Double diabetes-when type 1 diabetes meets type 2 diabetes: definition, pathogenesis and recognition.

Currently, the differentiation between type 1 diabetes (T1D) and type 2 diabetes (T2D) is not straightforward, and the features of both types of diabetes coexist in one subject. This situation triggered the need to discriminate so-called double diabetes (DD), hybrid diabetes or type 1.5 diabetes, which is generally described as the presence of the insulin resistance characteristic of metabolic syndrome in individuals diagnosed with T1D. DD not only raises the question of proper classification of diabetes but is also associated with a significantly greater risk of developing micro- and macroangiopathic complications, which was independent of glycaemic control. When considering the global obesity pandemic and increasing incidence of T1D, the prevalence of DD may also presumably increase. Therefore, it is of the highest priority to discover the mechanisms underlying the development of DD and to identify appropriate methods to prevent or treat DD. In this article, we describe how the definition of double diabetes has changed over the years and how it is currently defined. We discuss the accuracy of including metabolic syndrome in the DD definition. We also present possible hypotheses connecting insulin resistance with T1D and propose possible methods to identify individuals with double diabetes based on indirect insulin resistance markers, which are easily assessed in everyday clinical practice. Moreover, we discuss adjuvant therapy which may be considered in double diabetic patients.

Fear of hypoglycemia-An underestimated problem.

INTRODUCTION: Fear of hypoglycemia (FOH) is a phenomenon that affects people with diabetes experiencing hypoglycemia. On the one hand, FOH is an adaptive mechanism that helps to protect patients from hypoglycemia and its consequences. On the other hand, the non-normative level of FOH causes anxiety and tension, disturbs normal functioning, and makes normoglycemia maintenance difficult. OBJECTIVE: The main objective of this review was to describe factors influencing FOH and methods of measurement of FOH levels. Moreover, we highlighted the impact of the new technologies used in diabetes therapy on FOH and different therapeutic possibilities helping patients cope with excessive levels of FOH. We also presented clinical cases of patients with high FOH levels met in clinical practice and discussed methods to better diagnose and assist people with this kind of problem. METHODS: We searched for studies and articles via PubMed using the keywords fear of hypoglycemia, diabetes, and hypoglycemia. From screened documents identified from literature search, 67 articles were included in our review. RESULTS: We divided results from literature screening into five parts: fear of hypoglycemia and hypoglycemia definition, risk factors for the FOH, methods of measuring levels of FOH, therapies for the FOH, and modern technologies. We also described clinical examples of abnormal fear of hypoglycemia in patients. CONCLUSION: The review highlights the importance of taking into consideration fear of hypoglycemia phenomenon in diabetic patients in everyday clinical practice.

Personality Traits, Metabolic Control and the Use of Insulin Pump Functions in Adults With Type 1 Diabetes: An Observational Single-Visit Study.

INTRODUCTION: While a few studies have assessed the association between personality and metabolic outcomes in children and adolescents with type 1 diabetes (T1DM), there have been none in adults or in subjects treated with insulin pumps, and hypoglycaemic episodes have not been considered in these studies. The aim of this observational single-visit study was to assess the association between personality traits and metabolic control, hypoglycaemic episodes and insulin pump use in adult T1DM patients. METHODS: Data were obtained from 52 adults with T1DM treated in a tertiary care centre (no complications or comorbidities; aged 27 ± 8 years; diabetes duration of 12.8 ± 6.8 years; treated with insulin pumps for 6.3 ± 0.4 years). "Big Five" personality traits (neuroticism, extraversion, openness, agreeableness and conscientiousness) were assessed using the NEO-Five Factor Inventory questionnaire. Data on HbA1c, blood glucose levels, frequency of glucose testing, the number of hypoglycaemic episodes (< 3.9 mmol/l), basal and prandial insulin doses, and the number and types of boluses in the last 14 days were obtained from the insulin pumps and glucometers. RESULTS: The mean levels of the assessed parameters were: HbA1c 7.2 ± 1.2% (55.0 ± 13.1 mmol/mol), episodes of hypoglycaemia 7.0 (3.00-9.75) and glucose tests per day 7.3 ± 3.9. All personality traits showed average intensity. None of the traits were associated with HbA1c, glycaemia, number of glucose tests, or number or kind of insulin boluses. Conscientiousness was the only factor associated with the incidence of hypoglycaemia in both univariate (r = + 0.46, p < 0.001) and multivariate (ß = + 0.41, p < 0.001) analyses. CONCLUSIONS: Despite results reported for children and adolescents, personality traits of adult patients with T1DM were not essential for metabolic control assessed by HbA1c or for the use of insulin pump functions; however, higher conscientiousness may be related to more frequent hypoglycaemic episodes. Extrinsic factors should be searched as more relevant for metabolic control and proper use of very expensive insulin pump therapy.

