RESUMO

Non-ischemic priapism in children is an uncommon entity usually related to blunt trauma in the perineal region and subsequent fistula formation into the corpus cavernosum. In this report we present the case of a 7-year-old boy who had undergone perineal trauma and developed non-ischemic priapism confirmed radiologically. He was treated by conservative measures along with ultrasonographic monitoring. We discuss the diagnostic approach, the radiologic findings and the mainly conservative management of this infrequent pathology.

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Diabetic Nephropathy (DN) is a major chronic complication of diabetes mellitus (DM), and one of the main causes of new cases for dialysis, being associated with increasing mortality. The main risk factors for DN are hypertension, hyperglycemia, dyslipidemia, and genetic susceptibility. The renin-angiotensin system (RAS) plays an important role in genesis and progression of DN and there is evidence of an interrelationship between this system and the endothelins. Endothelins are powerful vasoconstrictor peptides and act as modulators of vasomotor tone, cell proliferation, and hormone production. These peptides act through two types of receptors (ET-A and ET-B) and are expressed on endothelial cells and vascular smooth-muscle cells. Activation of this receptor in renal cells leads to a complex signaling cascade resulting in stimulation of mesangial cell hypertrophy, proliferation, contraction, and extracellular matrix accumulation. These hemodynamic renal alterations are associated with the onset and progress of renal disease in DM. Elevated endothelin-1 (ET-1) levels have been reported in patients with DM. There is evidence suggesting that an increase in the production of ET-1 leads to glomerular damage. The use of ET receptor antagonists has been reported as renoprotective, correcting the early hemodynamic abnormalities in experimental DM, reinforcing the importance of this system in DN.

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A nefropatia diabética (ND) é uma importante complicação crônica do diabetes melito (DM), sendo uma das principais causas dos novos casos de diálise e está associada ao aumento da mortalidade. Os principais fatores de risco são a hiperglicemia, a hipertensão arterial sistêmica (HAS), a dislipidemia e a susceptibilidade genética. O sistema renina-angiotensina (SRA) tem papel importante na gênese e na progressão da ND e existem evidências de interação entre este sistema e as endotelinas. As endotelinas são peptídeos com potente ação vasoconstritora que atuam modulando o tono vasomotor, a proliferação celular e a produção hormonal. Estes peptídeos agem por meio de dois receptores (ET-A e ET-B), que são expressos nas células endoteliais e no músculo liso vascular. A ativação destes receptores nas células renais leva à complexa cascata de alterações, resultando proliferação e hipertrofia das células mesangiais, vasoconstrição das arteríolas aferentes e eferentes e acúmulo de matriz extracelular. Essas alterações hemodinâmicas renais estão associadas com o aparecimento e a progressão da doença renal no DM. Níveis plasmáticos elevados de endotelina-1 (ET-1) têm sido relatados em pacientes com DM e há algumas evidências que sugerem que o aumento da produção de ET-1 poderia levar a dano glomerular. O uso de drogas antagonistas do receptor da ET-1 em situações de DM experimental tem mostrado propriedades nefroprotetoras, reforçando a importância deste sistema na ND.

Diabetic Nephropathy (DN) is a major chronic complication of diabetes mellitus (DM), and one of the main causes of new cases for dialysis, being associated with increasing mortality. The main risk factors for DN are hypertension, hyperglycemia, dyslipidemia, and genetic susceptibility. The renin-angiotensin system (RAS) plays an important role in genesis and progression of DN and there is evidence of an interrelationship between this system and the endothelins. Endothelins are powerful vasoconstrictor peptides and act as modulators of vasomotor tone, cell proliferation, and hormone production. These peptides act through two types of receptors (ET-A and ET-B) and are expressed on endothelial cells and vascular smooth-muscle cells. Activation of this receptor in renal cells leads to a complex signaling cascade resultanting in stimulation of mesangial cell hypertrophy, proliferation, contraction, and extracellular matrix accumulation. These hemodinamic renal alterations are associated with the onset and progress of renal disease in DM. Elevated endothelin-1 (ET-1) levels have been reported in patients with DM. There is evidence suggesting that an increase in the production of ET-1 leads to glomerular damage. The use of ET receptor antagonists has been reported as renoprotective, correcting the early hemodynamic abnormalities in experimental DM, reinforcing the importance of this system in DN.

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AIM: To evaluate the relationship of plasma endothelin-1 (ET-1) levels, a marker of endothelial dysfunction, and urinary albumin excretion in patients with type 2 diabetes mellitus (DM). METHODS: Cross-sectional study was conducted in 279 patients (132 males, mean age: 58.7+/-11.0 years, mean DM duration: 11.3+/-8.1 years). Urinary albumin excretion, ET-1, and insulin were measured. Insulin sensitivity was estimated by homeostasis model assessment (HOMA-ir) index. RESULTS: ET-1 was associated with urinary albumin excretion after controlling for age, gender, body mass index, blood pressure, HbA1c test, and total cholesterol (R=0.436; adjusted R(2)=0.190, P<0.01). Furthermore, there was a progressive increase in plasma ET-1 levels from patients with normoalbuminuria (n=187, 0.92+/-0.50pg/ml), microalbuminuria (n=68, 1.13+/-0.52pg/ml) to macroalbuminuria (n=24, 1.93+/-1.10pg/ml, P<0.01). CONCLUSION: There is an independent association of plasma ET-1 levels with urinary albumin excretion. In addition, plasma ET-1 levels started to increase in the normal values of urinary albumin excretion suggesting that in patients with type 2 DM endothelial dysfunction is already present, in urinary albumin excretion values considered normal.

