Patricia Gatcomb

Sexual Dysfunction in Women With Type 1 Diabetes: Long-term findings from the DCCT/ EDIC study cohort

OBJECTIVE This study aimed to investigate the prevalence and risk factors associated with sexual dysfunction in a well-characterized cohort of women with type 1 diabetes. RESEARCH DESIGN AND METHODS The study was conducted in women enrolled in the long-term Epidemiology of Diabetes Interventions and Complications (EDIC) study, a North American study of men and women with type 1 diabetes. At year 10 of the EDIC study, 652 female participants were invited to complete a validated self-report measure of sexual function, standardized history and physical examinations, laboratory testing, and mood assessment. RESULTS Of the sexually active women with type 1 diabetes in the EDIC study, 35% met criteria for female sexual dysfunction (FSD). Women with FSD reported loss of libido (57%); problems with orgasm (51%), lubrication (47%), and arousal (38%); and pain (21%). Univariate analyses revealed a positive association between FSD and age (P = 0.0041), marital status (P = 0.0016), menopausal status (P = 0.0019), microvasculopathy (P = 0.0092), and depression (P = 0.0022). However, in a multivariate analysis, only depression (P = 0.004) and marital status (P = 0.003) were significant predictors of FSD. CONCLUSIONS FSD is common in women with type 1 diabetes and affects all aspects of sexual function and satisfaction. Depression is the major predictor of sexual dysfunction in women with type 1 diabetes. These findings suggest that women with type 1 diabetes should be routinely queried about the presence of sexual dysfunction and possible co-association with depression.

Clinical implications of amylin and amylin deficiency.

PURPOSE this paper presents an overview of the physiology of glycemic control and the mechanisms of amylin deficiency in people with diabetes. Benefits of replacement therapy with both pramlintide and insulin are discussed. METHODS The discovery of the pancreatic p-cell hormone amylin, which is cosecreted with insulin in response to hyperglycemia, has prompted a reanalysis of the mechanisms underlying the control of glucose homeostasis. A review of the current literature on amylin and amylin deficiency provides the basis of this reanalysis, with a discussion of the clinical implications for people with diabetes. RESULTS Amylin appears to work with insulin to regulate plasma glucose concentrations in the bloodstream, suppressing the postprandial secretion of glucagon and restraining the rate of gastric emptying. People with diabetes have a deficiency in the secretion of amylin that parallels the deficiency in insulin secretion, resulting in an excessive inflow of glucose into the bloodstream during the postprandial period. CONCLUSIONS While insulin replacement therapy is a cornerstone of diabetes treatment, replacement of the function of both amylin and insulin may allow a more complete restoration of the normal physiology of glucose control.

Exaggerated Hyperglycemia After A Pizza Meal in Well-Controlled Diabetes

OBJECTIVE To examine whether the postprandial hyperglycemic effect of pizza in well-controlled IDDM patients is related to overeating or to unique properties of this popular food. RESEARCH DESIGN AND METHODS On two evenings, each patient (n = 8) consumed a meal that was similar in macronutrient composition except that one consisted of pizza and the other was a control meal that included high glycemic index foods. The insulin regimen was held constant. RESULTS Postprandial glucose levels were within the target range (< or = 10 mM) after the control meal. Although the initial glucose increase was similar for the two meals, plasma glucose continued to rise and was significantly increased from 4 to 9 h after ingestion of pizza compared with the control meal (P < 0.05). This increase occurred even though free insulin, glucagon, and free fatty acid levels did not differ significantly. CONCLUSIONS Our data suggest that pizza has properties that accentuate and sustain postprandial hyperglycemia.

Musculoskeletal Complications in Type 1 Diabetes

OBJECTIVE The development of periarticular thickening of skin on the hands and limited joint mobility (cheiroarthropathy) is associated with diabetes and can lead to significant disability. The objective of this study was to describe the prevalence of cheiroarthropathy in the well-characterized Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) cohort and examine associated risk factors, microvascular complications, and the effect of former DCCT therapy (intensive [INT] vs. conventional [CONV]) on its development. RESEARCH DESIGN AND METHODS This cross-sectional analysis was performed in 1,217 participants (95% of the active cohort) in EDIC years 18/19 after an average of 24 years of follow-up. Cheiroarthropathy—defined as the presence of any one of the following: adhesive capsulitis, carpal tunnel syndrome, flexor tenosynovitis, Dupuytrens contracture, or a positive prayer sign—was assessed using a targeted medical history and standardized physical examination. A self-administered questionnaire (Disabilities of the Arm, Shoulder and Hand [DASH]) assessed functional disability. RESULTS Cheiroarthropathy was present in 66% of subjects (64% of the INT group and 68% of the CONV group; P = 0.1640) and was associated with age, sex, diabetes duration, skin intrinsic fluorescence, HbA1c, neuropathy, and retinopathy (P < 0.005 for each). DASH functional disability scores were worse among subjects with cheiroarthropathy (P < 0.0001). CONCLUSIONS Cheiroarthropathy is common in people with type 1 diabetes of long duration (∼30 years) and is related to longer duration and higher levels of glycemia. Clinicians should include cheiroarthropathy in their routine history and physical examination of patients with type 1 diabetes because it causes clinically significant functional disability.

