\r\n\tDiagnosis and management of complications while on ECMO therapy and weaning to recovery or advanced therapies will be also discussed.
\r\n\r\n\tChapters focusing on specific patient populations, such as cardiogenic shock, thoracic organ transplantation, trauma, and neonates, Covid-19 syndrome, will provide insight into the particular challenges in dealing with the unusual problems of these very diverse groups.
\r\n\r\n\tThe goal of this book is to provide, thanks to the thorough contributions by known experts in the field, a framework for successful program development. Hopefully, this text will also inspire others to further advance this delicate field.
",isbn:"978-1-80356-549-1",printIsbn:"978-1-80356-548-4",pdfIsbn:"978-1-80356-550-7",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"254c18981115aeda50bdf71829902141",bookSignature:"Dr. Antonio Loforte",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11718.jpg",keywords:"Heart Failure, Cardiogenic Shock, Respiratory Failure, Circulatory Failure, End-Organ Dysfunction, VA-ECMO, VV ECMO, Central ECMO, ECMO Running, Weaning off ECMO, Adverse Events While on ECMO, Survival on ECMO",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 10th 2022",dateEndSecondStepPublish:"April 7th 2022",dateEndThirdStepPublish:"June 6th 2022",dateEndFourthStepPublish:"August 25th 2022",dateEndFifthStepPublish:"October 24th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"3 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dr. Loforte is a dedicated and pioneering researcher in the surgical treatment of advanced heart failure in terms of LVAD, BVAD, ECLS, and TAH adoption in different clinical scenarios. He is a member of several professional organizations including the prestigious STS, ISHLT, ASAIO, EACTS, RHICS, SICCH, SITO, ELSO, and ESOT among others. His bibliography lists over 150 peer-reviewed original articles, 250 abstracts (communications) for international meetings, 20 book chapters, and 8 manuals.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"42172",title:"Dr.",name:"Antonio",middleName:null,surname:"Loforte",slug:"antonio-loforte",fullName:"Antonio Loforte",profilePictureURL:"https://mts.intechopen.com/storage/users/42172/images/system/42172.jpg",biography:"Dr. Loforte is currently staff surgeon and chair of the Mechanical Circulatory Support (MCS) program at the Department of Cardiothoracic, Transplantation and Vascular Surgery, S. Orsola Hospital, ALMA Mater Studiorum University of Bologna, IRCCS Bologna, Italy. He completed his cardiothoracic surgery recidency at the University of Bologna, S. Orsola Hospital (Italy), at St. Antonius Ziekenhuis, Nieuwegein (the Netherlands) and the Deutsches Herzzentrum Berlin (Germany). He additionally joined the Michael E. DeBakey Department of Surgery, Division of Transplant and Assist Devices, in Houston, Texas, USA.\nDr. Loforte is a member of several professional organizations including the prestigious STS, ISHLT, ASAIO, EACTS, RHICS, SICCH, SITO, ELSO, ESOT among others. His bibliography lists over 150 peer-reviewed original articles, 250 abstracts (communications) for international meetings, 20 book chapters, and 8 manuals. He serves as a reviewer for 25 international journals and is part of the editorial board in 10 of them. He received a ‘European Ph.D. label’ in Organ Transplantation and ten international awards in Europe and USA.",institutionString:"Division of Cardiac Surgery, S. 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With the progress of technology, new materials about growth factors are entering our lives. Tissue engineering is currently working hard to develop regenerative materials. The health sector and tissue engineering benefit from each other in this respect.
\nFirst-generation platelet concentrate platelet-rich plasma (PRP) was used as a biomaterial to speed up the process of healing of the tissues. PRP contains high concentrations of platelets and growth factors in the low-volume plasma. These growth factors stimulate cell proliferation, matrix formation, and angiogenesis [1].
\nIn 2001, platelet-rich fibrin (PRF), a second-generation platelet concentrate product, was developed in France, which was first developed for use in oral and maxillofacial surgery [2]. PRF preparation technique is based on the principle of collecting platelets and growth factors in the fibrin matrix by centrifuging venous blood from the patient. There are many forms of PRF materials such as P-PRF, L-PRF, A-PRF, I-PRF, and T-PRF used in oral and maxillofacial surgery.
\nPlatelets are cytoplasmic fragments of mature megakaryocytes in bone marrow. They are responsible for tissue regeneration by clotting, at the onset of wound healing, and by growth factors released from alpha granules. They are isolated from peripheral blood vessels [3].
\nBecause of their short lifespan, the megakaryocytes should produce about 1.5–4 × 1010 platelets per day to keep the platelet count in the normal blood count at 1.5–4.5 × 105 per microlitre (μL) of blood [4].
\nIn 1960s, the interaction between platelets and endothelial cells supporting capillary endothelin integrity was revealed [5, 6]. Initial work by Folkman and colleagues used autologous PRP-augmented media to feed microvascular endothelial cells to enhance vascular integrity preservation in organs subjected to perfusion for transplantation. It has been determined that human platelet lysate (HPL) was prepared by repeated freezing/thawing cycles throughout the 1980s, and cell lines and primer fibroblasts were promoted by fresh blood or old platelet concentrates [7, 8, 9].
\nPlatelets are quite active in terms of metabolism. Growth factors were released by platelet function with the phenomenon of “activation of macrophages by an increase in connective tissue healing, bone regeneration and repair, mitogenesis of fibroblasts, and angiogenesis of the wound area” by stimulating cell proliferation [10, 11].
\nAfter the resulting tissue damage, the platelets appear and the basal membrane of the collagen capillaries and the subendothelial microfibrils directly change shape. The alpha granules in the platelets engage the cell plasma membrane and release protein contents around with activation [11].
\nIf the defects are small, platelet clotting is sufficient, and large wounds may require blood clots. The blood clot is activated from intrinsic and extrinsic pathways. “Intrinsic pathway” begins when there is a change in tissue damage or in blood. The “extrinsic pathway” begins with blood contact with factors other than blood, such as damaged tissue. Although they start differently in two ways, they converge on the next steps and share the reaction series. Coagulation in the presence of calcium and thrombin occurs by fibrinogen polymerization of fibrinogen monomers. The fibrin clot also provides a matrix environment for migration of fibroblasts and other tissue-forming cells, including endothelial cells, other than hemostasis [12].
\nWound healing is a complex but a controlled mechanism regulated by growth factors and extracellular matrix.
\nHealing stages are:
hemostasis,
inflammation,
proliferation (granulation and contraction), and
remodeling (maturation) [13].
Platelets behave like workers who close the damaged gas and water lines and seal damaged blood vessels. Blood vessels react to injury by vasoconstriction, but this spasm ends loosely. Thrombocytes secrete vasoconstrictor substances to facilitate this process, but this is not the main role. The primary role of platelets is to form clots. Adenosine diphosphate (ADP) leaks from damaged tissues. Platelets adhering to type 1 collagen, which is activated by ADP, thus become active. They are viscous glycoproteins that secrete and cause platelet aggregation [14]. At the same time, thrombocytes secrete factors that interact with and stimulate intracellular coagulation by intrinsic thrombin production, which initiates fibrinogen to fibrin. Platelets also secrete platelet-derived growth factors, known as one of the initiating factors for the healing process.
\nInflammation is clinically associated with pain, swelling, temperature, and erythema, occurring between the first and fourth days after injury. Neutrophils perform their first defense against infection by phagocytosing existing debris and microorganisms. When the neutrophils digest bacteria and debris, they complete their task and die.
\nIn wound repair, communication between soluble proteins and cells is ensured. These soluble proteins are growth factors and cytokines released by the cell. The role of the extracellular matrix in wound healing is activation of platelets, epithelial migration, and interaction with cells through receptors called integrins that lead to the movement of fibroblasts [15].
\nMacrophages secrete bacterial phagocytes and extracellular enzymes, to break down necrotic tissues and form the second line of defense. Secreted extracellular enzymes and matrix metalloproteinases (MMP) are calcium and zinc sources for the active site. MMP is responsible for necrotic tissue removal and repair of damaged tissue. MMP metalloproteinases are inactivated by tissue inhibitors (TIMPs) and uncontrolled activities are counterbalanced. Macrophages, fibroblast growth factor, epidermal growth factor, transforming growth factor-beta (TGF-β) and interleukin 1, etc. stimulate proliferation by secretion of cytokines and growth factors [16].
\nProliferation begins after the injury of tissues and continues until the size of the wound and the systemic condition of the patient is up to 21 days in acute injuries. Characteristically, “angiogenesis,” “collagen deposition,” “granulation tissue” formation, “wound contraction,” and “epithelialization” are seen at this stage.
\nCells are introduced into the proliferation phase: macrophages, fibroblasts, pericytes, endothelial cells, and keratinocytes.
\nFibroblasts are responsible for the secretion of collagen. In case of a damaged home, “plumber” cells are pericytes that renew outer layers of capillaries and endothelial cells that “glue.” This process is called angiogenesis. Keratinocytes play the role of “roof plumber” and are responsible for epithelization.
