Prevalence of diabetes in Poland: a combined analysis of national databases

AIMS

To assess the number of people with diabetes in Poland using combined national sources and to evaluate the usefulness of data from an insurance system for epidemiological purposes.

METHODS

The data were collected from four sources: 1) 2013 all-billing records of the national insurance system comprising people of all age groups undergoing procedures or receiving services in primary healthcare, specialist practices and hospitals and also those receiving drugs; 2) an epidemiological study, NATPOL, that involved the assessment of people with undiagnosed diabetes; 3) the RECEPTOmetr Sequence study on prescriptions; and 4) regional child diabetes registries.

RESULTS

In 2013, 1.76 million people (0.98 million women and 0.79 million men) had medical consultations (coded E10-E14) and 2.13 million people (1.19 million women and 0.94 million men) purchased drugs or strip tests for diabetes. A total of 0.04 million people who used medical services did not buy drugs. In total, the number of people with diabetes in the insurance system was 2.16 million (1.21 million women and 0.95 million men), which corresponds to 6.1% (95% CI 6.11-6.14) of women and 5.1% (95% CI 5.12-5.14) of men. Including undiagnosed cases, the total number of people with diabetes in Poland was 2.68 million in 2013.

CONCLUSION

The estimated prevalence of diabetes (diagnosed and undiagnosed cases) in Poland is 6.97%. Data from the national insurance system with full coverage of the population can be treated as a reliable source of information on diseases with well-defined diagnosis and treatment methods, combined with an assessment of the number of undiagnosed individuals.

Declared and real physical activity in patients with type 2 diabetes mellitus as assessed by the International Physical Activity Questionnaire and Caltrac accelerometer monitor: a potential tool for physical activity assessment in patients with type 2 diabetes mellitus

AIMS

The aims of this study were to assess and compare declared and real volume of physical activity (PA), and to evaluate correlations of these measurements with glycemic control (HbA1c) and body mass index (BMI), in patients with type 2 diabetes mellitus (T2DM).

MATERIAL AND METHODS

A group of 31 (16 women and 15 men) type 2 diabetic patients treated with insulin monotherapy, from (mean age=54 ± 3.6 years, BMI=29.7 ± 4.8 kg/m(2), T2DM treatment=9 ± 8 years, HbA1c 7 ± 1%) and not professionally active (unemployed or retired) was recruited. An assessment of energy cost (EC) of their weekly PA using International Physical Activity Questionnaire (IPAQ), and an accelerometer assessment was performed.

RESULTS

Total energy expenditure of the declared weekly PA, calculated from the IPAQ (DPA) was 2513 ± 1349 METmin/week, and 2428 ± 1348, for male and female participants, respectively (p > 0.05). EC of the real PA (RPA), registered with the accelerometer was 4552 ± 2028 kcal/week, and 4032 ± 2288 kcal/week, for males, and females, respectively. Patients who demonstrated a high DPA, based on their IPAQ score, showed a significantly higher RPA, as registered by the accelerometer (p < 0.05). HbA1c and BMI did not correlate with their PA measurements.

CONCLUSIONS

Our findings indicate that the IPAQ may serve as a potential tool for physical activity assessment with no further requirement for more sophisticated methods. Our results suggest that habitual physical activity has no impact on glycemic control and BMI in type 2 diabetic patients. However, further studies on a larger population are needed to explore these issues.

Efficacy of short-term adjunctive subantimicrobial dose doxycycline in diabetic patients--randomized study

OBJECTIVE

To investigate the effectiveness of short-term adjunctive subantimicrobial dose doxycycline (SDD) treatment in patients with diabetes mellitus type 2 and chronic periodontitis (CP).

METHODS

Thirty-four patients with CP and type 2 diabetes mellitus were included in the placebo-controlled, double-blind study. After scaling and root planing (SRP), patients were randomly assigned to two groups, receiving either SDD or placebo bid for 3 months. The probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), approximal plaque index, glycated hemoglobin (HbA1c) level were recorded and gingival crevicular fluid (GCF) samples were collected at baseline and after 3-month therapy for the estimation of matrix metalloproteinase-8 levels.

RESULTS

Clinical attachment level, PD, and BOP improved significantly in both groups after therapy (P < 0.05). The statistically significant difference between the two groups after the therapy was observed only in PD in tooth sites with initial PD ≥ 4 mm (SRP + placebo: 3.41 ± 0.6 mm vs SRP + SDD: 2.92 ± 0.5 mm, P < 0.05). GCF matrix metalloproteinase-8 levels were significantly reduced only in SRP + SDD group (P < 0.01). There were no changes in HbA1c levels after therapy.

CONCLUSION

The short-term administration of SDD gives significant benefit at tooth sites with moderate disease (PD ≥ 4 mm) when compared to SRP alone in patients with diabetes and CP.

Effect of dapagliflozin in patients with type 2 diabetes who have inadequate glycaemic control with glimepiride: a randomized, 24-week, double-blind, placebo-controlled trial

AIMS

Progressive deterioration of glycaemic control in type 2 diabetes mellitus (T2DM) often requires treatment intensification. Dapagliflozin increases urinary glucose excretion by selective inhibition of renal sodium-glucose cotransporter 2 (SGLT2). We assessed the efficacy, safety and tolerability of dapagliflozin added to glimepiride in patients with uncontrolled T2DM.

METHODS

This 24-week, randomized, double-blind, placebo-controlled, parallel-group, international, multicentre trial (ClinicalTrials.gov NCT00680745) enrolled patients with uncontrolled T2DM [haemoglobin A1c (HbA1c) 7-10%] receiving sulphonylurea monotherapy. Adult patients (n = 597) were randomly assigned to placebo or dapagliflozin (2.5, 5 or 10 mg/day) added to open-label glimepiride 4 mg/day for 24 weeks. Primary endpoint was HbA1c mean change from baseline at 24 weeks. Secondary endpoints included change in body weight and other glycaemic parameters.

RESULTS

At 24 weeks, HbA1c adjusted mean changes from baseline for placebo versus dapagliflozin 2.5/5/10 mg groups were -0.13 versus -0.58, -0.63, -0.82%, respectively (all p < 0.0001 vs. placebo by Dunnett's procedure). Corresponding body weight and fasting plasma glucose values were -0.72, -1.18, -1.56, -2.26 kg and -0.11, -0.93, -1.18, -1.58 mmol/l, respectively. In placebo versus dapagliflozin groups, serious adverse events were 4.8 versus 6.0-7.1%; hypoglycaemic events 4.8 versus 7.1-7.9%; events suggestive of genital infection 0.7 versus 3.9-6.6%; and events suggestive of urinary tract infection 6.2 versus 3.9-6.9%. No kidney infections were reported.

