Endovascular treatment of symptomatic intracranial arterial stenosis: six-year experience in a single-center series of 42 consecutive patients with acute and mid-term results.

BACKGROUND: The limitations of the medical management of symptomatic intracranial arterial stenosis encourage the development of new therapeutic strategies such as intracranial stenting. OBJECTIVE: To report and analyze the results of a series of 42 patients treated with 3 different endovascular techniques: isolated angioplasty, balloon-expandable coronary stents, and the Wingspan self-expandable intracranial stent system. METHODS: Forty-two patients presenting with symptomatic intracranial arterial stenosis were treated with one of these techniques. Computed tomography angiography was performed 6 months after the procedure, and the clinical neurological statuses were categorized using the modified Rankin Scale and the National Institutes of Health Stroke Scale. RESULTS: A total of 42 lesions were treated: 9 with isolated angioplasty, 14 with balloon-expandable coronary stents, and 19 with Wingspan self-expandable intracranial stents. The mean patient age was 62.9 years, and the mean arterial diameter stenosis was 73.9%. Technical success was achieved in 97.6% of the patients. The overall incidence of procedural complications was 21.4%, and the postoperative permanent morbidity/mortality rate was 7.1%. There were 3 cases of in-stent thrombosis (1 fatal) and 5 cases of asymptomatic restenosis (11.9%), 3 in the isolated angioplasty group and 2 in the Wingspan self-expandable intracranial stent group (mean follow-up 20.4 months). The rate of restenosis was higher in the angioplasty group (33%) than in the coronary (0%) and Wingspan stent (10.5%) groups. CONCLUSION: Endovascular treatment of symptomatic intracranial stenosis has significant overall morbidity and mortality rates. Nevertheless, the very critical natural history of severe refractory lesions and the relatively favorable postoperative evolution suggest that it should be considered the first alternative strategy in cases in which medical therapy has failed.

Averting inflammation by targeting the cytokine environment.

Cytokines are key instigators and regulators of immune responses and therefore hold great potential as targets for new therapeutic strategies. However, the selection of which cytokines to target, and in particular the identification of which cytokines regulate the rate-limiting steps of disease pathways, is crucial to the success of such strategies. Moreover, balancing the need for ablating pathological inflammatory responses and simultaneously maintaining the ability to control infectious agents is a key consideration. Recent advances in our understanding of cytokine networks, as well as technical progress in blocking cytokines in vivo, are likely to be a source for new drugs that can control chronic inflammatory diseases.

Confirmation of persistent radio jets in the microquasar LS 5039

We present here new observations conducted with the EVN and MERLIN of the persistent microquasar LS 5039 discovered by Paredes et al. (2000) with the VLBA. The new observations confirm the presence of an asymmetric two-sided jet reaching up to 1000 AU on the longest jet arm. The results suggest a bending of the jets with increasing distance from the core and/or precession. The origin and location of the high-energy gamma-ray emission associated with the system is discussed and an estimate of the magnetic field at the base of the jet given. Our results suggest a well collimated radio jet. We also comment on new observing strategies to be used with satellites and forthcoming detectors, since this persistent source appears to be a rather good laboratory to explore the accretion/ejection processes taking place near compact objects.

Asiakkuudenhallinnan kehittäminen tietojärjestelmiä tuottavassa ohjelmistoyrityksessä

