Transformación digital en la relación entre industria y colectivo sanitario / Digital transformation of the relationship between industry and healthcare professionals

La pandemia por COVID-19 ha afectado gravemente a la dinámica de los sistemas de salud y ha tenido consecuencias muy negativas en la atención sanitaria. Sin embargo, ha impulsado en mayor o menor medida la transformación digital en muchos centros sanitarios y en la industria farmacéutica. En este artículo se revisa la experiencia de la transformación digital derivada de la pandemia desde la perspectiva de los profesionales sanitarios y de la industria farmacéutica, con énfasis en la teleconsulta, en la formación a distancia y en el modelo de interacción entre sanitarios e industria. Además, se dan algunas claves para llevar a cabo una transformación digital exitosa (AU)

The COVID-19 pandemic has affected healthcare systems severely and has had a negative impact on healthcare. However, it has also been a catalyst for digital transformation in many healthcare centers and in the pharmaceutical industry. In this article, the experience of digital transformation during the pandemic is reviewed from the perspective of healthcare professionals and the pharmaceutical industry, with a focus on digital visits, on-line education, and the model of interaction between healthcare professionals and the industry. Also, some key points are given to facilitate a successful digital transformation (AU)

Programa de cirugía bariátrica laparoscópica en la Clínica Universidad de Navarra-Complejo Hospitalario de Navarra: resultados a un año / Laparoscopic bariatric surgery program in the University Clinic of Navarre - Hospital Complex of Navarre: results after 1-year follow-up

Fundamento. La prevalencia de obesidad en España en los últimos años muestra un incremento alarmante. El fracaso repetido de las pautas de alimentación equilibrada, actividad física, educación nutricional y farmacoterapia han conducido a la necesidad de utilizar la cirugía bariátrica tanto para el mantenimiento de la pérdida ponderal a largo plazo, como para la resolución de las comorbilidades asociadas. En el presente trabajo se pretende analizar los resultados iniciales de la puesta en marcha del programa de cirugía bariátrica laparoscópica en Navarra obtenidos en un grupo de pacientes obesos con indicación quirúrgica e intervenidos mediante el bypass gástrico laparoscópico (BPGYR). Material y métodos. Desde enero de 2010 hasta diciembrede 2011 se realizaron 47 BPGYR por vía laparoscópica en la Clínica Universidad de Navarra procedentes todos ellos de la Comunidad Foral de Navarra y evaluados previa y posteriormente en el Complejo Hospitalario de Navarra. De ellos, se han seleccionado para este trabajo los primeros 19 casos por presentar al menos un año de seguimiento. Resultados. El porcentaje de exceso de IMC perdido (PEIMCP) fue del 65,47%, con una disminución del porcentaje de peso total de 31,68%. Las cifras de glucosa, ácido úrico, tensión arterial y metabolismo lipídico al año de la intervención presentaron un descenso progresivo muy significativo, No se presentaron complicaciones importantes médicas ni quirúrgicas. Conclusiones. El bypass gástrico por laparoscopia es una técnica eficaz para el tratamiento a largo plazo de la obesidad mórbida, con escaso número de complicaciones, excelente pérdida de peso y curación o mejora de las comorbilidades asociadas en estos pacientes(AU)

Background. The prevalence of obesity in Spain in recent years has shown an alarming increase. The repeated failure of balanced food patterns, physical activity, nutritional education and pharmacotherapy have led to the need touse bariatric surgery both to maintain long-term weight loss, and for the resolution of associated comorbidities. This article analyzes the initial results of the implementation of the laparoscopic bariatric surgery program in Navarre, obtained in a group of obese patients with surgical indication and operated on by means of the laparoscopic gastric bypass. Methods. From January 2010 until December 2011, 47 gastric bypasses were performed laparoscopic ally in the University Clinic of Navarre, all of them from the autonomous community of Navarre and previously and subsequently evaluated in the Hospital Complex of Navarre. The first 19cases amongst them were selected for this work, as they presented at least one year of follow-up. Results. The percentage of excess weight lost was 65.47%, with a 31.68% reduction of total weight. The figures for glucose, uric acid, arterial tension and lipid metabolism one year after the intervention presented a very significant progressive fall. No significant medical or surgical complications were presented. Conclusions. The laparoscopic gastric bypass is an efficient technique for the long-term treatment of morbid obesity, with a scant number of complications, excellent weight loss and curing or improvement of the associated comorbidities in these patients(AU)

[The registry of home artificial nutrition and ambulatory of the Spanish Society of Parenteral and Enteral Nutrition; SWOT analysis]. / El registro de Nutrición Artificial Domiciliaria y Ambulatoria de la Sociedad Española de Nutrición Parenteral y Enteral; análisis DAFO.