CONCLUSIONS

Dapagliflozin added to glimepiride in patients with T2DM uncontrolled on sulphonylurea monotherapy significantly improved HbA1c, reduced weight and was generally well tolerated, although events suggestive of genital infections were reported more often in patients receiving dapagliflozin.

Addition of insulin lispro protamine suspension or insulin glargine to oral type 2 diabetes regimens: a randomized trial

AIMS

The addition of basal insulin to existing oral therapy can help patients with type 2 diabetes (T2D) achieve glycaemic targets. This study compares the efficacy and safety of insulin lispro protamine suspension (ILPS) and insulin glargine in insulin-naive patients with T2D and inadequate control on oral antihyperglycaemic medication (OAM).

MATERIALS AND METHODS

An open-label, randomized, multicentre, multinational 24-week study of 471 patients receiving ≥2 OAMs for ≥3 months with a body mass index between 25 and 45 kg/m(2) and HbA1c 7.5-10.0% was conducted. ILPS was injected once or twice daily vs. glargine injected once daily plus prestudy OAMs. Primary objective compared the HbA1c change from baseline.

RESULTS

HbA1c change from baseline to endpoint was similar in both groups [-1.46% (ILPS) and -1.41% (glargine)]. Least-squares mean difference (95% CI) for HbA1c (-0.05 [-0.21, 0.11]%), glycaemic variability (0.06 [-0.06, 0.19] mmol/l) and weight change (-0.01 [-0.61, 0.59] kg) showed non-inferiority (margins of 0.4%, 0.8 mmol/l and 1.5 kg, respectively). Percentages of patients achieving HbA1c <7.0% were 43.8% ILPS and 41.2% glargine. Mean daily insulin dose was 0.39 vs. 0.35 U/kg (p = 0.02) and weight gain was 1.04 vs. 1.07 kg for ILPS vs. glargine (p = 0.98). Overall hypoglycaemia (episodes/patient/year) was similar for ILPS and glargine (24.2 ± 28.8 vs. 23.0 ± 30.9); nocturnal (6.1 ± 10.6 vs. 4.1 ± 9.4, p < 0.001) rates were higher for ILPS. Severe hypoglycaemia was higher for ILPS vs. glargine (n = 9 vs. n = 2; p = 0.04).

CONCLUSIONS

At endpoint, ILPS was non-inferior to glargine in HbA1c change from baseline, but associated with increased risk of hypoglycaemia.

Prevalence of diabetes and cardiovascular risk factors of industrial area in southern Poland

BACKGROUND

Diabetes mellitus (DM) is a serious health and social problem. We assessed the prevalence of DM and metabolic syndrome in an urban population in southern Poland.

METHODS

Sample of 782 subjects randomly selected from adult inhabitants of industrial district (23 442 voters registered) was invited. The response rate was 56% (including 85% of those aged over 50 years) mean age 53+/-15 years. 75 g OGTT and serum concentration of triglycerides, total cholesterol and HDL/LDL fractions were measured. The percentage+/-assessment error for the disorders were calculated assuming not-responders represented normal glucose tolerance.

RESULTS

Prevalence of DM was 8.06+/-0.9% (7.15+/-1.25 M and 8.94+/-1.3 F) including 5.56+/-0.77% (5.56+/-1.13 M and 5.56+/-1.06 F) with known and 2.52+/-0.55 (1.59+/-0.64 M and 3.37+/-0.89 F) newly diagnosed. Impaired glucose tolerance (IGT and/or IFG) was found in additional 8.44+/-0.93% (6.09+/-1.17 M and 10.7+/-1.41 F). Extrapolated to the general population shown the prevalence 6.54+/-0.73% (5.8+/-1.02 M and 7.25+/-1.05 F). Features of the metabolic syndrome (IDF criteria) were found in 34% of the participants - 75% of patients with DM, 63% with glucose intolerance (IGT and/or IFG) and 19% of individuals with NGT (p<0.001 as compared to other groups). CONCLUSIONS The study confirmed high prevalence of diabetes mellitus with lower percentage of undiagnosed disease. Presence of impaired glucose tolerance allows to identify the high risk of metabolic syndrome and in consequence high risk of cardiovascular disease.

The efficacy of self-monitoring of blood glucose in the management of patients with type 2 diabetes treated with a gliclazide modified release-based regimen. A multicentre, randomized, parallel-group, 6-month evaluation (DINAMIC 1 study)

AIM

To determine if therapeutic management programmes for type 2 diabetes that include self-monitoring of blood glucose (SMBG) result in greater reductions in glycated haemoglobin (HbA1c) compared with programmes without SMBG in non-insulin requiring patients.

METHODS

Multicentre, randomized, parallel-group trial. A total of 610 patients were randomized to SMBG or non-SMBG groups. Patients in both groups received the same oral antidiabetic therapy using a gliclazide modified release (MR)-based regimen for 27 weeks. The primary efficacy end-point was the difference between groups in HbA1c at the end of observation.

RESULTS

A total of 610 patients were randomized: 311 to the SMBG group and 299 to the non-SMBG group. HbA1c decreased from 8.12 to 6.95% in the SMBG group and from 8.12 to 7.20% in the non-SMBG group; between-group difference was 0.25% (95% CI: 0.06, 1.03; p = 0.0097). Symptoms suggestive of mild to moderate hypoglycaemia was the most commonly reported adverse event, reported by 27 (8.7%) and 21 (7.0%) patients in the SMBG and non-SMBG groups, respectively; the incidence of symptomatic hypoglycaemia was lower in the SMBG group.

CONCLUSION

In patients with type 2 diabetes, the application of SMBG as an adjunct to oral antidiabetic agent therapy results in further reductions in HbA1c.

Expression pattern of genes in peripheral blood mononuclear cells in diabetic nephropathy

AIMS

Only one-third of Type 1 diabetes patients develop diabetic nephropathy, and a genetic predisposition is postulated. To obtain more insight into processes that lead to diabetic nephropathy, messenger RNA expression profiles of peripheral blood mononuclear cells from patients with and without diabetic nephropathy were compared.