\nSimilarly, collagen tissue must be rearranged to provide greater tensile strength in wound repair. In addition, the density of cells and capillaries is reduced. The main cells involved in this process are fibroblasts. Remodeling can last up to 2 years after wounding [17].
\nPrimary wound healing is called healing if the cleaved cleft is closed without any complications. Within 24 h, the minimal space existing between them is filled with fibrin and makes fibrinous adhesion.
\nThe healing form of granulation tissue in open wounds is called “secondary wound healing.” Initially wounded with clots and exudates, the wound is filled by fibroblasts 4–5 days after injury. In this type of healing, the wound surface is covered with scar tissue after 30–40 days following injury.
\nIn case of infection, in the over-devitalized tissues and in the presence of a foreign body, the improvement observed by closing the wound after a few days is called “delayed primary healing” (tertiary wound healing).
\nPlatelet-rich plasma (PRP) was first developed in the early 1970s, but it was used rarely. PRP was mixed with thrombin and excess calcium resulting in activated platelets trapped within the fibrin network; within the matrix, platelets secrete bioactive substances that slowly diffuse into the surroundings tissues. PRP was introduced to the dental community by Whitman and colleagues, who hypothesized that the activation of platelets and the subsequent release of growth factors would enhance surgical healing [10]. PRP is now commonly applied to surgical sites and injuries to promote wound healing. PRP is rich in growth factors (PRGF), platelet-rich fibrin matrix (PRFM), and platelet-rich fibrin (PRF) [18].
\nThe natural blood clot contains 95% of red blood cells, 5% of platelets, and 1% of white blood cells; thrombocyte-rich plasma obtained by centrifugation of blood tissue contains 4% of red blood cells, 95% of platelets, and 1% of white blood cells. Platelet concentrates in plasma are called “platelet-rich plasma.” The goal of using platelet-rich plasma is to accelerate healing. High levels of platelets and growth factors also include all components of clotting factors. At least 5 ml of plasma is required for platelet-rich plasma to be clinically effective in order to have 106 μl of platelets. The platelet-rich plasma should be prepared in nonclotted form and should be used within 10 min from the start of coagulation [19, 20].
\n“Platelet-rich plasma” is administered by “injection” to the site of interest or by mixing with “grafts.” “Platelet-rich plasma” has a long storage period, but should be used quickly when used. It takes up to 7 days in the region where the growth factors are applied [21].
Preparation of platelet-rich plasma
Nowadays, there are many preparation methods. These are as follows:
Preparation with standard blood bank procedures:
It can be prepared in Aferez units
It can be prepared from whole blood donors
It can be prepared with the aid of a test tube with 20–60 cc of blood.
It can be prepared using commercially available automatic preparation devices [22, 23].
PRP is subjected to a process known as differential centrifugation. It is prepared clinically by “PRP method” or “buffy coat method” [22, 23].
In the PRP method, an initial centrifuge (3000 rpm for 3 min) at low speed separates red blood cells (RBC), and then a second centrifuge (4000 rpm for 3 min) is applied at high speed to concentrate the platelets. In the initial centrifuge, the venous blood is centrifuged in tubes containing citrate dextrose. Acid citrate dextrose is an anticoagulant agent.
\nAfter the initial centrifugation, the whole blood is divided into three layers:
A top layer (platelet poor plasma) containing mostly “platelets” and “white blood cells (WBCs)” is of 40%.
An intermediate layer is rich in white blood cells known as the buffy coat and is of 5%.
A lower layer consisting mostly “red blood cells” is of 55% [23].
For the production of pure PRP (P-PRP), the top layer and the cover of the intermediate layer known as the buffy coat are transferred into an empty sterile tube. For the production of leucocyte-rich PRP (L-PRP), the top layer known as “PPP” is transferred to the entire layer of the “buffy coat” and a few “red blood cells.” By the second centrifuge, the “red blood cells” and the PRP are separated. The PRP obtained after the second centrifugation is activated with thrombin and calcium chloride to prepare a PRP gel. PRP gel contains high amounts of platelets and natural fibrinogen. It takes approximately 30 min to prepare PRP with this technique. Prepared PRP should be used within 6 h.
\n\n
In acid citrate dextrose (ACD-A), tubes should be obtained with whole blood by venipuncture.
Blood should not be chilled at any time before platelet separation or platelet separation.
Whole blood must first be centrifuged at “low speed.”
Supernatant containing platelets (floating on top of the precipitate) should be transferred into another sterile tube (no anticoagulant).
Tube should be centrifuged at a higher speed (hard spin) to obtain platelet concentrate.
At the end of centrifugation, bottom 1/3 of the tube consists of PRP and the top 2/3 consists of PPP. At the bottom of the tube platelet, pellets are observed.
It is necessary to suspend platelet pellets in a minimum amount of plasma (2–4 ml) by removing the PPP and gently shaking the tube [24, 25].
There are also several factors that influence platelet concentration, such as the size of the platelets, the biological differences between individuals, and the hematocrit variability. It is more critical after the second centrifuge because the process of separating red blood cells intended for the first centrifugation may not be fully realized and erythrocytes may be present in the transferred volume. The remaining erythrocytes form a pellet at the base of the tube. Approximately, 20% of the platelets remain adsorbed on erythrocyte globules [26].
\nAnother issue to be aware of is the impossibility of obtaining platelet-rich plasma from a non-anticoagulated blood. Platelets are responsible for the initiation of hemostasis and healing. Since platelets do not have platelets in the serum, it is not possible to obtain platelet-rich plasma from the serum, only anticoagulant platelets are possible.
\nClinically, acid citrate dextrose or citrate phosphate dextrose is frequently used for anticoagulation. Citrate phosphate dextrose, acid citrate dextrose, has similar properties but has been suggested to be 10% less effective in protecting thrombocyte vitalites in studies. EDTA is not recommended because it will damage the platelet membrane.
\nDual centrifugation technique is necessary to prepare platelet-rich plasma. Not enough platelets can be obtained with a single centrifugation and a mixture of both platelet-rich plasma and thrombocyte poor plasma cannot be separated completely [26].
\nGrowth factors alone do not increase bone production. Platelets increase in the area applied with platelet-rich plasma. The increase in platelets also increases the growth factors numerically. PRP also contributes to bone regeneration by increasing the number of stem cells in a small number. Marx used a combination of bone graft and platelet-rich plasma in mandibular defects and attributed the contribution of platelet-rich plasma to bone regeneration to the function of growth factors in the environment [27].
\nPlatelet-rich plasma is the basis for the activation of defense mechanisms by the activation of macrophages and the formation of a nonspecific immunoreaction with the leukocytes and interleukins involved.
\nThe platelet-rich plasma has antimicrobial properties against microorganisms such as “
The duration of action of PDGF and TGF-β in the platelet-rich plasma was investigated and a reduction in cell growth stimulating activity between 4 h and 3 days after venous blood ingestion was reported [29]. It is recommended to use PRP within the first 6 h after its preparation to keep the prepared biomaterials at a minimum level of contamination and to minimize disease transmission risks [30, 31]. It has been suggested that the degranulation of platelets and the release of growth factors are within the first 3–5 days; therefore, the effect of platelet-rich plasma is also 7–10 days [32]. Although the direct effects of platelets and growth factors are lost, bone regeneration is expected to continue, since the lifespan of active osteoblasts is approximately 3 months [33, 34].
\nUsing only the upper part of the yellowish layer to inhibit the presence of leukocytes, resulting biomaterial leads to a lower platelet count. Because it is possible to prepare clinically, it is a low-cost application [33, 35].
\nBlood in sterile tube containing no anticoagulants is subjected to initial centrifugation. All of the poor plasma and buffy coat layers from the cell and a portion of the bottom layer containing the red blood cells are transferred to a new tube. At a high speed, a second centrifugation is carried out and the poor plasma layer from the cell is withdrawn by pipetting. Coagulation is achieved by adding thrombin or calcium chloride as the activator. L-PRP, which takes time to prepare by hand, also has low density [35].
\nThe “P-PRP,” “L-PRP,” and “P-PRF” biomaterials all contain too much tombocytes from physiological values. It is reported in the literature that biomaterials with platelet content 2.5 times more than the number of platelets present are most effective [36].
\nL-PRF is a platelet concentrate containing all components of blood. There is no need for any anticoagulant agents in the preparation of L-PRF, so it can be regarded as a second-generation platelet concentrate. It is used in oral, maxillofacial, otorhinolaryngology, and plastic surgery. In the technique of preparing L-PRF, platelets and leukocytes are obtained with high efficiency. With the activation of L-thrombocytes, thrombocyte and leukocyte growth factors are embedded in the fibrin matrix [37, 38, 39, 40, 41, 42, 43, 44]. In the biomaterial prepared, leukocytes act as an infection-preventive cells and immunomodulator [45, 46].
