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Apparently the group counseling option represents a best of both worlds option for diabetes patient care. This is important for all the nurse diabetes educators out there and I hope that local facilities will look into implementing this type of research as we continue to look at how we can reduce costs while improving patient outcomes.
Make sure you follow-up on the links for this news item and all of the other news and additional resource links from this week’s episode – Household Product Poisonings and Episode 306.
Looking for something?Use the form below to search the site:Still not finding what you're looking for? Quick Manuscript Submission - The procedure of submitting your manuscript is easy and quick. Testosterone deficiency syndrome (TDS) is a clinical and biochemical syndrome frequently associated with age and co-morbidities and is characterized by deficiency in testosterone and relevant androgen-deficiency symptoms.
Significant progress has been made in the field of medicine for erectile dysfunction (ED) since 1970s.
Testosterone is vital for normal functioning throughout a mana€™s life and a reduced testosterone level could compromise the mana€™s general well-being and his sexual function. Apart from penile erection, testosterone also regulates other aspects of male sexual desire. There is strong evidence that ED is an independent marker for subsequent cardiovascular disease and that the incidence of ED is more common in older patients with higher cardiovascular risks. The clinical presentation of TDS, defined as both low testosterone level and clinically significant symptoms, can be at times nonspecific and often overlooked or under-diagnosed.
Patients with ED, together with other symptoms such as reduced libido, decreased muscle mass and strength, presence of type 2 diabetes mellitus and metabolic syndrome should be screened for TDS (Figure 1).
Physical examination should focus on cognition, neurological, cardiovascular and urological findings. Laboratory diagnosis of testosterone deficiency: The exact pathogenesis of low testosterone remains contentious and several proposed mechanisms include decreased Leydig cell function, age-related increased in sex hormone binding globulin (which binds testosterone and lowers free bioavailable testosterone level), blunted circadian steady state of testosterone and decreased luteinizing hormone (LH) pulse by the hypothalamus [12]. The biochemical diagnosis of TDS is based on the measurement of serum total testosterone (TT), preferably before 11 am, though the diurnal rhythm of testosterone is less marked in men aged over 40 years. While theoretically serum FT is more representative of the biological activity of testosterone, these assays may be more difficult to carry out (especially equilibrium dialysis, the reference method for FT), inaccurate (FT assay by testosterone analogue and a€?Free Androgen Indexa€™), or can only be performed by some laboratories. In the case of low or borderline testosterone value, the assay should be repeated, because of the frequent intra-individual fluctuations of serum testosterone, unless physical evidence of hypogonadism (i.e.
When choosing which TRT to prescribe, primary care physician must exercises good clinical judgment together with adequate knowledge of the advantages and drawbacks of TRT and considers the bioavailability, safety, tolerability, efficacy and preference of each TRT product (Table 1). The effects of TRT may be perceived within 2-4 weeks, but sexual effects may sometimes take 3-6 months to become apparent and even up to 1 year for the nocturnal erections to reach normal range in previously untreated hypogonadal patients [16]. Since the occurrence of any adverse events during therapy (such as an elevated hematocrit or PSA) requires rapid discontinuation of TRT, short-acting preparation is preferred over long-acting depot preparation in the initial treatment of hypogonadal men, but there is no contraindication to start with longer acting preparations. Testosterone & PDE5 Inhibitors in ED: As previously mentioned, testosterone modulates the expression of isoforms of nitric oxide synthase and PDE5 enzyme [19]. At present controversies exist whether men with hypoandrogenism and ED should be treated initially with PDE5 inhibitors, TRT or in combination [16].
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Thankfully, companies aren't just making straight-up gadgets anymore for helping us manage our diabetes.
We're still catching our breath following the American Diabetes Association's huge 76th Scientific Sessions conference in New Orleans, where diabetes tech and treatments and other science took center stage.
This year marks the 17th anniversary of Friends For Life, the annual diabetes fest hosted at the Orlando Disney World Resort by the non-profit Children with Diabetes, with the 2016 event wrapping up last week. Last week, I was able to sit in on a training webinar for CDEs on recognizing and treating depression.
There have been some new items in the news recently around diabetes education and since nurses are most often involved in diabetes education for patients I thought it would be a good idea to look at what’s going on. They wrote about a new study that looks at how 1-on-1 counseling compares to group counseling for education and maintenance of diabetes. Group counseled patients seem to get additional accountability to maintaining their illness better when working in groups. Getting that chronic diabetes patient who always seems to show up in the ER to go to group counseling may be just the trick to keep them out of trouble next time. What are you doing in your facility to help with diabetes education and referrals to counseling for your diabetes patients?