METHODS

We studied seven male patients with Type 1 diabetes and proteinuria and 12 male patients with Type 1 diabetes and normoalbuminuria after at least 20 years of diabetes duration. The expression of genes was examined using the microarray method with Human Genome U133A Arrays (Affymetrix, Santa Clara, CA, USA). We analysed the expression of all candidate genes suggested to be involved in the pathogenesis of diabetic nephropathy in previously published articles. Altogether, expression of 198 genes was analysed.

RESULTS

We found that thrombospondin 1 (THBS1) and cyclooxygenase 1(COX1) genes were over-expressed in patients with diabetic nephropathy, and matrix metalloproteinase 9 (MMP9) and cyclooxygenase 2 (COX2) genes had lower expression in diabetic nephropathy. For other genes, we did not observe different expression between patients with and without diabetic nephropathy,or the expression was too low for analysis.

CONCLUSIONS

The different gene expression pattern in peripheral blood mononuclear cells in patients with diabetic nephropathy might indicate an important pathway in the pathogenesis of this complication.

Charcot's Joint of the Wrist in Type 2 Diabetes Mellitus

In patients with diabetes mellitus, Charcot's neuroarthropathy mainly affects major weight-bearing joints, especially the foot and ankle. Remarkably, we report a case of Charcot's joint of the wrist - an unusually rare localization in type 2 diabetic patient. A review of medical literature identified only three such cases so far.

Initiating oral glucose-lowering therapy with metformin in tyape 2 diabetic patients: an evidence-based strategy to reduce the burden of late-developing diabetes complications

A major aim of glucose-lowering therapy in people with diabetes is to delay or prevent the late-developing complications of diabetes that threaten the quality and duration of life. While intensive interventions to control hyperglycaemia may impair well-being to some extent, the balance of quality of life is usually highly positive. Diet and exercise therapy remains the cornerstone of management, and should usually be given a trial alone first. However, the magnitude and duration of benefit from this intervention is insufficient for most people. More frequent, early, use of metformin is an evidence-based strategy for reducing the risk of adverse outcomes of diabetes in people with type 2 diabetes with sub-optimal glucose control on lifestyle measures alone. This has been recognised in recent evidenced-based guidelines from the UK National Institute for Clinical Excellence and from Diabetes UK, which now support the use of metformin as initial pharmacological therapy for all people without contraindications to the drug. Other national and local guideline committees should consider updating their recommendations on diabetes management in line with these findings.

Retrospective analysis of cardiovascular outcomes in patients with type 2 diabetes mellitus after the first acute myocardial infarction

We retrospectively analyzed survival in patients with type 2 diabetes mellitus (DM) after first acute myocardial infarction (AMI). The study was conducted in 5 sites in Poland and involved 521 patients who survived more than 30 days after AMI. In the 5-year period after the acute event, we investigated the following cardiovascular (CV) outcomes: death (overall mortality), next MI, stroke, hospitalization due to acute coronary symptoms (HACS), and composite outcomes (whichever occurred first). We also assessed: age, smoking habit, obesity, hypertension, dyslipidemia and coronary artery disease (CAD) diagnosed before AMI, and gender. 269 patients (52%) suffered one of the outcomes from the composite CV endpoint. HACS was the first event in 164 cases, MI in 59, death in 32, and stroke in 14 patients. Analyzing the prevalence of individual CV events, we found: HACS in 184 patients (35%), next MI in 79 patients (15%), death in 59 patients (11%), and stroke in 30 patients (6%). Only dyslipidemia, arterial hypertension, and CAD were independent risk factors with an impact on composite CV endpoint. Other analyzed risk factors like smoking and obesity did not have independent effects on the CV risk. In the retrospective analysis, we found that HACS was the most frequent CV event in individuals with type 2 DM after AMI. The CV risk in type 2 diabetics who suffered at least one myocardial infarction was further increased in those with coexisting dyslipidemia, arterial hypertension or CAD. These findings support the current guidelines which recommend aggressive management of CV risk factors including hypertension, dyslipidemia and CAD before a first myocardial infarction.

Features of macrovascular complications in type 2 diabetic patients

Macroangiopathy is the most frequent complication in type 2 diabetic patients. Coexistence of atherosclerosis and diabetes may cause diagnostic difficulties resulting from an asymptomatic course. Alternatively, patients may overexpress their symptoms as the result of awareness the consequences of the disease. Careful assessment of clinical symptoms followed by preventive diagnosis of high-risk patients as well as proper patient education allow for significant reductions of hazard of the consequences of macrovascular complications in diabetic patients

Cochlear dysfunction and diabetic microangiopathy

The aim of this study was to evaluate the cochlear micromechanics in type 1 diabetic patients and to compare these findings with diabetic microvascular complications (retinopathy and nephropathy). Cochlear activity was evaluated by recording 2f1-f2 DPOAE. DPOAEs were performed using an ILO92 Otodynamics Ltd Analyser. DPOAEs were measured in 42 normally hearing IDDM patients aged between 21 and 42 years, and 33 age-and sex-matched non-diabetic control subjects. IDDM patients were divided into two groups: 17 patients without microangiopathy and 25 with microangiopathy. Microangiopathy was evaluated with ophthalmoscopy and 24-hour albumin excretion rate into urine. Both groups (diabetic and control) had normal and undifferentiated results in tonal and impedance audiometry. The mean amplitudes of various DPOAEs were significantly reduced in the diabetic groups (with and without microangiopathy) compared with control subjects. No correlation was found between diabetic microvascular complications and DPOAE amplitudes reduction. Our results indicate the existence of an alteration in cochlear micromechanics in diabetic patients with microangiopathy as well as in patients without microangiopathy. The lack of significant correlation between the degree of microvascular complications in the retina or kidneys and DPOAEs amplitude reduction suggest that the impaired functional properties of the outer hair cells are probably caused by early metabolic complications in diabetes (among other things non-enzymatic glycation related to hyperactivity of free oxygen radicals) and not directly by diabetic microangiopathy.

Sympathetic overactivity and arterial hypertension in renal failure

In the past, it had been presumed that hypertension in chronic renal disease can be explained by the dual effects of sodium retention and inappropriate activity of the renin-angiotensin system. Recent experimental and clinical data provide strong evidence that the increase in blood pressure is to a large part due to sympathetic overactivity which is triggered by afferent signals emanating from the kidney and resetting sympathetic tone by stimulation of hypothalamic centres. The sequelae of sympathetic overactivity extend beyond their effects on blood pressure and include accelerated progression of renal failure and presumably increased cardiac arrhythmia.