OBJECTIVE: To evidence by means of a SWOT-R analysis performed by an expert consensus the most worrying characteristics of the register on Home-based and Outpatient Artificial Nutrition. MATERIAL AND METHODS: SWOT-R analysis with expert consensus. We requested the participation of the active members of the NADYA group within the last 5 years with the premise of structuring the SWOT-R based on the characteristics of the NADYA registry from its beginning. RESULTS: 18 experts from hospitals all over Spain have participated. The internal analysis seems to be positive, presenting the registry as having important resources. The external analysis did not show a great number of threats, there are very potent factors, "the voluntariness" of the registry and the "dependence on external financing". The opportunities identified are important. The recommendations are aimed at stabilizing the system by decreasing the threats as one of the main focus of the strategies to develop as well as promoting the items identified as opportunities and strengths. CONCLUSIONS: The analysis shows that the NADYA register shows a big potentiality for improvement. The proposed recommendations should be structured in order to stay on the track of development and quality improvement that has characterized the NADYA register from the beginning.

El registro de Nutrición Artificial Domiciliaria y Ambulatoria de la Sociedad Española de Nutrición Parenteral y Enteral; análisis DAFO / The registry of home artificial nutrition and ambulatory of the Spanish Society of Parenteral and Enteral Nutrition: SWOT analysis

Objetivo: Evidenciar mediante un análisis DAFO-R realizado por consenso de expertos las características más acuciantes del registro de Nutrición Artificial Domiciliaria y Ambulatoria. Material y método: Análisis DAFO-R por consenso de expertos. Se solicitó la participación de los miembros del grupo NADYA activos en los últimos 5 años bajo la premisa de estructurar el DAFO-R sobre las características del registro NADYA desde su inicio. Resultados: Han participado 18 expertos de diferentes hospitales de la geografía española. El análisis interno se inclina positivamente presentando al registro con recursos importantes. En el análisis externo no son numerosas las amenazas, hay factores de gran potencia, "la voluntariedad del registro" y la "dependencia externa de financiación". Las oportunidades identificadas son importantes. Las recomendaciones se dirigen a la estabilización del sistema disminuyendo las amenazas como foco principal de las estrategias a desarrollar al mismo tiempo que se debe potenciar los puntos identificados en oportunidades y fortalezas. Conclusiones: El registro NADYA se muestra en el análisis con gran potencialidad de mejora. Las recomendaciones propuestas deberán estructurarse para continuar la tendencia de desarrollo y perfeccionamiento de la calidad que ha caracterizado al registro NADYA desde su inicio (AU)

Objective: To evidence by means of a SWOT-R analysis performed by an expert consensus the most worrying characteristics of the register on Home-based and Outpatient Artificial Nutrition. Material and methods: SWOT-R analysis with expert consensus. We requested the participation of the active members of the NADYA group within the last 5 years with the premise of structuring the SWOT-R based on the characteristics of the NADYA registry from its beginning. Results: 18 experts from hospitals all over Spain have participated. The internal analysis seems to be positive, presenting the registry as having important resources. The external analysis did not show a great number of threats, there are very potent factors, "the voluntariness" of the registry and the "dependence on external financing". The opportunities identified are important. The recommendations are aimed at stabilizing the system by decreasing the threats as one of the main focus of the strategies to develop as well as promoting the items identified as opportunities and strengths. Conclusions: The analysis shows that the NADYA register shows a big potentiality for improvement. The proposed recommendations should be structured in order to stay on the track of development and quality improvement that has characterized the NADYA register from the beginning (AU)

[Laparoscopic bariatric surgery program in the University Clinic of Navarre - Hospital Complex of Navarre: results after 1-year follow-up]. / Programa de cirugía bariátrica laparoscópica en la clínica Universidad de Navarra-Complejo hospitalario de Navarra: resultados a un año.

