Analysis of Grafting Techniques

Analysis of Grafting Techniques Procedure: In this method a split-thickness skin graft is harvested from the donor site, either thigh or buttocks. It is then meshed either manually or in an Ampligreffe or any other suitable meshing apparatus.[40,41] Meshing of the graft causes an expansion in its size to 4 or 6 times its original one. The meshed graft is then applied on the dermabraded recipient skin and bandaged as in any other form of tissue grafting. The main advantage of this technique is that the graft can take care of a vitiligo lesion that is 4-6 times that of its original size. Additionally meshing allows the graft to be applied on areas over joints and other areas with difficult contours. This technique is increasingly being practiced in India and is a simple, cost- effective procedure with good cosmetic results. Principle: In this technique of vitiligo, grafting the split-thickness or ultra-thin skin graft is cut or smashed into very small pieces and applied to the dermabraded recipient skin.[42,43] The donor: recipient ration is approximately 1:10. Procedure: A split-thickness or ultra-thin skin graft is first taken from the donor area preferably thigh or buttocks. It is then smashed/cut into thin pieces.The cutting process is continued till the graft is converted into a uniform mesh or paste. This mesh is then mixed with either hyaluronic acid or antibiotic ointments and is then spread evenly over the dermabraded recipient area as in any other form of tissue grafting.[42] The recipient area is then covered with a collagen dressing and this dressing is removed after 7-8 days. The advantage of this method is that a relatively larger area can be covered by a small sized graft. The results are almost similar to those achieved with non-culture epidermal cell suspension (NCES) technique. Additionally, no expensive reagents or laboratory support is required as in NCES procedure. Some difficult to treat areas like the hairy skin, the joints and bony prominences can also be treated with this technique. The disadvantage is that it is di fficult to spread the grafted tissue evenly on to the recipient area. Figures 34.7 and 34.8 shows good results with smash graft on joints. Three main cellular grafting techniques are described in the world literature. These are non-culture epidermal cell suspension technique, cultured melanocyte transplant and non-culture follicular suspension technique Synonyms: non culture melanocyte transplant, non-culture melanocyte-keratinocyte cell transplant (NCCT), basal cell suspension technique. Principle: The different cellular components of a STSG are separated and a suspension is prepared out of these cellular components. The suspension contains epidermal keratinocytes and melanocytes’ this is applied on to a dermabraded recipient area. The donor: recipient ration is 1:10. In this cellular grafting procedure a split-thickness skin graft is harvested from a suitable donor area and this is treated with 5 ml of Trypsin-EDTA solution for about 45-60 minutes in an incubator at 37 °C. This step separates the cells of the epidermis from the underlying dermis. The next step is the neutralization of Trypsin which is achieved either by using 2 ml of 0.5% trypsin inhibitor solution or washing the graft with DMEM or any other suitable medium repeatedly. The treated graft is then taken in a petridish with the epidermal side downwards and the dermal cells are teased out of the graft with forceps. The overlying dermal tissue is discarded and the solution with the cellular component is centrifuged for about 10 minutes at the end of which the cells pellet are seen suspended at the bottom of the centrifuge tube and the epidermal pieces are floating at the top, which is discarded. The cell pellet is then mixed with a about 0.8 ml of Dulbecco’s Modified Eagleâ₠¬â„¢s Medium (DMEM) medium (also called M2 melanocyte medium) and the suspension thus obtained is transferred to a 1 ml tuberculin syringe. After the recipient bed is created, the cell suspension is spread thinly and evenly with a spatula on to the dermabraded recipient skin after removing needle. The area is then dressed with collagen dressingto hold the transplanted cells and the dressings are removed after 1 week. As an alternative to the DMEM medium, patient’s own serum or hyaluronic acid can be used as it improves the viscosity of the cellular suspension.