ISSUE 01 – APRIL/2011
Focus – page 12
INNOVATION
IN LATIN
AMERICA
Interview – page 4
Dr. Almino Ramos is our guest to talk
about technology at the service of health
Opinion – page 16
Three professionals share their
impressions about the first anniversary
of Johnson & Johnson Medical Innovation Institute
Health On Target – page 28
Veridex invests in next generation
of tests for Circulating Tumor Cells
[EDITORIAL]
Get to Know Johnson & Johnson
*
Medical Innovation Institute
In 2010, Johnson & Johnson Medical companies in Latin
America took a very important step in their history with
the launch of Johnson & Johnson Medical Innovation
Institute*, in São Paulo, Brazil, to provide services to all
countries in Latin America.
From the moment the project was approved to the beginning
of activities, only 11 months went by — the time to turn the
dream into reality and open a facility that is considered a key
element in our strategies to improve healthcare throughout
the region, according to Antonio Ferreira, Johnson & Johnson
Medical Regional vice-president for Latin America.
In line with Our Credo1 at Johnson & Johnson, the Institute
was born a year ago with the mission of promoting continuous
advances in the quality of healthcare, offering physicians,
nurses, technicians, public managers, hospital administrators
and healthcare plans the most modern training in equipment
and medical and diagnostic procedures. We believe we are
not only responsible for delivering high quality products
and services but also for helping healthcare professionals make
the best use of them.
1 “Our Credo” is a chart of principles wrote in 1943, by Robert Wood Johnson. Nowadays,
his philosophy is taught and followed by Johnson & Johnson worldwide.
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda.
2 - INNOVATE MAGAZINE
To celebrate the first anniversary of Johnson & Johnson Medical
Innovation Institute*, we are launching INNOVATE, an electronic
magazine directed to our internal and external partners.
The first issue brings a special cover story about the Institute’s inception.
In the section Interview, a chat with dr. Almino Ramos, from Gastro
Obeso Center clinic, highlights the importance of the Institute for
the medical community. Three other renowned specialists – dr. Gilberto
Barbosa, from UFRGS, nurse Janete Akamine, from SOBECC, and
dr. Claudio Bresciani, from USP and Hospital Alemão Oswaldo Cruz –
are featured in the section Opinion, with articles that discuss the impact
of professional education in health.
I invite you to learn more about Johnson & Johnson Medical
Innovation Institute* from the perspective of those who have been
participating in it actively in their day-to-day activities. Enjoy your reading!
George Marques Filho
Director of Johnson & Johnson Medical Innovation Institute*
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda.
ISSUE 01 | APRIL/2011 - 3
[INTERVIEW]
TECHNOLOGY
AT THE SERVICE
OF HEALTH
In its first year of activity, Johnson & Johnson Medical
Innovation Institute* promoted important advances in
the training of healthcare professionals in Latin America.
According to the industry specialists, its structure is comparable
to the best training centers in the world and its courses are very
well-evaluated by physicians of different specialties.
In this interview with INNOVATE, dr. Almino Ramos –
gastroenterologist, general clinician and director of Gastro Obeso
Center – talks about the benefits that Johnson & Johnson Medical
Innovation Institute* provides to the medical community
throughout Latin America, highlights the importance of investing
in technology for more efficient courses and shares his experiences
in coordinating surgical trainings.
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda.
4 - INNOVATE MAGAZINE
ISSUE 01 | APRIL/2011 - 5
[INTERVIEW]
INNOVATE – What has the Johnson & Johnson
Medical Innovation Institute* initiative
represented for the medical community,
both for experienced physicians
and medicine students?
Dr. Almino Ramos – It surely represents a major
advance that will certainly have an important role
in surgical training in Brazil and Latin America.
Experienced surgeons need enhancement in new
products and techniques, and your surgeons
and residents will improve their learning. It is
important to highlight that, until the opening
of Johnson & Johnson Medical Innovation
Institute*, the region did not have a training
center at the level of the best international centers.
INNOVATE – What are the key benefits the
Institute provides in terms of concepts,
structure and technology?
