ABSTRACT Introduction: “Diabetes and pregnancy” has historically been a social and health problem. Before the discovery of insulin, the complications suffered by pregnant women with diabetes and the product of conception were numerous and serious. However, new difficulties have appeared, such as birth defects in the offspring of women with pregestational diabetes and even a type of diabetes related to pregnancy: gestational diabetes. Together with this, there are also currently, both in Cuba and in the rest of the world, multiple ethical dilemmas in relation to “diabetes and pregnancy”. Objective: To explain why “diabetes and pregnancy” is currently a problem for both society and science and for some ethical dilemmas related to this topic. Methods: An analysis of the bibliography extracted from the electronic databases, Google Scholar, Pubmed, LILACS and SciELO, was carried out through the Google search engine. Conclusions: Currently, there are many problems of a social, scientific and ethical nature in “diabetes and pregnancy”, which involve both pregestational and gestational diabetes. The solution of these represents a great challenge for modern society and science.

RESUMEN Introducción: “Diabetes y embarazo” ha constituido históricamente un problema social y de salud. Antes del descubrimiento de la insulina las complicaciones sufridas por la mujer embarazada con diabetes y el producto de la concepción eran numerosas y graves. No obstante, han aparecido nuevas dificultades como los defectos congénitos en la descendencia de las mujeres con diabetes pregestacional e incluso, un tipo de diabetes relacionada propiamente con el embarazo: la diabetes gestacional. Unido a esto, también existen en la actualidad, tanto en Cuba como en el resto del mundo, múltiples dilemas éticos en relación con “diabetes y embarazo”. Objetivo: Explicar por qué “diabetes y embarazo” constituye en la actualidad un problema tanto para la sociedad como para la ciencia y para algunos dilemas éticos relacionados con este tema. Métodos: Se realizó un análisis de la bibliografía extraída de las bases de datos electrónicas, Google Scholar, Pubmed, LILACS y SciELO, a través del motor de búsqueda Google. Conclusiones: En la actualidad, existen muchos problemas de índole social, científico y ético en “diabetes y embarazo”, que implican tanto a la diabetes pregestacional como a la gestacional. La solución de estos representa un gran reto para la sociedad y la ciencia modernas.

ABSTRACT Diabetes mellitus is an entity with a high prevalence that in recent years has had an upward trend, mainly in the economically active population, implying that more and more women of childbearing potential with this disease will exist. It is recommended that these women receive a type of specialized care such as preconception care, at least three months before conception, to help achieve favorable gestational outcomes. It is then desirable that this clinical activity can be registered in order to standardize and facilitate professional practice in this field, in order to improve the quality of this care service. This is the fundamental reason for the implementation of the preconceptional care protocol in diabetes, at the Diabetic Patients Care Center of the Institute of Endocrinology, that is presented in this article.

RESUMEN La diabetes mellitus constituye una entidad con una elevada prevalencia que en los últimos años ha tenido una tendencia ascendente, principalmente en población económicamente activa, lo que implica que cada vez existirán más mujeres en edad fértil con esta enfermedad. Se recomienda que estas mujeres reciban un tipo de atención especializada como la atención preconcepcional, tres meses antes de la concepción como mínimo, para coadyuvar al logro de resultados gestacionales favorables. Es conveniente, entonces, que esta actividad clínica sea protocolizada para normalizar y facilitar la práctica profesional en este campo, con el fin de mejorar la calidad de este servicio asistencial. Este constituye el motivo fundamental de la implementación del protocolo de atención preconcepcional en diabetes, en el Centro de Atención al Diabético del Instituto de Endocrinología, que se presenta en este artículo.

ABSTRACT Cuban participation in and contributions to education, medical care and research on diabetes and pregnancy in Latin America dates back to the 1970s when the Latin American Diabetes Association was founded. The Cuban health system and its professionals recognized early the problems presented by diabetes during pregnancy for the health of an expectant mother and her children and assimilated and disseminated important lessons that became influential in the region. These included: importance of adopting a program within primary health care that offers national coverage for diabetic pregnant women, with a special focus on pre-conception monitoring of diabetic women; benefits of defining a specific range for application of a fasting glucose test to identify risk of gestational diabetes through selective screening for the disease; using insulin to treat gestational diabetes; controlling excessive weight at the beginning and during pregnancy; and underscoring the importance of interdisciplinary treatment of diabetes in pregnancy. The goal was to improve care and research in reproductive health for diabetic pregnant women and their children in Cuba.