Rapid-acting and Regular Insulin are Equal for High Fat-Protein Meal in Individuals with Type 1 Diabetes Treated with Multiple Daily Injections.

INTRODUCTION: The fat and protein content can impact late postprandial glycemia; therefore, prolonged insulin boluses for high-fat/-protein meals are recommended for patients with type 1 diabetes on insulin pump therapy. It is not clear how to translate these findings to multiple daily injection (MDI) therapy. We hypothesized that regular insulin with a slower onset and a longer duration of action might be advantageous for such meals. METHODS: Twenty-five patients with well-controlled type 1 diabetes (mean HbA1c 6.8%, 51 mmol/mol, no episodes of hypoglycemia) on MDI therapy, aged 27.9 ± 4.3 years and well trained in flexible intensive insulin therapy, were given three test breakfasts with the same carbohydrate (CHO) content. The amount of fat and protein was low (LFP) or high (HFP). For LFP meals, patients received a rapid-acting insulin; for HFP meals, a rapid-acting or regular insulin was given in individual doses according to the CHO content and individual insulin-CHO ratios. Postprandial glycemia was determined by 6-h continuous glucose monitoring. RESULTS: Acute postprandial glucose levels measured for 2 h were similar after LFP and two HFP meals (7.8 ± 2.0, 8.1 ± 2.1, 8.0 ± 1.9 mmol/l). Late postprandial glycemia measured from 2 to 6 h was significantly lower after the LFP meal (6.7 ± 1.8 mmol/l, p < 0.05) than after the HFP meals, but there was no difference between the rapid-acting or regular insulin on HFP days (8.6 ± 2.6 and 8.9 ± 2.8 mmol/l, NS). CONCLUSION: The preliminary results of this study indicate no benefit to cover fat-protein meals with regular insulin in individuals with type 1 diabetes treated with MDI.

Is Uric Acid a Missing Link between Previous Gestational Diabetes Mellitus and the Development of Type 2 Diabetes at a Later Time of Life?

INTRODUCTION: A high level of uric acid (UA) is a strong, independent risk factor for type 2 diabetes mellitus. The relationship between UA levels and the development of type 2 diabetes in women with previous gestational diabetes mellitus (pGDM) remains unclear. The aim of study was to evaluate the UA levels in pGDM women in relation to their current nutritional status and carbohydrate metabolism. MATERIAL AND METHODS: 199 women with pGDM diagnoses based on oral glucose tolerance tests (OGTTs) 5-12 years previously and a control group of 50 women without pGDM. The assessment included anthropometric parameters, body composition (Tanita SC-330S), current OGTT, insulin resistance index (HOMA-IR), ß-cell function (HOMA-%B), HbA1c, lipids, and uric acid. RESULTS: No differences between groups were found in terms of age, time from the index pregnancy, anthropometric parameters, lipids or creatinine levels. The incidences of overweight and obesity were similar. Carbohydrate abnormalities were more frequent in the pGDM group than the control group (43.2% vs 12.0% p<0.001). The women with pGDM had significantly higher fasting glucose, HbA1c, glucose and insulin levels in the OGTTs, but similar HOMA-IR values. Their UA levels were significantly higher (258±58 vs 230±50 µmol/L, p<0.005) and correlated with BMI and the severity of carbohydrate disorders. The normal weight and normoglycemic pGDM women also demonstrated higher UA levels than a similar control subgroup (232±48 vs 208±48 µmol/L, p<0.05). Multivariate analysis revealed significant correlations of UA level with BMI (ß = 0.38, 95% CI 0.25-0.51, p<0.0001), creatinine level (ß = 0.23, 95% CI 0.11-0.35, p<0.0005), triglycerides (ß = 0.20, 95% CI 0.07-0.33, p<0.005) and family history of diabetes (ß = 0.13, 95% CI 0.01-0.25, p<0.05). In logistic regression analysis, the association between higher UA level (defined as value ≥297 µmol/L) and presence of any carbohydrate metabolism disorder (IFG, IGT or diabetes) was statistically significant (odds ratio 3.62 [95% CI 1.8-7.3], p<0.001). CONCLUSIONS: Higher UA levels may be associated with the development of type 2 diabetes in pGDM women, also in these with normal body weights.

Assessment of selected lipid parameters in in children exposed to gestational diabetes (GDM) in utero.