\nFor L-PRF preparation, centrifugation for 12 min at a speed of 2700 rpm is required, but at a slower speed such as 1500 rpm for A-PRF preparation, longer time such as 14 min is required. Studies have shown that the number of viable cells, including platelets, is higher in A-PRF. Clinically, it will be beneficial for increasing amounts of growth factor and cytokine release. Reported that the levels of growth factors (TGF, PDGF-AB, VEGF) released from A-PRF are less than those of L-PRF when compared to that of L-PRF [47].
\nOne of the latest developments in PRF technology is the production of injectable PRF (I-PRF). For preparation of I-PRF, blood samples are taken in plastic tube without anticoagulant and centrifuged at 2400–2700 rpm at about 700°C for 2–3 min [48].
\nDuring PRF preparation, different products are obtained using different materials for blood processing. Medical titanium tubes to produce PRF and 111333, named this material T-PRF [49]. In one study, it was observed that T-PRF samples had a fairly regular network than L-PRF samples [49]. In addition, the T-PRF fibrin network was observed to cover the wider area of the L-PRF fibrin network and the fibrin was thicker in the T-PRF specimens. T-PRF was obtained by centrifugation of 20 ml of blood at 2800 rpm for 12 min in medical titanium tubes in a human study. T-PRF membranes were found to have positive effects on palatal mucosal wound healing [49].
\nThe most important different CD34 stem cell content from the thrombocyte-rich plasma and fibrin of the concentrated growth factor is the content. CGF-CD34 is the name of the layer containing platelets, leukocytes, growth factors, and cytokines by separating the autologous blood into its components by centrifugation at four different rpm at the same time. Concentrated growth factor does not cause any infection or immunological reaction as it is prepared from the own blood of the person, and no chemicals are used during the process. CGF causes less inflammation, bleeding, and pain than other materials. Due to the stem cell content of CD34, regeneration capacity is higher than other biomaterials [50].
\nAlthough the clinical use of PRP and PRF is widespread in oral and maxillofacial surgery, the mechanism of cellular action has not yet been clearly elucidated. Although in vitro studies have been carried out on dental-derived cells, there is no comprehensive study describing the mechanism of action of stem cells. A limited number of in vitro studies do not provide a convenient and reliable basis for clinical practice.
\nThrombin-activated plasma stimulate “adhesion,” “migration,” and “myofibroblastic differentiation” of human gingival fibroblasts [51]. In another study, PPP and 50% PRP resulted in the greatest increase in cellular proliferation and differentiation at various concentrations, the proliferation of osteoblast and periodontal connective tissue cells in platelet-rich plasma and platelet-poor plasma, and the effect on calcium formation [52].
\nFunctions of the platelet-rich plasma are obtained from periodontal ligament tissue and pulp of human tooth root cells [53]. Colony formation and cellular proliferation of dental cells reduced platelet-rich plasma at concentrations of 0.5 and 1% [53].
\nThrombocyte-rich fibrin regulates cell proliferation in a cell-type-specific manner, and that the thrombocyte-rich fibrin can promote cell proliferation [54].
\nIn vitro studies of “platelet-rich plasma” have shown that the “PDGF-AB” and “TGF-β” factors are in high concentrations in platelet-rich plasma preparations and that the platelet—the proliferation [55, 56]. In another study of the same researchers, it was observed that the fibrinogen used with growth factors in platelet-rich plasma effectively increased wound healing in periodontal tissues.
\nContrary to in vitro studies, there is extensive literature in clinical trials. Thrombocyte-rich plasma in dentistry is used to increase tissue regeneration in periodontal disease, to accelerate healing of alveolar plugs after tooth extraction, and to accelerate osseointegration around dental implants [48, 56, 57].
\nFirst time, 88 mandibular bone defects were treated with autogenous bone graft, some with autogenous bone graft, and some with platelet-rich plasma. As a result of the study, it was observed that platelet-rich plasma significantly increased bone regeneration [27]. After tooth extraction, many complications can occur. There are studies showing that the graft site is covered with thrombocyte-rich plasma and local conditions such as “dry socket” and “abscess” formation are prevented, and conditions are improved. It has been reported that high aftertouch growth factor concentration increases tissue regeneration [58, 59, 60, 61, 62]. There are also studies in the literature, which show conflicting results with other studies suggesting that the platelet-rich plasma administered after tooth extraction does not have a significant effect. There are also observations that thrombocyte-rich plasma does not increase bone regeneration alone, as is the case with osseointegration at dental implant placement and studies that give positive platelet-rich plasma to accelerate new bone formation.
\nThere are reports of positive results associated with thrombocyte-rich fibrin in sinus augmentation therapy prior to placement of the dental implant [62, 63, 64, 65, 66]. Co-use of deproteinized bovine bone (Bio-Oss) and thrombocyte-rich fibrin is only compared with Bio-Oss use; combined use of maxillary bone atrophy has been reported to give better results [67, 68].
\nContradictory results have also been observed in the use of platelet-rich plasma in periodontal surgery. There are studies reporting increased tissue regeneration when applied with platelet-rich plasma graft materials [68, 69] while some studies suggest no improvement in healing process after thrombocyte-rich plasma implantation [70, 71]. The same conflicting results exist in the literature for thrombocyte-rich fibrin. Thrombocyte-rich fibrin in the third molar withdrawal of the mandible did not increase bone repair.
\nIt has been demonstrated that the application of “thrombocyte-rich plasma” is effective in the “bison-linked osteonecrosis (BRONJ)” treatment of the jaw. The application of surgical debridement procedures in conjunction with autologous thrombocyte-rich plasma was reported that increased bone and soft tissue regeneration, increased neovascularization, and reduced tissue inflammation [71, 72, 73, 74, 75, 76]. According to some investigators, thrombocyte-rich plasma regeneration capacity is a low biomaterial and may have a short-lived effect in the early phase of bone healing, flattening between the third and sixth months of treatment.
\nThrombocyte-enriched plasma to the suction ports and stitch area of 170 patients after withdrawal of third molar teeth and alveolar osteitis was prevented with less pain and more intense bone formation [48].
\nIn 20 patients with “periodontal defect” and “vertical root fracture” in two groups as thrombocyte-rich plasma and autogenous bone graft applied, only autogenous bone graft was applied. As a result, epithelialization of the group with autogenous bone grafting with thrombocyte-rich plasma and bone healing was faster [77].
\n“Autogenous bone graft” and “platelet-rich plasma” combination in “mandibular reconstruction” significantly improves bone healing [78]. Patients who underwent “partial mandibulectomy” combined “autogenous bone graft” and “thrombocyte-rich plasma” for reconstruction. After 6 months, they found that the biopsy bone they had received was sufficient and they applied the implant after 1 year [79].
\nImplants in patients were done by injecting “mesenchymal stem cells” and “platelet-rich plasma” into the distraction range to obtain three-dimensional bones in the distraction osteogenesis of the mandible and to shorten the consolidation period. They reported that platelet-rich plasma was effective at the end of the study [80].
\nInjected mesenchymal stem cell and thrombocyte-rich plasma derived from bone marrow were used for “achondroplasia” and “congenital pseudoarthrosis. As a result of the study, they reported that short-term minimally invasive procedure is an advantage of increasing bone regeneration [81].
\nPatients with alveolar congenital defects were using bone and tibia-derived grafts plus thrombocyte-rich plasma and reported that the corresponding region was rapidly restored according to the patient group, who had never used thrombocyte-rich plasma [82].
\nAutogenous bone grafts, in five of 12 patients with alveolar cleft, and the remaining seven were combined with autogenous bone and thrombocyte-enriched plasma in the remaining seven and closed the scales. They reported that regeneration in patients who were closed by a combination of autogenous bone and thrombocyte-rich plasma in a computed tomography scan was better than the other group [83].
\nLecovic et al. reported that the combination of thrombocyte-rich plasma and bovine peroneal bone mineral was effective in the treatment of intrabony defects in patients with chronic periodontitis, although no directed tissue regeneration was performed [84].
\nPeripheral nerve injuries may occur after surgical operations in the maxillofacial region and after trauma to the maxillofacial region. “Microsutures,” “fibrin-cyanoacrylate adhesives,” “grafting,” and “laser” applications are preferred in the treatment of injured nerve tissue. However, the regenerative capacity of the nerve tissue is limited and heals very slowly. The use of platelet-rich plasma was considered to speed up this process of healing. An animal study was conducted using rats, although there is no human study on the subject. After the sciatic nerves of the rats were cut bilaterally, the nerve was connected with “cyanoacrylate” on one side and “platelet-rich plasma” on the other side. The number of nerve fibers formed on the treated side of the biopsied platelet-rich plasma after 12 weeks was higher than the other side [85].
\nPlatelet-rich plasma is also effective in soft tissue injury as it is effective in hard tissue repair. Two groups were formed in the study in which 59 patients with acute traumatic soft tissue injury were treated. Thirty-two patients were treated with routine wound care while the remaining 27 patients were treated with routine thrombocyte-rich plasma as well as with routine wound healing. As a result, wound healing was faster in the platelet-rich plasma group [85].