Early Identification of Hearing Impairment in Patients With Type 1 Diabetes Mellitus

OBJECTIVE

The aim of this study was to evaluate the cochlear micromechanics and central auditory function in patients with type I diabetes mellitus and to identify the site of possible dysfunction.

METHODS

Cochlear activity was evaluated by recording distortion product otoacoustic emissions (DPOAEs). DPOAEs were performed using an ILO 92 Otodynamics Analyser. Functional changes in the retrocochlear auditory pathway were evaluated by auditory brainstem responses (ABRs). DPOAEs and ABRs were measured in 42 normally hearing patients with type 1 diabetes mellitus aged 21 to 42 years, and 33 age- and sex-matched nondiabetic control subjects.

RESULTS

Both of the groups (diabetic and control) had normal and undifferentiated results in tonal and impedance audiometry. ABR peripheral transmission time (wave I) and central transmission time (interpeak latencies I-V) were significantly delayed in the diabetic compared with normal subjects, and the mean amplitudes of various DPOAEs were significantly reduced in the diabetic patients compared with the control subjects.

CONCLUSIONS

Combined use of different procedures for monitoring central and peripheral portions of the auditory pathway in diabetic patients showed alterations in cochlear micromechanics and the retrocochlear auditory pathway. Hearing impairment in diabetic patients is usually mild and subclinical, and can be detected early by accurate and objective audiometric methods.

[A grid pattern type of photocoagulation in treatment of diabetic maculopathy--personal experience]

PURPOSE

The aim of the present study was the evaluation of visual outcome of 425 eyes in 283 patients treated by focal and grid pattern photocoagulation for clinically significant macular edema according to the recommendations of the Early Treatment Diabetic Retinopathy Study (ETDRS).

MATERIAL AND METHODS

On the basis of baseline status of macula, eyes were classified into three groups: group I--eyes treated by focal photocoagulation (39 eyes), group II--eyes treated by focal photocoagulation and/or modified grid (84 eyes), group III--eyes treated by focal photocoagulation and/or grid pattern (302 eyes). Eligibility criteria for this retrospective study included a diagnosis of clinically significant macular edema according to the ETDRS scale. The baseline examination for all patients presented in this review included: the best corrected visual acuity (VA), slit lamp with contact lens indirect ophthalmoscopy, fundus color photography and fluorescein angiography. All patients were treated with argon green by grid with Nidek 2300 laser. Modified grid or focal photocoagulation according to the ETDRS recommendations were performed. Patients with proliferative diabetic retinopathy (PDR) were transferred to panretinal photocoagulation (PRP) after treatment of maculopathy. Development of VA from the baseline to last checkup in treated eyes was reported and compared. Follow-up ranged widely from 6 to 45 months.

RESULTS

General stabilization was achieved in 51.3%, improvement in 10.1% and deterioration in 38.6% of eyes. The best results were achieved after selective and focal and/or modified grid treatment: in the Ist group stabilization of VA was achieved in 43.6% and improvement in 41% of eyes; in the IInd group: stabilization in 60.7% and improvement in 21.4% were stated; in the IIIrd group: stabilization in 49.7% and improvement only in 3.0%. In 164 (38.6%) cases supplemental treatment was administered.

CONCLUSION

Photocoagulation has proved effective in the treatment of diabetic clinically significant macular edema.

[The estimation of L-ascorbic acid serum concentration and selected parameters of metabolism of serum lipids in pregnant women with diabetes]

Diabetes during pregnancy is a pathological state causing many metabolic disorders, not only in carbohydrate metabolism. The aim of the study was to estimate the changes of lipids metabolism and changes of L-ascorbic acid serum concentration in pregnancy complicated by diabetes. In tested groups values of lipids metabolism parameters were lower in diabetic group compared to control group. The lowest mean values of concentration of total cholesterol, LDL cholesterol and triglycerides were found in gestational diabetes group, while the lowest mean value of HDL cholesterol concentration was found in pregestational diabetic group. The L-ascorbic acid mean values correlated negatively with total cholesterol concentrations, LDL cholesterol and triglycerides levels.

Reduced insulin-mediated glucose uptake by euglycemic clamp in offspring of patients with type 2 diabetes

Family studies point to an important genetic element in the genesis of type 2 diabetes. A variety of metabolic abnormalities have been documented in offspring of patients with type 2 diabetes. It has not been shown, however, at what age reduced insulin sensitivity is demonstrable using the sensitive the euglycemic clamp technique. To address this issue we screened 425 consecutive type 2 diabetic patients and examined all available (n = 48) normotensive, normoglycemic, non-smoking offspring (mean age 31.4+/-0.9 years) and compared them to 22 healthy offspring of non-diabetic parents (controls). The two groups were of similar age and BMI. Measurements in offspring and controls included baseline IRI, tissue glucose uptake (TGU, using euglycemic hyperinsulinemic clamp technique), and 24 hour ambulatory blood pressure (ABP). TGU was significantly (p < 0.001) lower in offspring of diabetic parents (338.8+/-19.9 (mol/kg/min) when compared to controls (516.6+/-22.2 micromol/kg/min). 24 h systolic ABP was significantly higher (p < 0.02) in propositi compared to controls (121.2+/-2.2 mm Hg and 113.8+/-1.7 mm Hg, respectively). No difference in triglycerides concentration was found. A borderline negative correlation was observed, however, between triglyceride levels and TGU (R = -0.48, p < 0.001). TGU was not related to the presence or absence of diabetic nephropathy in the parents. We conclude: Insulin resistance and various facets of the metabolic syndrome are demonstrable even at age 30 years in young non-obese, normotensive offspring of patients with type 2 diabetes. These disturbances are not related to the presence of microvascular complications in parents.

