[Implementation of a protocol of management of chronic kidney disease between Nephrology and Primary Health Care. Preliminary results]. / Resultados preliminares de la implantación de un protocolo conjunto de manejo de la enfermedad renal crónica entre atención primaria y nefrología.

During the last years there has been an important advance in the knowledge of chronic kidney disease (CKD). In order to adapt our clinical practice to these new data, a protocol of management of CKD between Nephrology and Primary Health Care has been developed. The protocol includes several items like cardiac and renal protection strategies, diagnosis and treatment of complications, use of drugs and clear derivation criteria. Implementation of the protocol has been only partial and has implied, for the Renal Unit, an increase in the number of patients,specially the oldest ones, but a clear improve in the quality of the information too,and a first positive step in the right way to face the challenge of CKD. In view of analysed data we propose some modifications for the protocol.

Resultados preliminares de la implantación de un protocolo conjunto de manejo de la enfermedad renal crónica entre atención primaria y nefrología / Implementation of a protocol of management of chronic kidney disease between nephrology and primary helath care. Preliminary results

En los últimos años se ha producido un importante avance en el conocimiento de la enfermedad renal crónica (ERC). Con el objetivo de adaptar la práctica clínica a los nuevos conocimientos se ha puesto en marcha en el Departamento 5 de la Agencia Valenciana de Salud un protocolo conjunto de manejo de la ERC entre Atención Primaria y Nefrología. El protocolo desarrolla una serie de puntos entre los que se incluyen medidas de cardio y renoprotección, detección y manejo de complicaciones, uso de fármacos y criterios claros de derivación. La implantación de este protocolo hasta el momento ha sido parcial y ha supuesto, para el Servicio de Nefrología, un aumento del número de consultas y un aumento de la remisión de pacientes mayores de 80 años, pero también una mejora clara en la información con la que llegan los pacientes y un primer paso, consideramos que claramente positivo, en la dirección correcta para afrontar el reto de la ERC. A la luz de los datos analizados se proponen también algunas modificaciones del protocolo

During the last years there has been an important advance in the knowledge of chronic kidney disease (CKD). In order to adapt our clinical practice to these new data, a protocol of management of CKD between Nephrology and Primary Health Care has been developed. The protocol includes several items like cardiac and renal protection strategies, diagnosis and treatment of complications, use of drugs and clear derivation criteria. Implementation of the protocol has been only partial and has implied, for the Renal Unit, an increase in the number of patients, specially the oldest ones, but a clear improve in the quality of the information too, and a first positive step in the right way to face the challenge of CKD. In view of analysed data we propose some modifications for the protocol

Compromiso de gestión guía de indicadores / Involvement of management guiding of indicators

El modelo de atención vigente en el Ministerio de Salud y Previsión Social; incluye los compromisos de gestión como importantes instrumentos para la evaluación por resultados. Estos contienen indicadores de proceso y resultados dirigidos a alcanzar las metas propuestas de cada unidad prestadora de servicios (en este caso los SEDES). Para la selección de estos indicadores, se han considerado los compromisos asumidos por el Gobierno Nacional con organismos internacionales y que éstan orientados básicamente a la reducción de las tasas de mortalidad materno infantil y el control de enfermedades. La presente guía define cada uno de estos indicadores; el concepto de numerador y denominador; la fuente de información oficial utilizada y considera posibles problemas que pueden presentarse en el proceso de medición y/o evaluación

[Catheterization of the tubal ostium using hysteroscopy under laparoscopic guidance]. / Cateterización del ostium tubario bajo guía histeroscópica con control laparoscópico.