BACKGROUND: The prevalence of obesity in Spain in recent years has shown an alarming increase. The repeated failure of balanced food patterns, physical activity, nutritional education and pharmacotherapy have led to the need to use bariatric surgery both to maintain long-term weight loss, and for the resolution of associated comorbidities. This article analyzes the initial results of the implementation of the laparoscopic bariatric surgery program in Navarre, obtained in a group of obese patients with surgical indication and operated on by means of the laparoscopic gastric bypass. METHODS: From January 2010 until December 2011, 47 gastric bypasses were performed laparoscopically in the University Clinic of Navarre, all of them from the autonomous community of Navarre and previously and subsequently evaluated in the Hospital Complex of Navarre. The first 19 cases amongst them were selected for this work, as they presented at least one year of follow-up. RESULTS: The percentage of excess weight lost was 65 .47%, with a 31.68% reduction of total weight. The figures for glucose, uric acid, arterial tension and lipid metabolism one year after the intervention presented a very significant progressive fall. No significant medical or surgical complications were presented. CONCLUSIONS: The laparoscopic gastric bypass is an efficient technique for the long-term treatment of morbid obesity, with a scant number of complications, excellent weight loss and curing or improvement of the associated comorbidities in these patients.

Características de los episodios de cetoacidosis diabética en adultos evaluados en el Servicio de Urgencias del Hospital General Universitario Gregorio Marañón durante el año 2002 / Characteristics of diabetic ketoacidosis episodes in adults evaluated in the emergency service of Gregorio Marañón Hospital in 2002

La cetoacidosis diabética es una de las urgencias endocrinológicas más frecuente y que, habitualmente, se asocia con la diabetes tipo 1. Estudios recientes1-3 confirman que la incidencia de esta complicación aguda está aumentando en los diabéticos tipo 2. En este estudio analizamos las características principales de los episodios de cetoacidosis diabética en pacientes adultos valorados en el Servicio de Urgencias del Hospital General Universitario Gregorio Marañón durante el año 2002. En una muestra de 46 episodios de cetoacidosis, 22 correspondieron a pacientes con diabetes tipo 1 y 24 a pacientes con diabetes tipo 2, con igual porcentaje de casos de inicio como de descompensación en ambos grupos. Se observó una diferencia significativa en cuanto a la edad, que fue menor en los pacientes con diabetes tipo 1, en cuanto a la gravedad y en la etiología desencadenante (AU)

Diabetic ketoacidosis is one of the most frequent endocrinological emergencies and is usually associated with type 1 diabetes. Recently, various publications have suggested that the incidence of this acute complication is increasing among type 2 diabetic patients. We analyzed the main characteristics of diabetic ketoacidosis events in adults evaluated at the Emergency Service of Gregorio Marañón Hospital in 2002. In a sample of 46 ketoacidosis episodes, 22 corresponded to type 1 diabetes and 24 to type 2. A similar percentage of events was found at onset and in known diabetes in both groups. Significant differences were observed in age, severity, and etiology (AU)

[Refeeding syndrome. A review]. / Síndrome de realimentación. Revisión.

Refeeding syndrome is a complex clinical picture that encompass all those alterations that can occur as a consequence of the nutritional support (oral, enteral or parenteral) in malnourished patients. Refeeding syndrome is classically characterized by neurological alterations, respiratory symptoms, cardiac arrhythmias and heart failure few days after beginning of refeeding, with life-threatening outcome. Its pathogenesis includes alterations in the corporal fluids, and in some electrolytes, minerals and vitamins. In this article a review of refeeding syndrome pathogenesis and clinical manifestations is carried out, with a final series of recommendations for lowering the risk of this syndrome and for facilitate the early diagnosis and the treatment.

Síndrome de realimentación. Revisión / Refeeding syndrome. A review

El síndrome de realimentación es un cuadro clínico complejo que engloba todas aquellas alteraciones que pueden ocurrir como consecuencia del soporte nutricional (oral, enteral o parenteral) en pacientes malnutridos. Clásicamente se caracteriza por la aparición de alteraciones neurológicas, r espiratorias, arritmias e insuficiencia cardíaca que ocurren pocos días después del inicio de la realimentación y que pueden tener un desenlace fatal. En su patogenia intervienen alteraciones en los fluidos corporales, en algunos electrolitos, minerales y vitaminas. En este artículo se hace una revisión de su patogenia y características clínicas, haciendo finalmente una serie de recomendaciones encaminadas a disminuir el riesgo de aparición, facilitar el diagnóstico precoz y el tratamiento