[Insulin resistance in offspring of type 2 diabetic patients]

Diabetes mellitus is the disease with heterogeneous aetiology. Among the causes of hyperglycaemia the insulin resistance with it's genetical background is mentioned. The aim of the study was the assessment of insulin resistance in healthy offspring of type 2 diabetic patients as well as assessment whether the coexistence of nephropathy in parents has an impact on insulin resistance in offspring. 56 subjects with positive familial history of diabetes type 2 divided into 2 groups were admitted. Subgroup A1 30 subjects (mean age 33.0 +/- 8.5 years) consisted of those who had familial history of diabetes without nephropathy and subgroup A2 26 subjects (mean age 33.0 +/- 6.5 years) with familial history of diabetic nephropathy. Control group consisted of 30 healthy volunteers without familial history. Euglycemic hyperinsulinemic clamp test was performed in all subjects studied. Tissue glucose uptake (TGU) was significantly lower while fasting insulinemia In0 was significantly higher in A1 and A2 groups when compared to controls (respectively TGU 5.6 +/- 2.2, 6.3 +/- 2.5 and 9.5 +/- 2.2 mg/kg/min p < 0.005, In0 19.4 +/- 8.3, 20.8 +/- 8.9 and 11.4 +/- 6.0 p < 0.001). No differences in TGU and In0 when compared A1 vs. A2 group were found. In-depth analysis did not show any differences in relation on whether diabetes was inherited from father's or mother's side. It was also shown that BMI did not interfere on insulin resistance in patients with positive familial history of diabetes. We conclude that insulin resistance has the genetical background and that insulin resistance and nephropathy are inherited separately.

[Microangiopathic complications in type 2 diabetes]

The current knowledge concerning macroangiopathic complications of type 2 diabetes was presented in the review. The prevalence of atherosclerosis in coexistence with diabetes was indicated as well as the factors involved in the increased progression of the complication. The clinical differences in the course of particular types of atherosclerosis were described. The risk factors of atherosclerosis and the potential possibilities of the prevention were also analyzed.

A polymorphism in the gene for the atrial natriuretic peptide and diabetic nephropathy. Diabetic Nephropathy Study Group

BACKGROUND

Atrial natriuretic peptide is involved in blood pressure regulation via its vasodilating and natriuretic actions. Since diabetic nephropathy and hypertension are closely related, ANP is a reasonable candidate gene for diabetic nephropathy (DN).

METHODS

We genotyped 410 patients with type I diabetes (without DN n = 307; with DN n = 103) and 658 patients with type II diabetes (without DN n = 464; with DN n = 194). In the patients the duration of diabetes was at least 10 years. Diabetic nephropathy was defined as urinary albumin excretion of > or = 30 mg/24 h. The HpaII polymorphism in intron 2 of the ANP gene was determined using PCR amplification followed by restriction digest. Alleles were separated on agarose gels stained with ethidium bromide.

RESULTS

We compared genotype distribution and allele frequencies between patients with and without nephropathy. No significant difference was observed either in type I (allele frequency without DN H1, 0.02/H2, 0.98 vs with DN H1, 0.05/H2, 0.95; P = 0.132) or in type II diabetes (allele frequency without DN H1, 0.04/H2, 0.96 vs with DN H1, 0.05/H2, 0.95; P = 0.551).

CONCLUSIONS

The polymorphism in the gene for the atrial natriuretic peptide does not seem to play a major role in the development of diabetic nephropathy in either type I or in type II diabetes.

Pathogenesis and course of renal disease in IDDM/NIDDM: differences and similarities

In the past the opinion prevailed that renal prognosis was less adverse in non-insulin-dependent diabetes mellitus (NIDDM) as compared with insulin-dependent diabetes mellitus (IDDM). This notion has to be revised in the light of recent evidence, based on epidemiologic data of NIDDM patients reaching endstage renal failure and a comparison of the cumulative prevalence of proteinuria and renal failure, respectively, in NIDDM as compared with IDDM. It has also been established that initial renal hemodynamic changes are quite comparable in NIDDM and in IDDM. It follows that past complacency about the renal sequelae of NIDDM is no longer justified and that preventive measures to interfere with the development of diabetic nephropathy are similarly important in NIDDM and IDDM.

[Nephropathy and hypertension in type II diabetes]

BACKGROUND

In Germany nephropathy in patients with type II diabetes has become the most frequent single cause of uremia requiring renal replacement therapy. This calls for effective measures of prevention.

DIABETIC NEPHROPATHY AND HYPERTENSION

In patients with established diabetic nephropathy, hypertension is the most important pathogenetic factor which is susceptible to therapeutic intervention. Some pathogenetic mechanisms are discussed which impact on antihypertensive therapy. Interaction between hypertension and diabetic nephropathy is analyzed.

CONCLUSION

Diabetic nephropathy in patients with type II diabetes has become the most frequent cause of endstage renal failure in Germany. Preventive measures, i. e. near normal glycemia and particularly antihypertensive treatment, have been proven to interfere with progression of renal failure in diabetic nephropathy. Early recognition is possible by testing for urinary albumin (microalbuminuria). In patients with diabetic nephropathy, blood pressure should be lowered to values well within the range of normotension by dietary salt restriction and antihypertensive drug therapy.

Nephropathy of type II diabetes: evidence for hereditary factors?

Family studies point to an important genetic element in the genesis of diabetic nephropathy, but it is not known whether renal abnormalities are present prior to the onset of diabetes. To address this issue we examined all consecutive patients suffering from type II diabetes with a duration of more than 10 years who attended a diabetes outpatient clinic. Ninety-four patients had nephropathy, 307 did not. All offspring who were phenotypically normal (no hypertension, normal oral glucose tolerance, non-smoking) and agreed to participate were examined, 26 from nephropathic and 30 from non-nephropathic diabetic parents. They were compared with 30 offspring matched for age, gender and BMI from non-diabetic parents as controls. We measured urinary albumin excretion under baseline conditions and at several time points after ingestion of 300 g cooked beef and submaximal treadmill exercise, respectively. In addition, casual blood pressure, ambulatory blood pressure, urinary albumin and urinary alpha-1-microglobulin were measured. Primary renal disease was excluded by clinical examination. Under baseline conditions, median urinary albumin excretion rate (AER; microgram/min) was significantly (P < 0.005) higher in offspring of nephropathic type II diabetic patients (7.8; range 1.04 to 19.5) than in the offspring of non-nephropathic type II diabetic patients (4.8; 0.36 to 17.5) and controls (4.4; 0.16 to 18.4). Submaximal treadmill exercise caused a greater proportional increase of AER in offspring of nephropathic type II diabetics (median 16-fold) than in offspring of non-nephropathic diabetic patients (6.3-fold) or controls (4.8-fold). In offspring of nephropathic diabetic patients casual and particularly ambulatory systolic blood pressures were significantly higher, but AER was not correlated with blood pressure. In summary, higher values, albeit within the normal range, for baseline and postexercise albuminuria were noted in phenotypically normal offspring of parents with type II diabetes and nephropathy. The observation suggests that changes in transglomerular albumin traffic are demonstrable prior to the onset of diabetes and diabetic nephropathy in subjects with a potential genetic predisposition to these conditions.