Työssä on tutkittu asiakkuudenhallintaan liittyvää kirjallisuutta tarkoituksena löytää tekijöitä, joilla tietojärjestelmiä tuottavan ohjelmistoyrityksen asiakkuudenhallintaa voidaan kehittää. Samalla työn tarkoitus on nostaa esille tekijöitä, joihin työn kohteena olevassa yrityksessä tulisi keskittyä asiakkuudenhallinnan näkökulmasta tulevaisuuden toimintaa suunniteltaessa. Kirjallisuusosassa käsitellään asiakaslähtöistä toimintaa, asiakkuuden elinkaaren vaiheita, asiakkuuden arvoa yritykselle ja teoreettisia malleja asiakaskannan analysointiin. Tutkimuksen soveltavassa osassa käydään läpi kohdeyritystä ja sen toimintaa, sekä analysoidaan yrityksen asiakkaat ja muodostetaan analysoinnin perusteella asiakassalkkuja, jotka muodostavat kohdeyrityksen asiakasportfolion. Muodostettuja asiakasryhmiä käytetään hyväksi, kun muodostetaan uusia asiakastrategioita tuotekehitykseen, asiakaspalveluun ja myyntiin sekä markkinointiin.

Induced pluripotent stem cells as a promising tool to study the effect of interleukin-22 in multiple sclerosis

