispro in addition to NPH 
insulin programmed for baseline glucose greater than 180 mg/dL using a supplemental 
insulin protocol (Annex 1). If fasting or postprandial capillary glucose 
persists>180mg/day despite the previously assigned scheme: 
- If a patient can eat all or most of their meals, administer supplemental insulin Lispro 
following the "usual" column. 
- If a patient cannot eat, is>70 years old, soft tissue infection or has a glomerular 
filtration rate of 16-30ml/min, administer supplemental insulin Lispro following the 
"insulin-sensitive" column. 
- If the capillary glucose is persistently>180 mg/dl in the absence of hypoglycemia, 
increase the insulin scale from the "sensitive“ to "usual" column or from the "usual 
“column to the "resistant“ column. 
 
3. Management of Hypoglycemia 
 
If a capillary glucose measurement of the patient has <70mg/dl, either by hourly 
capillary glucose or by the presence of clinical symptoms (sweating, chills, dizziness, 
nausea, hunger, blurred vision, numbness, paresthesia of the lips or tongue) and is 
alert, provide oral feeding equivalent to 15 grams of carbohydrates (1 serving of food 
or 1-2 tablespoons of sugar) or 30ml of 50% glucose solution. 
If the patient presents altered state of consciousness (drowsiness, confusion, or 
stupor) or does not tolerate the oral route, apply 30ml of 50% glucose solution (15 
grams of carbohydrates) and 15 minutes later take a new capillary blood glucose 
measurement. If glucose levels continue <70mg / dl, a new dose of 15g of 

carbohydrate is applied every 15 minutes until glucose >70mg/dl is reached. 
 
If during the study patients present more than 1 event of hypoglycemia after 
adjustment with a 20% decrease in insulin dose after a first event, in the absence of 
fasting, suspend the insulin regimen. Only restart insulin scheme in the case of 
disappearance of the hypoglycemia risk factor.  
 
 
 

 
 
STATISTICAL ANALYSIS 
 
The descriptive statistical analysis was carried out in the following way: for the 
qualitative variables proportions and percentage rates (%) were reported; for the 
quantitative variables, mean and standard deviation or median and interquartile range 
(Q1 to Q3) were reported according to the distribution of the data. The normality of 
the distribution was determined by the Kolmogorov-Smirnov test. 
The univariate inferential analysis was performed using the chi-square test or Fisher's 
exact test for the qualitative variables, according to the distribution of the expected 
values in the contingency table. For the numerical variables, the t test was used for 
two independent samples or its non-parametric version, according to the nature of the 
distribution of the numerical data. A p value <0.05 was considered significant. 
For the analysis of the treatment, the risk analysis model will be used with the 
calculation of the RR, RAR, RRR, its 95% Confidence Interval (95% CI) and the NNT was 
determined for the traditional scheme, once the data were concluded. The analysis was 
considered by protocol and by intention to treat. 
 
 

RESULTS 
 
PATIENTS OF THE STUDY 
A total of 111 hospitalized DM2 patients not critical to the study were evaluated. Of 
these, 35 did not meet the inclusion criteria and the 76 included participants were 
randomized into two groups. The recruitment of patients began on November 15, 2017 
and ended on June 1, 2018. The "physiological" insulin group with 37 participants and 
the traditional group with 39 participants. Within the "physiological" group, 1 patient 
was eliminated before initiating the insulin regimen, presenting acute abdomen and 
requiring intensive therapy. Therefore, 36 patients in the "physiological" group and 39 
patients in the traditional group began treatment, who entered the analysis for 
intention to treat. From the physiological group 6 patients did not conclude the 
treatment by discharge before the control and 2 patients due to poor adherence to the 
treatment. In the traditional group, 5 patients withdrew before the control, 1 patient 
due to poor adherence to treatment, 1 patient died before the control, and 1 patient 
was suspended due to critical condition. At the end of the study, 28 patients in the 
"physiological" group and 31 patients in the traditional group were completed in the 
analysis per protocol. In 20 (71.4%) patients in the first group and in 30 (96.8%) patients 
in the second group, treatment was completed until discharge. 
 
POPULATION CHARACTERISTICS 
Of the total patients analyzed for intention to treat, 34 (45.3%) patients were men and 
41 (54.7%) women. According to the place of hospitalization, 18 (24%) were in the 
internal medicine service, 29 (38.7%) in traumatology and orthopedics and 28 (37.3%) 
in general surgery. The mean age of the patients was 57.83 ± 13 years. The average 
body mass index was 26 ± 5.1 kg / m2. The mean random glucose at admission was 
230.5 ± 70.2 mg / dL, the glycosylated hemoglobin level was 8.3 ± 2.3%, and the serum 
creatinine was 1 ± 0.5 mg / dL. The treatment before admission was with oral 
hypoglycemic agents in 25 (33.3%) patients, with insulin in 25 (33.3%) patients, the 
combination of oral hypoglycemic agents and insulin in 12 (16%) patients and 13 (17.3%) 
patients. they received treatment or were diagnosed at the time of admission. The 
average dose of insulin administered was 29.6 ± 11.6 IU and the number of days of 
hospital stay was 9.3 ± 5 days. The reasons for admission to the hospital were: abscesses 
and soft tissue infection, hip fracture, diabetic foot, other fractures, cancer, heart 
disease, gastrointestinal bleeding, acute cholecystitis, stage IV chronic kidney disease, 
pneumonia, gonarthrosis, pathway infection urinary tract, intoxications, meningitis, 
alveolar obesity-hypoventilation syndrome, peripheral thrombosis and obstructive 
uropathy. 
 