Refeeding syndrome is a complex clinical picture that encompass all those alterations that can occuras a consequence of the nutritional support (oral, enteral or parenteral) in malnourished patients. Refeeding syndrome is classically characterized by neurological alterations, respiratory symptoms, cardiac arrhythmias and heart failure few days after beginning of refeeding, with life-threatening outcome. Its pathogenesis includes alterations in the corporal fluids, and in some electrolytes, minerals and vitamins. In this article a review of refeeding syndrome pathogenesis and clinical manifestations is carried out, with a final series of recommendations for lowering the risk of this syndrome and for facilitate the early diagnosis and the treatment

Obesidad como factor de riesgo cardiovascular / Obesity as cardiovascular risk factor

La obesidad es una enfermedad metabólica crónica con riesgo cardiovascular asociado y una morbimortalidad aumentada. Actualmente el sobrepeso y la obesidad se consideran tan importantes como otros factores de riesgo clásico relacionados con la enfermedad coronaria. El tejido adiposo no sólo actúa como almacén de moléculas grasas, sino que sintetiza y libera a la sangre numerosas hormonas relacionadas con el metabolismo de principios inmediatos y la regulación de la ingesta. Asimismo, la obesidad se asocia a numerosos factores de riesgo cardiovasculares como dislipidemia, hipertensión, diabetes, marcadores inflamatorios y estado protrombótico. La pérdida de peso puede evitar la progresión de la placa de aterosclerosis y los eventos coronarios agudos en los sujetos obesos

Obesity is a chronic metabolic disease associated with cardiovascular risk and increased morbidity and mortality. Being overweighted and obese are now considered to be as important as other classic risk factors related to heart disease. Fatty tissue not only acts as stores of fat molecules but synthesizes and releases hormones to the blood which are related to the metabolism of basic food molecules and regulation of food intake. Likewise, obesity is associated with numerous cardiovascular risk factors such as dyslipidemia, hypertension, diabetes, inflammatory markers and prothrombotic state. Weight loss can prevent acute progression of atherosclerotic plaque and coronary events in obese subjects

Influence of hepatocyte-rich liver cell mixture and liver fibroblasts on prolonging graft islet survival in rats without immunosuppressive drugs.

BACKGROUND: We noted that a liver cell suspension, made up of a mixture of several kinds of hepatic cells, affected allogenic islet survival when it was transplanted into the liver, mixed with the islets or separately. AIM: To study if this effect was related to a liver cell mixture rich in hepatocytes (hp) or to liver fibroblasts (fb). METHODS: We studied 14 groups of rats: (A) a sham group with saline; (B) a group receiving transplantation with hepatic cells alone; (C) a control group, with islets alone via the portal vein, without hepatic cells (hp or fb). For the other groups, we used a different ratio of cells/islets (100 : 1, 150 : 1 and 200 : 1) and different co-transplantation techniques with both types of cells. For the D, E, J groups, a mixture of hepatocytes (hepatocyte-rich liver cell mixture) or fibroblasts with islets was injected into the portal vein. For the other groups, we used a sequential procedure with a 15 minute interval between a first injection of hp or fb into the portal vein or into the vena cava, and a second injection of islets always into the portal vein; thus, it was a sequential portal/portal procedure with hepatocyte-rich liver cell mixture (hp) (F, G) or fibroblasts (K, L) and a sequential cava/portal with hp (H, I) or fibroblasts (M, N). RESULTS: Most of the co-transplantation groups showed functional islets (blood glucose < 250 mg/dl) on the first or second day of transplantation; after several days they once again had high glucose levels, though not as high as pre-transplantation. There was statistical significance (p < 0.001) between the presence or not of hepatic cells to obtain prolongation of graft survival (blood glucose < 250 mg/dl). Statistical significance (p < 0.001) was found for several sequential groups with hp (F, I) and fb (K, L). It was also remarkable that 3 rats (37.5 %) from the I group (sequential cava/portal with hp/islets 200 : 1) were euglycemic (blood glucose < 150 mg/dl) for more than 3 months. ANOVA showed a large interaction between the type of transplant performed and the cellular ratio used, with a significance of p < 0.001. Histological studies in rats with prolonged euglycemia, showed insulin-producing cell aggregates in the liver, while there was a remarkable decrease in insulin-producing cells in the remaining islets of pancreatic tissue. CONCLUSION: The results showed a marginal prolongation of islet graft survival when they are co-transplanted with a hepatocyte-rich liver cell mixture or with liver fibroblasts. The mechanism does not seem to be a cellular interaction between different hepatic cells and islets, but some kind of cellular interaction or released factor from either two cell types on the immune system, blocking or modulating it, at least temporarily.

