Type 2 diabetes mellisu (DM) is a global issue in this world, most because of the higher commodities and mortality. Erectile dysfunction (ED), once was thought to be a localized genitourinary disorder, was proposed to a maker of the systemic disease. Indeed, existing evidence has been well established that type 2 DM is a major determinants of ED. However, the risk stratification tool for ED in type2 DM is limited in the literature. Recently, adapted diabetes complications severity index (aDSCI) incorporating seven DM associated comorbidites, has been validated in several studies beyond its initially designed purpose and was reported be of appropratie ability. To enhance the awareness with further compliance and adherence of treatment of ED in people affected by type2 DM, a convenient,easy-to-use risk estimator is warranted.Hence, the authors present a hypothesis generating retrospective observational study on patients with diagnosed DM to explore if the use of the aDSCI would be predictive in a population of 84288eligible patients. The subgroup analysis on age stratification was also investigated.

Male patients diagnosed with type IIdiabetes mellitus (ICD-9-CM: 250.x0 and 250.x2) between 2000 and 2011 wereenrolled. The index date was the date of initial diagnosis of diabetes.The end date of follow-up was the date of onset of erectily dysfunction(ICD-9-CM: 607.84),the date of patient withdrawal or death, or December 31^st, 2011.Patients younger than 18 years and diagnosed with erectilydysfunciton before the index date were excluded. The progression ofdiabetes was defined as yearly increased aDCSI scores, and four groups ofprogression were defined as yearly increased aDCSI scores of 0.0-0.5, 0.5-1.0,1.0-2.0, and > 2.0. Baseline comorbidities were asfollows: asthma, chronic liver disease, gout, hypertension, chronic obstructionpulmonary disease, hyperlipidemia, alcohol-related illness, obesity,depression, and parkinson's disease. Diabetes complications includedretinopathy, nephropathy, neuropathy, cerebrovascular, cardiovascular, peripheral vascular disease,and metabolic.   

Patient characteristics were shown in Table 1. The average age in yearly aDCSI changes of 0-0.5,0.5-1.0, 1.0-2.0, and > 2.0 was 54.9 ± 13.6, 60.4± 13.0, 62.6± 13.8,and 64.0± 14.2years. The percentages of patients with any of the comorbidities in changes of0.0-0.5, 0.5-1.0, 1.0-2.0, and > 2.0 aDCSI scores each year were listed asfollows: 9.25%, 11.4%, 11.5%, and 12.6% with asthma; 43.0%,39.4%,32.7%,and 29.6%with chronic liver disease; 24.8%,24.4%,21.8%,and 19.9%with gout; 52.3%,63.1%,64.5%,and 62.2%with hypertension; 17.4%,21.9%,23.9%,and 25.6%with COPD; 47.1%,43.0%,40.8%,and 33.6%with hyperlipidemia. In the same way, thepercentages of patients with any of diabetes complications in changes of0.0-0.5, 0.5-1.0, 1.0-2.0, and > 2.0 aDCSI scores each year were also listedas follows: 14.7%,40.8%,35.6%,and 24.5%with retinopathy; 22.3%,47.9%,42.4%,and 31.4%with nephropathy; 22.3%,47.9%,42.4%,and 31.4%with neuropathy; 18.3%,52.7%,51.6%,and 46.7%with cerebrovascular; 41.9%, 67.5%, 65.5%, and 57.0% with cardiovascular; 17.6%, 47.8%, 47.8%, and 38.3% with peripheralvascular disease; 2.78%,13.6%,16.8%,and 16.3%with metabolic.   Incidence and HRs of erectile dysfunction for different yearly aDCSI changes in diabetes cohort were shown in Table 2. The incidence rate of erectile dysfunction in aDCSI changes of 0.0-0.5, 0.5-1.0, 1.0-2.0, and > 2.0 per year was 3.34 per 1,000person-years, 3.36 per 1,000 person-years, 13.5 per 1,000 person-years, and 35.3per 1,000 person-years. Compared to the change of aDCSI score of 0.0-0.5 peryear, the aHRs and the corresponding 95% CIs were summarized below: 1.09 (0.89,1.33) in the change of aDCSI score of 0.5-1.0 per year; 4.41 (3.44, 5.65) inthe change of aDCSI score of 1.0-2.0 per year; 10.9 (7.45, 15.8) in the change of aDCSI score of > 2.0 per year. It was shown that patients with yearly changes of ≥ 1.0 in aDCSI scores were at higher risk of erectile dysfunction in contrast to those with yearly changes of 0-0.5 in aDCSI scores, and there was statistical significance in tests for trend (p<0.001).

The authors performed a Taiwannationwide study to investigate the risk discrimination of ED in patients affected by DM. The main results showed that DM patients with aDCSI changes of> 1.0 each year were more likely to develop ED and these effect is even more stronger in the subgroup of those with younger age. Indeed, the huge sample size and the comprehensive and proper statistical analysis are major stregenth sof this investigation, making our finding reliable and convincing.ED is a major threat in DM group, not only physical but also psychological issue is involving in this topic (9-11). Incomparison with published studies on the same topic, this study is a pioneer one to introduce, validate and confirm that a DSCI can be used for risk stratification for ED among DM patients. The physiological rationale is clear.First, the component of this score incorporating into seven parameter. Moreover, the nature of this dynamic score is a novel finding since the disease is not static and the status or comorbidities usually changes over time, making the clinical relevance strong and useful. While exploring and dissecting the exact component of this score, some might argue that some of the variables are not closely related to the incidence of ED; however, it should have been taken into account in the analysis that the primary aim of this investigation is to validate a pre-existing formula instead of creating a new one. In our subgroup analysis, the effect is even obvious in the subgroup of younger age, implying that this younger DM patients should be pay more attention to the dynamic change of the score so that the any signs of ED can be found earlier.