INTRODUCTION: The assessment of maternal hyperglycemia during pregnancy and lipid profile in the offspring is recently highlighted. AIM: The study was undertaken to assess the selected lipid parameters in children exposed to gestational diabetes (GDM) in utero. MATERIAL AND METHODS: 50 children, 7-15 years of age, exposed to GDM were compared with 46 control subjects (7-16 years old). In all participants anthropometric parameters (height, weight, waist and hip circumferences) and values of total cholesterol, LDL-, HDL-cholesterol and triglycerides (TG) were measured. BMI, waist-to-hip ratio (WHR) and TG to HDL-cholesterol ratio were calculated. RESULTS: The prevalence of overweight/obesity in the study cohort was 38% and 41% in the control (p=0.19). Higher total cholesterol level (p=0.002) and LDL-cholesterol (p=0.007) were found in the study group. In children exposed to GDM significantly higher values of LDL-cholesterol (p=0.02), triglycerides (p=0.02), TG to HDL-cholesterol ratio (p=0.007) and lower HDL-cholesterol (p=0.02) were observed in overweight/obese children compared to slim participants. In the control group, similar results were not noted. In the study group, a positive correlations of TG to HDL-cholesterol ratio and BMI SDS (RS=0.47, p=0.0006), WHR (RS =0.31, p=0.03), SDS of birth weight (RS =0.47, p=0.0006) were found. CONCLUSION: Children exposed to GDM in utero could have a higher risk of dyslipidemia with its cardiovascular complications. Towards observed worse lipid parameters in children with excessive body mass born from pregnancies with GDM, prevention of overweight and obesity in this group seems to be essential.

Assessment of selected carbohydrate parameters in children exposed to gestational diabetes in utero.

OBJECTIVES: The study was undertaken to assess the selected carbohydrate parameters in children exposed to gestational diabetes in utero. METHODS: 50 children exposed to gestational diabetes were compared with 46 control subjects. Anthropometric parameters of a newborn were obtained from the medical records. In all participants height, body mass, waist and hip circumferences were measured; BMI, WHR and WHtR were calculated. Values of fasting glucose, insulin, C-peptide and HbA1c were measured and HOMA2-IR, HOMA2-S, HOMA2-B were calculated. In obese children (BMI ≥95th percentile) OGTT was performed. RESULTS: The prevalence of overweight/obesity in the study group was 38%, in the control group 41% (p=0.19). Higher fasting glucose level (p=0.02) and HbA1c (p=0.00004) were found in the study group comparing to the control. In children exposed to GDM in utero a positive correlation of fasting insulin and WHR (Rs=0.31, p=0.028) as well as significantly lower HOMA2-B (p=0.03) were observed. In the study group higher HOMA2-IR (p=0.0002) and HOMA2-B (p=0.0000039) and also lower HOMA2-S (p=0.0002) were observed among participants with overweight/obesity comparing to children with normal body weight. In the study group a correlation of HOMA2-IR and SD of the birth weight was found (Rs=0.28, p=0.049). CONCLUSIONS: Children exposed to gestational diabetes in utero, in spite of similar prevalence of overweight/obesity comparing to their non-exposed peers, could have higher risk of glucose intolerance and diabetes mellitus in future. Towards observed decreased insulin sensitivity and compensatory increase in insulin secretion, prevention of overweight and obesity in this group seems to be essential.

[Assessment of selected anthropometric parameters in children exposed to gestational diabetes in utero - preliminary results]. / Ocena wybranych parametrów antropometrycznych u dzieci urodzonych z ciaz powiklanych cukrzyca ciazowa - doniesienie wstepne.

INTRODUCTION: Current studies show uncreased risk of obesity cardiovascular diseases and diabetes mellitus in children exposed to gestational diabetes in utero. AIM: The aim of this study was to assess the selected anthropometric parameters in children exposed to gestational diabetes in utero. MATERIAL AND METHODS: 43 children, 7-15 years of age, exposed to gestational diabetes in utero were included in the study. Data including mother's pregestational anthropometric parameters, the course of pregnancy and anthropometric parameters of a newborn were obtained from the interview and medical records. Pediatric physical examination with Tanner assessment of pubertal development was conducted. In children and mothers the height and body mass were measured, and body mass index (BMI) was calculated. In participants of the study waist and hip circumferences were measured. RESULTS: Higher birth weight (p=0.02), head and chest circumferences (p=0,02 and p=0.03) were observed in newborns of mothers with pregestational overweight and obesity. The analysis of newborns growth parameters and type of gestational diabetes did not show a significant difference. Obesity (BMI z 95th percentile) was diagnosed in 9 children (20.9 %) and overweight (BMI between 85th and 94th percentile) in 6 participants (13.9%). Higher body mass (p=0.02), BMI (p=0.02) and waist circumference (p-0.03) were observed in children who reached III-V Tanner stage, comparing to participants in Tanner Ml. Higher body mass, BMI, waist and hip circumferences were observed in the offspring of mothers with pregestational overweight and obesity. Mothers of children with BMI > 90th percentile currently show higher body mass and BMI in comparison to mothers of slimmer participants. CONCLUSIONS: Excessive body weight before pregnancy in mothers with gestational diabetes can influence not only the anthropometric parameters of newborns and lead to fetal macrosomy, but also can be a predisposing factor for overweight and obesity in later childhood.