\nPlatelet-rich preparations are a safe (PRP) and is a preparation of plasma that contains an increased concentration of platelets compared to blood. PRP is autologous: for the recipient of the PRP to be the same person. PRP is used for both soft and hard tissue and also used in clinical dentistry, because it accelerates bone formation and induces healing.
\nMany studies support the use of autologous PRP in clinical practice, including for soft tissue injuries, chronic diabetic ulcers; injuries to muscles, tendons, or ligaments; bone fractures; molar extractions; urologic, dental, ophthalmic, and plastic surgery procedures; and periodontal, sinus lift, and oral/maxillofacial surgeries. Since growth factors play crucial roles in soft and hard tissue regeneration, the proposed mechanism for the enhanced healing outcomes by PRP is through the release of critical growth factors by activated platelets [86, 87].
\nBone lesions and defects may arise out of many kinds of traumas. Due to the high prevalence of trauma, bone is the most transplanted tissue.
\nThe use of autologous grafts is a gold standard to the biomaterial filling of bone defects. However, the limitation of tissue available, risks of infection, and necrosis re-motivated the proposition on synthetic biomaterials, which by turn are not biologically functional and adapted to remodeling bone tissue.
\nThe use of biological factors, such as PRP and bone morphogenetic proteins (BMP), has shown good results in bone reconstructions, since they are directly associated with the tissues. Platelet growth factors such as platelet-derived growth factor (PDGF), transforming growth factor-b (TGF-b), fibroblast growth factor (FGF), vascular endothelial growth factor (VEGF)-A, and insulin-like growth factor (IGF-1) regulate bone regeneration, proliferation, and differentiation of osteoblasts, for the therapeutic use.
\nThe use of PRP in the treatment of bone lesions has shown significant results from 1990s. PRP also used as an alternative to fibrin glue or platelet gel is frequently employed in maxillofacial defects. The therapeutic benefits and the reparative power of PRP consist of one action faster than conventional treatments maximized by autologous growth factors and are free from immune complications.
\nPRP action with the concentration of bone marrow had better consolidation and greater bone quantity by area in the PRP group. The superior result obtained can be explained by the immediate recruitment of all proteins necessary to start the healing cascade, while the concentration of bone marrow demanded longer time to recruit these elements. Thus, it can be assumed that the monitoring for a period of time up to 4 weeks, this group might have had similar results of consolidation. However, there were no new studies that could confirm this hypothesis.
\nSeveral studies reporting the association of PRP and artificial bone grafts showed improvement in the quality of healing. However, only PRP was used, and the short-term and/or long-term results, were positive but not significant. PRP could be beneficial and contribute to the morphological and functional improvement in chronic tendinopathy [86, 87].
\nIn treatment of tendinopathy, PRP plays an important role. Physical therapy and a program of activities after injection of PRP, adopted in most studies, demonstrate better results in tendon lesions [88].
\nPlatelet-rich plasma is a blood-derived product used for local healing. Interest in their activity over the last two decades has increased significantly in different disciplines. It is widely accepted that these materials stimulate soft and hard tissues to mimic the physiological healing process. The reason is that it contains high amounts of blood components such as fibrinogen, platelets, etc.
\nThese biomaterials have been proposed for various uses in oral and maxillofacial surgery. Most studies in the literature: improvement of alveolar sockets after shrinkage, osseointegration of dental implants, sinus lifting procedures, improvement of periodontal bone defects, etc., examine the effects on the case. It has also been observed that platelet concentrations increase cell migration and neovascularization in vitro studies.
\nIn addition to having many advantages of platelet-rich plasma, there are also disadvantages: increased risk of malign transformation as the PDGF release increases in chronic wounds, and the lack of factor V of the bovine thrombin used for anticoagulants and immunological reactions.
\nThe activity of the platelet concentrates is expected with the high amounts of active growth factors and cytokines they contain. Nowadays, the preparation of these platelet concentrates is very different from each other. When platelet concentrates are compared, thrombocyte-rich fibrin is thought to have a higher regenerative potential than thrombocyte-rich plasma.
\nPlatelet-rich plasma is a blood-derived product used for local healing. Interest in their activity over the last two decades has increased significantly in different disciplines. It is widely accepted that these materials stimulate soft and hard tissues to mimic the physiological healing process. The reason is that fibrinogen contains high amounts of blood components such as platelets.
\nBone defects caused by infection, tumor, trauma, metabolic disease, or massive osteolysis due to prosthesis still remain a major clinical concern. Unfortunately, the self-repair capacity of the critically bone defected is extremely limited and this condition generally requires bone grafting. Osteoinductivity, osteoconductivity, and osteogenesis are optimal bone graft substitute. Allografts or xenografts have unique osteoconductive properties and rarely cause disease transmission. Because of these limitations, synthetic bone grafts are being used. Osteoinductive growth factors, autogenic bone marrow, and mesenchymal root cells promote osteogenesis while demineralized bone matrix (DBM) and platelet-rich plasma (PRP) induce formation of progenitor cells from surrounding tissues. However, each of these substitutes has its own significant limitations and none of them meets full expectations to serve as bone substitute in instance of bone defect.
\nBoth PRP and DBM are osteoinductive substitutes that have shown satisfactory results for fracture healing. A number of growth and differentiation factors are liberated, including platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), transforming growth factor-1 (TGF-1), insulin-like growth factor-1 (IGF-1), hepatocyte growth factor, platelet factor-4, fibroblast growth factor (FGF), trombospondin-1, osteonectin, and fibronectin via activation of platelets. These factors play an important role in intracellular matrix formation, osteoid production, and the collagen synthesis involved in fracture healing. DBM is an organic collagen matrix that includes various types of bone morphogenetic proteins (BMP), which are responsible for its osteoinductive properties. PRP can be prepared easily with two-step centrifugation of autogenous blood, and DBM can be obtained commercially.
\nThrough positive impacts of PRP and DBM based on these findings, the present study evaluated the impact of individual and combined applications of PRP and DBM on fracture healing of critical bone defects. Allogeneic PRP would have beneficial effect on treatment of segmental bone defects, comparable to DBM. Possibility of agonistic or additive osteoinductive effects of DBM and PRP combination was also investigated [89].
\nDespite the large number of clinical trial studies, there is little evidence of the cellular effect of blood derivatives. The lack of standard protocols leads to the lack of reliable clinical results. Frequent and unnecessary application of blood-derived products, especially in the maxillofacial region, results in both an increase in procedures and a significant increase in costs to clinicians and patients. The indications of the protocols for the application and preparation of blood derivatives should be made absolutely widespread and systematic in order to clarify the benefits for patients of blood derivatives. This can be achieved through a collaborative work between clinical and in vitro researchers. Further research on thrombocyte-rich plasma and thrombocyte-rich fibrin activity on dental cell biology, more clinical application of platelet concentrates, and greater use in the oral and maxillofacial region may provide a stable basis for more predictable outcomes.
\nWe declare that there is no conflict of interest with any financial organization regarding the material discussed in the chapter.
Justice has been studied in several organizational disciplines, the most important being ethics and human resource management. But this is not all the picture, as justice has also been studied in some research that fundamentally tries to show how to design systems and decision processes with justice in the core of their formal and informal elements. Trust has been considered the best intangible asset that serves as an invisible glue that sets together people and organizations to coordinate for common goals. Trust is necessary to be in place between people in organizations and between organizations and their stakeholders. Being an intangible, the mechanisms to generate and promote trust are hidden; therefore trust is not possibly exchanged as a normal asset, and in fact, organizations that “buy” trust from their stakeholders usually do not generate anything close to it. The mere fact of entering in a conventional exchange involving trust (try buying with money trust) removes the motives that people hold when willing to trust others, and even poses red flags that motivate just for the opposite. Trust, when in place, allows performance as a consequence for the long run, promoting socially sustainable organizations.
The relationship between trust and justice has been also considered crucial, as both are aspects that involve social interaction, better fulfillment, and increasing alignment of people’s and organizational goals (goal congruence). Many researches in management have concentrated on these two elements, and how both can mutually affect each other. In this chapter I am going to devote time to propose a way of how both are important and should be brought together to promote long run organizational performance and sustainability.
I proceed to study first trust, then justice and eventually the interaction of both, to conclude which may be a good approach to understand both in terms of implications in organizational management. Finally, I end up stressing the importance of ethics and specifically see how ethics come in the form of showing trust and justice to be the crucial embedded aspects of ethical relationships.
Including the ethical dimensions of justice and trust into organizational relationship and coordination allow going beyond the social and psychological characteristics already posed. Then, ethics, or the principles that guide and serve as basis of what should be done, make justice and trust the two intangibles that are the most important in organizational relationships and therefore in the long-run survival of organizations as a social system of coordination, relationships, interactions, and worth exchanges.