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The daily use of aspirin in patients with type 2 diabetes mellitus (DM2) reduces significantly cardiovascular events (CVE). In the absence of contraindications, American Diabetes Association (ADA) recommends the use of aspirin to all DM2 patients older than 40 years of age. To evaluate aspirin use among 636 out patients with DM2 who participate in a regional multicenter study in Southern Brazil, a standard questionnaire was used. Patients also underwent a physical examination and laboratorial tests. All patients were older than 40 years (mean 58 ± 11 years old; 42 percent male) and by ADA guidelines most of them should be using aspirin. However, only 177 (27.5 percent) were on this medication. The use of aspirin was higher when any CVE were present. However, the percentage of users was still below the expected, not even reaching 50 percent. In conclusion, even though the use of aspirin is greater in patients with CVE, and its benefits are well documented, it is still underutilized. Strategies to enhance the use of aspirin should be developed to reduce the morbidity and mortality from cardiovascular diseases in patients with DM2.

O uso diário de aspirina em pacientes com diabetes mellitus do tipo 2 (DM2) reduz significantemente os eventos cardiovasculares (ECV). Na ausência de contraindicações, a ADA (American Diabetes Association) recomenda o uso de aspirina para todos os pacientes com DM2 maiores de 40 anos de idade. Para avaliar o uso de aspirina em 636 pacientes ambulatoriais com DM2 que participaram de um estudo multicêntrico na região Sul do Brasil, utilizamos um questionário padrão. Os pacientes foram também examinados e submetidos a testes laboratoriais. Todos eram maiores de 40 anos (média 58 ± 11 anos; 42 por cento homens) e a maioria deles deveria estar usando aspirina, de acordo com as orientações da ADA. Entretanto, somente 177 (27,5 por cento) estavam com esta medicação. O uso de aspirina era maior em presença de qualquer ECV. Contudo, a porcentagem dos que a usavam estava ainda abaixo do esperado, não atingindo 50 por cento. Em conclusão, mesmo sendo o uso da aspirina maior em pacientes com ECV, e seus benefícios bem documentados, ela ainda é subutilizada. Assim, estratégias para aumentar o uso de aspirina devem ser desenvolvidas para reduzir a morbi-mortalidade decorrente da doença cardiovascular em pacientes com DM2.

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RESUMO

The daily use of aspirin in patients with type 2 diabetes mellitus (DM2) reduces significantly cardiovascular events (CVE). In the absence of contraindications, American Diabetes Association (ADA) recommends the use of aspirin to all DM2 patients older than 40 years of age. To evaluate aspirin use among 636 out patients with DM2 who participate in a regional multicenter study in Southern Brazil, a standard questionnaire was used. Patients also underwent a physical examination and laboratorial tests. All patients were older than 40 years (mean 58 +/- 11 years old; 42% male) and by ADA guidelines most of them should be using aspirin. However, only 177 (27.5%) were on this medication. The use of aspirin was higher when any CVE were present. However, the percentage of users was still below the expected, not even reaching 50%. In conclusion, even though the use of aspirin is greater in patients with CVE, and its benefits are well documented, it is still underutilized. Strategies to enhance the use of aspirin should be developed to reduce the morbidity and mortality from cardiovascular diseases in patients with DM2.

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The intestinal fatty-acid binding protein-2 (FABP2) gene codes a protein responsible for the absorption of long-chain fatty acids. To test whether FABP2 is a candidate gene for renal disease in patients with type 2 diabetes, a functional A54T polymorphism was genotyped in 1,042 Brazilians with type 2 diabetes. Patients were classified as having normoalbuminuria (urinary albumin excretion [UAE] <20 microg/min; n = 529), microalbuminuria (UAE 20-199 microg/min; n = 217), or proteinuria (UAE >199 microg/min; n = 160). Patients with end-stage renal disease (ESRD) (n = 136) were also included. The prevalence of the TT genotype was higher in patients with renal involvement compared with those with normoalbuminuria (odds ratio [95% CI] 2.4 [1.1-5.4]) following adjustment for type 2 diabetes duration, BMI, hypertension, A1C, and cholesterol levels. The risk was similar considering different stages of renal involvement. In a second independent patient sample (483 type 2 diabetic Caucasians residing in Massachusetts), a significant association was also observed between the TT genotype and proteinuria or ESRD (2.7 [1.0-7.3]; P = 0.048). This study thus provides evidence that FABP2 confers susceptibility to renal disease in type 2 diabetic patients.

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