ABSTRACT Introduction: Gestational diabetes is the most frequent endocrine disease of pregnancy and generally appears when there are risk factors. Objective: To describe the risk factors for gestational diabetes. Methods: Cross-sectional and descriptive study of a database that included 242 women with gestational diabetes, treated at América Arias Gyneco-obstetric Hospital in Havana, in the period 2004-2006. Categorical (dichotomous) variables were analyzed, considered as risk factors for gestational diabetes: diabetes in a first-degree relative, age equal to or over 30 years, excessive pre-pregnancy weight, clinical history of gestational diabetes, fetal macrosomia and unexplained fetal death, pregnancy-related high blood pressure, and at-risk fasting blood glucose. Percentage analysis (determination of relative frequencies) was carried out. Results: The mean age was 29.2±5.3 years. The mean body mass index was 27.1±4.2 kg/m2. 96.69% had risk factors; 79.49% of these had more than one risk factor. The most frequent were at-risk fasting blood glucose (64.53%), age equal to or over 30 years (60.26%), and excessive pre-pregnancy weight (51.71%). There was a predominance in manifestation of combined risk factors; manifestation of one risk factor alone occurred only in at-risk fasting blood glucose (14.57%), diabetes in first-degree relative (8.43%), age equal to o over 30 years (7, 80%), and excessive pre-pregnancy weight (5.79%). Conclusions: The risk factors for gestational diabetes appeared in the majority of women with the disease, mainly in combination.

RESUMEN Introducción: La diabetes gestacional constituye la enfermedad endocrina más frecuente del embarazo y aparece generalmente cuando existen factores de riesgo. Objetivo: Describir los factores de riesgo de la diabetes gestacional. Métodos: Estudio transversal-descriptivo de una base de datos que incluyó a 242 mujeres con diabetes gestacional, atendidas en el Hospital Ginecobstétrico “América Arias” de La Habana, en el periodo 2004-2006. Se analizaron variables categóricas (dicotómicas), consideradas como factores de riesgo de diabetes gestacional: diabetes en familiar de primer grado, edad ≥ 30 años, peso pregestacional excesivo, historia de diabetes gestacional, macrosomía fetal y muerte fetal inexplicable, hipertensión arterial relacionada con embarazo y glucemia en ayunas de riesgo . Se efectuó análisis porcentual (determinación de frecuencias relativas). Resultados: La media de edad fue 29,2 ± 5,3 años y de índice de masa corporal, 27,1 ± 4,2 kg/m2. Un 96,69 % tenía factores de riesgo y 79,49 % de estas, más de uno, los más frecuentes fueron: glucemia en ayunas de riesgo (64,53 %), edad ≥ 30 años (60,26 %) y peso pregestacional excesivo (51,71 %). Predominó la forma combinada de presentación de factores de riesgo, en forma única solo se presentó: glucemia en ayunas de riesgo (14,57 %), diabetes en familiar de primer grado (8,43 %), edad ≥ 30 años (7,80 %) y peso pregestacional excesivo (5,79 %). Conclusiones: Los factores de riesgo de diabetes gestacional se presentaron en la mayoría de las mujeres con la enfermedad, fundamentalmente de forma combinada.

ABSTRACT Introduction: The glycemia-triglyceride index is used for the presumptive diagnosis of insulin resistance, which in hypertensive patients is related to the severity of high blood pressure. Objective: To determine the utility of the glycemia-triglyceride index as a marker of insulin resistance in adult patients diagnosed with essential arterial hypertension. Methods: A descriptive cross-sectional study was carried out in 232 patients diagnosed with essential arterial hypertension. The glycemia-triglyceride index was calculated and compared with HOMA index. For this analysis, ROC curve, Pearson correlation and Kappa index were used, p value less than 0.05 was considered significant. Results: We obtained an 8.1 cut-off point, showing 98.6 sensitivity and 41.4 specificity. The area below the ROC curve showed 0.694 ≈ 0.7 value. Positive correlation was observed (p = 0.008). Kappa index = 88.4%. Conclusions: The glycemia-triglyceride index turned out to be useful in patients with essential hypertension as a marker of insulin resistance with a cut-off point of 8.1.