It is considered that one out of five couples present a transitory problem of infertility during their reproductive life and the most frequent cause is the tubarian pathology; from these, the proximal obstruction occupies between 25 and 30% of the cases. Unfortunatelly, the conventional method use to study tubarian patency such as histerosalpingography or the direct observation by laparoscopy and selective chromotubation, frequently do not allow to differentiate between an insufficient filling of the tubes, tubarian spasm or a true mechanical obstruction. There are certain selective tubarian cannulation techniques, for example, the catheterism with hysteroscopic guidance which is extremely usefull in the diagnosis of tubarian patency or in the confirmation of partial or total proximal tubal disease. The procedure permits to diagnosticate precisely the tubarian obstruction and also if it is due to the presence of a true pathology or simply functional, or secondary to a tubarian spasm; besides it also works as a therapeutic procedure since in the first case permits the lysis of laxe adherencies and the removal of the amorfus material that obstructs the tube and permits the catheterization. The present study determines the utility of catheterization of the tubarian ostium by hysteroscopy with laparoscopic control using the Novy (Cook, Ob/ Gyn) catheter in patients with infertility problems due to proximal obstruction of one or both of the fallopian tubes, to confirm or discard the presence of a pathological obstruction. The results are evaluated in terms of tubarian permeability and the pregnancy rate after the procedure.

[Laparoscopy and hysteroscopy in Müllerian duct malformations: usefulness and reproductive results]. / Laparoscopia e histeroscopia en malformaciones müllerianas: utilidad y resultados reproductivos.

Determine the type and the possibility of corrective surgery, reproductive results of infertility patients with Müllerian malformations. The clinic and the laparoscopic and hysteroscopic evaluation were performed to 40 patients with Müllerian anomalies and infertility history analyzing the reproductive results. The uterine septum was present in 23/40 patients (57.5%), bicornual uterus in 6/40 (15%), didelfus uterus 5/40 (12.5%), arcuate uterus 4/40 (10%), unicorn uterus 2/40 (5%). After septum resection we had 13 pregnancies (56.5%). 2 abortions, 4 already delivered and 7 continue normal evolution with on twin case. Strassman metroplasty by laparotomy was performed in 4 cases of bicornual uterus achieving pregnancy in two cases. In one didelfus uterus, a salpingoclasy of the smaller horn was done as an alternative. Of the arcuated uterus, the small septum was removed. Of the unicorn uterus, one pregnancy was lost in the first trimester and the other one reach the term date. Our data show that the endoscopic procedures can perform the correct diagnosis of the Müllerian anomalies and of course the best surgical treatment improving the fertility rates.

[Occurrence of pregnancy after microsurgical treatment of sterile patients with tubo-ovarian adhesive diseases]. / Frecuencia de embarazos después de tratamiento microquirúrgico en pacientes estériles por enfermedad adherencial tuboovárica.

In the last years, the adherence adnexal disease has been increased due to pelvic infections. This may cause infertility problems depending, of the nature, extension and localization inside the pelvis. In this paper we inform the results obtained in 70 patients with adnexal adhesions to whom it was performed a salpingo-ovariolysis with microsurgery technology, with the purpose of promote the fertility. All the patients received pre, trans and postoperative support (Heparin, steroids and antimicrobials). The minimal time of postoperative observation was at least 6 months. In 27 (Group I) of the 70 cases (38.6%), the adherences were avascular (IA & IIA based on Hulka's classification); and in the 43 patients of the group II (61.4%), the lesions were dense and vascular (IB & IIB). In group I, 15 pregnancies were obtained (55.6%), 13 at term, 1 miscarriage and 1 ectopic pregnancy; in the group II we documented 9 pregnancies (20.9%), 5 at term, 4 miscarriage (I trimester).

[Current state of conservative management of ectopic pregnancy]. / Estado actual del manejo conservador del embarazo ectópico.

The ectopic pregnancy constitutes a disease that require the most diagnostic accuracy, not only for the biologic importance of its clinical manifestations, but for the sequelae of its treatment too, in relation with the fertility of a patient frequently affected with infertility so far. The increase in its frequency, by multiple factors, including treatment of infertility itself and Assisted Reproduction techniques, make the clinician must be alert and have availability of all diagnostic tools for the establishment of an oportune and conservative treatment, directed to prevent an acute alteration of the hemostasis and a shadowy reproductive future. The present review of the literature about the conservative management of the ectopic pregnancy let us have to know the criteria neccessary for giving the optimum treatment to our patients and offering them a better reproductive future.