The main physiological action of testosterone in male sexual function is in sexual desire by regulating the timing of the penile erectile with sex. In the past, male sexual dysfunction was thought to be purely psychogenic but increased understanding in the erectile physiology at molecular level has shown that testosterone deficiency plays a major role in sexual dysfunction. Published literature showed that testosterone controls, directly or indirectly, several mechanisms pertinent to penile erectile function such as the promotion and differentiation of penile stem cells to penile smooth muscle cell phenotype, activity of cavernosal nitric oxide synthase and that of RhoA-kinase pathway [1]. While erections are possible in hypogonadal conditions, studies showed that patients with decreasing levels of sexual desire have progressively lower concentrations of testosterone than men who maintain their sexual desire.
The clinical symptoms associated with TDS can be divided into 3 main groups, namely psychosomatic, metabolic and sexual related problems.
The initial assessment of subjects with clinical suspicion of TDS should include a comprehensive evaluation of medical and psychosocial, associated co-morbidities as well as identification of any reversible factors and conditions that could impact on the prescription of testosterone replacement therapy (TRT) such as in subjects with undiagnosed prostate cancer, obstructive sleep apnea and congestive heart failure (Figure 1). In men over the age of 40 years, prior to TRT, the risk of prostate cancer must be assessed and if the digital rectal examination of the prostate gland or prostate specific antigen (PSA) reading is abnormal, further urological assessment should be arranged [10].
Transient decrease in serum testosterone level such as in acute physical illness should be excluded by careful evaluation and repeat testosterone measurement. Furthermore there are no accepted lower limits of free testosterone for the diagnosis of TDS [10].



Hypogonadal men restored to eugonadal state with TRT will experience improvement in sexual functions, particularly erectile, ejaculation, orgasm and penile sensations; and restored or enhanced responsiveness to PDE5 inhibitors [10].
At present the use of gonadotophic hormones such as human chorionic gonadotropin and selective estrogen receptor modulator (such as clomifene citrate) is not recommended except in selected cases of male infertility [18]. Several studies have demonstrated that TDS is associated with a reduced PDE5 inhibitors efficacy [19].
Testosterone and erectile function: from basic research to a new clinical paradigm for managing men with androgen insufficiency and erectile dysfunction. Investigative models in erectile dysfunction: a state-of-the-art review of current animal models.
Autoeroticism, mental health, and organic disturbances in patients with erectile dysfunction.
Hysterical traits are not from the uterus but from the testis: a study in men with sexual dysfunction. Dose-response relationship between testosterone and erectile function: evidence for the existence of a critical threshold. Hypogonadism, ED, metabolic syndrome and obesity: a pathological link supporting cardiovascular diseases.
ANDROTEST: a structured interview for the screening of hypogonadism in patients with sexual dysfunction.
The controversial role of phosphodiesterase type 5 inhibitors in the treatment of premature ejaculation. Testosterone use in men with sexual dysfunction: a systematic review and meta-analysis of randomized placebo-controlled trials.
Improvement of sexual function in men with late-onset hypogonadism treated with testosterone only. Oral testosterone undecanoate reverses erectile dysfunction associated with diabetes mellitus in patients failing on sildenafil citrate therapy alone.
Randomized study of testosterone gel as adjunctive therapy to sildenafil in hypogonadal men with erectile dysfunction who do not respond to sildenafil alone. Oral testosterone undecanoate reverses erectile dysfunction associated with diabetes mellitus in patients failing on sildenafil citrate therapy alone. Randomized study of testosterone gel as adjunctive therapy to sildenafil in hypogonadal men with erectile dysfunction who do not respond to sildenafil alone.
They looked at 75,000 diabetes patients in this study trying to determine if group counseling was not only cost effective but also created better outcomes for the diabetes patients.
Not only did they have better blood sugar labs after the study when in group counseling, but they also had fewer ER visits, fewer hospitalizations related to diabetes, and fewer foot ulcers.
However sexual dysfunction associated with TDS also includes erectile dysfunction (ED) and delayed ejaculation.
Men with low testosterone levels may often be overlooked as the association between testosterone deficiency syndrome (TDS) and its related co-morbidities such as cardiovascular disease and metabolic syndrome is not appreciated and at times, the symptoms and signs of TDS may not be obvious.