RESUMEN Introducción: El índice glucemia-triglicéridos se utiliza para el diagnóstico presuntivo de la resistencia insulínica, que en los pacientes hipertensos se relaciona con la severidad de la hipertensión arterial. Objetivo: Determinar la utilidad del índice glucemia-triglicéridos como marcador de resistencia a la insulina en pacientes adultos con diagnóstico de hipertensión arterial esencial. Métodos: Se realizó un estudio descriptivo transversal en 232 pacientes con diagnóstico de hipertensión arterial esencial. Se calculó el índice glucemia-triglicéridos y se comparó con el índice HOMA. Para este análisis se utilizó la curva ROC, la correlación de Pearson y el Índice de Kappa, se consideró significativo un valor de p menor a 0,05. Resultados: Se obtuvo un punto de corte de 8,1 que mostró una sensibilidad de 98,6 con una especificidad de 41,4. La curva ROC mostró un área bajo la curva con valor de 0,694 ≈ 0,7. Se observó correlación positiva (p=0,008) Índice de Kappa=88,4 %. Conclusiones: El índice glucemia-triglicéridos resulto ser útil en pacientes con hipertensión arterial como marcador de resistencia a la insulina con un punto de corte de 8,1.

ABSTRACT Dr. Jacinto Lang Prieto was one of the pioneers of preconception care for women suffering from diabetes in Cuba, which began in the early 1990s at the Center for Diabetic Care of the National Institute of Endocrinology. Together with his tutor, Dr. Antonio Márquez Guillén, he created a consultation at this institution in order to offer this care. Thanks to the work of these doctors, in 2007, the expansion of preconceptional care throughout the country began and this activity was established nationwide in 2012. At present, preconception care is part of the risk management to the diabetes reproductive women. Primary health care professionals should play a leading role in providing this care. Improving preconceptional care for diabetes women as part of national strategy of is one of the current challenges in this field in Cuba.

RESUMEN El doctor Jacinto Lang Prieto fue uno de los pioneros de la atención preconcepcional a la mujer con diabetes en Cuba, la cual inició a principios de la década de los años 90 del siglo pasado en el Centro de Atención al Diabético del Instituto Nacional de Endocrinología. Junto a su tutor, el Dr. Antonio Márquez Guillén, creó en esta institución una consulta con la finalidad de ofrecer este tipo de atención. Gracias a la labor de estos galenos comenzó, en 2007, la expansión de la atención preconcepcional a todo el país y en 2012, esta actividad estaba establecida a nivel nacional. En el presente, la atención preconcepcional forma parte de la atención al riesgo reproductivo de la mujer con diabetes, labor en la que deben desempeñar un papel preponderante los profesionales de la atención primaria de salud. Lograr la mejoría de este aspecto de la actividad nacional de diabetes y embarazo constituye uno de los retos actuales en este campo en Cuba.

Diabetic foot syndrome is one of the most feared chronic complications of diabetes mellitus. In terms of its treatment, the ideal thing to do would be to prevent its appearance by acting upon the risk factors for diabetic foot ulceration. However, once the syndrome is present, comprehensive treatment should be applied which extends beyond podiatric care and is geared to educate and support patients as well as achieve optimal glycemic control and ensure attention to vascular risk factors, so as to make sure ulceration is healed, thus preventing the worsening of this complication, which might otherwise lead to lower limb amputation. The present review deals with the comprehensive broadened treatment of diabetic foot syndrome.

El síndrome del pie diabético constituye una de las complicaciones crónicas más temidas de la diabetes mellitus. En cuanto a su tratamiento, lo ideal sería prevenir su aparición actuando sobre los factores de riesgo de la úlcera del pie diabético. Sin embargo, una vez que el síndrome está presente, se reconoce la importancia que tiene para garantizar la cura de la úlcera y evitar el agravamiento de esta complicación, incluida la amputación de miembros inferiores, instaurar un tratamiento integral que se extienda más allá de la atención podálica, encaminado tanto a educar y apoyar al paciente, como a lograr un control glucémico óptimo y a atender los factores de riesgo vascular. Acerca del tratamiento integral y ampliado del síndrome del pie diabético trata esta revisión.