La sclérose en plaques (SEP) est une maladie démyélinisante du système nerveux central (SNC) provoquant des pertes motrices, sensitives et cognitives. La SEP se déclare chez le jeune adulte ayant des prédispositions génétiques, mais semble induite, par des facteurs environnementaux. La SEP touche principalement les femmes et sa prévalence dans les zones à haut risque, tel que la Suisse, est de 0.1%. Bien que son étiologie exacte reste méconnue, nous savons que la maladie est médiée par des lymphocytes T autoréactifs périphériques, qui infiltrent le SNC où ils activent d'autres cellules immunitaires ainsi que les cellules du SNC elles-mêmes, créant un foyer inflammatoire, qui va attaquer et finir par tuer les oligodendrocytes et les neurones. Les épisodes inflammatoires sont entrecoupés par des phases de rémission associées à une guérison partielle des lésions. Cette première phase de la maladie, comprenant des épisodes inflammatoires et de rémissions est appelé SEP récurrente-rémittente (SEP-RR) et touche 90% des patients. Elle évolue, dans deux-tiers des cas, vers une SEP secondaire progressive (SEP-SP), qui est caractérisée par une progression constante de la maladie, associée à une réduction de l'inflammation mais une augmentation de la neurodégénérescence. Les patients souffrants de SEP primaire progressive (SEP-PP) développent directement les symptômes de la phase progressive de la maladie. Les thérapies disponibles ont considérablement amélioré l'évolution de la maladie des patients SEP-RR, en agissant sur une diminution de la réponse immunitaire et donc de l'inflammation. Cependant, ces traitements sont inefficaces chez les patients SEP-SP et SEP-PP, n'agissant pas sur la neurodégénérescence. IL-22, une cytokine sécrétée notoirement par les cellules Th17, a été associée à la SEP en contribuant à la perméabilisation de la barrière hémato-encéphalique et à l'inflammation du SNC, qui sont des étapes clés de la pathogenèse de la maladie. En outre, le gène codant pour un inhibiteur puissant d'IL- 22, 'IL-22 binding protein' (IL-22BP), a été démontré comme un facteur de risque de la SEP. Ces indices nous ont poussés à nous intéresser de plus près au rôle de l'IL-22 dans la SEP. Nous avons pu montrer qu'IL-22 et IL-22BP étaient augmentées dans le sang des patients SEP par rapport à des sujets sains. Nous avons trouvé qu'IL-22 cible spécifiquement les astrocytes dans le SNC et que son récepteur est particulièrement exprimé dans les lésions des patient SEP. Contre toute attente, nous avons pu montrer que l'IL-22 semble soutenir la survie des astrocytes. Cette découverte, suggérant qu'IL-22 serait protecteur pour le SNC et pour la SEP, confirme de récentes publications et ouvre la voie à de potentielles applications thérapeutiques. En parallèle, dans le but de mieux comprendre l'immunopathogenèse de la SEP, nous avons développé les techniques de culture de cellules souches pluripotentes induites (iPSC). Nos iPSC sont dérivées du sang des donneurs et acquièrent toutes les propriétés des cellules souches embryonnaires après induction. Les iPSC peuvent ensuite être différenciées en différents types de cellules, dont les cellules du SNC. Nous avons ainsi pu obtenir avec succès des neurones, dérivés de cellules du sang, en passant par le stade des iPSC. La prochaine étape consiste à générer des cultures d'astrocytes et d'oligodendrocytes et ainsi obtenir les principales cellules du SNC, le but étant de former de véritables 'cerveaux-en-culture'. Cet outil semble particulièrement adapté à l'étude de l'activité de diverses molécules sur les cellules du SNC, comme par exemple l'IL-22 et d'autres molécules ayant un potentiel intérêt thérapeutique au niveau du SNC. Le but ultime étant de développer des co-cultures de cellules du SNC avec des cellules immunitaires autologues, de patients SEP et de sujets sains, afin de mettre en évidence l'attaque des cellules du SNC par des leucocytes autoréactifs. Ce projet prospectif a permis d'accroître nos connaissance sur des aspects immunitaires de la SEP et à pour but de mieux comprendre l'immunopathogenèse de la SEP afin d'élaborer de nouvelles stratégies thérapeutiques. -- La sclérose en plaques est une maladie auto-inflammatoire du système nerveux central conduisant à la destruction de la myéline, indispensable à la conduction nerveuse, et finalement à la mort des neurones eux-mêmes. Cela a pour conséquence des pertes motrices, sensorielles et cognitives, qui ont tendance à s'aggraver au fil de la maladie. Elle se déclare chez le jeune adulte, entre l'âge de 20 et 40 ans, et prédomine chez la femme. En Suisse, environ une personne sur l'OOO est atteinte de sclérose en plaques. Les causes exactes de cette maladie, qui incluent des facteurs génétiques et environnementaux, sont encore mal connues. Des traitements de plus en plus efficaces ont été développés ces dernières années et ont permis de drastiquement améliorer l'évolution de la maladie chez les patients atteints de sclérose en plaques. Cependant, ces traitements ne sont efficaces que sur certaines catégories de patients et peuvent engendrer de lourds effets secondaires. Ces thérapies agissent presque exclusivement sur les cellules du système immunitaire en les désactivant partiellement, mais pas sur les cellules nerveuses, qui sont pourtant celles qui conditionnent le devenir du patient. Le développement de médicaments protégeant ou permettant la régénération des cellules du système nerveux central est donc primordial. L'étude de l'interleukine-22 nous a permis de montrer que cette cytokine ('hormone' du système immunitaire) pouvait cibler spécifiquement les astrocytes, des cellules gliales qui jouent un rôle central dans le maintien de l'équilibre du système nerveux central. Nos recherches ont montré que cette interleukine-22 permettrait une meilleure survie des astrocytes durant la phase aiguë de la maladie et aurait aussi des propriétés neuroprotectrices. En parallèle, nous sommes en train de développer un nouveau modèle in vitro d'étude de la sclérose en plaques grâce à la technologie des cellules souches pluripotentes induites. Ces cellules souches sont induites à partir de cellules du sang du donneur et acquièrent toutes les caractéristiques des cellules souches embryonnaires présentes dans un organisme en formation. Ainsi, ces cellules souches pluripotentes ont, par exemple, la capacité de se différencier en cellules du système nerveux central. Nous avons pu, de cette manière, obtenir des neurones. Le but ultime serait de pouvoir reconstituer une ébauche de cerveau in vitro, en cultivant ensemble différents types de cellules du système nerveux central, afin d'y réaliser des expériences avec des cellules immunitaires du même donneur. Ces travaux ont pour but d'améliorer notre compréhension de la pathogenèse de la sclérose en plaques et de permettre le développement de nouvelles stratégies thérapeutiques. --Multiple sclerosis (MS) is a demyelinating disease of the central nervous system leading to cognitive, sensitive and motor disabilities. MS occurs in genetically predisposed young adults with probable environmental triggers. MS affects predominantly women and its prevalence in high risk area such as Switzerland is 0.1%. Though its exact aetiology remains undetermined, we know that autoreactive T cells from de periphery are reactivated and recruited into the central nervous system (CNS) were they further activate other immune cells and resident cells, creating inflammatory foci, where oligodendrocytes and neurons are insulted and, eventually, killed. Inflammatory episodes, called relapses, are interspersed with remission phases where partial recovery of the lesions occurs. This first phase of the disease, occurring in 90% of the patients, is called relapsing-remitting MS (RR-MS) and is leading, in two-third of the cases, to secondary-progressive MS (SP-MS), where there is a continuous steady progression of the disease, associated with reduced inflammation but increased neurodegeneration. Primary-progressive MS (PP-MS) patients experience directly this progressive phase of the disease. Whereas disease modifying therapies have dramatically ameliorated the disease course of RR-MS patients by dampening immunity and, in turn, inflammation, treatments of SP-MS and PP-MS patients, who suffer primarily from the neurodegenerative aspect of the disease, are still inexistent. IL-22, a pro-inflammatory Th17 cell cytokine, has been associated with MS by participating to blood-brain barrier infiltration and CNS inflammation, which are crucial steps in MS pathogenesis. In addition, the gene coding for IL-22 binding protein (IL-22BP), which is a potent secreted IL-22 inhibitor, has been associated with MS risk. These findings call for further investigation on the role of IL-22 in MS. We detected increased IL-22 and IL-22BP in the blood of MS patients as compared to healthy controls. Acting exclusively on cells of nonhematopoietic origin, we found that IL-22 targets specifically astrocytes in the CNS and that its receptor is highly expressed in the lesion of MS patients. Unexpectedly, we found that IL-22 seems to promote survival of astrocytes. This finding, suggesting that IL-22 might be protective for the CNS in the context of MS, is consistent with recent publications and might open putative therapeutic applications at the CNS level. In parallel, with the aim of better understanding the immunopathogenesis of MS, we developed induced pluripotent stem cell (iPSC) techniques. IPSC are derived from blood cells of the donors and bear embryonic stem cell properties. IPSC can be differentiated into various cell types including CNS cells. We successfully obtained neurons derived from the donor blood cells, through iPSC. We further aim at developing astrocytes and oligodendrocytes cultures to recreate a 'brain-in-a-dish'. This would be a powerful tool to test the activity of various compounds on CNS cells, including IL-22 and other putative neuroprotective drugs. Ultimately, the goal is to develop co-cultures of CNS cells with autologous immune cells of MS patients as well as healthy controls to try to expose evidence of CNS cells targeted by autoreactive leukocytes. This prospective project has increased our knowledge of immune aspects of MS and further aims at better understanding the immunopathology of MS in order to pave the way to the elaboration of new therapeutic strategies.