Excess of DD homozygotes in haemodialysed patients with type II diabetes. The Diabetic Nephropathy Study Group

The role of the insertion/deletion polymorphism of the angiotensin-converting enzyme (ACE) gene in the genesis of diabetic nephropathy has been controversial. It has recently been proposed that progression occurs more rapidly in individuals with diabetic and non-diabetic renal disease who are homozygous for the D allele. We studied 658 patients with type II diabetes, 347 without diabetic nephropathy and 311 with various stages of diabetic nephropathy, and determined the I/D polymorphism of the ACE gene. Patients at the extremes of renal risk, i.e. normotensive patients without antihypertensive treatment and without nephropathy (n = 144), vs patients on dialysis (n = 61), differed with respect to genotype (DD 36.8% vs 57.4%; P = 0.007) and allele frequencies (D 0.59 vs 0.76; P < 0.001). In contrast, patients with and without presumed nephropathy as assessed by albuminuria did not differ with respect to DD genotype. In conclusion, in this study, which was limited by sample size, patients with the highest renal risk more frequently had the DD genotype. This would be compatible with a greater risk of (or rate of) progression to end-stage renal failure.

Risk factors for development of diabetic nephropathy: a review

Recently evidence has accumulated that diabetic nephropathy clusters in families, both in insulin-dependent (IDDM) and non-insulin-dependent (NIDDM) diabetic patients. Furthermore, hypertension and cardiovascular accidents are found more frequently in families of NIDDM with diabetic nephropathy. Some observations in offspring of NIDDM patients with diabetic nephropathy point to high urinary albumin excretion and slightly greater blood pressure values, both within the normal range compared to offspring of patients without diabetic nephropathy. Further follow-up is required to assess whether these findings are indicative of a possible genetic predisposition to diabetic nephropathy.

Angiotensinogen gene M235T polymorphism is not associated with diabetic nephropathy. The Diabetic Nephropathy Study Group

BACKGROUND

There is agreement that a family history of hypertension (HT), is a predictor for the risk of diabetic nephropathy (DN) in patients with type 2 diabetes, and possibly also type 1 diabetes. It follows that genes related to the risk of hypertension must also be considered candidate genes for DN. The 235T allele of the angiotensinogen gene was found to be related to primary HT.

METHODS

To examine whether it is predictive for DN as well, we examined the angiotensinogen gene polymorphism in 230 healthy local controls, 423 patients with type 1 diabetes (n = 180 with DN; n = 243 without DN) and 663 patients with type 2 diabetes (n = 310 with DN; n = 353 without DN). The angiotensinogen gene M235T polymorphism was determined using PCR amplification.

RESULTS

The following results were obtained (i) no significant difference of genotype distribution (type 1: MM/MT/TT (%) 27.6/57.2/15.2 vs 27.2/56.1/16.7 (P = 0.92); type 2; MM/MT/TT (%) 31.7/48.2/2/20.1 vs. 32.9/46.8/20.3 (P = 0.93) or allele frequencies (type 1: M 0.56 vs. 0.55 (P = 0.795); type 2; M 0.56 vs. 0.56 (P = 0.86)) was found, between diabetic patients with or without DN, (ii) no difference was found between normotensive and hypertensive diabetic patients.

CONCLUSION

The data argue against a role of the angiotensinogen gene M235T polymorphism in the manifestation of diabetic nephropathy or hypertension in diabetic patients.

[Albumin excretion with urine in a population of healthy individuals]

Increased urine albumin excretion is the significant prognostic factor for diabetes, hypertension and coronary artery disease. Divergences of the evaluation of albuminuria in different ethnic groups were found. The aim of our study was to evaluate albumin excretion in large group of healthy individuals. 301 healthy subjects (110 female and 191 male), age 20-60 years (mean 32.9 +/- 9.7), were admitted. A questionnaire including data concerning familial history, smoking habits was fulfilled. Subsequently nighttime urine sample was collected in all examined subjects and albumin to creatinine ratio (A/K) was counted. A/K value varied between 0.03-14.1 mg/mmol of creatinine median 1.18. Significantly higher albuminuria in female v male group was found (respectively 1.39; 0.14-14.1 and 1.03; 0.03-11.4 p < 0.05). Reference value for albuminuria was estimated at 3.35 mg/mmol in whole group, and respectively 4 mg/mmol in female and 2.6 mg/mmol in male. There were not differences in A/K ratio in relation to familial history however smoking men excreted more albumin v non smoking (respectively 1.27, 0.03-11.4 and 0.95, 0.14-14.1 mg/mmol p < 0.005). Performed analysis allowed to calculate the value for albuminuria in healthy subjects. Analysis also showed significant influence of gender and smoking habits and no influence of familial history for albumin excretion.

Increased prevalence of salt sensitivity of blood pressure in IDDM with and without microalbuminuria

In insulin-dependent diabetes mellitus (IDDM) elevated exchangeable sodium (Na) levels are found even in the absence of hypertension, but it is not known whether this is associated with increased sensitivity of blood pressure to sodium level. To clarify this issue we compared 30 patients with IDDM (19 without and 11 with microalbuminuria, i.e. more than 30 mg albumin/day) and 30 control subjects matched for age, gender and body mass index. The subjects were studied on the 4th day of a low-salt diet (20 mmol/day) under in-patient conditions and were subsequently changed to the same diet with a high-salt supplement, yielding a total daily intake of 220 mmol Na/day. Circadian blood pressure, plasma renin activity (PRA), plasma atrial natriuretic factor (p-ANF), plasma cyclic guanosine 5'-phosphate (p-cGMP) and urinary albumin were measured. The proportion of salt-sensitive subjects, i.e. showing increment of mean arterial pressure > or = 3 mmHg on high-salt diet, was 43% in diabetic patients (50% of diabetic patients with and 37% without microalbuminuria) and 17% in control subjects (p < 0.05). Lying and standing PRA levels on low- or high-salt diet were significantly lower in diabetic patients than in control subjects. Salt-sensitive diabetic patients had significantly higher lying ANF on high-salt (38.7 +/- 4.2 pmol/l vs 20.1 +/- 2.3 pmol/l, p < 0.005) than on low-salt diet. The results suggest that (i) the prevalence of sodium sensitivity is high in IDDM (ii) sodium sensitivity is found even in the absence of nephropathy as indicated by albuminuria.