 

EFFECTIVENESS RESULTS 
When evaluating efficacy, by protocol, the following was observed: The fasting glucose 
average in the "physiological" group was 130.3 ± 20.9 mg / dl, while in the traditional 
group it was 126 ± 22 mg / dl (p = 0.114); the average postprandial glucose in the 
physiological group was 150.8 ± 22.8 mg / dl and in the traditional group it was 149.4 ± 
28.1 mg / dl (p = 0.833). The average morning glucose in the first group was 130.9 ± 
18.3 mg / dl and 125.9 ± 26.7 mg / dl in the second group (p = 0.081). 
In the analysis by intent to treat in the same way control was achieved in goals in both 
groups. The average fasting glucose in the "physiological" group was 135 ± 22.6 mg / dl, 
while in the traditional group it was 129.6 ± 23.6 mg / dl (p = 0.114); the average 
postprandial glucose in the physiological group was 156.2 ± 27.2 mg / dl and in the 
traditional group it was 155.4 ± 29 mg / dl (p = 0.902). The average morning glucose in 
the first group was 136.2 ± 21.2 mg / dl and 127.4 ± 26.6 mg / dl in the second group 
(p = 0.081).  
The number of days to reach control during the hospital stay statistically were not 
different between groups (by protocol 4.9 ± 2.2 days vs 4.7 ± 2.4 days, p = 0.553, by 
intention to treat 4.9 ± 2.1 days vs 4.7 ± 2.3 days, p = 0.445). 
 
SAFETY RESULTS 
Safety was evaluated with episodes of hypoglycemia and complications associated with 
diabetes. In the "physiological" group it was observed that 15 (41.6%) patients had at 
least one event of hypoglycemia during their entire stay; On the other hand, in the 
traditional group 15 (38.4%) presented at least one event of hypoglycemia (per 
protocol, RR: 1.11, 95% CI: 0.62 to 1.97, p = 0.729; intention to treat, RR = 1.08, 95% 
CI: 0.62 to 1.89, p = 0.777). The presence of more than 2 hypoglycemic events during 
their hospitalization was observed in 8 (22.2%) patients of the "physiological" group and 
in 2 (5.1%) patients of the traditional group (per protocol, RR = 7.75, 95% CI: 1.02 a 
59.13, p = 0.021; by intention to treat, RR: 4.33, 95% CI: 0.98 to 19.07, p = 0.041). 
In the analysis by protocol, the rate of the number of total events / patients with 
hypoglycemia in the "physiological" group was 2.4 ± 1.3 events / patient, while in the 
traditional group it was 1.6 ± 0.7 events / patient (p = 0.129) ; in the intention-to-treat 
analysis in the "physiological" group it was 2.5 ± 1.6 events / patient, whereas in the 
traditional group it was 1.7 ± 0.9 events / patient (p = 0.182) 
Thirty-eight hypoglycemic events were found in the "physiological" group and 26 
hypoglycemic events in the traditional group; of which, 36 were mild hypoglycemia in 
the "physiological" group and 24 events in the traditional group (RR per protocol: 1.02, 
95% CI: 0.91 to 1.19, p = 1.0; RR by intention to treat: 1.03, 95% CI: 0.90 to 1.17, p = 
1.0). 
Regarding the complications associated with diabetes, soft tissue infection was the 
most frequent, one patient had pneumonia, one acute renal failure, one acute 

respiratory failure, and no patient presented bacteremia, diabetic ketoacidosis or 
hyperosmolar state. Two of the patients included in the study died from complications 
not associated with hypoglycemia, one in the physiological group secondary to 
progression of the infectious process, sepsis and septic shock, and one in the group 
Traditionally associated with acute respiratory failure. 
 
SECONDARY RESULTS 
There was a significant difference in the sustained control of blood glucose that was 
reported in 20 (55.6%) of the cases in the physiological group compared to 30 (76.9%) 
of the traditional group (per protocol, RR: 0.74, 95% CI: 0.58 to 0.94, p = 0.009; by 
intention to treat, RR: 0.72, 95% CI: 0.51 to 1.01, p = 0.049). 
The causes of failure of the sustained control were discharge before control in goals, 
progress to critical state, death before glycemic control, poor adherence to the 
protocol and suspension for sustained hypoglycemia. With the "physiological" scheme it 
was necessary to suspend or change by another scheme in 8 (22.2%) patients, in 
comparison with the traditional scheme where only the scheme was suspended or 
changed in 1 (2.6%) patient (by intention to treat, RR: 8.67, 95% CI: 1.14 to 65.92, p = 
0.011). There were no adverse effects to the use of insulin in both groups. 
 