Tukiverkosto yrityksen perustamisessa. Case loviisalaiset yrittäjät

Tavoitteena tutkimuksessani oli saada selville, mistä pienen kaupungin uudet pienyrittäjät hakevat ja saavat neuvoja yrityksen perustamisvaiheissa. Olen myös kartoittanut yrittäjän perustamispäätöksen taustaa ja idean lähdettä. Tutkimukseni alkoi kyselylomakkeen lähettämisellä koko tutkimuksen kohdejoukolle. Tutkimusongelman hahmotuttua valitsin tutkimustavaksi teemahaastattelun. Haastattelin yhteensä yhdeksää uutta yrittäjää vuosilta 1998 ja 1999. Kohderyhmä koostui eri sukupuolta olevista ja eri ikäisistä henkilöistä. Yleisesti ottaen yrittäjien tukiverkostot olivat melko laajoja. Neuvoja haettiin ahkerimmin uusyrityskeskuksesta ja kirjanpitäjiltä. Perheellä ja tuttavilla on myös roolinsa tukiverkostossa. Näyttäisi siltä, että nuoremmat yrittäjät ovat ahkerampia neuvojen kyselijöitä kuin vanhemmat. Tutkimuksen tulosten valossa näyttäisi siltä, että uusi yrittäjä saa tarvitsemansa tuen ja avun