[Use of fructosamine serum level measurements for diagnosis of insulin-dependent diabetic in pregnancy]

In this study it has been tested the usefulness of serum glycosyl protein (fructosamine) to diagnose diabetic pregnant women requiring insulin therapy. The analysis was performed on the base of obtained results of glucose tolerance test, glycemia level in diurnal profile, fructosamine level and its relationship to albumin level and total protein amount in serum pregnant women with carbohydrates intolerance. Calculated specificity and sensitivity of above mentioned measurements was too low. We can not concluded that it is necessary to include insulin-therapy in diabetic pregnancy on the base of fructosamine serum level even corrected by protein or albumin serum level.

[Does an association between angiotensin I converting enzyme gene polymorphism and the prevalence of diabetic nephropathy in patients with diabetes type II exist?]

In type I diabetic patients association has been found between the insertion/deletion (I/D) polymorphism in the gene of angiotensin converting enzyme and the presence of diabetic nephropathy. The aim of that study was to assess this association in a cohort of type II diabetics. We examined 109 patients of more than 10 years duration of type II diabetes. Nephropathy (defined as at least confirmed albuminuria > 30 mg/24h) was present in 37 subjects. The I/D polymorphism was analyzed with PCR technique. Allele frequencies in the overall diabetic population did not differ significantly from the normal population. Distribution of genotypes was not significantly different between examined patients with and those without nephropathy. We conclude that the distribution of ACE gene polymorphism is similar in diabetic subjects and in general population and there is not association between I/D polymorphism and nephropathy in type II diabetic patients.

[Activity of the renin-angiotensin-aldosterone system in euglycemic type I diabetic patients on intensive insulin treatment without diabetic neuropathy]

Arterial hypertension increase progression of late diabetic complications. Renin-angiotensin-aldosterone system plays an important role in the regulation of arterial pressure. The aim of the study was the assessment of plasma renin activity (PRA) and aldosterone (aldo) in type I euglycaemic diabetic patients on intensive insulin treatment without autonomic neuropathy. 30 type I diabetic patients (including 11 with nephropathy defined as urinary albumin excretion > 30 mg/24 h and 19 without albuminuria) were admitted into the trial. Mean age 31.9 + 1.4 years, duration time of disease was 9.1 + 1.5 years, HbA1c level 7.6 + 0.25%; GFR 124.7 + 3.9 ml/min/1.73 m2 (135.8 + 5.1 in subgroup with nephropathy and 118.2 + 5.08 in non-nephropathic group). Blood samples were taken during normal sodium intake (120 mmol/24 h) after 0.5 h supine. PRA was significantly lower in type I diabetics vs control (0.27 + 0.04, 0.61 + 0.09 pmol/l/s respectively-p < 0.005). PRA was significantly lower both in nephropathic and non-nephropathic diabetic group vs control (respectively 0.22 + 0.06 and 0.31 + 0.05-p < 0.05). Aldo in diabetic patients and in subgroups with and without nephropathy was significantly lower vs controls (respectively 173 + 12.9, 165.1 + 14.4, 182.1 + 18.8 and 257.1 + 24.1 pmol/l; p < 0.01, p < 0.05). Significant differences in hormonal changes between diabetic patients with and without nephropathy were not found. Basing upon the results we conclude that in euglycemic intensively insulin treated type I diabetic patients without neuropathy presented decreased level of PRA and aldo. Early stage of diabetic nephropathy does not influence the examined hormones level.

[Effect of health resort treatment on the circadian rhythm of follicle-stimulating hormone (FSH), lutropin (LH), and testosterone in male patients with diabetes mellitus]

In diabetic patients disturbances of pituitary-gonadal axis are observed. The aim of the study was to investigate whether in male diabetic patients the circadian rhythms of FSH, LH and testosterone are maintained normal and whether the treatment in a health resort affects the circadian rhythms of investigated hormones. The study regards 5 male patients with insulin dependent diabetes mellitus type I and in 10 male patients with diabetes mellitus type II. In order to assess the circadian rhythm serum FSH, LH and testosterone were determined four times a day at 6.00, 12.00, 18.00 and 24.00. Serum concentration of FSH and LH was determined by LIA and testosterone by RIA. The investigation was done twice: on the third day of a health resort treatment and then on the 23rd day of the treatment. The results were analysed using the Cosinor test. It has been shown that the circadian rhythm of LH, FSH and testosterone is maintained in diabetic patients. During the health resort treatment the midline value (mesor) of serum concentration and the amplitude of of circadian rhythms of LH and testosterone increased in diabetic patients, whereas the FSH circadian rhythm did not change. During the health resort treatment a significant change of testosterone circadian rhythm acrophase from 7.32 to 5.16 was observed in diabetic patients.

Platelet aggregation in IgE-mediated allergy with elevated soluble Fc epsilon RII/CD23 level

In 25 house dust mite-sensitive patients with perennial allergic rhinitis, an analysis of platelet aggregation tests (dual-channel aggregometer, Chronolog Corp, 345 model) induced by adenosine diphosphate (ADP) was carried out. The levels of total serum IgE specific antibodies against Dermatophagoides pteronyssinus and the soluble form of the low affinity IgE receptor (sFc epsilon RII/sCD23) were estimated as well. The study was carried out in a dynamic state, before and after 2 years of treatment with specific immunotherapy. We observed a significantly diminished platelet aggregation response, which partially improved after treatment. The results of this study suggest that platelet hyporesponsiveness might be involved in the pathogenesis of house dust mite hypersensitivity.

[Myoglobinuria. Clinical aspects]

General data is presented on myoglobin structure and function, the pathomechanism of myoglobinuria and on its main causes. Attention was also paid to the most serious result of massive rhabdomyolysis-acute renal failure, taking into account the mechanism of its development. Apart from traumatic causes of myoglobinuria and myoglobinaemia, where the usefulness of these determinations is unquestionable, certain other diseases were compared in which the determination of the concentration of this haemoprotein is of important practical aspect.