Trust has been an elusive concept that has been studied in many fields, most importantly in economics and management. From an economic perspective it is the necessary intangible glue that makes people exchanges progress in a smoother way. Trust should be built to make coordination last, but economists discovered that it is not a commodity that has its own market to be exchanged. This implies that trust has value but there is no price of acquisition, so it is generated in a way that incorporates personal morality and the willingness to do good for ourselves and, in case of trust, for the others. Arrow, a preeminent Nobel awarded economist arrived to this conclusion, as we will show below [1]. In the “Limits of Organization” in fact what Arrow is showing is more the “limits of the markets” to organize interaction, as precisely organizations as a coordination mechanism, involving trust, is what go beyond the pure market reasoning of facilitating exchanges in a pure monetary basis.
Trust is needed when people as consumers decide over a set of potential options, as they eventually chose one option that they trust. But also, into organizations to make people rely on other people assessments and opinions, when they cannot arrive to one personal opinion due to lack of information or expertise. Or complementary to this, when people rely on other’s information to form their own opinion.
Justice is both a cause and effect of some specific characteristics that are incorporated into relationships, their process and distributions. Studied as the main moral virtue of character, the mother of moral virtues, it makes people pursue their own good and the overall good of the organization and its participants. Both concepts, trust and justice, are crucial in the ethical dimension of business interactions and relationships.
In the next sections, I am going to study both of them separately and then explain the relationship between the two, to generate socially and economically sustainable organizations. I am going to stress that trust and justice should incorporate their ethical dimension as these are the ones that allow nurturing interactions between people and between people and organizations for the final end people have, which implies fulfilling themselves through their purposes and mutual supporting.
Trust has been studied in several organizational disciplines, the most important ones being economics and management. Trust is not an easy intangible to study. All incumbents in organizations are talking about trust generation as one of the crucial aspects to be promoted to generate involvement in coordination for the common goals, and specifically, a long-term coordination. Brands talk about trust generation and use brand ambassadors for that purpose. Organizations talk about generating trust and care for their employees first and the rest of the stakeholders afterwards. So, all management disciplines talk about trust as the most necessary intangible to be incorporated in their relationships with clients, workers, and all the stakeholders. Trust should be built and not destroyed; these two objectives are clear and widely shared. But how to achieve those goals? This is a complete personal career in any managerial field, no matter which discipline, no matter which organization. All managers care about this but are not sure how to implement it successfully. Another aspect of trust is that it is hard to build and easy to lose in any reputational dispute, so it is not only that trust is important, but managing any short-term reputational effects over the trust that has been long term generated, is also very important (i.e. it is important to note that as people have their own perceptions of trust, managing them is important, and making them close to factuals).
One of the scholars worried about trust has been Kenneth Arrow. In his book “The Limits of Organization”, Arrow considers trust as the necessary glue of economic systems. Trust, according to Arrow, is elusive and non quantificable, and without trust desired transactions do not occur [1]. In fact, he considers that trust is in the boundaries between authority and responsibility, as a crucial aspect that has value but not clearly an exact and known transactional price. Therefore, in Arrow’s words, if you have to purchase trust, you are not really sure about what you have really bought. In fact, we can even say that when you try to put trust as a mere exchange good, what happens is that at some point you force people to concentrate in mere motivations that imply short-term win/lose analyses. Then the prophecy self-fulfills and finally you have people that usually mistrust the rest and only focus on the short term.
So, if trust is not a commodity this means that cannot be easily transacted. Thus, it is difficult to know how to generate and destroy trust which makes more important its study as a worth ethical characteristic of economic and organizational systems. And on top of that, trust is unavoidable in exchanges and coordination, if we want it to last, so the fact is that trust is not exchangeable easily but at the same time it is a must.
In fact, organizations that try to buy trust among their employees are paving the way to precisely generate the opposite. Why? Because, people are easily aware that the interest of the organization is instrumentally using trust as an excuse for something else, so not being transparent of their real interest and purpose, so ending up generating just the opposite: distrust. So, looking for trust generation should bring something genuine in place so people could think it is for the best of all, not merely a few or for some spurious organizational interest.
Arrow was a preeminent economist, and his last work was devoted precisely to the nature and value of trust, that he considered an ethical concept, to be necessary in economic interactions. He considers trust to be the most efficient lubricant in social interactions as it allows to save lots of resources. Therefore, he looks at trust as an ethical aspect with real pragmatic value, so, trust is not only a nice thing to have in organizations but a necessary ethical requisite. Markets and ethics are confluent, and this confluence needs specific attention and implementation. In the end morality is unavoidable to get markets that work [2]. You should be more or less confident that persons interacting in a market generally act in a morally sound way and so should build relationships that make them trust each other. From the point of view of an economist, Arrow considered trust as a social norm based on morality, that equals transparency, integrity, and honesty to make reciprocal social interactions follow the right path to bring good for everyone. The fact that Arrow considers trust, and ethics (as the broader recipient of the first), as the foundational aspects that make organizational deals work, is seeing trust as the cause of worth relationships in business.
To put it simply, trust in its minimal approach implies 1) two persons, the trustor and the trustee, 2) evaluation from trustor to decide whether to follow the trustee advice in something of his or her interest, 3) an act from the trustee that shows whether the trustee honors or betrays the trustor’s trust on him or her, and 4) an evaluation of the interaction from the trustor of whether it has been worth to trust the trustee.
Following this simple trusting mechanism, several definitions of trust have been posed from the researchers’ community. There is a broad conceptual definition of trust that summarizes the concept in a meaningful way. According to Zand, trust is composed by the “actions that increase one’s vulnerability to another whose behavior is not under one’s control in a situation which the penalty one suffers if the other abuses that vulnerability is greater than the benefit one gains if the other does not abuse this vulnerability” [3]. So, there is something to lose from the trustor’s perspective. Also, not honoring trust from the trustee can have some short-term surplus gain compared to honoring it (so trustee is better off when not honoring trust compared to honoring it), because otherwise, there is simply a win-win game, without any need for trust to be in place. Of course in this situation of win-win, the trust specific interaction does not exist, but it could happen that trust over that person in general exists anyway, the issue is that the trust interaction does not start, or it is not even necessary when everyone earns trusting the other, usually, trusting in a specific moment in time, should imply having some tradeoff, so there is something to lose when the trustee honors trust compared to some gain for taking advantage of not honoring it. The same happens for the trustor that she/he is worse off in case the trustee does not honor the trust compared to honoring it.
So, first, there is the decision to trust, and enter into a trustworthiness evaluation (from the trustor about the trustee), and afterwards the decision to honor the trust (from the trustee). Of course, for trust to last, both parties (specially the trustor) should evaluate how worth has been the actual interaction and therefore as a consequence how probable it is to trust the other party again. Meaning, how probable is to enter into a long-lasting trust, that is the glue that is needed in Arrow’s terms [4].
But which is the process of trust generation, and which the process of mistrust generation or trust destruction? More recently, organizational scholars have tried to see trust as a sequence of personal dynamics that involve at least two parties, in which, one of the two (trustor) decides whether to assign to the other party (trustee) the required trustworthiness. In case the required trustworthiness is assessed and the trustor considers it enough, then this makes the trustor trust the trustee. As Dietz believes, there is a basic dynamic, common to all trust encounters, in which “an assessment of the other party’s trustworthiness which informs a preparedness to be vulnerable that, in genuine acts of trust, leads to a risk-taking act” [5, p. 215]. Then, trust, looked at this way, is a consequence of trustworthiness (defined as a perception of trust placed on a person who is evaluated as to whether he or she deserves to be trusted or not).
So, trust is a consequence of trustworthiness which acts then as a cause. So, it is a risk-taking activity that involves some time of perceptional process of the trustor about the trusted party (trustee).
Some researchers consider that there are several types of trust, for instance rational calculative trust, altruistic trust, or blind trust, or also depending on the parties, if these are two individuals, the trust is labeled “personal trust,” or in case of involving organizations, then it is called “institutional trust” [6].
But, other scholars, like Dietz, suggest that trust can be considered as general trust experience process that, depending on the individual and group characteristics, may differ in how this universal trust experience or process occurs, and which steps are more or less prevalent when compared to the others. This group of scholars consider that different evaluations of trustworthiness, cognitions, and actions of trust will thus originate different effects coming from the trust experience [5].
Then, trust is a choice? Not always, as people may be obliged to enter into trust, as maybe they are interdependent to the other party. In this situation there is no decision of trusting the trustee, so this specific condition is not there, but still the rest of the trust process remains. In this case, trust is not a decision, but the process of generating trust should occur for sure. So risk and interdependence are intrinsic elements of trust, the definition then being more a general one, so trust is ‘the willingness to be vulnerable in conditions of risk and interdependence’ [7]. Considering trust this way, trust is not a cooperative behavior or a choice of taking some risk, but instead a situation in which risk and interdependence may generate necessarily an evaluation that once is positive, conduces to trust generation, and then, implies cooperation and taking the risk.