Further molecular profiling of tumors harboring therapeutic targets within non-small cell lung cancer

Background: Treatment of NSCLC has been revolutionized in recent years with the introduction of several targeted therapies for selected genetically altered subtypes of NSCLC. A better understanding of molecular characteristics of NSCLC, which features common drug targets, may identify new therapeutic options. Methods: Over 6,700 non-small cell lung cancer cases referred to Caris Life Sciences between 2009 and 2014. Diagnoses and history were collected from referring physicians. Specific testing was performed per physician request and included a combination of sequencing (Sanger, NGS or pyrosequencing), protein expression (IHC), gene amplification/rearrangement (CISH or FISH), and/or RNA fragment analysis. Results: Tumors profiles from patients with hormone receptor positive disease (HER2, ER, PR, or AR positive by IHC) (n=629), HER2 mutations (n=8) ALK rearrangements (n=55), ROS1 rearrangement (n=17), cMET amplification or mutation (n=126), and cKIT mutation (n=11) were included in this analysis and compared to the whole cohort. Tumors with ALK rearrangement overexpressed AR in 18% of cases, and 7% presented with concomitant KRAS mutation. Lower rates of PTEN loss, as assessed by IHC, were observed in ALK positive (20%), ROS1 positive (9%) and cKIT mutated tumors (25%) compared to the overall NSCLC population (58%). cMET was overexpressed in 66% of ROS1 translocated and 57% of HER2 mutated tumors. cKIT mutations were found co-existing with APC (20%) and EGFR (20%) mutations. Pathway analysis revealed that hormone receptor positive disease carried more mutations in the ERK pathway (32%) compared to 9% in the mTOR pathway. 25% of patients with HER2 mutations harbored a co-existing mutation in the mTOR pathway. Conclusions: Pathway profiling reveals that NSCLC tumors present more often than reported with several concomitant alterations affecting the ERK or AKT pathway. Additionally, they are also characterized by the expression of potential biological modifiers of the cell cycle like hormonal receptors, representing a rationale for dual inhibition strategies in selected patients. Further refining of the understanding of NSCLC biomarker profile will optimize research for new treatment strategies.

Animal modelling for inherited central vision loss.

Disease-causing variants of a large number of genes trigger inherited retinal degeneration leading to photoreceptor loss. Because cones are essential for daylight and central vision such as reading, mobility, and face recognition, this review focuses on a variety of animal models for cone diseases. The pertinence of using these models to reveal genotype/phenotype correlations and to evaluate new therapeutic strategies is discussed. Interestingly, several large animal models recapitulate human diseases and can serve as a strong base from which to study the biology of disease and to assess the scale-up of new therapies. Examples of innovative approaches will be presented such as lentiviral-based transgenesis in pigs and adeno-associated virus (AAV)-gene transfer into the monkey eye to investigate the neural circuitry plasticity of the visual system. The models reported herein permit the exploration of common mechanisms that exist between different species and the identification and highlighting of pathways that may be specific to primates, including humans.

Integrating quantitative proteomics and metabolomics in a cellular model of diabetic retinopathy