[Retrospective analysis of secondary failure of oral hypoglycemic drugs in patients with diabetes type II]

The analysis of the incidence and risk factors of oral antidiabetic drugs secondary failure (sf) in type II diabetic patients was carried out in the study. The population of 1262 patients who felt into diabetes between 1980 and 1984 year from Zabrze area was analyzed retrospectively. The analysis was done in relation to 1989 year (after 10 year of the observation). In 194 (15%) of patients secondary failure was diagnosed. Sf appeared in 150 (17%) women and 44 (11%) men (p < 0.005). Multi factor analysis confirmed the higher susceptibility of females to the appearance of sf. Analysis also showed that significant risk factor of sf is the diagnosis of diabetes in 6th life decade in the patients with normal body mass. The percentage of sf varied between 5.1% and 19.5%. Performed analysis showed the higher sf incidence in female group and the influence of age at the moment of diagnosis in non obese patient son the appearance of sf.

[Adenosine. Evaluation of diagnostic efficiency and therapeutic use in paroxysmal supraventricular tachycardia]

Paroxysmal supraventricular tachycardias are an important therapeutic problem and belong to the most frequently occurring arrhythmias. On the basis of a literature review the authors describe an alternative method of treatment of these conditions with adenosine and point also to its additional applications. The diagnostic use of adenosine and its safety in rhythmic undefined tachycardias with broad ventricular complexes is a therapeutic model worth of popularization.

[Does hypoglycemic treatment with gliclazide and gliquidone affect platelet function in type II diabetic patients?]

The estimation of the influence of gliclazide and gliquidone treatment on platelet function in type II diabetic patients was undertaken in the study. Aggregation parameters were assessed before and after the change of hypoglycemic therapy. Gliclazide was applied in the group I (11 patients, mean age 63.1 +/- 7.22 years, duration of diabetes 5.63 +/- 2.98 years), group II (19 patients, mean age 58.3 +/- 12.4 years, duration of diabetes 7.1 +/- 2.4) received gliquidone. The reference group consisted of 10 healthy volunteers (mean age 51.7 +/- 6.9). Aggregation parameters (threshold ADP concentration, intensity and velocity of the aggregation) were measured in examined groups of subjects. Metabolic control was estimated basing upon spectrophotometric measurement of fructosamine level. Significant increase in threshold ADP concentration (1.89 +/- 0.47 mumol/l before and 2.36 +/- 0.58 mumol/l after the treatment change p < 0.05) in group II was found. Threshold ADP concentration did not change significantly in group I (2.5 +/- 0.8 mumol/l before v 2.14 +/- 0.68 mumol/l after treatment). Significant decrease in the aggregation intensity was found in both groups (in group I 8.48 +/- 1.7 before v 6.39 +/- 2.17 after; in group II 7.35 +/- 1.73 before v 6.05 +/- 1.6 after 1 month treatment--both p < 0.05). The aggregation velocity did not change significantly (group I 61. +/- 11 before v 51.3 +/- 18.7 after, group II 63.2 +/- 14.8 and 62.8 +/- 13.7 respectively). Reference group values were ADP 2.7 +/- 0.16, intensity 6.22 +/- 0.53, velocity 63.2 +/- 2.2.(ABSTRACT TRUNCATED AT 250 WORDS)

[Method of treatment and platelet aggregation in patients with diabetes mellitus type II]

Platelet aggregation after ADP administration in 84 diabetic patients and in 14 healthy subjects were examined. ADP concentration indispensable to start aggregation, velocity and intensivity of this process using Born method were measured. In diabetic patients (independently of kind of therapy) the increase platelet aggregation activity were found (significant difference between kind of insulin therapy).

Pulmonary complications of type 1 (insulin-dependent) diabetic patients

We have investigated the influence of diabetes mellitus including the presence of late complications of the pulmonary system. To check this relationship 31 Type 1 (insulin-dependent) diabetic patients (mean age 30.6 +/- 5.32 years, mean duration of diabetes 12.9 +/- 5.05 years) were admitted into the trial and compared with 18 control subjects. Pulmonary function tests were measured including spirometric parameters, diffusing capacity, specific diffusing capacity and dynamic compliance measured at 20 and 60 breaths per min. No disturbance of the spirometric parameters was observed in the diabetic patients. Diffusing capacity in the diabetic patients with complications was significantly lower than in both the diabetic patients without complications and the control group (81.2 +/- 16.2%, 104 +/- 13.7%, 99.3 +/- 2.8%; p < 0.001, p < 0.005 respectively). Specific diffusing capacity was significantly lower in the diabetic patients than in the control subjects (80.3 +/- 13.1% vs 89.4 +/- 12.9%; p < 0.05). In the group with late complications specific diffusing capacity was lower than in the group without complications (69.7 +/- 9.17%; 87.2 +/- 10.7%, respectively; p < 0.001). Dynamic compliance at 20 breaths per min in diabetic patients was 84.06 +/- 17.08% vs 95.2 +/- 11.59% in the control subjects (p < 0.05). It was particularly low in the group with late complications 80.6 +/- 13.2% and patients with metabolic poor control, 80.3 +/- 12.02% (both p < 0.005 vs the control group). Dynamic compliance at 60 breaths per min was 60.1 +/- 15.0% as compared to 83.2 +/- 13.3% in the control group (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of determining fructosamine levels in serum of pregnant patients with diabetes to evaluate the level of compensation for glycemia]

The results in 16 pregnant women with diabetes mellitus are analysed. All patients were treated with an intensive insulin-therapy at the Voivodeship Clinic for Diabetic Patients in Zabrze. Multipoint glycaemia profiles made by the treated patients as a self control were compared with serum fructosamine and HbAlC concentrations. A significant correlation of fructosamine levels with glycaemia and HbAlC levels was noted. No significant dependence of fructosamine and glycaemia fasting levels, incidence of hyperglycaemia and Schlichtkrull's Mw index was noted. Results suggest, that the fructosamine serum concentration is a useful marker of metabolic compensation in pregnant women with diabetes mellitus. It enables less frequent performance of the daily profiles of glycaemia by the patients.

[A proposed model of the treatment of diabetes mellitus in pregnancy]

A model of management of pregnant diabetic patients is proposed. Such a model has been implemented at the Voivodeship Out-patient Clinic for Diabetics. Proposed model includes recent data on diabetes mellitus complications and the effect of coexisting diseases on the mother and fetus health. Management was adapted to the real and potential possibilities of health service in Poland. A decrease in the rate of mortality of fetuses under 7% was achieved. It is worth emphasizing despite higher value than those reported in the literature.