Therapeutic education is one of the fundamental aspects in the treatment of people with diabetes mellitus. In the case of the elderly with this disease, this activity has peculiarities. At first, a comprehensive evaluation of the patient is recommended to identify physical, mental or social problem that may interfere with the educational-therapeutic process. Then, education must be adapted to the subject, taking into account the precept that it is not "education for treatment", but "education as treatment". This demands training the health professionals in charge of this task, in which the family doctor must play a fundamental role in Cuba. The main goal of therapeutic education is to promote self-care and ensure therapeutic adherence without deteriorating the quality of life, while teaching the patient to live with the chronic condition.

La educación terapéutica constituye uno de los aspectos fundamentales del tratamiento de las personas con diabetes mellitus. En el caso del adulto mayor con la enfermedad, esta actividad tiene sus peculiaridades. Se recomienda, en un primer momento, realizar una evaluación integral del paciente, con el propósito de identificar algún problema físico, mental o social, que pueda interferir en el proceso educativo-terapéutico. Después, debe adaptarse la educación al sujeto, teniendo en cuenta el precepto de que esta no consiste en una "educación para el tratamiento", sino en "la educación como tratamiento". Esto demanda capacitación de parte de los profesionales de la salud encargados de afrontar esta tarea, en lo cual debe jugar un papel fundamental en Cuba el médico de la familia. El objetivo cimero de la educación terapéutica consiste en fomentar el autocuidado y garantizar la adherencia terapéutica sin que se deteriore la calidad de vida, a la vez que se enseña al paciente a vivir con la condición crónica.

ABSTRACT Gestational diabetes is the most common endocrine disorder affecting pregnant women and its prevalence is on the rise. Prevalence in Cuba is about 5.8%, and global prevalence ranges from 2% to 18% depending on the criteria applied. Gestational diabetes can lead to adverse gestational outcomes, such as fetal death, preterm delivery, dystocia, perinatal asphyxia and neonatal complications. Prompt, accurate diagnosis allowing early treatment can benefit both mother and child. The disease is asymptomatic, so clinical laboratory testing plays a key role in its screening and diagnosis. Cuba’s approach to diabetes screening and diagnosis differs from some international practices. All pregnant women in Cuba are screened with a fasting plasma glucose test and diagnosed using modified WHO criteria. Some international recommendations are to skip the screening step and instead follow the diagnostic criteria of the Hyperglycemia and Adverse Pregnancy Outcomes study. In Cuba, gestational outcomes for women with diabetes (including gestational diabetes) are satisfactory (preeclampsia 5%; preterm delivery 12%; neonatal macrosomia 7.5%; congenital abnormalities 4.3% and perinatal deaths 4.8%). These data do not indicate a need to change established screening and diagnostic criteria.

INTRODUCTION Fetal macrosomia is the most important complication in infants of women with diabetes, whether preconceptional or gestational. Its occurrence is related to certain maternal and fetal conditions and negatively affects maternal and perinatal outcomes. The definitive diagnosis is made at birth if a newborn weighs >4000 g. OBJECTIVE Identify which maternal and fetal conditions could be macrosomia predictors in infants born to Cuban mothers with gestational diabetes. METHODS A case-control study comprising 236 women with gestational diabetes who bore live infants (118 with macrosomia and 118 without) was conducted in the América Arias University Maternity Hospital, Havana, Cuba, during 2002–2012. The dependent variable was macrosomia (birth weight >4000 g). Independent maternal variables included body mass index at pregnancy onset, overweight or obesity at pregnancy onset, gestational age at diabetes diagnosis, pregnancy weight gain, glycemic control, triglycerides and cholesterol. Fetal variables examined included third-semester fetal abdominal circumference, estimated fetal weight at ≥28 weeks (absolute and percentilized by Campbell and Wilkin, and Usher and McLean curves). Chi square was used to compare continuous variables (proportions) and the student t test (X ± SD) for categorical variables, with significance threshold set at p <0.05. ORs and their 95% CIs were calculated. RESULTS Significant differences between cases and controls were found in most variables studied, with the exception of late gestational diabetes diagnosis, total fasting cholesterol and hypercholesterolemia. The highest OR for macrosomia were for maternal hypertriglyceridemia (OR 4.80, CI 2.34–9.84), third-trimester fetal abdominal circumference >75th percentile (OR 7.54, CI 4.04–14.06), and estimated fetal weight >90th percentile by Campbell and Wilkin curves (OR 4.75, CI 1.42–15.84) and by Usher and McLean curves (OR 8.81, CI 4.25–18.26). CONCLUSIONS Most variables assessed were predictors of macrosomia in infants of mothers with gestational diabetes. They should therefore be taken into account for future studies and for patient management. Wide confidence intervals indicate uncertainty about the magnitude of predictive power.