Homocysteine levels in women with a history of gestational diabetes mellitus.

BACKGROUND: Previous gestational diabetes (pGDM) is a risk factor of type 2 diabetes, hypertension and cardiovascular diseases. Homocysteine is one of markers of cardiovascular risk. The aim of this study was to assess the homocysteine levels in women with pGDM and to evaluate its relationship with current carbohydrate metabolism and nourishment status. METHODS: The study group comprised 199 women at 7.8 ± 1.0 years after pGDM and 50 control women in whom pGDM was excluded. The analyzed parameters: BMI, WHR, body composition (Tanita SC-330S analyzer), glucose and insulin levels in oral glucose tolerance test (OGTT), insulin resistance index (HOMA-IR), HbA1c, lipid profile, homocysteine, creatinine and creatinine clearance. The Mann-Whitney test and Chi-squared test were used for comparison of continuous and nominal variables, respectively. Correlations between continuous variables in each group were analyzed using Spearman's rank correlation coefficient (Rs). A logarithmic transformation was applied for variables with non-normal distribution. RESULTS: There were no differences between the pGDM women and controls in terms of age, number of childbirths, time from indexed pregnancy, pre-pregnancy BMI, or current anthropometric parameters. In pGDM women HbA1c and all glucose levels in OGTT were significantly higher, but still within the normal range. No significant differences were found in homocysteine levels, HOMA-IR, blood lipids, creatinine and creatinine clearance. Homocysteine levels did not differ significantly in subgroups categorized according to the current OGTT results or BMI. Carbohydrate metabolism disorders, overweight and obesity were associated with higher creatinine clearance. Positive correlation between homocysteine and creatinine (r = 0.21, p < 0.004), and a negative correlation with creatinine clearance (r = -0.16, p < 0.03) were found. CONCLUSIONS: In women with pGDM, homocysteine is not a marker of glucose tolerance disturbances and cardiovascular risk. Increased glomerular filtration rate, observed in more severe disorders of carbohydrate metabolism and greater BMI, may temporarily protect against an increase of proatherogenic homocysteine.

Adipokines and ß-cell dysfunction in normoglycemic women with previous gestational diabetes mellitus.

INTRODUCTION: An increased risk of developing type 2 diabetes in women with a history of gestational diabetes mellitus(gestational diabetes mellitus - GDM) may be associated with increased insulin resistance and subclinical inflammation. However, approximately half of women with previous GDM (pGDM) do not develop diabetes. These women were the population of focus in the present study. OBJECTIVES: The aim of the study was to assess ß-cell function, insulin resistance, and the levels of pro- and anti inflammatory adipokines in normoglycemic women with pGDM. PATIENTS AND METHODS: A study group included 199 women with pGDM; the mean time after delivery was 7.4 years. A control group included 50 women without pGDM. All patients underwent an oral glucose tolerance test (OGTT) with the assessment of glycemia and insulinemia, ß-cell function (HOMA-%ß), and insulin resistance (HOMA-IR), as well as the levels of soluble tumor necrosis factor α receptor (sTNF-α-R2), interleukin 6 (IL-6), adiponectin, and visfatin. RESULTS: Normal glucose tolerance was found in 113 women with pGDM (56.8%; the NGT-GDM[+] group) and in 44 control subjects (88.0%). In comparison with controls, the NGT-GDM[+] group had significantly higher glycemia in the OGTT and significantly lower HOMA-%ß values, with comparable HOMA-IR and body mass index values. The NGT-GDM(+) group was shown to have significantly higher levels of sTNF-α-R2 and IL-6, with similar adiponectin and visfatin levels. CONCLUSIONS: Normoglycemic women with a history of GDM are characterized by concomitant disturbances in insulin secretion and subclinical inflammation, with normal body weight and insulin sensitivity. It is not known whether these disturbances were present before a GDM-complicated pregnancy or whether they were induced by pregnancy.