[53] This technique requires expensive laboratory equipment and is usually practiced only at research centres. Principle: It replenishes melanocytes selectively by creating a melanocyte rich suspension. The donor: recipient ration can be as high as 1:100 Procedure: The epidermis undergoes trypsinization and the melanocytes and keratinocytes are dissociated. The melanocytes are further seeded in a melanocyte medium containing growth factors and cultured over 15 to 30 days. The cultured melanocytes (free suspension or epidermal sheets) are then transplanted on to dermabraded recipient skin. This is a novel cellular graft technique by using the hair follicle outer root sheath cell for transplant. Cosmetic results obtained with this procedure are almost similar to those seen with NCES technique. Principle: This is another cellular grafting technique wherein the melanocytes present in the hair follicles are utilized in repigmenting resistant vitiligo. The outer root sheath of the hair follicle is a rich source of inactive melanocyte. Theseinactive melanocytes function as stem cells and hence can be harvested and used in vitiligo. Procedure: The procedure is almost similar to NCES technique but here extracted hair follicles are used instead of a split-thickness skin graft. The hair follicles can be extracted by the follicular unit extraction (FUE) method. The hair follicle is decontaminated by washing with antibiotics. Enzymatic dissociation of ORS is done by addition of trypsin and incubated at 37 C.Mechanical disruption of the ORS is done by vortexing and the ORS cells are separated from the hair shaft by a cell strainer. The dissociated cells are examined microscopically for viability and the cell suspension can be transplanted onto the prepared recipient site. This technique is in a nascent stage, however it has shown good repigmentation comparable to NCES . The surgical techniques discussed above have various advantages and disadvantages. (Table 34.3) [50, 58] Table 34.3: Advantages and Disadvantages of grafting techniques In addition to the grafting techniques, various other methods also have been used including tattooing, excision with primary closure and therapeutic wounding. Tattooing: In tattooing, artificial pigments are introduced into the depigmented lesions for permanent camouflage. This can be done with a hand held pin vise or an electrical device. Excision with primary closure: The depigmented areas are removed and the wound is sutured; this technique is useful for small vitiligo lesions. Therapeutic wounding: Wounding of the lesions stimulate the melanocytes from the periphery of the lesion as well as from the hair follicles which migrates and re-pigments the lesion. Various modalities which are used for therapeutic wounding include dermabrasion, laser ablation, cryosurgery, needling, and local application of phenol or trichloroacetic acid. [59] Besides the technical aspects of various procedures (detailed in the earlier section), the other important practical aspects include: Choice of technique (Which procedure should be performed, where and why?) General pre and post-operative considerations, Role of phototherapy, Complications and their management. The choice of technique depends on the dermatosurgeons’ skills, experience and the availability of facilities in the dermatosurgery set up. However, the factors which are considered while planning a vitiligo surgery also determine the choice of surgical technique employed. Based on these factors, an algorithmic approach to choosing an appropriate surgical technique in stable vitiligo can be evolved. (Illustration 34.3 In cases of pediatric segmental vitiligo, NCES is suitable. It can be followed by phototherapy for faster results. Tissue grafting techniques are usually not recommended due to constraints of immobility in this population subset. In adult, population both tissue grafting and cellular techniques can be employed based on the site and total area of depigmentation. Segmental and focal vitiligo are most amenable to surgical treatment. Amongst the non- segmental type, lesions located on the glabrous skin are suitable for surgical intervention. The acromucosal types are usually not responsive. The location of the lesion plays an important role in determining the choice of grafting technique. (Table 34.4) Table 34.4: Anatomical location and choice of grafting technique Small areas (1-4 cm) – All techniques work well in vitiligo involving small areas (1-4 cm) and technique should be chosen based on anatomical location and cost to the patient. In cases of large areas, NCES, smash or UTSG is preferred. The general pre and post-operative aspects have been outlined in Box 34.6. Specific pre and post-operative procedural aspects have been dealt with in the description of procedures. Box 34.6: General pre and post-operative aspects The role of phototherapy (narrow band UVB) post vitiligo surgery has been well demonstrated with various tissue grafting and cellular techniques. Phototherapy can be started within 1-2 weeks following surgery. Concurrent use of narrow band UVB exerts a stimulatory and proliferative effect on the grafted melanocytes; thus post- surgery phototherapy enhances and accelerates the repigmentation. In cases of UVB therapy which is initiated after split thickness skin grafting, repigmentation can occur within two weeks and a better colour match at the recipient site is seen. Repigmentation with cellular techniques has been observed within 3-4 weeks after surgery and can progress till 6 months and this can be enhanced with phototherapy. Use of excimer laser has also shown good results post punch grafting.