Diabetic retinopathy is the leading cause of visual loss in individuals under the age of 55. Most investigations into the pathogenesis of diabetic retinopathy have been concentrated on the neural retina since this is where clinical lesions are manifested. Recently, however, various abnormalities in the structural and secretory functions of retinal pigment epithelium that are essential for neuroretina survival, have been found in diabetic retinopathy. In this context, here we study the effect of hyperglycemic and hypoxic conditions on the metabolism of a human retinal pigment epithelial cell line (ARPE-19) by integrating quantitative proteomics using tandem mass tagging (TMT), untargeted metabolomics using MS and NMR, and 13C-glucose isotopic labeling for metabolic tracking. We observed a remarkable metabolic diversification under our simulated in vitro hyperglycemic conditions of diabetes, characterized increased flux through polyol pathways and inhibition of the Krebs cycle and oxidative phosphorylation. Importantly, under low oxygen supply RPE cells seem to consume rapidly glycogen storages and stimulate anaerobic glycolysis. Our results therefore pave the way to future scenarios involving new therapeutic strategies addressed to modulating RPE metabolic impairment, with the aim of regulating structural and secretory alterations of RPE. Finally, this study shows the importance of tackling biomedical problems by integrating metabolomic and proteomics results.

L’aprenentatge de càlcul mental a través de jocs a un aula d’educació primària

Aquest treball es basa en identificar les estratègies de càlcul mental que fan servir alumnes de quart de primària. Aquesta identificació es realitza a partir de la resolució d’operacions per part dels alumnes i el seu posterior anàlisi. A partir de les estratègies que hagin sorgit, es realitzarà una intervenció didàctica basada en jocs matemàtics per tal de descobrir i treballar noves estratègies matemàtiques. Finalment, amb una nova prova es comprovarà si els nens i nenes coneixen i apliquen diferents estratègies pel càlcul mental. Amb aquesta intervenció es pretén comprovar si a partir de jocs els nens i nenes milloren les estratègies de càlcul mental.

Activation of p53 by nutlin-3a induces apoptosis and cellular senescence in human glioblastoma multiforme

Glioblastoma multiforme (GBM) is the most common and aggressive primary brain tumor in adults. Despite concerted efforts to improve current therapies and develop novel clinical approaches, patient survival remains poor. As such, increasing attention has focused on developing new therapeutic strategies that specifically target the apoptotic pathway in order to improve treatment responses. Recently, nutlins, small-molecule antagonists of MDM2, have been developed to inhibit p53-MDM2 interaction and activate p53 signaling in cancer cells. Glioma cell lines and primary cultured glioblastoma cells were treated with nutlin-3a. Nutlin-3a induced p53-dependent G1- and G2-M cell cycle arrest and apoptosis in glioma cell lines with normal TP53 status. In addition, nutlin-arrested glioma cells show morphological features of senescence and persistent induction of p21 protein. Furthermore, senescence induced by nutlin-3a might be depending on mTOR pathway activity. In wild-type TP53 primary cultured cells, exposure to nutlin-3a resulted in variable degrees of apoptosis as well as cellular features of senescence. Nutlin-3a-induced apoptosis and senescence were firmly dependent on the presence of functional p53, as revealed by the fact that glioblastoma cells with knockdown p53 with specific siRNA, or cells with mutated or functionally impaired p53 pathway, were completely insensitive to the drug. Finally, we also found that nutlin-3a increased response of glioma cells to radiation therapy. The results provide a basis for the rational use of MDM2 antagonists as a novel treatment option for glioblastoma patients.

Activation of p53 by nutlin-3a induces apoptosis and cellular senescence in human glioblastoma multiforme

Glioblastoma multiforme (GBM) is the most common and aggressive primary brain tumor in adults. Despite concerted efforts to improve current therapies and develop novel clinical approaches, patient survival remains poor. As such, increasing attention has focused on developing new therapeutic strategies that specifically target the apoptotic pathway in order to improve treatment responses. Recently, nutlins, small-molecule antagonists of MDM2, have been developed to inhibit p53-MDM2 interaction and activate p53 signaling in cancer cells. Glioma cell lines and primary cultured glioblastoma cells were treated with nutlin-3a. Nutlin-3a induced p53-dependent G1- and G2-M cell cycle arrest and apoptosis in glioma cell lines with normal TP53 status. In addition, nutlin-arrested glioma cells show morphological features of senescence and persistent induction of p21 protein. Furthermore, senescence induced by nutlin-3a might be depending on mTOR pathway activity. In wild-type TP53 primary cultured cells, exposure to nutlin-3a resulted in variable degrees of apoptosis as well as cellular features of senescence. Nutlin-3a-induced apoptosis and senescence were firmly dependent on the presence of functional p53, as revealed by the fact that glioblastoma cells with knockdown p53 with specific siRNA, or cells with mutated or functionally impaired p53 pathway, were completely insensitive to the drug. Finally, we also found that nutlin-3a increased response of glioma cells to radiation therapy. The results provide a basis for the rational use of MDM2 antagonists as a novel treatment option for glioblastoma patients.