Risk Factors for Urinary Incontinence Among Women With Type 1 Diabetes: Findings From the Epidemiology of Diabetes Interventions and Complications Study

OBJECTIVES To determine risk factors for, and long-term effects of, glycemic control on urinary incontinence among women with type 1 diabetes enrolled in the Epidemiology of Diabetes Interventions and Complications study. METHODS The Diabetes Control and Complications Trial (1982-1993) cohort follow-up, Epidemiology of Diabetes Interventions and Complications trial, began in 1994. In 2004, the female participants (n = 550) completed a self-administered questionnaire on incontinence. Our primary outcome was weekly or greater incontinence, overall and by type. Multivariate regression models were used to determine independent predictors of weekly urinary incontinence, both overall and by type. RESULTS Overall, 38% of women reported any incontinence and 17% reported weekly or greater incontinence. An increasing body mass index (odds ratio 1.1, 95% confidence interval 1.1-1.2) was significantly associated with weekly incontinence, overall and by type. Advancing age and >/=2 urinary tract infections in the previous year were associated with weekly urge incontinence (odds ratio 1.4, 95% confidence interval 1.0-2.0 per 5 years, and odds ratio 4.9, 95% confidence interval 1.8-13.5, respectively). Weaker evidence was seen for increased risk with age for overall weekly incontinence (22% per 5 years, P = .06) and stress incontinence (21% per 5 years, P = .08). CONCLUSIONS Urinary incontinence is common among women with type 1 diabetes and the risk factors, including advancing age, increased weight, and previous urinary tract infection, are important. Weight reduction and the treatment of urinary tract infections might have the additional benefit of preventing incontinence or reducing its severity.

Urinary Incontinence Among Women With Type 1 Diabetes—How Common is it?

PURPOSE We compared the prevalence, level of bother and effect on daily activities of urinary incontinence among women with type 1 diabetes enrolled in the Epidemiology of Diabetes Interventions and Complications study to a population based sample of women with normal glucose. MATERIALS AND METHODS We performed a cross-sectional analysis of women with type 1 diabetes and normal glucose tolerance using 2 study populations. The Diabetes Control and Complications Trial cohort followup, Epidemiology of Diabetes Interventions and Complications, began in 1994. In 2004 women participants (550) completed a self-administered questionnaire on urinary incontinence. Our primary outcome was weekly or greater incontinence, overall and by type. Prevalence of urinary incontinence was compared to a subgroup of women with normal glucose in the 2001 to 2002 National Health and Nutrition Examination Survey (NHANES). RESULTS Overall 65% of women with type 1 diabetes reported any urinary incontinence (17% reported weekly incontinence). Nearly 40% of these women were greatly bothered by their incontinence and 9% believed it affected their day-to-day activities. Women with type 1 diabetes had a nearly 2-fold greater prevalence of weekly urge incontinence compared to those without diabetes in the NHANES cohort (8.8% vs 4.5%, p = 0.01). CONCLUSIONS Urinary incontinence is common in women with type 1 diabetes and the prevalence of weekly urge incontinence is far greater compared to that in women with normal glucose levels. Moreover, the prevalence of urinary incontinence in women with type 1 diabetes was greater than that of neuropathy, retinopathy and nephropathy. These findings highlight the importance of screening for urinary incontinence among women with type 1 diabetes. Studies examining factors associated with urinary incontinence in women with type 1 diabetes are warranted.

Vacuum-Assisted Lancing of the Forearm: An Effective and Less Painful Approach to Blood Glucose Monitoring

A vacuum-lancet device was applied to the forearm for the purpose of obtaining capillary blood samples for glucose monitoring with minimal pain. In four clinical trials, a total of 215 individuals aged 12-77 years were tested four times using standard conditions and four times with either a different depth of lancing, different brand of lancet or a larger-sized device. The volume of blood collected using one-half atmosphere of vacuum in 40 sec was measured. The sensation and visual appearance of each lancet puncture on the forearm was recorded. Glucose was measured in forearm and in conventional fingerstick blood samples. The distribution of volumes was skewed to higher values with median values for each trial in the range of 3-10 microL. Ninety-five percent of the lancet sticks were judged as less painful than a fingerstick. Redness and bruising around the lanced sites were noted in some patients but disappeared within a few days. Overall correlation of the forearm versus fingerstick glucose values was 0.96. The vacuum-lancet device was very successful in obtaining capillary blood samples for glucose testing in a relatively painless manner. Incorporation of a glucose measuring system into the device might improve testing compliance among those who fear pain or the sight of blood.