The Intruder – Creative Writing

‘It's always best when the light is out, I am the pick in the ice Do not cry out or hit the alarm, you know we're friends 'til we die' – Thom Yorke (Radiohead), ‘Climbing Up The Walls' ‘Alone. The most awful word in the English tongue. Murder doesn't hold a candle to it and hell is only a poor synonym.' Humphrey had read this somewhere, probably in a Stephen King book, he couldn't remember exactly which, but he agreed with the passage then and he sure as hell agreed with it now. Though Humphrey was not alone, he was anything but alone. Humphrey was crumpled into the corner of his bedroom, his arms covering his head, his entire frame trembling, his pores and eyes unreservedly discharging sweat and bitter tears. He sat there in his darkened room with Dread, who poked him mischievously with his cold fingers. With Sorrow, who warped his heart and ate him alive. With Darkness, who shrouded Humphrey and the entire room under his tattered cloak. But worse than any twisted emotion, worse than any mutual deception of the eye and the light, worse than any melancholic betraying thoughts Humphrey may have had, was Death, who came in the guise of an Intruder that occupied the downstairs of his house, ravaging his house in a relentless chaotic frenzy. Despite Humphrey's feeble efforts to block out the noise, he could still hear everything. The crash of the tableware and glass, falling and ultimately exploding into pieces as they collided with the floor and the walls. The loud bang as his television was thrown across the room, smashing into a wall and the sizzle of the circuits bursting. The scornful cackle of the Intruder. It was a hair-raising, vulgar, sharp screech that penetrated Humphrey's delicate ear-canal-walls, went straight to his brain and exploded, the shrapnel of the explosion cutting his soft organ. It took a moment for Humphrey's mind to register that all sound and movement had ceased downstairs. Gradually his brain escaped from the cycle of fear and earthly senses returned to him. He realised his pants were drenched in urine, which made him click his tongue disapprovingly. Humphrey's aged brain was working overtime attempting to process what had happened. Most of the day was a nauseating blur to him and passed by rather uneventfully, but he remembered dozing off, and he remembered Sleep's grasp on him loosening and faltering to the hostile sound of his back door crashing in. That's when the Intruder broke in. But the dust has settle and the Intruder has departed now, probably satisfied with the destruction caused and the items burgled. Humphrey picked up his walking stick and with immense effort he managed to summon the strength to get up. He intended to go downstairs and phone the police, but only managed two steps before he heard a bang on his door. The Intruder was still in the house. The Intruder was right outside his room. Humphrey's legs collapsed right on the spot, and that frosty familiar feeling of numb helplessness enveloped him again. He shrunk back into his corner and broke into a fit of hysterical sobbing. Outside the Intruder was pounding at the door. ‘Open up,' the Intruder said hoarsely, ‘open up, man, you've gotta open up. I need her back, man, open up!' The Intruder proceeded to pound at the door, slowly at first, but then he snapped and broke into a violent fury of pounding. ‘OPEN UP!!' After what felt like an eternity to Humphrey, the Intruder ceased pounding at the door and fell to the floor and, to Humphrey's great surprise, began to weep. ‘Open up,' the Intruder wailed, ‘I can get her back, he said I can, just open up.' For a brief moment a spark of pity for the Intruder lighted up in Humphrey's mind, but the spark dimmed as soon as it appeared, and Humphrey was back in his hopeless state of terror. Silence slithered around the room, but his tyranny was brief and hastily retreated when Humphrey's bedroom door collapsed in with an earth-shattering BANG, rattling Humphrey's brain inside his skull. The Intruder got in. He was a tall man, of medium build, in his mid-thirties with moon-pale complexion, as if the sunlight had only a nodding acquaintance with his skin. The Intruder stood there, looking down at Humphrey with the look of absolute discontent on his face, a sandwich in his