[Practical implementation of recommendations concerning diagnostic procedures in gestational diabetes]. / Praktyczna realizacja zalecen dotyczacych diagnostyki cukrzycy ciazowej.

BACKGROUND: Gestational diabetes mellitus (GDM) is associated with health consequences for both, the mother and her offspring. In Poland, the diagnosis of GDM is based on the recommendations of the Polish Gynecological Society (PTG) and is usually made by obstetricians. OBJECTIVE: The aim of the study was to assess practical implementation of PTG standards of GDM screening and diagnosis. MATERIAL AND METHODS: The study group consisted of 351 pregnant women consulted by a diabetologist: 102 patients between 2008-2010 (PTG guidelines of 2005) and 249 patients between 2011-2013 (PTG guidelines of 2011). Data concerning diagnostic procedures performed by obstetricians--time of diagnostic tests, fasting glucose levels, oral glucose tolerance test (OGTT) results, and GDM risk factors--were collected. Adherence to the diagnostic procedures was assessed. RESULTS: Adherence to the diagnostic guidelines for 2008-2010 was 42.2%. The most common errors were incorrect time of OGGT (36.4%) and wrong interpretation of glycaemia (34.1%). Between 2011-2013 incorrect diagnostic testing was detected in 78.3% of the affected women. The most common deviation was lack of OGTT at the beginning of pregnancy in women with GDM risk factors (91.3%). CONCLUSIONS: A considerable number of GDM women underwent incorrect diagnostic procedures. More precise description of GDM risk factors in PTG recommendations seems to be necessary.

False diagnosis of type 1 diabetes mellitus and its complications in Wolfram syndrome--is it the reason for the low number of reported cases of this abnormality?

Wolfram syndrome (WS), also known as DIDMOAD (Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness), is a rare autosomal recessive syndrome (1/770,000 in the United Kingdom), characterised by juvenile onset of diabetes mellitus, optic nerve atrophy, diabetes insipidus, sensorineural deafness, renal tract and neurological abnormalities, and primary gonadal atrophy. WS is caused mainly by biallelic mutations in the WFS1 gene, which encodes wolframin. Wide tissue distribution of wolframin and many mutations in the wolframin gene resulting in Wolfram syndrome may contribute to different phenotypes and the unusual combinations of clinical features. We describe a female patient with Wolfram syndrome diagnosed at the age of 25, with a previous false diagnosis of type 1 diabetes mellitus and misdiagnosed diabetic complications. The patient was found to be a compound heterozygote for two novel mutations in exon 8 of WFS1 gene: a 2-bp deletion AT at nt 1539 leading to a frameshift (Y513fs) and a single-base substitution 1174C > T resulting in a stop codon (Q392X). A detailed analysis of the patient's medical history and a review of the literature suggest that many cases of Wolfram syndrome may remain undiagnosed due to misdiagnosis as type 1 diabetes mellitus and incorrect interpretation of clinical symptoms of neurodegenerative abnormalities, especially in their early stages.

Thoracic spine fracture in the course of severe nocturnal hypoglycemia in young patients with type 1 diabetes mellitus--the role of low bone mineral density.

Thus far, only a few spine fracture cases related to severe nocturnal hypoglycemia in type 1 diabetes patients have been reported. Due to the relatively young age of these subjects, osteoporosis was not taken into consideration and bone mineral density was not assessed. We report three type 1 diabetes cases in young patients with durations of 2, 4, and 19 years. These patients had severe hypoglycemic attacks during night sleep with subsequent compression thoracic vertebrae fractures. Laboratory parameters for diabetes control, calcium, phosphate metabolism and celiac-specific antibodies were assessed. Moreover, kidney, thyroid, and parathyroid gland functions were also measured. Bone mineral density was assessed by dual energy x-ray absorptiometry. Lumbar spine x-ray absorptiometry revealed very low bone mineral density in all three patients. In all subjects, metabolic control was good, no chronic diabetes complications were found and other laboratory parameters were within a normal range. For the first time, it was demonstrated that low bone mineral density in young type 1 diabetes patients may contribute to an increased compression fracture risk of the dorsal spine during severe nocturnal hypoglycemia courses. The possibility of osteoporosis in young patients with short diabetes durations suggests it might be advisable to perform bone mineral density testing during diabetes diagnoses. Spinal pain occurrences in young patients after severe nocturnal hypoglycemia should be investigated using procedures for the diagnosis of vertebral compression fracture, even if there is no evident trauma.