Dr. Almino – The major benefit is to offer
a modern, advanced structure. Spaces adapt
to several needs, such as theoretical courses,
with the possibility of establishing conference calls
to any part of the world, and practice in simulators
that can reach different levels of difficulty.
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda.
6 - INNOVATE MAGAZINE
“JOHNSON & JOHNSON MEDICAL
*
INNOVATION INSTITUTE
REPRESENTS THE GREATEST
ADVANCE IN SURGICAL TRAINING
IN THE PAST 20 YEARS.”
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda.
ISSUE 01 | APRIL/2011 - 7
[INTERVIEW]
“WE HAVE A TRADITION IN
TRAINING AND NOW, WITH
JOHNSON & JOHNSON MEDICAL
*
INNOVATION INSTITUTE , RESULTS
WILL BE EFFICIENT FOR EVERYONE.”
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda.
8 - INNOVATE MAGAZINE
INNOVATE – You already have coordinated
the bariatric surgery course throughout
Brazil, Mexico and for residents in Latin
America (BILA). Tell us about your experience.
Dr. Almino – When I heard the courses would
be here I was a little apprehensive about the
responsibility of giving continuity to courses with
such tradition, offered by the Institute of Cincinnati
(in Ohio in the U.S.). However, the experience
was very gratifying since I realized we could offer
courses in Brazil with the same structure
and quality offered abroad.
INNOVATE – What was the greatest news
that you saw for your medical specialty,
presented by Johnson & Johnson Medical
Innovation Institute*?
Dr. Almino – We had lots of good news. However,
I believe the best was the use of simulators for
training because the sensation that the surgeons
have when handling this equipment is very close
to what will happen in their day-to-day practice.
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda.
ISSUE 01 | APRIL/2011 - 9
[INTERVIEW]
INNOVATE – What is the future of minimally
invasive surgery in your opinion?
Dr. Almino – Minimally invasive surgery represents
the future of surgery. We will increasingly offer
less aggressive methods, with excellent results
and greatly facilitating our patients’ recovery.
INNOVATE – How did you get
invited to participate in the events
of Johnson & Johnson Medical
Innovation Institute*?
Dr. Almino – My partnership with
Johnson & Johnson Medical Innovation Institute*
was the natural consequence of a relationship
with Ethicon Endo-Surgery2: the first bariatric
surgery course was held in 2001 and the first
metabolic surgery course in 2005. In this period,
my team and I trained groups from almost all
countries in Latin America, Portugal, Spain, India,
Austria and the Philippines, in addition to groups
coming from several places in Brazil. We have
a tradition in training and now that we can count
on the Johnson & Johnson Medical Innovation
Institute* infrastructure and partnership,
the results will be more efficient for everyone.
2 Ethicon Endo-Surgery is a business unit of Johnson & Johnson Medical Brazil,
a division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos
para a Saúde Ltda.
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos
para Saúde Ltda.
10 - INNOVATE MAGAZINE
INNOVATE – This kind of partnership
promotes advances in medicine
or transformations in the health industry.
How can they be established?
Dr. Almino – There are huge advances and,
quite often, they take place sooner than
expected. The best example of this is the change
accomplished with regard to laparoscopic and open
bariatric surgery. With suitable training for surgical
teams using video laparoscopy, most procedures
are now performed with the abdomen closed.
In this manner, we provided major benefits
to the population, with a less aggressive
technology, a less painful postoperative period
and faster recovery.
INNOVATE – What is the value of
Johnson & Johnson Medical Innovation Institute*
for the Latin America reality?
Dr. Almino – Johnson & Johnson Medical
Innovation Institute* represents the greatest
advance in surgical training in the past 20 years,
helping surgeons with technologies we did not
have access to before. The society benefits when
it can count on the best physicians and
treatments. The Institute has the same expertise
and the same quality facilities you can find
in Cincinnati, U.S., or Hamburg, Germany.
* A division of Johnson & Johnson do Brasil Indústria e Comércio de
Produtos para Saúde Ltda.