hand. And a gun in the other. The Intruder's eyes were dim, with a hint of triumph in them, and Humphrey noticed that he was salivating. ‘I find you at last, demon!' the Intruder exclaimed with triumph. He fiddled with his gun, groping it with his index finger. It was not point directly at Humphrey, but it was dangerously close. The Intruder made a slight a motion, which made Humphrey recoil and defensively position his arms in front of his face, as if trying to defend against an incoming strike, but the Intruder merely took a giant bite of his sandwich, the rest of which he tossed away, along with his gun. ‘I have been lookin' for ya' for so long,' the Intruder grunted, ‘you ‘ave taken away that I hold dearest, you ‘ave taken away my light. Where is she?' Dread glumly retired his post behind Humphrey and was replaced by Confusion. Humphrey was flabbergasted, ‘what is this madman talking about?' he thought, but out loud he said, ‘I- I'm afraid I have no idea what you are talking about.' ‘Ya' know damn well wha' I'm on about. I wan' her back.' The Intruder spat. ‘I think y-you're mistaken, s-sir,' Humphrey murmured, ‘I'm just an innocent ol-‘ ‘WHAT DO YOU WAN' FROM ME?' The Intruder snapped, his eyes budging and his breathing getting heavy. Dread cheerfully resumed his post. ‘Listen, man, I'm begging you to give her back to me,' The Intruder got down on both knees and clasped his hands together and tears gathered in the corner of his eyes, ‘I'm an empty shell wiv' out her. An insect, I'll do anythin'!' Humphrey was cornered; he had not a hint of how to proceed. The Intruder was utterly insane, fragile, and capable of cracking at a moment's notice. He was a danger to himself and, more importantly, a danger to Humphrey. Humphrey's eyes desperately scanned the room, looking for something, anything, he could use against the Intruder. Time, that's what he needed. Time. And a damn miracle. In the past, time and time again, Humphrey's mind had failed him. Whether it was through an examination when he was young, an important job interview, when proposing or just during everyday endeavours. And today it was no different. Humphrey couldn't even move, he felt like a spectator observing through the eyes of someone else's body, he could only watch and not take party. ‘Fine. He told me you wouldn' cooperate. He told me you wouldn' give her back to me, he told me everythin'. But there's another way, if I kill you now, she will return to me. He told me.' The Intruder said through gritted teeth, as he progressed towards Humphrey. His teeth bared, his eyes filled with contagious madness and his veins popping out, on the verge of bursting. His bare, cold hands made contact with Humphrey's neck, which made Humphrey shiver, and squeezed. Humphrey's eyes started seeing shades of black, then stars and then no more. *** Humphrey woke up, rubbed his eyes, and then wearily scanned the environment. He had been here before, he couldn't remember when but he was certain he had definitely been here before. ‘Good morning,' a cheerful voice said, ‘are we doing alright?' Humphrey looked to his right and saw a young, pleasant man in a uniform. ‘Who are you? Where am I?' Humphrey asked, dazed. His eyes were burning ‘I'm officer Peter, just call me Peter, and you're in Worthington Hospital, you were brought in last night,' Peter replied in his cheery manner. ‘What happened last night?' ‘Well, we got a call from your neighbour reporting a break-in, and we came over as soon as we could and came just in time and the intruder is in custody now.' ‘What did the intruder want with me?' Humphrey questioned. ‘His name was John Gates, and he recently lost his wife in a car accident. Poor man was mad with grief, and was only last week taken into an insane asylum, from which he miraculously escaped and came for you.' Peter nervously answered. ‘He†¦' Humphrey trailed off, ‘he kept referring to a third-party who told him to come for me. Are you sure there was no real motive after coming after me?' ‘I can only speculate on who he was referring to, but Gates was mad beyond help. That person could have just been a persona, driving him to psychotic acts, which seemed reasonable to Gates.' Peter responded. ‘Oh†¦' They had said their goodbyes and Officer Peter left, leaving Humphrey alone. All alone.