Increased concentration of C-reactive protein in obese patients with type 2 diabetes is associated with obesity and presence of diabetes but not with macrovascular and microvascular complications or glycemic control.

The purpose of this study was to assess the concentration of C-reactive protein (CRP) in obese type 2 diabetes mellitus (DM2) patients and its association with macrovascular and microvascular complications. The study group consisted of 80 obese DM2 patients, including 20 macrovascular, 20 microvascular, 20 both macrovascular and microvascular, and 20 with no complications patients. The control group comprised 40 normoglycemic subjects--20 obese and 20 of normal body weight. Highly sensitive CRP and metabolic control parameters were assessed. CRP levels in obese diabetes subgroups and normoglycemic obese were similar and significantly higher than those in nonobese controls. No correlation was found between CRP and diabetes control parameters. There was a strong positive correlation between CRP level and body mass index in all groups. A multivariate analysis showed that DM2 and obesity are independent factors increasing CRP levels. Increased concentration of CRP in obese DM2 patients is related to obesity and diabetes itself. The lack of association between CRP and vascular complications remains unclear.

The common C49620T polymorphism in the sulfonylurea receptor gene SUR1 (ABCC8) in patients with gestational diabetes and subsequent glucose metabolism abnormalities.

AIM: The aim of this study is to investigate the relationship between the common C49620T polymorphism in the sulfonylurea receptor (SUR1) gene and glucose metabolism, ß-cell secretory function and insulin resistance in women with a history of gestational diabetes (GDM). MATERIAL AND METHODS: Study group included 199 women, diagnosed GDM within the last 5-12 years and control group of comparable 50 women in whom GDM was excluded during pregnancy. Blood glucose and insulin levels were measured during oral glucose tolerance test. Indices of insulin resistance (HOMA-IR) and ß-cell function (HOMA %B) were calculated. In all patients, the C49620T polymorphism in intron 15 of the SUR1 gene was determined. RESULTS: The distribution of the studied polymorphism in the two groups did not differ from each other (χ(2) = 0.34, P = 0.8425). No association between the distribution of polymorphisms and coexisting glucose metabolism disorders (χ(2) = 7,13, P = 0, 3043) was found. No association was also observed between the polymorphism and HOMA %B or HOMA-IR. CONCLUSIONS: The polymorphism C49620T in the SUR1 gene is not associated with insulin resistance and/or insulin secretion in women with a history of GDM and does not affect the development of GDM, or the development of glucose intolerance in the studied population.

From open to laparoscopic adrenalectomy: thirty years' experience of one medical centre.

INTRODUCTION: Laparoscopic adrenalectomy (LA) has become the standardized treatment of benign adrenal lesions over the last two decades, making the indications to open adrenalectomy (OA) limited. The purpose of this study was to show the thirty years of experience in open (OA) and laparoscopic adrenalectomy (LA) gained in one medical centre as well as to compare the results of OA and LA performed for benign adrenal lesions. MATERIAL AND METHODS: Three hundred patients underwent 127 open and 173 laparoscopic adrenalectomies between 1979 and 2009 at M. Curie Hospital in Szczecin, Poland. Analyzed factors included patients demographic data, ASA score, indication for surgery, tumour size and side, characteristics of the removed tumours, intraoperative and postoperative outcome of LA and OA, postoperative pain sensation, intraoperative and postoperative complications, and conversion rate from LA to OA. Tumours with diameter exceeding 8 cm were excluded. RESULTS: There were no significant differences regarding the analyzed preoperative data in both groups of patients. The mean operative time was longer in the LA group (137 v. 82 min., p < 0.0001) and the blood loss was lower in LA group (110 v. 254 mL, p < 0.0001). The mean time until resumption of normal diet was shorter after LA (22 v. 44 h), as was the mean time until ambulation (17 v. 36 h), mean length of the hospital stay (4.6 v. 6.8 days), and mean time until return to normal activities (14 v. 23 days, p < 0.0001 for each difference). The analgesic requirement on the first and the second day postoperatively was lower in the LA group (p < 0.0001). The incidence of intraoperative and postoperative complications did not differ significantly between both analyzed groups. The rate of the conversion from LA to OA was 16%. The histopathological diagnosis was adenoma of the adrenal gland in the majority of cases. CONCLUSIONS: This study shows that LA is a safe, effective, and well-tolerated procedure. It may be recommended as a "gold standard" surgery in a case of benign functioning or non-functioning adrenal tumours with diameter less than 8 cm. (Pol J Endocrinol 2010; 61 (1): 94-101).