ISSUE 01 | APRIL/2011 - 11
[FOCUS]
INNOVATION
IN LATIN
AMERICA
PLANS FOR THE INSTALLATION OF AN INSTITUTE SIMILAR
TO THE MORE THAN 20 TRAINING CENTERS SPREAD
THROUGHOUT THE WORLD STARTED BACK IN THE 1990s.
THIS SPACE SHOULD MEET THE NEEDS OF HEALTHCARE
PROFESSIONALS IN LATIN AMERICA AS WELL AS ITS
TEACHING INSTITUTIONS.
12 - INNOVATE MAGAZINE
ISSUE 01 | APRIL/2011 - 13
[FOCUS]
From project inception, going through legal and financial
approvals, only 11 months were necessary for Johnson & Johnson
Medical Innovation Institute* to be opened on February 1st,
2010, in São Paulo, Brazil. Although the Institute’s building
process was quite fast, all details were addressed very
carefully, always having as our pillar high quality professional
training for the benefit of the population.
Regina Navarro, president of Johnson & Johnson Medical Brazil*,
explains that the Institute represents an important advance since
it is the only one of its nature among Johnson & Johnson
Medical companies in Latin America to offer an encompassing
portfolio of training programs, focused on medical devices
and diagnostic solutions.
“The key purpose of this Institute is to promote
the development of health in Brazil and in the whole
of Latin America”, Regina says.
Professional Education, in which Johnson & Johnson Medical
companies in Latin America invest so much, has two main
pillars: the first encompasses learning and use of products
marketed by Johnson & Johnson Medical Brazil* medical units
and the second promotes basic learning in any surgical
technique that the use of such products may require.
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda.
14 - INNOVATE MAGAZINE
FIRST YEAR
The proposal of Johnson & Johnson Medical Innovation Institute*
has always been to gather, in a single environment,
state-of-the-art infrastructure and technology which could offer
healthcare professionals in Latin America the most modern
training in medical equipment and diagnostic procedures.
George Marques Filho, director of Johnson & Johnson Medical
Innovation Institute*, says that a year after the Institute’s
opening, the results and evaluation exceeded all expectations.
Approximately three thousand professionals (including
physicians, nurses, technicians, public managers, hospital
administrators and healthcare plans) and also hundreds
of employees of Johnson & Johnson Medical companies
in Latin America visited the Institute.
Another major accomplishment is a reason of pride for
Johnson & Johnson: important partnerships were established
in the past year with universities, hospitals and medical entities,
strengthening the Institute’s image as a serious institution
prepared for building professional capacity at all levels – from
students to experienced physicians. “These innovations enabled
Johnson & Johnson Medical Innovation Institute* to positively
contribute to a changein the parameters of Professional
Education in Latin America”, George concludes.
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda.
ISSUE 01 | APRIL/2011 - 15
[OPINION]
PHYSICIANS CELEBRATE
THE FIRST ANNIVERSARY
JOHNSON & JOHNSON
MEDICAL INNOVATION
*
INSTITUTE
BY PROFESSOR DOCTOR GILBERTO V. BARBOSA
Associate Professor of Cardiovascular Surgery
of the Medicine School of the Federal University
of Rio Grande do Sul
PhD in Surgery by UFRGS
Member of the Clinical Staff of Hospital das Clínicas of Porto Alegre
Former President of the Brazilian Society of Cardiovascular Surgery
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda.
16 - INNOVATE MAGAZINE
ISSUE 01 | APRIL/2011 - 17
[OPINION]
“MEDICINE INCORPORATES
PROCEDURES THAT DEMAND
SPECIAL SKILLS TO BE
FULLY MASTERED.”
18 - INNOVATE MAGAZINE
Surgical actions trained using
powerful simulators or animals
provide professionals the expertise
that can decrease their learning
curve in surgical procedures.
An institution like Johnson & Johnson Medical
Innovation Institute*, with its leading objective
to offer conditions for professional training,
is highly relevant for Latin America. The benefits
for our medical community are immeasurable.
We have in our hands the privilege of testing
state-of-the-art surgical products in laboratories
furnished with equipment for procedures
of multiple complexities. Concomitant to practical
training, the Institute provides courses for
cognitive understanding of medical science
in auditoriums equipped with the most modern
audiovisual methods.