[Bariatric surgery: an update]. / Cirugía bariátrica: situación actual.

The indication of bariatric surgery as therapeutic procedure for morbid obese patients requires the application of selection criteria which deal with the degree of obesity, associated complications and previous failure of conventional therapy. Alcohol or drug addiction and concomitant serious disease are contraindications for bariatric surgery. Before operation, a full assessment is needed to identify possible eating behaviour disturbances and associated comorbidity such as cardiovascular disease, sleep apnoea, metabolic and psychiatric alterations which might induce intra and postoperative complications. Surgical techniques can be classified as restrictive, malabsortive and mixed procedures. Gastroplasty and adjustable gastric banding are restrictive techniques, which are indicated in obese patients with body mass index less than 45 kg/m2. Mixed techniques are the most used procedures. They include gastric by-pass which causes a reduction of 60-70% of weight excess, biliopancreatic diversion and duodenal switch which can eliminate a 75% of body weight excess. Following bariatric surgery a dramatic improvement in associated comorbidity can be demonstrated, specially in what refers to diabetes, hypertension, dislipidaemia and apnoea. Postoperative mortality is around 1-2%. Peritonitis and venous thromboembolism are the most serious complications. Postoperative follow-up should be lifelong and requires a progressive nutrition planning and vitamin supplementation.

[Incidental diagnosis of medullary thyroid carcinoma (MTC) after performing 123I-metaiodobenzylguanidine (123I-MIBG) gammagraphy]. / Diagnóstico de carcinoma medular de tiroides (CMT) de forma casual tras realización de gammagrafía 123I-metayodobencilguanidina (123I-MIBG).

UNLABELLED: The objective of this clinical note is to emphasize diagnostic efficiency of 123I-MIBG scintigraphy in the initial diagnosis and follow-up of medullary thyroid carcinoma within MEN2. MATERIALS AND METHODS: We present the case of a patient who, during a scintigraphic study with 123I-MIBG for the diagnosis of pheochromocytoma, was unexpectedly found to suffer from medullary carcinoma of the thyroid. Prior to performing the test, we proceeded to block uptake into the thyroid gland through the administration of Lugol. We carried out the scintigraphic study by intravenously injecting 370 MBq 123I-MIBG. RESULTS: A pathological uptake of the radiopharmaceutical compound over the right suprarenal gland, and unexpectedly, over the thyroid gland was detected, thus confirming the existence of medullary carcinoma of the thyroid in this patient, and obtaining the diagnosis of Type MEN2A polyglandular syndrome. CONCLUSIONS: From our experience, we can manifest the value of scintigraphy using 123I-MIBG in the diagnosis and localization of medullary carcinoma of the thyroid. Furthermore, it is indicated in patients suspected of MEN, since it makes it possible to reach a diagnosis of this kind of syndrome through the performance of just one test.

Detección de diabetes gestacional en población general: rentabilidad diagnóstica de la aplicación de los criterios de la ADA en una zona sanitaria de Madrid / No disponible

Nos planteamos conocer la utilidad de una estrategia selectiva para el diagnóstico de diabetes gestacional (DG) en nuestro medio, como la recomendada en el IV International WorkshopConference on Gestational Diabetes Mellitus. Con este fin, durante un año en todas las gestantes, se registró: edad, índice de masa corporal (IMC) pregestacional, antecedentes personales o familiares de diabetes y complicaciones obstétricas previas. Se realizó test de O´Sullivan; si el resultado era mayor de 140 mg/dl se efectuó una curva de glucemia. Cada enferma fue clasificada en uno de los tres grupos de riesgo siguiendo las recomendaciones de la ADA. Se estudiaron 369 gestantes de 29,6 ± 4 años (15,4% con menos de 25 años); 7,9% presentaban DG. Por grupos de riesgo la distribución fue: bajo 11,7%, medio 74,1%, alto 14,2%. La edad y el IMC eran superiores en DG (32,6 ± 3 años; 25,9 ± 3 kg/m 2 ) que en no-DG (29,3 ±4 años; 24,2 ± 4 kg/m ), p<0,001 y p<0,05 respectivamente. La aparición de DG en cada grupo fue: bajo 0%, medio 8,9%, alto 15,5%. El total de DG se distribuyeron 76% en medio y 24% en alto riesgo. En conclusión, la utilidad práctica, en nuestro medio, de la clasificación en grupos de riesgo de DG para limitar el número de test de despistaje es escasa (sólo se evitan el 11,7%). Si que puede ayudar para el diagnóstico precoz de casi la cuarta parte de las DG. Queda resaltada la importancia del control del peso en la prevención de DG (AU)