[Diabetes control in type 2 diabetic subjects treated in primary health care--how far is from life to standards?]. / Wyrównanie cukrzycy typu 2 u chorych pozostajacych pod wylaczna opieka lekarzy rodzinnych--jak daleko od zycia do standardów?

UNLABELLED: In Poland, as in many other countries, majority of type 2 diabetics subjects (80%) is treated by general practitioners (GPs). Aim of the study was to assess control of type 2 diabetic subjects treated by GPs in one of the big cities in Poland. Achievement of treatment goals was assessed according to recommendations of European Diabetes Policy Group (EDPG) published in 1998-1999 and used in Poland till 2004 and according to more rigorous criteria recommended in 2005 by Polish Diabetological Association (PDA). Study was conducted in 2004 year in 355 consecutive type 2 diabetic subjects coming for a visit to GPs in one of the primary health care centries. Group consisted of 205 women and 150 men, mean age 65.7 +/- 10.3 years, mean diabetes duration 9.2 +/- 7.3 years, mean BMI 29.9 +/- 4.9 kg/m2. In all patients blood pressure measurements were performed in sitting position and blood samples for HbA1c, fasting glycaemia, total cholesterol, LDL, HDL and triglicerides were taken. Mean HbA1c was 7.2 +/- 1.3%; HbA1c < or = 6.5% recommended by EDPG was found in 34,6% of patients, HbA1c < or = 6.1% recommended by PDA was achieved in 19.7% of subjects. Mean fasting glycaemia was 144 +/- 48 mg/dl; glycaemia < or = 110 mg/dl recommended by EDPG and PDA was present in 24% of patients. Dyslipidaemia was present in 62% of diabetics. Mean total cholesterol was 203.7 +/- 45 mg/dl, LDL 118 +/- 33 mg/dl, HDL 51 +/- 13 mg/dl. LDL cholesterol < 100 mg/dl recommended by EDPG and PDA was observed in 28.7% of subjects. HDL cholesterol > 46 mg/dl (EDPG criteria) was found in 61% of patients. HDL cholesterol > 40 mg/dl in men and > 50 mg/dl in women ( PDA criteria) was present 64.5% of subjects. Mean triglycerides level was 182 +/- 108 mg/dl; concentrations < 150 mg/dl (EDPG and PTD criteria) were observed in 46.2% of subjects. Hypertension was present in 81.4% of patients. Mean systolic blood pressure (SPB) was 146.1 +/- 20.4 mmHg, diastolic (DBP) 83.0 +/- 11.1 mmHg. Recommended by EDPG, SPB < 140 mmHg was observed in 47,9%, DBP < 85 mmHg--in 69.9%. Recommended by PTD, SBP < 130 mmHg was found in 16.1%, DBP < 80 mmHg--in 24.5%, and both values only in 8.2% of diabetics. All treatment goals recommended by EDPG-1998-1999 were achieved only in 2 patients. No one person achieved all goals of treatment recommended by PDA-2005. CONCLUSIONS: Great majority of type 2 diabetic subjects treated in primary health care failed to attain treatment goals recommended by EDPG 1998-1999 and by PDA 2005.

Diabetes care and self-monitoring of type 2 diabetic patients in a rural district of West-Pomeranian Province.

INTRODUCTION: Few surveys conducted in diabetic patients from rural regions show that in these subjects monitoring of diabetes is worse than in patients from urban areas. OBJECTIVES: To assess methods of diabetes care provided for type 2 diabetic patients residing in a rural region and methods of the patient self-monitoring of glycemia, blood pressure and foot self-care. PATIENTS AND METHODS: The survey was conducted in a rural district of West-Pomeranian province, in the primary health care center, where 279 type 2 diabetic patients were registered. Out of all patients invited to participate in a questionnaire survey, 168 were enrolled. The mean age of subjects was 67.2 +/- 9.9 years (range 46-91 years), diabetes duration of 8.2 +/- 6.6 years, and body mass index of 32.6 +/- 6.3 kg/m2. Data concerning diabetes care and methods of the patient self-control of glycemia, blood pressure and foot self-care were collected. RESULTS: The majority of patients (62%) were treated only by general practitioners, but 80% reported that they visited their doctors for diabetes treatment once a month. For 90% of subjects the term ,HbA1c" was unknown. Only 40% of patients performed self-monitoring of glycemia, 55%--of blood pressure and 34% examined their feet. CONCLUSIONS: The vast majority of patients from a rural region in West-Pomeranian province is treated only by general practitioners. Despite quite frequent medical visits related to diabetes, education of patients is still unsatisfactory, which was demonstrated by patients' lack of knowledge concerning the basic parameter of laboratory monitoring, HbA1c, as well as insufficient self-management of glycemia, blood pressure and infrequent foot exam.