Medicine incorporates procedures that demand
special skills to be fully mastered. Along their career,
physicians go through constant update processes.
Undergraduate students, long-time professionals,
resident physicians and professionals taking graduate
programs find in Johnson & Johnson Medical
Innovation Institute* a rare and important
route, which helps in the qualification of their
daily practice.
The Brazilian Society of Cardiovascular
Surgery was the first institution to
propose a partnership for scientific
and technological cooperation with
Johnson & Johnson Medical
Innovation Institute*. In the next five
years, we plan to train 300 surgeons
in the most diverse areas of specialty
and develop the research projects
of our members. As a cardiovascular
surgeon, I think the Institute is,
undoubtedly, the most efficient
way to provide our surgeons
opportunities to get better.
Physicians feel capable of providing
more qualified care to the Brazilian
population. For this reason,
we believe that its inception
and installation in our country
was the greatest contribution
of a company to build the capacity
of Brazilian medical professionals
in recent years.
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda.
ISSUE 01 | APRIL/2011 - 19
[OPINION]
KNOWLEDGE AND
TECHNOLOGY ON
BEHALF OF THE PATIENT
BY NURSE JANETE AKAMINE
President of Brazilian Society of Nurses
in Operating Rooms, Anesthetic Recovery
and Material and Sterilization Center (SOBECC)
Nurse at Hospital Vitória
The development of healthcare professionals requires
evidence-based practice. With Johnson & Johnson Medical
Innovation Institute*, the medical community could count
on a space in which learning takes place by means of practice
that is very close to reality. The Institute team has major talents,
who challenge professionals with teaching, research
and development of high level projects.
Surgical techniques allied to technology – such as robotics,
neuro navigation and minimally invasive surgeries – benefit
results and diagnoses. The evolution of medical sciences,
accompanied by quality and safety, qualifies hospital practices.
We, healthcare professionals, have to update ourselves
at the same pace and learn how to deal with technology
without losing the human essence of care.
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda.
20 - INNOVATE MAGAZINE
ISSUE 01 | APRIL/2011 - 21
[OPINION]
“WE, HEALTHCARE PROFESSIONALS,
HAVE TO UPDATE OURSELVES AT
THE SAME PACE AND LEARN HOW
TO DEAL WITH TECHNOLOGY
WITHOUT LOSING THE HUMAN
ESSENCE OF CARE.”
22 - INNOVATE MAGAZINE
Nursing studies follow the same paths of other
areas in healthcare. Universities qualify specialists,
masters and PhDs. Nevertheless, it is with practice
that we acquire expertise and the Institute has
come to complement our training. Associations
Partnerships should be created
and added for professional
enhancement. We consolidate
knowledge from the moment we
associate it to skills and possibilities.
promote seminars, courses and symposiums,
and professionals from São Paulo have major
possibilities for enhancement. However, this reality
is not observed in other regions and we are right
now reflecting about how we can contribute
to the ideal development of these professionals.
We can find just one answer: through partnership
based on the dream of better health.
Johnson & Johnson Medical
Innovation Institute* was born from
a dream, to be idealized and shared.
The Institute structure is unique
and innovative and develops skilled
professionals who are confident
about their practices.
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda.
ISSUE 01 | APRIL/2011 - 23
[OPINION]
24 - INNOVATE MAGAZINE
AN IMPORTANT
SOURCE OF RENEWAL
FOR HEALTHCARE
PROFESSIONALS
BY PROFESSOR DOUTOR CLÁUDIO BRESCIANI
Associate Professor of Digestive System Surgery of the
Medicine School of USP and Hospital Alemão Oswaldo Cruz
It would not be an exaggeration to say that Johnson & Johnson
Medical Innovation Institute* facilities in São Paulo were a gift
for the medical community of Latin America and, mostly,
for Brazilians. Our region still suffers from the absence
of training centers exclusively organized to enhance the work
of healthcare professionals.
* A division of Johnson & Johnson do Brasil Indústria e Comércio de Produtos para Saúde Ltda.