A Química na agricultura: perspectivas para o desenvolvimento de tecnologias sustentáveis

Food production and preservation of the environment are among the challenges faced by contemporary society. In Brazil, as in most parts of the world, the possibility of increasing the agricultural area is limited by several factors. Thus, an increase in productivity through the application of innovative technologies is regarded as the best solution to overcome such a problem. For long, chemistry has contributed to agricultural innovations such as synthetic pesticides for pest management. However, due to the well-known adverse effects of these compounds, new "greener" strategies are being explored. Research in chemical ecology, in combination with other emerging sciences, is leading to the development of new technologies such as plant-based pesticides (biopesticides); synthetic pheromones and plant volatile organic compounds, both of them to manipulate insect behavior; chemical elicitors to boost plant resistance; and genetic engineering of plant varieties. In these, chemistry plays an important role in the identification and synthesis of functional compounds. These techniques may be incorporated in integrated pest management programs and may contribute to a sustainable agriculture in the future.

Luottamuksen rooli sidosryhmäyhteistyössä - Case: uuden teollisen yrityksen perustaminen

This study examines the role of trust in collaboration between stakeholders when establishing a new industrial company in Finland. Small and medium size company has been established about four years ago and nowadays it employs some tens of employees. Company is handled in this study as anonymous. Growth of the company has been fast, which means that stakeholder collaborations have been successful. The aim of the study is to examine what is the relation between trust and risk while establishing a new company. Secondly, the study examines what are the key expectations of the trust of new company. Third aim of this study is to examine how founders could build up trust among stakeholders The theoretical part of this qualitative research was done by using the theme interviews. The empirical material consisted of theme interviews of 8 persons, who are representing stakeholders of the new industrial company. The results of this study suggest that, when establishing an industrial company with aggressive growth plan, process is vulnerable and trust is having an important role. Stakeholders made some risk studies comparing to trust. Stakeholders were dependent of each others. Founder team consisted of trusted persons, which helped to have success in establishment process. Members of founder team have created all the elements of trust: honest, technical competence and attitude & behavior.

Damage control surgery: it's evolution over the last 20 years

In less than twenty years, what began as a concept for the treatment of exsanguinating truncal trauma patients has become the primary treatment model for numerous emergent, life threatening surgical conditions incapable of tolerating traditional methods. Its core concepts are relative straightforward and simple in nature: first, proper identification of the patient who is in need of following this paradigm; second, truncation of the initial surgical procedure to the minimal necessary operation; third, aggressive, focused resuscitation in the intensive care unit; fourth, definitive care only once the patient is optimized to tolerate the procedure. These simple underlying principles can be molded to a variety of emergencies, from its original application in combined major vascular and visceral trauma to the septic abdomen and orthopedics. A host of new resuscitation strategies and technologies have been developed over the past two decades, from permissive hypotension and damage control resuscitation to advanced ventilators and hemostatic agents, which have allowed for a more focused resuscitation, allowing some of the morbidity of this model to be reduced. The combination of the simple, malleable paradigm along with better understanding of resuscitation has proven to be a potent blend. As such, what was once an almost lethal injury (combined vascular and visceral injury) has become a survivable one.