Effect of Glycemic Treatment and Microvascular Complications on Menopause in Women with Type 1 Diabetes in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Cohort

OBJECTIVE We examined the impact of intensive versus conventional diabetes treatment upon menopause among women with type 1 diabetes in the Diabetes Control and Complications Trial (DCCT), a randomized controlled trial of intensive diabetes treatment, and its observational follow-up, the Epidemiology of Diabetes Interventions and Complications (EDIC) study. RESEARCH DESIGN AND METHODS In a secondary analysis of women in the DCCT/EDIC (n = 657), outcomes were the cumulative incidences of natural menopause and surgical menopause. Cox regression analyses were used to examine associations with treatment group, time-varying estimates of hemoglobin A1c (HbA1c), insulin dosage, BMI, and microvascular complications (retinopathy, nephropathy, and neuropathy). RESULTS By EDIC year 18, after an average of 28 years of follow-up, 240 (38%) women had experienced natural menopause and 115 (18%) women had experienced surgical menopause. Age at natural menopause was similar in the intensive versus conventional groups (49.9 vs. 49.0 years; P = 0.28), and age at surgical menopause was similar in the intensive versus conventional groups (40.8 vs. 42.0 years; P = 0.31). In multivariable models, treatment group, HbA1c, and microvascular complications were not associated with risk of natural or surgical menopause. Each 10 unit/day increase in insulin dosage decreased risk of natural menopause (hazard ratio [HR] 0.91, 95% CI 0.75–0.98) and each kg/m2 increase in BMI increased risk of surgical menopause (HR 1.08, 95% CI 1.00–1.16). CONCLUSIONS In the DCCT/EDIC, intensive versus conventional treatment group and HbA1c level were not associated with menopause risk. Greater insulin dose was associated with lower menopause risk.

Prevalence of low testosterone and predisposing risk factors in men with type 1 diabetes mellitus: Findings from the DCCT/EDIC

CONTEXT Previous studies have demonstrated lower testosterone concentrations in men with type 2 diabetes mellitus. Data in men with type 1 diabetes mellitus (T1DM) are limited. OBJECTIVE Our objective was to determine the prevalence of low testosterone in men with T1DM and identify predisposing factors. DESIGN, SETTING, AND PARTICIPANTS This was a cross-sectional study of men with T1DM participating in UroEDIC (n = 641), an ancillary study of urologic complications in the Epidemiology of Diabetes Interventions and Complications (EDIC). MAIN OUTCOME MEASURES Total serum testosterone levels were measured using mass spectrometry, and SHBG levels were measured using sandwich immunoassay on samples from EDIC year 17/18. Calculated free testosterone was determined using an algorithm incorporating binding constants for albumin and SHBG. Low testosterone was defined as total testosterone <300 mg/dL. Multivariate regression models were used to compare age, body mass index, factors related to diabetes treatment and control, and diabetic complications with testosterone levels. RESULTS Mean age was 51 years. Sixty-one men (9.5%) had testosterone <300 mg/dL. Decreased testosterone was significantly associated with obesity (P < .01), older age (P < .01) and decreased SHBG (P < .001). Insulin dose was inversely associated with calculated free testosterone (P = .02). Hypertension retained a significant adjusted association with lower testosterone (P = .05). There was no observed significant relationship between lower testosterone and nephropathy, peripheral neuropathy, and autonomic neuropathy measures. CONCLUSION The men with T1DM in the EDIC cohort do not appear to have a high prevalence of androgen deficiency. Risk factors associated with low testosterone levels in this population are similar to the general population.

The Diabetes Control and Complications Trial (DCCT): The Trial Coordinator Perspective Report by the DCCT Research Group

We present an overview of the role of the trial coordinator in the Diabetes Control and Complica tions Trial (DCCT). The DCCT is a multicenter clinical trial designed to examine the effects of two different diabetes treatment regimens on the appearance and progression of the early vascular complications of IDDM. Although the specific responsibilities assumed by the trial coordinators differ from center to center, in general they include adminis tration, recruitment, eligibility testing, and patient management. The trial coordinators role has evolved with the needs of the DCCT, and may serve as a model for other large multicenter trials.