But one caution here, the mere existence of risk and interdependence may not need trust process to occur. In some cases there is only the need to calculate to arrive to a decision; then, it is not easy if this can be considered “calculative trust” or really trust is not even in place nor needed [8]. Boundaries of the concept of trust still exist and there is not a complete agreement between researchers.
In all instances, even if trust is a decision or a situation in which there is some obligation to be interdependent with some other party, trust requires an evaluation from the trustor about the trustworthiness of the trustee. This trustworthiness is a construct formed by the perceptions of some trustee’s aspects, that were revised in an integrative paper by Mayer, Davis, and Schoorman [9].
When assessing trustworthiness people evaluate the following three aspects of the trustee: ability, benevolence, and integrity. However, in a more recent paper about trust quoting this research by Mayer et al., it has been argued that “the Mayer et al. definition misses an important aspect of trust, though: in order for the situation to be meaningful, the potential trustee has to have something to gain by performing an action that is not favorable to the interests of the trustor. If not, the interests of the two people are perfectly aligned and thus, in general, there should be no problem” (8, p3). Meaning again, that boundaries of trust are still there in discussion. This latest boundary incorporates, then, the avoidance of trustee’s opportunistic behavior, seen from the perspective or assessment of the trustor [10]. This evaluation of the trustworthiness of the trustee is done in some specific situation, that is, the specific “trust encounter” or in other words, the trust exchange.
This vision of trust being a consequence of trustworthiness incorporates morals, and each of the three aspects go parallel to the Aristotle concepts incorporated into his book Rhetoric. Ability corresponds to Aristotle’s concept of “intelligence.” integrity to Aristotle’s “character,” and benevolence to Aristotle’s “goodwill”. Then, the Aristotle concept of persuasion that would imply making appealing what a trustee says to convince others of being trusted is linked to the building blocks of the trustworthiness concept, a very successful construct in the literature of organizational trust.
In general, when trusting someone implies an assessment about this person’s consistency (sometimes even we think that this person in that matter is even more consistent than ourselves), to actually make this person capable of putting into practice what is good for all (also ourselves) according to his or her system of values. Then what we in the end trust is his or her capacity to do that, to act in that specific ethical way. In consequence, we think that the trustee is a person that shows the integrity between his or her actions and values and does this for the good of the ones involved in the relationship or also for the entire organization (in case of he or she acting on its behalf). Then trust is linked to believing from the trustor’s perspective that the trustee is a virtuous person and so pursues the good. Here comes the ethical part of trust, that is, the trustee’s capability of making right choices about what is good to be pursued. Right choices imply deciding over which objectives area good, and it is here when justice comes to place into the trust equation. As being good and right implies being just. So, looking at the ethical dimension of trust, this implies we trust someone because we consider she or he is the one that is just when deciding, and therefore incorporates in the decision-making, standards of just behavior. We trust in his or her justice standards.
In conclusion, we trust someone because the choices he or she usually makes are leading to generate just outcomes; therefore this person shows up justice standards and learns and evolves to individually increase these justice standards over time. We are going to examine justice as the moral virtue that managers need to put in place to generate trust. Managers should include justice into their decision-making process to generate trustworthiness and therefore trust among organizational relationships between individuals and between individuals and the organization.
But first, I should examine justice as a crucial concept in many disciplines, including management, to finally look into the concepts that are worth to be built-in trust generation.
Justice has been studied in several organizational disciplines, the most important ones being ethics and human resource management. But these are not the only ones. Justice is studied in management control systems to show that managers should design systems and decision processes with justice in mind (formal and informal management control systems with justice incorporated) [11]. Justice is also the basis for the full theory of law, and it is also a social norm, in the discipline of sociology. In ethics or normative theories justice is considered a virtue or a mandatory set of requisites for a worth societal scheme. I am going to revise all the concepts of justice and how they have been integrated to some extent.
Organizational justice has started some decades ago, with the study of the perceptions of justice that people have regarding aspects related to processes, distributions, relationships, and information. Under the label of ‘organizational justice’, perceptions of justice from organizational participants have been rated to decide whether the organization or the manager is fair or not. Organizational justice is formed by four justice types: distributive, procedural, informational, and interpersonal, depending on the aspect of perceptions people focus on. Distributive justice refers to the perception of what people receive, as rewards or resources, tangible or intangible. Procedural justice asks about the perceptions regarding the processes to arrive at any decision that people consider may generate some effect upon them. Informational justice refers to the fairness people perceive about the information a manager shares and delivers in the process of deciding. And interpersonal justice measures fairness of the treatment received by a decision-maker in decision processes that affect the recipient. Research has linked organizational justice and close constructs to many desired performance effects in organizations [12]. Recently in the actual investigations around sharing economy, organizational justice has been found as a requisite to build socially sustainable organizations over time, as it serves as an antecedent of knowledge sharing among organizational participants [13].
The entire field of organizational justice has usually evolved through empirical enquiry. Researchers have studied perceptions and how people react to these aspects of distributions, procedures, information, and interpersonal treatment. The underpinning of this reasoning relies on Adams’ equity theory [14]. Adam’s equity theory states that people compare their own ratios of output and input with the same ratios of others, which is similar to Aristotle’s concept of merit. Of course, there are other underlying mechanisms for people to judge fairness, in which people assess what they actually receive compared to what they think they “ought to” receive [15]. In this last one, some ethical standards about what should be are necessary. In this respect the worries are not about deciding between ethical standards and which are sounder, but in understanding that people when assessing fairness have implicit in mind some ethical standards. Both approaches are based on psychology, and some way of looking at justice as a subjective aspect of people’s thinking, without caring about which should be the good justice for everyone, or the good thinking of justice or ways to compare which thinking of justice is better suited than the other to generate the good.
But some questions still remain unanswered, as, for instance, are some concepts of justice better than others? Is there a way to decide which justice is better suited to generate the good? And this is the type of questions answered by ethic theories. Ethics is concerned about what is good and what is better. The ethical individual reasoning, subjective in nature, that makes people assess something to be fair or not, treats justice as a black box, subjective and personal, and does not care about the actual black box, containing some specific justice definition or standards. In fact, it presumes all individual standards of justice are equally good. But, here is when ethical reasoning enters into the picture to underline that some justice norms are a central requirement to create good societies for everyone, and therefore, justice is the foundation for a correct functioning of society that aims at providing high levels of happiness and common good to its constituent members [16, 17].
Therefore, once entering into the philosophy and ethical domains, some concepts like justice norms and justice standards appear to be defined, and along with them, specific ways to reason which requirements are needed to generate the best conditions for justice, that in turn may be the foundations of the good and the better.
There is an ongoing discussion of whether justice is a fact or more an ideal to be attained, so a desirable value. And in fact, justice may be, to some extent, both. Of course, justice is not only what people thinks is just, as people can be misled. But justice is also not only what some ethical standards think it is.
Both aspects of justice are important and correspond to different concerns. Normative research remains into the “ought to” type of reasoning that does not attempt to discover at all “what actually is”. The same with looking at what people perceive as just. This can indicate whether some justice is in place and, of course, can be an indicator of what people think regarding justice, but these perceptions cannot be a guide to generate norms of what “ought to be” and following implementations. All of these have their own role, as perceptions of justice indicate the actual state of justice implementation and justice while the “ought to be” justice should guide what reasonably people should follow to achieve a long-run just result in their interactions.
But people’s actual subjective thinking of what ought to be is also linked to the ethical reasoning of what ought to be. Some research has focused on interconnecting both types of queries, to find out whether people’s concepts of justice are actually aligned to the notions ethicists claim justice to be. From existing data, we know that favorability tend to be correlated to positive perceptions of justice of actual outcomes received, meaning that we believed we deserve (and find it just), the outputs that favor us. In specific distributions, people tend to value just what they positively receive (as they believe they deserve it) and unjust when they are not receiving anything (as they think they deserve it), even if in the normative sense it does not follow justice requirements. This is even stronger in some real and actual situations and not some hypothetical ones. In the hypothetical people tend to be more prompt to actually match what they think about justice ought to be and what theories reason justice ought to be.
Both types of justice, perceptions of fairness and justice as a virtue or ideal for systems and decision-making processes, have some connections and attempts of integration. In fact, moral motives are a very strong psychological motivation to care about justice, even if there is nothing to gain personally in this specific caring. It means people see justice as a moral value and not just a means to achieve selfish ends. Some research asks respondents how they perceive the work behavior “ought to be” and how they perceive “actually is.” And surprisingly these are not that far away. This means that, first, as my actual subjective “ought” thinking is not far from the philosophical normative theories, and as I try to be consistent with this, in the end what I do tends to get closer to what I should do, over time. And when asked about perceptions I tend to be consistent on what I think it should be and what I think it actually is regarding what it should be.