We try to konw how useful was a selective screening strategy for detecting gestational diabetes mellitus (GDM), as the one recommended by the IV International Workshop-Conference on Gestational Diabetes Mellitus, in our population. To this end we examined all the pregnant referred to obstetric clinic for one year and recorded: age, body mass index (BMI) before pregnancy, family history of diabetes and personal history of abnormal glucose control or poor obstetric outcome. O´Sullivan test was performed and, if the result was over 140 mg/dl, a 3-h 100-g glucose tolerance test was carry out. The sample was classified in three groups according to ADA recommendations. 369 women were studied, aged 29.6 ± 4 years (15.4% were less than 25 years), 7.9% were GDM. Distribution by groups was: low 11.7%, average 74.1%, and high 14.2%. Age and BMI were higher in GDM (32.6 ± 3 years; 25.9 ± 3 kg/m 2 ) than in non-GDM (29.3 ± 4 years; 24.2 ± 4 kg/m) p < 0.001 and p < 0.05 respectively. Frequency of GDM in each group was: 0% in low, 8.9% in average, 15.5% in high. The GDM were 76% in average group and 24% in high group. In summary: the classification in risk groups is not useful in order to limit the screening test (only 11.7% could be avoided). But this strategy can help to diagnose almost 25% of GDM. Weight control is very important in the GDM prevention (AU)

Influencia del cocultivo de islotes pancreáticos con células hepáticas sobre la liberación de insulina y sobre la implantación de los islotes en hígado sin inmunosupresión / Influence of co-culture of pancreatic islets with hepatic cells on insulin release and on implantation of islets in liver without immunosuppression

El objetivo de este trabajo es estudiar la influencia de las células hepáticas sobre la liberación de insulina cuando se co-cultivan con islotes, así como la influencia que puedan tener sobre la implantación de los islotes en el hígado en ratas Wistar, sin el empleo de drogas inmunosupresoras. In vitro tenemos 2 grupos: A) Cultivo de islotes solos y B) Co-cultivo de islotes y células hepáticas, ambos durante 7 días. Se realiza un estudio morfológico, numérico y de liberación de insulina. In vivo tenemos 7 grupos de Tx: A) Tx ficticio con suero fisiológico (4), B) Tx-ch solas (4), C) Tx-1 solos (6), D) Tx-I solos tras cultivo 7 días (5), E) Tx-1 co-cultivados con ch 24 h (5), F) Tx-I co-cultivados con ch 7 días (7) y G) Tx-I co-cultivados con ch 48 h, en placas transwell (5). La proporción de ch/I ha sido de 150:1. ENI ha sido de 1678 ñ 343 con pureza del 90 por ciento. Análisis de datos mediante el test de ANOVA del SPSS 8.0.In vitro: observamos una gran diversidad celular hepática, un descenso en el ENI durante el co-cultivo, sin embargo la insulino-liberación es mayor en los islotes co-cultivados con ch (p < 0.005). In vivo: Los días de euglucemia tras el Tx han sido: grupo A (0 ñ 0), B (0 ñ 0), C( 2.0 ñ 3.098), D 1.8 ñ 2.17), E (8.6 ñ 12.33), F (9.14 ñ 11.02) y G (0 ñ 0). Los resultados de E y F, confirman un efecto favorable de las ch sobre la implantación de los islotes alogénicos en hígado, consiguiéndose un 20 por ciento y un 14.3 por ciento de reversión de la diabetes. El resultado de G parece indicar la posibilidad de que más que una interacción celular entre las ch e islotes, se trate más bien de la secreción constante de algún producto, y este sea el responsable de la supervivencia de los islotes implantados en hígado. (AU)