[Relationship between I/D polymorphism of angiotensin I converting enzyme gene and microvascular complications in type 2 diabetic patients]. / Zaleznosc miedzy polimorfizmem I/D genu enzymu konwertujacego angiotensyne I a powiklaniami o typie mikroangiopatii u chorych na cukrzyce typu 2.

BACKGROUND: Type 2 diabetes mellitus is an increasing problem in developed countries. Microvascular diabetic complications can lead to worsening of the quality of life and lifespan shortening of diabetic patients. The renin-angiotensin system (RAS) seems to play an important role in microvascular blood flow. I/D polymorphism of angiotensin I converting enzyme (ACE) affecting activity of RAS may contribute to development of microvascular diabetic complications. AIM: The aim of the study was to evaluate association between I/D polymorphism of ACE gene and presence of microangiopathic complications in type 2 diabetic patients. MATERIAL AND METHODS: 108 type 2 diabetic patients (70 men and 38 women), mean age 60.0 +/- 9.1 years with mean duration of diabetes 9.1 +/- 6.7 years were assessed for presence of microvascular complications (nephropathy, retinopathy, peripheral neuropathy). Subjects were examined for metabolic control of diabetes, lipid profile and degree of insulin resistance based on HOMA rate. I/-D ACE gene polymorphism was evaluated using polymerase chain reaction (PCR). RESULTS: Diabetic nephropathy was diagnosed in 44 patients (42.7%), retinopathy in 34 patients (31.8%), and peripheral neuropathy in 58 patients (53.7%). Microvascular complications were found (at least one complication) in 83 patients (76.9%). Patients with microangiopathy and without microangiopathy were characterized by similar distribution of I/D ACE gene polymorphism. In carriers of DD ACE genotype blood pressure and HDL-cholesterol serum concentrations were higher than in patients with II polymorphism. CONCLUSIONS: 1. The ACE genotype is not associated with the presence of microvascular complications in type 2 diabetic patients. 2. In type 2 diabetic patients there is an association between DD genotype and higher blood pressure and serum HDL-cholesterol level.

[I/D polymorphism of angiotensin I converting enzyme gene and arterial hypertension in patients with type 2 diabetes mellitus]. / Polimorfizm I/D genu enzymu konwertujacego angiotensyne I a nadcisnienie tetnicze u chorych na cukrzyce typu 2.

UNLABELLED: Type 2 diabetes mellitus and arterial hypertension coexist very frequently. About 80% patients with type 2 diabetes suffer for hypertension, which is connected with higher morbidity and mortality from cardiovascular diseases. There are evidences that activation of the renin-angiotensin system (RAS), one of the most potent factors in blood pressure regulation, can decrease insulin sensitivity of tissues. As I/D polymorphism of angiotensin converting enzyme (ACE) gene can influence the activity of RAS, it may also influence both carbohydrate metabolism and blood pressure. AIM OF THE STUDY: To assess the relationship between the I/D polymorphism of ACE gene and frequency of hypertension and values of blood pressure in type 2 diabetic patients. MATERIAL AND METHODS: Examined group: 108 type 2 diabetic patients (38 women and 70 men), with mean duration of disease 9.07 +/- 6.68 years, mean age 59.98 +/- 9.10 years. We assessed following parameters: body mass index (BMI), waist/hip ratio (WHR), arterial blood pressure. Laboratory tests: concentration of the glucose, glycosylated hemoglobin (HbA1c), creatinine and urinary albumin excretion rate (UAER). Insulin resistance was calculated by the HOMA rate. I/D ACE gene polymorphism was evaluated by polymerase chain reaction (PCR). RESULTS: DD genotype carriers had significant higher systolic and diastolic blood pressure (147.8 +/- 19.8 vs 138.2 +/- 16.5 mm Hg, p = 0.03; 89.2 +/- 9.6 vs 81.7 +/- 8.6 mm Hg p = 0.004; respectively) than II patients. Groups with II, ID and DD genotype were not different in age, BMI, WHR, duration of diabetes, the prevalence and duration of arterial hypertension, degree of metabolic control of diabetes and insulin resistance assessed by HOMA rate. CONCLUSION: In type 2 diabetic patients the DD genotype of ACE gene is not connected with higher prevalence of hypertension, but it is associated with higher systolic and diastolic blood pressure.