OTHER RESULTS 
If the suspension of the scheme is considered for sustained hypoglycemia of 8 patients 
in the physiological group vs 1 patient in the control group, a risk ratio of 8.67 (95% CI: 
1.14 to 65.9) and a number necessary to harm of 5.09 was calculated (95% CI: 2.93 to 
19.23) patients with the physiological scheme to produce 1 event of hypoglycemia. 

INFORMED CONSENT 
 
INFORMED CONSENT 
Date: 
Registry number: 
 
Comparative study of Physiological insulin scheme vs Traditional scheme for glycemic control in not 
critical hospitalized patients with type 2 diabetes mellitus. 
 
Responsible researches:  José Antonio de Jesús Álvarez Canales 
Thesis:  Paulina Berenice Crespo Morfin 
Institution: University of Guanajuato Division of Health Sciences  
Place where the study will be conducted: General Hospital León. 
 
You are being invited to participate in this medical research study. Before deciding if you accept or not, 
you must know and understand each of the following sections. This process is known as informed consent. 
Feel absolutely free to ask about any aspect that helps you to clarify your doubts about it. Once you have 
understood the study and if you wish to participate, then you will be requested to sign this informed 
consent, from which will be delivered a signed and dated copy. 
 
 
 
 
 
 
Justification of the study: 
 
High and low glucose (blood sugar) in patients admitted to a hospital is a common health problem, which 
generates high costs to hospitals and is associated with an increased risk of complications and death. 
The control of blood sugar levels and the choice of insulin schemes (medicine to control high blood sugar) 
has been controversial. The "physiological" insulin regimen is recommended by the American Diabetes 
Association for the non-critical hospitalized patient, however, it has an increased risk of hypoglycemia 
(low blood sugar). 
 
 
 
 
 
Objectives of the study: 
 
You are being invited to participate in a research study which has the purpose to: 
find if it is better the Physiological Scheme or the Traditional Scheme of insulin for the control of blood 
sugar in patients with type 2 diabetes. 
 
Benefits of the study: 
 
By means of this study we pretend to find which insulin scheme is more effective and safer for the 
hospitalized patient with type 2 diabetes mellitus. 
This represents fewer symptoms and complications during your hospital stay, less time to control your 
sugar, and less costs. 
In previous studies by other researchers, it has been observed that the "physiological" scheme is the best 
for lowering high blood sugar, although there are other studies about the low sugar it generates. There 
are few studies that show if the traditional scheme is as effective as the physiological scheme and with 
less risk of low blood sugar. 
 
This study will allow future patients to benefit from the knowledge we acquire from this study, by 
implementing a new treatment proposal or defending the one currently established. 
 
Study procedure: 
 
The next study will consist in selecting two groups to apply insulin in the arm as management and control 
of type 2 diabetes mellitus during their hospital stay. A group with a physiological insulin scheme 
consisting of four insulin applications per day, the second group of a traditional scheme consisting of two 
insulin applications per day. If the blood sugar levels are higher than expected, doses of supplemental 

insulin will be applied. If blood sugar levels are lower than expected, the dose of sugar will be applied 
through the vein. A picket will be taken on the finger every 4 hours to monitor blood sugar levels and 
based on that result the insulin adjustment will be made. You may present the next symptoms in case of 
hypoglycemia: sweating, chills, dizziness, nausea, feeling hungry, blurred vision, numbness, paresthesia 
in lips or tongue. In this case a qualified nurse must be informed for proper treatment and to raise blood 
sugar levels. 
 
You cannot choose a group to pertain. The selection will be made at random. Upon leaving from your 
hospitalization you will receive a report of the outline of what was selected with the optimal insulin dose 
calculated for you. 
If you present adverse effects, the specialist will decide if the treatment will be changed or even the 
possibility of suspending the insulin. 
 
 
 
 
 
 
 
 
 
 
Clarifications: 
 
-You can deny participating in the study. The decision to participate is completely voluntary. 
- Your personal data are confidential and will be safeguarded for research purposes and will be protected 
in accordance with the law of protection of personal data.  
-In the course of the study you can request to the responsible researcher for updated information about 
it. 
-There is no risk in participating in this study.  
 
Informed consent letter. 
I, ____________________________________________________, have read and understood the above 
information and my questions have been answered satisfactorily. I have been informed and I understand 
that the data obtained in the study can be published or disseminated for scientific purposes. I agree that 
I participate in this research study. I will receive a signed and dated copy of this consent form. 
 
_____________________________________ 
SIGNATURE OF THE PARTICIPANT 
 
_____________________________________ 
WITNESS 1 
 
_____________________________________ 
WITNESS 2 
 
I have explained the nature of the research, about the risks and benefits involved in their participation. 
I have answered the questions as much as possible and asked if you have any questions. I accept that I 
have read and I´m aware of the regulations that are involved with humans’ research, and my attachment 
with the study. Once the question and answer session were concluded, this document was signed. 
 
__________________________________________ 
SIGNATURE OF THE MAIN INVESTIGATOR