Then not all organizational groups think the same; for instance managers think they are implementing justice following this “ought to be” standard, whereas the rest of the organization thinks differently, as they report managers acted differently from what they ought to [18]. All stated before is important, as understanding normative theories people adhere to can improve predictions. And for ethicists, empirical studies about perceptions can also indicate the behavioral and perceptual constraints of justice desired ideals, and how far or close to the standards people think the others and themselves are.
But we should also be aware that differences exist even if researchers come from a similar background. Justice studied from the perspective of organizational justice differs from justice studied from a behavioral sciences perspective. Organizational justice research has assumed individuals are motivated for selfish reasons and by social identities, while behavioral ethics has usually focused on internalized moral convictions and duties and on moral identities. So, justice has different underlying concepts even if the mainstream approach is from a psychological background and through empirical studies. Then it seems justice take several approaches because the questions to answer differ and the visions of humans differ as well.
There is also a paper summarizing justice concepts and providing a useful way to integrating inquiries in a meaningful way in organizational contexts [19]. In this it is explained that a full concept of justice across disciplines would be difficult to incorporate and arrive at. But, instead, we should be aware of the matters and questions around justice that are responded following each approach.
Investigation of perceptions alone cannot replace reflection and discussion about justice. Many situations in organizations reflect this. Imagine the case of an organization in which employees experience a really bad environment, even if they are given voice to express it. And this given voice has not positively converted into a real change. When they are asked about “procedural justice” they rate it high. However procedural justice is upheld, the voice they are actually given has no real impact on their actual working conditions. So, managing group’s perceptions of justice without addressing real issues of power distribution and safety at the workplace could be judged as unjust from a beholder perspective or from an ethical point of view, even if the worker is rating justice high.
This late example does not mean that perceptions of justice are not important, if correctly managed for the good purposes and for the change towards a greater justice environment. In fact, if we just follow a normative approach without caring for actual perceptions about justice, this dogmatic approach can generate unhappiness in case people’s preferences are not incorporated to some extent, or people feel they are not capable to follow the normative approach in place. And moreover, some existing normative approaches are a close system and are simply obsolete. Many normative systems are closer to societal norms at some past point in time rather than being a truly humanistic approach for promoting the rights of all. It should be important to create a paved way to change the current norms for some better ones, in all instances. Discussions in normative approaches cannot be avoided in any instance. Even claiming around legality, when legal norms are outdated, is even worse, as in some moments in time, some norms in institutions followed strictly the legality and were totally unjust (i.e. apartheid). So thankfully, societies evolve in terms of updating their normative and legal systems to improve justice over time. Another aspect in terms of normative approaches is that in some specific instances, competing normative approaches exist when solving specific ethical dilemmas, and so, it is not clear which is the best one to choose.
In summary, justice has been studied as a social norm in sociology; as a minimum set of rights or duties in law; as a perception of specific instances regarding distributions, procedures, information, and treatment; in organizational justice; and as a moral motivation in behavioral sciences. All are valid and useful concepts around justice worth taking into account, even if some are invalid or useless because they have become outdated or show incompatible visions of human beings.
With respect to the questions responded and the methods used, organizational justice is concerned with the perceptions of justice from the individual point of view, the group point of view, or the beholder point of view, as a psychological construct. Organizational justice addresses questions regarding why people care about justice, how people judge justice, and which are the effects of justice or injustice perceptions.
The questions aimed at being responded in normative justice theories are concerned with justice as an ideal, precisely trying to figure out what a just society is and should be and what is and should be a just person. Responding to these questions could characterize how should be individuals and socities as to be considered just. Or similarly, knowing the requirements for just leaders, companies and society. This then responds also to the additional query of why justice is important. There are connections between both, as it is presumed that in good (therefore just) societies or organizations, people can develop also personal justice skills and so become fairer over time.
Usually the concepts of justice useful in management implementation are the ones concerned with design of systems and their use, which take a normative approach, and also measuring perceptions of actual justice, once these systems are used and implemented. This is nicely explained in this research that proposes a model of formal and informal justice and how when they are present, generate a greater alignment between the interests of stakeholders, and then build the way to increase justice perceptions of individuals under those systems [20].
In the next section I am incorporating practical wisdom as the required virtue of knowledge that Aristotle incorporates as crucial for organizational decision-makers. This is also a point to be made as practical wisdom is a necessary requirement for taking commonsensical decisions in specific organizational situations and arrangements and so, part of situational knowledge that a decision maker faces when deciding over anything today that has huge consequences in the long term.
It is important to notice that apart from justice, there is another virtue (the main virtue of knowledge, in Aristotelian terms) that has been considered important in managerial decision-making, and this is practical wisdom [21]. Even if some research has given more importance to this virtue than to justice, in fact there are virtues of a different type. Justice is a moral virtue concerned with what is a good objective to pursue, so it comes first. And afterwards, practical wisdom is the process of implementing that objective to improve the chances of success. Also, when there are several possible good (so just) objectives to choose among, practical wisdom assists to determine which is (or are) the best suited to prosper.
Thus, justice is a moral virtue, and therefore informs about which options are good, and practical wisdom is the virtue associated with the process of decision making; once good options (just options) are in place, practical wisdom is necessary for implementing them, so to build the process to be followed for that implementation. Therefore, practical wisdom is not really useful to discuss about the morality but helps to follow a rationalistic approach of implementing the good and just option in place, or to choose details to make proper just alternatives when several of them are available.
In short, justice is the main moral virtue that allows us to have sound objectives in organizations. Once there are alternatives that accomplish justice requirements, situational knowledge, specific for real life implementation, requires managers with practical wisdom. This practical wisdom is the virtue associated with the practical knowledge to apply specific courses of action that have proven possible in specific situations. This process is clearly explained in this article and proves to be generating learning processes of acquiring practical wisdom over time [22]. It seems that as practical wisdom and justice, put together, help to align people’s goals with the organization, this can also be seen as a limit for the need of trust in terms of specific transactions, as the general trust on the virtues of the decision maker, which in turn increases this alignment over time, goes for a lesser need of specific transactional trust.
But, it is the combination of practical wisdom as the principal virtue of situational knowledge, and justice as the moral prevalent virtue in social systems and interpersonal relationships for the good, that makes the organization fulfill its endeavor and be socially and economically sustainable over time [23].
From the trust literature and the seminal ethical literature, we have arrived at the conclusion that justice is a generator of trustworthiness, and therefore potential trust. Justice in this vein is one of the components that are incorporated into the assessment of trustworthiness of the trustee from the trustor’s point of view.
Trust is not a considered a virtue, but it is considered an ethical fundamental concept, that is referred as an intangible asset that serves as a glue to increase efficiency of human interaction at the market and organizational level. Also, trust is a result of trustworthiness evaluation, meaning that, to trust someone, first the trustor needs to evaluate whether the trustee deserves to be trusted or not. As a characteristic of the trustee, trustworthiness also has many ethical elements, mainly involving justice and fairness. Then, trustor should judge the trustee fair to enter into the trusting process; otherwise it is difficult that trust could be built over time. And this can happen in both voluntary and forced trust events in which risk is involved and interdependence exists between the trustor and the trustee.
Justice as a requisite then is an antecedent of trustworthiness and also an antecedent of systems requisites to generate future fairness perceptions, that are also necessary to generate future trustworthiness, once some trust interaction has started. Therefore, justice is both an antecedent and a consequence of trust in someone.
In organizations justice has been considered as a construct based on perceptions, on the form of organizational justice that is the aggregation of perceptions of how fair are procedures, distributions, relationships, and information. It has also been studied as being part of formal systems and system’s use (what has been labeled as informal systems). Following this late definition, a seminal paper in the literature of management control systems and justice has considered that there are two types of justice, the formal justice (attached to system design) and informal justice (attached to system use or managerial use of the system, which is the same). Then informal justice is linked to the informal organization and formal justice to the formal organization. Both formal and informal justice have a positive effect over goal congruence, meaning that people that perceive the system and its use are fair tend to increase their alignment between their individual goals and organizational goals over time. So, justice tends to increase the alignment of interests between the institutions and participants [11]. Even if in terms of justice, it seems that informal justice has more potential to actually change the system and generate greater improvements over time rather than formal justice alone, the use following justice criteria seems more appropriate to learn and suggest improvements [24]. So, the ethical or virtuous use of the systems (which mainly should be just) generates greater alignment of goals and greater overall future fairness compared to the mere implementation of formal justice in a mechanical way.
Additional research on the matter uses this underlying relationship between justice and goal congruence, and incorporates also the trust in managers variable [25]. In this model, ex-ante justice (formal and informal), trust in managers, and interest alignment between participants are shown to generate future perceptions of justice over time. This means that when managers use the system following justice requirements, people trust them, their interests are more aligned with the organization, and finally justice is generated also in the long term. This is creating a virtuous cycle, as once this starts, this new justice perceptions reinforce future trust generation, helping to improve the system and its use over time.