Diabetes mellitus is the metabolic disease that more often complicates pregnancy and even emerges during pregnancy, namely gestational diabetes mellitus. Adequate preconceptional care to woman with diabetes mellitus remarkably reduces the risk of congenital malformations in the child. The pregnant women with some risk factor of this disease should be screened for gestational diabetes mellitus. Cuba follows the modified criteria of the World Health Organization to diagnose the disease. The pregnant women suffering this condition require special obstetric and endocrine care. Diabetes mellitus has negative impact on the child of a diabetic mother at short, medium and long terms. Likewise, those women with gestational diabetes mellitus have the risk of developing diabetes mellitus in the future, mainly the type 2.

La diabetes mellitus constituye la enfermedad metabólica que con mayor frecuencia complica el embarazo, pudiendo aparecer, incluso, durante este (diabetes mellitus gestacional). Una atención preconcepcional adecuada a la mujer con diabetes mellitus disminuye ostensiblemente el riesgo de malformaciones congénitas en el hijo de madre diabética. Debe hacerse la pesquisa de la diabetes mellitus gestacional, fundamentalmente, en las embarazadas que presentan algún factor de riesgo de esta enfermedad. En Cuba, se utilizan para su diagnóstico los criterios de la Organización Mundial de Salud modificados. Las mujeres embarazadas con diabetes mellitus requieren de una atención obstétrico-endocrinológica especial. La diabetes mellitus repercute de forma negativa en el hijo de madre diabética, a corto, mediano y largo plazo. Asimismo, las mujeres con diabetes mellitus gestacional tienen riesgo de presentar en un futuro una diabetes mellitus, sobre todo, de tipo 2.

To achieve healthcare excellence, an inviolable principle should be established: Doctor-patient relationship is the most sensitive and humane aspect of medical practice. EHealth, also known as cyberhealth, is the use of information and communication technologies in support of health programs, including medical care. A discussion is provided about the concepts of doctor-patient relationship, information and communication technologies and eHealth, and about the links between them. EHealth (cyberhealth) and information and communication technologies have achieved undeniable progress in the field of medical sciences. However, such impetuous development of technology applied to medicine should be rationally controlled to prevent doctor-patient relationship from becoming a dehumanized patient-device relationship. Healthcare personnel have the unpostponable duty to cultivate and improve doctor-patient relationship, a sacred principle in medical practice.

Para lograr una excelencia en la atención médica, se debe establecer un principio inviolable, la relación médico-paciente, aspecto más sensible y humano de la medicina. La eSalud, también denominada Cibersalud, es la utilización de las tecnologías de la información y las comunicaciones en el apoyo a la salud, incluida la asistencia médica. Se propone una reflexión alrededor de los conceptos de relación médico-paciente, tecnologías de la información y las comunicaciones, eSalud y la relación entre estos. Incuestionables son los logros de la esalud (Cibersalud) y las tecnologías de la información y las comunicaciones en las ciencias médicas. Este desarrollo impetuoso de la tecnología aplicada a la medicina, si no es controlado racionalmente por el hombre puede convertir la relación médico-paciente en una deshumanizada relación paciente-aparato. Se impone el deber impostergable para todo el personal de salud el cultivar y perfeccionar la relación médico-paciente, principio sagrado en el ejercicio medico.