ISSUE 01 | APRIL/2011 - 25
[OPINIÃO]
[OPINION]
“MEDICAL SERVICES TO THE
POPULATION ARE VISIBLY BETTER
WHEN PROFESSIONALS ARE
PREVIOUSLY TRAINED.”
26 - INNOVATE MAGAZINE
Among so many benefits, I would highlight training in new
surgical methods and laboratory equipment. Medical services
to the population are visibly better when professionals are
previously trained.
Medicine is a dynamic science and we have witnessed how
fast new techniques and equipment have been created,
particularly in the last decade. It would be incorrect to say that
all treatments will be useful for physicians in their day-to-day
practice but familiarity with them and training are a must.
Even the most experienced surgeons have to return many times
to the laboratories during their career in search of updated
training. Thus, the Institute’s modern structure and specially
trained teams from business units play an important
role in the application of knowledge.
The Institute also has become a key
resource for medical students.
The cost of training centers is very
high for Brazilian teaching institutions.
Partnerships between universities
and the private sector have become
essential. The basic guidelines
of medical training in the country call
for professionals who are aware
of the importance of medical and,
mainly, social inclusion, rationalizing
costs and choosing appropriate surgical
or clinical treatment processes.
ISSUE 01 | APRIL/2011 - 27
[HEALTH ON TARGET]
VERIDEX, LLC,
ANNOUNCES COLLABORATION WITH
MASSACHUSETTS GENERAL HOSPITAL
TO DEVELOP NEXT GENERATION
TECHNOLOGY FOR CIRCULATING
TUMOR CELLS
IN THE BEGINNING OF THE YEAR, THE HEALTH-SPECIALIZED
PRESS THROUGHOUT THE WORLD ANNOUNCED NEWS IN THE
DIAGNOSIS OF CANCER: AMERICAN SCIENTISTS AT HARVARD
UNIVERSITY AND MASSACHUSETTS GENERAL HOSPITAL
(IN THE STATE OF MASSACHUSETTS, U.S.), IN PARTNERSHIP
WITH JOHNSON & JOHNSON MEDICAL, DEVELOPED A TEST
THAT CAN IDENTIFY A SINGLE CANCEROUS CELL IN THE BLOOD.
28 - INNOVATE MAGAZINE
Veridex, LLC3, announced, in January 2011, its collaboration with Massachusetts General
Hospital to develop and market the next-generation technology in Circulating Tumor Cells
(CTC) to capture, count and characterize tumor cells found in patients’ blood.
The partnership will involve Ortho Biotech Oncology Research & Development (ORD),
a unit that belongs to Johnson & Johnson Pharmaceutical Research & Development.
Studies will focus on the development of a next-generation system that will enable
oncologists to use CTCs as a diagnostic tool to customize patient care as well
as by researchers to accelerate and enhance the process to discover
and develop new drugs.
3V
eridex, LLC, a Johnson & Johnson company, is an organization dedicated to providing physicians with high-value
diagnostic oncology products. Veridex’s IVD products may significantly benefit patients by helping physicians make
more informed decisions that enable better patient care. Veridex’s Clinical Research Solutions provide tools and
services that may be used for the selection, identification and enumeration of targeted rare cells in peripheral
blood for the identification of biomarkers, aiding scientists in their search for new targeted therapies.
ISSUE 01 | APRIL/2011 - 29
[HEALTH ON TARGET]
“THE CHALLENGING GOAL
OF SORTING EXTREMELY RARE
CIRCULATING TUMOR CELLS FROM
BLOOD REQUIRES CONTINUOUS
TECHNOLOGICAL, BIOLOGICAL
AND CLINICAL INNOVATION.”
30 - INNOVATE MAGAZINE
The collaboration will rely on the collective scientific, technical,
clinical and commercial expertise between the partners:
Massachusetts General Hospital’s experience in clinical research
and novel CTC technologies; the experience of Veridex
as the only diagnostics company to have brought CTC
technology to the U.S. market as an FDA-cleared in vitro
diagnostic (IVD) assay for capturing and counting the number
of tumor cells in the blood to help inform patients and their
physicians about prognosis and overall survival in certain
types of metastatic cancers; and ORD’s expertise in oncology
therapeutics, biomarkers and companion diagnostics.