More importantly, testosterone also regulates the expression of phosphodiesterase type 5 (PDE5), and in so doing maintains a homeostatic ratio between isoforms of nitric oxide synthase and PDE5 enzyme that is responsible for penile erection [2]. The association between ED, low testosterone level and cardiovascular disease are well recognized and these disorders are associated with the presence of metabolic syndrome [9].
Unfortunately none of the symptoms is specific to the low androgen state but each symptom may raise the suspicion of TDS. While standardized questionnaires such as the Androgen Deficiency in Aging Male (ADAM) checklist is designed to identify symptoms and signs of TDS [10], they are not very specific but may play a role in encouraging men to discuss their symptoms and for monitoring changes in symptoms. The recommended tests for men with ED are fasting glucose, cholesterol, lipids and testosterone level. The FT assays are generally set aside for the repeat assay and to certify the significance of a borderline TT level, or when SHBG concentration may be altered. The magnitude of the effect on erectile function is inversely related to baseline concentration of testosterone. This underlies the important concept that TDS must be ruled out, or if present, should be adequately treated, before PDE5 inhbitors are prescribed in men with ED.
Furthermore, some studies have suggested that erectile response may actually decreased when higher levels of testosterone were reached in men who were not hypogonadal [21]. Although hypoandrogenism can be the main cause of ED in younger patients, ED is often multi-factorial in pathophysiology and therefore it is unlikely that TDS is the sole contributor for the development and progression of ED. Now we've learned that there's a new non-profit organization on the block aimed specifically at serving those diabetes educators who already have the "certified" tag behind their names.It's called the Academy of Certified Diabetes Educators (ACDE), and as the name suggests, it's all about training and connecting CDEs working "in the trenches" with PWDs.
NCBDE understands the increasing need for educators to support a growing population of people with diabetes, but also feel it's important to balance access with ensuring a level of quality to that educational process. Frankly, I think the diabetes community is looking for a certification for non-health (formally) educated experts.
All three of these professions require their members to log a certain number of continuing medical education (so-called CME) hours to maintain their licenses. The link between ED, testosterone deficiency and cardiovascular disorders is well documented. This review article aims to provide primary care practitioners a practical approach to the diagnosis and management of testosterone deficiency in patients with ED. It appears that testosterone is responsible in the regulation of the timing of the erectile process as a function of sexual desire, thereby coordinating erection with sex [4]. In fact a clear negative relationship exists between the presence of the risk factors for metabolic syndrome and levels of circulating testosterone in patients with ED [9].
Previously, a brief (12 items) structured interview called the ANDROTEST has been designed specifically to screen for hypogonadism in patients with sexual dysfunction [11].
As a general rule of thumb, the mean serum total testosterone decreases by 1% per year after the age of 40 years [13].
The indication to start TRT must be based on complete clinical assessment with an evidence of hypoandrogenism.
Men with severe lower urinary tract symptoms, polycythaemia (hematocrit >50%), untreated obstructive sleep apnoea, severe congestive cardiac failure, breast or prostate cancer should not be started on TRT without appropriate assessment and treatment by the respective specialists.


Patients should be monitored at 3 months initially, and later at 3 to 6 monthly follow-up for adjustment of TRT and surveillance for any complication.
Published literature showed the combination of TRT and PDE5 inhibitors enhances the overall efficacy in men with were previously PDE5 inhibitors unresponsive [19]. Hence, further studies are needed to evaluate the benefits of combination TRT and PDE5 inhibitors. For this reason, combination therapy using TRT and PDE5 inhibitors should be considered as first line in the majority of cases as it might improve the clinical outcome better than TRT only. Unfortunately, I do not have a nursing degree, nor an MSW, nor am I a registered dietician.
The organization has made a number of changes over the past few years regarding eligibility that people might not be aware of and we hope people will visit our web site (ncbde.org) for the most current information.
I know there are constraints about offering that type of certification, but it can be done. Maybe you can come on the show as a guest and talk about how all nurses can be better at managing their diabetic patients.
The recommended tests for men with ED include fasting glucose, cholesterol, lipids and testosterone level.
Some studies showed that higher androgen level potentially play a dominant role in increased frequency of autoeroticism behaviors [5] and propensity for extramarital affairs [6]. The use of TRT in clinically symptomatic hypoandrogenism men treated previously for localized prostate cancer remains controversial [15].
Longer duration of combination TRT and PDE5 inhibitors use appeares to increase the patient response rate to PDE5 inhibitors [20].