Goal congruence or interest alignment on its own, when high also makes people increase fairness perceptions, meaning that it increases how they perceive the justice in all organizational dimensions (distributions, processes, information, and personal treatment). Then, once informal justice is in place, it generates a positive effect trusting managers, and this in turn has a positive effect in future perceptions of fairness that following this virtuous circle feeds again the process of trust generation. The previous virtuous circle, once in place reinforces the alignment between the interests of the organization and stakeholders, increasing the willingness of a shared meaningful purpose.
Trust is the most desired intangible to be generated in economic exchanges. Trust functions to bring ethics into the market interactions and into the organizational relationships, which is considered the best way to increase efficiency. The big characteristic of trust is that it increments efficiency but in nature is a moral aspect that cannot be traded. In fact, thinking of its tradability makes it clear that we are trading something that we can assure is not trust at all [1]. So, ethics should be incorporated into this with a genuine interest for the good, and when doing so, it is trust, this ethical intangible, that eventually makes the economic world function smoothly and with ease.
But trust needs to be generated, and fundamentally foundations of trust rely on how trust is generated and so, how one party (trustor) makes a specific assessment to what extent the other party (trustee) deserves to be trusted or not. Fundamentally this assessment is based on ability, integrity. and benevolence, psychological characteristics that are found also in the Aristotelian Rhetoric, being there labeled intelligence, character, and goodwill.
The first (ability) is more linked to technical skills and expertise (I am trusting your ability to perform efficiently and effectively some specific tasks and duties), but the other two (character and goodwill) are mainly linked to building the specific virtuous aspects of managers. And which are the aspects of managers that generate trust? Managers generate trust when acting according to what they say and based on a system of values that incorporate virtues, justice being the mother of moral virtues, central to generate the good in organizations. Therefore, managers generate trust when the ones that are affected by their decisions judge they are going to act according to justice for the good of all, not for selfish interests. This good, then, can be judged by the ones that have trusted managers, in terms of justice perceptions related to processes, information, relationships, and outcomes. Once these perceptions are present can feed new trust interactions, which in turn affect future generation of trust and trustworthiness. Justice is an antecedent of trustworthiness, and future justice is an antecedent of future trustworthiness. Thus, the loop generated is clear, and the virtuous circle is clear too. Both trust and justice are crucial ethical dimensions in organizational relationships to serve as the long-term fuel to build social and economic sustainable institutions. Trust cannot be generated out of the blue; instead it needs strong justice implementation and performance to start being generated. Once the virtuous circle is implemented it should be fueled over time, as learning to be fairer is a path of improving character and goodwill of managers that never ends. Ethical standards and justice standards evolve, and managers should evolve too. This learning is necessary to allow trust to increase, as if the process of increasing trust is not in place the process of destroying has, for sure, started.
I acknowledge the invaluable help of my colleagues at Open University of Catalonia and IESE Business School for our discussions on the topics of this chapter, mainly Josep Maria Rosanas, my advisor and colleague with whom I have shared uncountable hours of conversation and fruitful debates.
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Dual-beam platforms, combining a high-resolution scanning electron microscope (HR-SEM) and an FIB column, additionally equipped with precursor-based gas injection systems (GIS), micromanipulators, and chemical analysis tools (such as energy-dispersive spectra (EDS) or wavelength-dispersive spectra (WDS)), serve as multifunctional tools for direct lithography in terms of nano-machining and nano-prototyping, while advanced specimen preparation for transmission electron microscopy (TEM) can practically be carried out with ultrahigh precision. Especially, when hard materials and material systems with hard substrates are concerned, FIB is the only technique for site-specific micro- and nanostructuring. Moreover, FIB sectioning and sampling techniques are frequently used for revealing the structural and morphological distribution of material systems with three-dimensional (3D) network at micro-/nanoscale.This book chapter includes many examples on conventional and novel processes of FIB technologies, ranging from analysis of semiconductors to electron tomography-based imaging of hard materials such as nanoporous ceramics and composites. 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Electron diffraction patterns are used to obtain quantitative data including phase identification, orientation relationship and crystal defects in materials, etc. At first, a general introduction including a geometrical and quantitative approach to electron diffraction from a crystalline specimen, the reciprocal lattice and electron diffraction in the electron microscope are presented. The scattering process by an individual atom as well as a crystal, the Bragg law, Laue conditions and structure factor are also discussed. Types of diffraction patterns such as ring pattern, spot pattern and Kikuchi pattern, and general and unique indexing diffraction patterns are explained. The procedure for indexing simple, complicated and imperfect patterns as well as Kikuchi lines and a combination of Kikuchi lines and spots is outlined. The known and unknown materials are identified by indexing patterns. Practical comparisons between various methods of analysing diffraction patterns are also described. The basic diffraction patterns and the fine structure in the patterns including specimen tilting experiments, orientation relationship determination, phase identification, twinning, second phases, crystallographic information, dislocation, preferred orientation and texture, extra spots and streaks are described in detail. Finally, electron diffraction patterns of new materials are investigated.",book:{id:"5075",slug:"modern-electron-microscopy-in-physical-and-life-sciences",title:"Modern Electron Microscopy in Physical and Life Sciences",fullTitle:"Modern Electron Microscopy in Physical and Life Sciences"},signatures:"Mohsen Asadi Asadabad and Mohammad Jafari Eskandari",authors:[{id:"176352",title:"Dr.",name:"Mohsen",middleName:null,surname:"Asadi Asadabad",slug:"mohsen-asadi-asadabad",fullName:"Mohsen Asadi Asadabad"},{id:"177600",title:"Dr.",name:"Mohammad",middleName:null,surname:"Jafari Eskandari",slug:"mohammad-jafari-eskandari",fullName:"Mohammad Jafari Eskandari"}]},{id:"38543",title:"Application of FTIR Spectroscopy in Environmental Studies",slug:"application-of-ftir-spectroscopy-in-environmental-studies",totalDownloads:27659,totalCrossrefCites:10,totalDimensionsCites:42,abstract:null,book:{id:"2397",slug:"advanced-aspects-of-spectroscopy",title:"Advanced Aspects of Spectroscopy",fullTitle:"Advanced Aspects of Spectroscopy"},signatures:"Claudia Maria Simonescu",authors:[{id:"142381",title:"Dr.",name:"Claudia Maria",middleName:null,surname:"Simonescu",slug:"claudia-maria-simonescu",fullName:"Claudia Maria Simonescu"}]}],onlineFirstChaptersFilter:{topicId:"228",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:318,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:106,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:15,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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Recently, bioinspired systems have been successfully employing biomechanics to develop and improve assistive technology and rehabilitation devices. The research topic "Bioinspired Technology and Biomechanics" welcomes studies reporting recent advances in bioinspired technologies that contribute to individuals\' health, inclusion, and rehabilitation. Possible contributions can address (but are not limited to) the following research topics: Bioinspired design and control of exoskeletons, orthoses, and prostheses; Experimental evaluation of the effect of assistive devices (e.g., influence on gait, balance, and neuromuscular system); Bioinspired technologies for rehabilitation, including clinical studies reporting evaluations; Application of neuromuscular and biomechanical models to the development of bioinspired technology.',coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",hasOnlineFirst:!1,hasPublishedBooks:!0,annualVolume:11404,editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",slug:"adriano-andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",biography:"Dr. Adriano de Oliveira Andrade graduated in Electrical Engineering at the Federal University of Goiás (Brazil) in 1997. He received his MSc and PhD in Biomedical Engineering respectively from the Federal University of Uberlândia (UFU, Brazil) in 2000 and from the University of Reading (UK) in 2005. He completed a one-year Post-Doctoral Fellowship awarded by the DFAIT (Foreign Affairs and International Trade Canada) at the Institute of Biomedical Engineering of the University of New Brunswick (Canada) in 2010. Currently, he is Professor in the Faculty of Electrical Engineering (UFU). He has authored and co-authored more than 200 peer-reviewed publications in Biomedical Engineering. He has been a researcher of The National Council for Scientific and Technological Development (CNPq-Brazil) since 2009. He has served as an ad-hoc consultant for CNPq, CAPES (Coordination for the Improvement of Higher Education Personnel), FINEP (Brazilian Innovation Agency), and other funding bodies on several occasions. He was the Secretary of the Brazilian Society of Biomedical Engineering (SBEB) from 2015 to 2016, President of SBEB (2017-2018) and Vice-President of SBEB (2019-2020). He was the head of the undergraduate program in Biomedical Engineering of the Federal University of Uberlândia (2015 - June/2019) and the head of the Centre for Innovation and Technology Assessment in Health (NIATS/UFU) since 2010. He is the head of the Postgraduate Program in Biomedical Engineering (UFU, July/2019 - to date). He was the secretary of the Parkinson's Disease Association of Uberlândia (2018-2019). Dr. Andrade's primary area of research is focused towards getting information from the neuromuscular system to understand its strategies of organization, adaptation and controlling in the context of motor neuron diseases. 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