“This new technology has the potential to facilitate an easy-toadminister, non-invasive blood test that would allow us
to count tumor cells”, and to characterize the biology
of the cells,” said Robert McCormack, head of Technology
Innovation and Strategy, Veridex. “Harnessing the information
contained in these cells in an in vitro clinical setting could enable
tools to help select treatment and monitor how patients
are responding”.
“The role of CTCs in drug discovery and development
is growing as new technologies allow us to use CTCs
for the first time as templates for novel DNA, RNA
and protein biomarkers”, said Nicholas Dracopoli, vice
president, biomarkers, ORD. “Given the demand for actionable
data to guide personalized medicine for patients with cancer,
there is a rapidly growing need for advanced, automated
non-invasive technologies that can aid in selection
of treatment and monitor response throughout the course
of their disease”.
ISSUE 01 | APRIL/2011 - 31
[HEALTH ON TARGET]
“The challenging goal of sorting extremely rare Circulating
Tumor Cells from blood requires continuous technological,
biological and clinical innovation to fully explore the utility
of these precious cells in clinical oncology”, said Mehmet
Toner, Ph.D., director of the BioMicroElectroMechanical
Systems Resource Center in the MGH Center for Engineering
in Medicine. “We have developed and continue to develop
a broad range of technologies that are evolving what we know
about cancer and cancer care. This collaboration is an opportunity
to apply our past learning to the advancement of a platform
that will ultimately benefit patients with cancer”.
The platform to be developed will be a bench-top system
to specifically isolate and explore the biology of rare cells
at the protein, RNA and DNA levels.
Clinical validation and regulatory submissions for future
diagnostic applications of this new technology will be guided
by Veridex. Veridex launched the first commercial CTC test
in 2004 and has demonstrated an ongoing commitment
to advancing innovation in CTC testing and expanding
the utility of CTCs as an IVD tool in clinical oncology practice.
32 - INNOVATE MAGAZINE
In the research setting, Veridex’s Clinical Research Solutions group
works with partner companies to offer technology and expertise
in rare cells for R&D efforts that aim to develop more targeted
and effective therapies in cancer and other diseases.
Ortho Biotech Oncology Research & Development, a unit
of Johnson & Johnson Pharmaceutical Research & Development,
is a research and development organization that strives
to transform cancer to a preventable, chronic or curable disease
by delivering extraordinary and accessible diagnostic and therapeutic
solutions that prolong and improve patients’ lives.
Building on its successful development and evolution of CTC
technology, as well as contributions to the body of science in
the CTC field, Massachusetts General Hospital aims to revolutionize
how oncologists detect, monitor and potentially treat cancers.
ABOUT CIRCULATING TUMOR CELLS
Circulating tumor cells are cancer cells that have detached from the tumor
and are found at extremely low levels in the bloodstream. The value
of capturing and counting CTCs is evolving as more research data
is gathered about the utility of these markers in monitoring disease
progression and potentially guiding personalized cancer therapy.
ISSUE 01 | APRIL/2011 - 33
Technical crew | INNOVATE is an electronic newsletter produced by Johnson & Johnson Medical
Innovation Institute, directed to healthcare professionals and Johnson & Johnson Medical employees.
The texts published here do not necessarily reflect the corporation’s opinion and are responsibility
of their authors.
Contact us. Send your critics and suggestions to [email protected].
Johnson & Johnson Medical Innovation Institute Director: George Marques Filho |
Editorial coordination: Luciana Leite and Marcos Fujihara | Editorial Board: George Marques
Filho, Marcos Fujihara, Luciana Leite, Camila Cavicchioli | Approval: Legal, Copy Review,
Johnson & Johnson Medical Innovation Institute and Communication departments |
Editorial production: Renata Santos (writing) and Rejane Carvalho (editing – MTB 46024) |
Pictures: personal files | Graphic design: fmcom