We don't want to reinvent the wheel, but we have to bring all of these resources together so they're more well-publicized, affordable and accessible," Day says.AADE itself appears to be blindsided and somewhat disgruntled about this. Here are some important facts: 1) the professional practice aspect of the eligibility requirements for the CDE credential is not 2000 hours of diabetes education within 2 years. The first person perspective is so valuable to us PWDs, NCBDE would be re-miss and is certainly missing an opportunity to meet this need. Recent studies have also highlighted the role of testosterone in ejaculatory dysfunction via the effect of testosterone on nitric oxide metabolism in the central and peripheral control of ejaculation that could be accountable in condition such as premature ejaculation [7]. The selection of the TRT preparation should be a joint decision between an informed patient and his physician. I am hoping I can become a dietician, but wonder if I will ever be able to accrue the necessary 2,000 hours. It's 2 years of general experience (not necessarily diabetes) and a minimum of 1000 hours doing diabetes education over a maximum window of 4 years. A range of testosterone preparations are available for supplementation, and the combination of testosterone replacement therapy and phosphodiesterase type 5 inhibitors might improve outcomes in some cases. It is important to counsel younger men who wish to father children that exogenous TRT paradoxically results in infertility and this could potentially be irreversible.
In any case, a point I would like to make here is that while I have met a handful of CDE's who really seem to understand what it is like to really live with this disease, I have met many who do not.
The selection of the testosterone replacement therapy should be a joint decision between an informed patient and his primary care physician, and regular follow-up should be conducted to assess treatment efficacy and surveillance for adverse events. Nelson, at first glance, seems an odd choice to teach diabetes educators about PWDs and depression. The only true way to recognize those in diabetes education is through certification," says Dr. I am not saying that just living with Type I diabetes successfully should be enough to make a person a CDE, but this disease is so very complex that only those truly qualified to advise patients (and their caregivers, if they are children, or their spouses, if they are married) should ever endeavor to enter the field of diabetes education. But Nelson spent 19 years in our trenches working at the International Diabetes Center in Minneapolis, from 1984 until 2003, when he went into private practice.
Since that time he has worked with PWDs on both sex issues and garden variety depression, been a speaker at many TCOYD events, and has written for the Diabetes Self-Management blog .
The ACDE operates as a "virtual" organization but has a mailing address in the Chicago area, where the group can meet in a geographically-central spot.Status QuarrelThe NCBDE certification process has long been criticized as a barrier to bringing new blood into this profession.
Rather, the current model that is being used when promoting licensure includes a pathway where a health professional can become licensed without passing a psychometrically valid examination verifying their diabetes knowledge.
To become certified, one must be a licensed healthcare professional and then rack up 2,000 hours of experience over two years working directly with diabetes patients (without yet having certification to do so) to be eligible to sit for an extensive exam. However, people with diabetes need to be assured that an individual who is licensed by their state as a diabetes educator has proven that they have a certain level of diabetes knowledge.
Without the hours of work experience, hopefuls are not eligible for the exam, which is clearly a hurdle to many. With a pathway that allows licensure without an examination, the current model does not address this need. Also, as Pihos notes, some educators may work in facilities where research is the priority, rather than hands-on patient care, and some folks in rural areas may not have access to a center where the NCBDE exam is given.So AADE has been working in recent years to be more inclusive of educators who do not have certification, and to afford them a tiered-level status of state licensed educator (FAQ here).
Note that a little over 60% of AADE members are CDEs, but you don't have to be a CDE to be a member.The new ACDE rejects this approach.
Limited access to these programs is the other beef that ACDE aims to address.During her time as an auditor for ADA programs in the past, Day says she'd noticed that many small D-education programs have been cutting back on their continuing education.
There's likely going to be an increasingly steep decline in CDEs over the coming decade, especially as more and more of those professionals opt for higher-paying corporate jobs over clinical practice.One way to counteract that CDE drain is to focus more on the aspiring educators and students, Day says. That's something the existing organizations haven't been doing effectively, and the shortage of CDEs will become critical if more work isn't done to usher a new generation into the profession. And the academy plans to make its website a "one-stop shop" for CDEs to get low-cost (or even free) access to webinars and resources to help them in their jobs.Already, the academy has a career center on its site where CDEs or those entering the field can post a resume and look for job opportunities. And to help recruit new members, the ACDE is offering free membership for the first two years.Patient VoicesWith six initial board members, Day says they're planning to recruit more later this year and they'd like to include student and patient voices in that group (which we applaud).



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