The Political Establishment in Germany Succeeded in Maintaining

The political establishment in Germany succeeded in maintaining the political status quo through a policy of moderate reform. How far do you agree? The junkers succeeded in keeping the existing political system the same through moderate reform, to what extent? When assessing whether maintaining the status quo in Germany was down to the effective use of moderate reform, we should also assess the effects of force maintaining status quo. Some would argue that it was indeed the use of moderate reform using Bulow’s reforms such as the tariff law and sickness insurance.However others would argue that it was the use of force, using ideas such as the Herero uprising. Some people may also use the policy introduced the Bulow called the Flottenpolitik. Furthermore; we should consider the economical and social factors which could have influenced this. The view that the policy of moderate reform succeeded in maintaining the political status quo; could be argued against by the fact that; Bu low’s strengths and interests lay firstly in foreign powers but he also implemented some reforms such as the tariff law in December 1902.This restored a higher duty on imported agricultural products which had a knock on effect on food prices which ended up rising. This helped maintain status quo because this would have made the public angrier henceforth could have made people rebel against the Junkers. Adding to this point; others could argue against moderate reform being the main cause of maintaining status quo on the basis that it was down to the use of force.To do this they could refer to the Herero uprising this makes clear the weaknesses of moderate reform maintaining status quo by showing one way that it led to the complete opposite; a rebellion. This uprising and how it was dealt with shows the strength and the forces and led to some members of the more conservative element of leadership of the centre part being cautious about challenging Bulow’s government. Thi s helped maintain status quo.On the other hand; Bulow created sickness insurance in April 1903 which gave ill workers longer and more generous help. This helped maintain status quo because this gave some people more reform which made people a little more happy which lowered the risk of them rebelling against the Junkers. Bethmann was Bulow’s successor as chancellor. He created reforms such as the imperial insurance 1911; this consolidated all previous workers’ insurance. This meant that some workers were now insured against sickness, old age and death.This also helped maintain status quo through moderate reform. Law such as the Sammlungpolitik also helped to maintain status quo; this law had the aim of trying to init people for the right wing leadership and take support away from the socialists. This was introduced by Bulow and he created a strategy called weltpolitik to achieve this take over the world using an army to unit people under the right wing leadership and a gainst the socialists which would help maintain the same political system and status quo.On the contrary to the above point others could argue that social or economical factors could have influenced this; for example workers wages were increasing (this made them the most urbanised state in Europe). This led to maintaining status quo because of something called the knife and fork question, this status that states that during periods of economical depression support for groups such as the socialists increase. This would be dangerous for the Junkers as they are left wing and conservatives (Junkers) are right wing.To conclude, the idea that the political establishment in Germany succeeded in maintaining the political status quo through a moderate policy of reforms can be supported using facts like how some of the reforms put forward by Bulow were successful at maintaining the same system and keeping people happy. However it can be argued against using facts like how some of the reforms put forward by Bulow and Bethmann were not successful and could be argued they did the opposite.When weighing these facts up its important to asses each of their impacts they made for example the unsuccessful reforms could be seen as having a bad impact of making the workers n happy with the system and lead to people rebelling this can be shown through the Herero uprising. The judgement I have reached is that. It wasn’t only down to moderate reform because other factors like force and also helped maintain status quo, due to the fact these factors could be seen as taking support away from the socialists which were the right wing leader’s main rival, therefore helping maintain the status quo.

The Manager Conducts Team Building Activities - 1694 Words

The manager conducts team building activities from time to time. One of these activities includes Stereotype Party, meant to reduce or eliminate Stereotypes and related issues such as Labeling. This activity can be done by a small, medium or a large group. In this activity, the participants are given name tags where they are asked to write personality types and after doing that are asked to put them on the back of their colleagues where they will be able to see every ones tag except theirs. Nobody knows the tag on their back, but is able to see the others tag. The manager then asked each participant to figure out the type of personality on their back and this he does by asking the questions about other participants, such as â€Å"Am I a man?†Ã¢â‚¬ ¦show more content†¦In this regard, the manager had instituted a companywide team building initiative that is aimed at changing the employees mind set about diversity; address intersections of diversity, influence on culture, ge nder as well as age differences and attitudes and performance as well as overall team dynamics, reduce tension and help employees work together and enhance collaboration, understanding as well as innovation and trust among the employees. The manager had clear goals expected outcome as well as implementation process. According to King et al., (2010), naturally, the effectiveness of such training is closely linked to the goals, outcomes and implementation. There instances where the manager fails to effectively communicate to the employees. Blunt is an Australian manager and as afore mentioned, the company has over one hundred employees from different backgrounds. The company has more than 20 employees from South East Asia and out of them eight are Chinese. As much as the manager expects these employees top perform, the employees themselves feel subjected to the manager and look at him as some sort of God. The Chinese background is collective where a person is seen as having no rights except those which society allows them to enjoy (Biddle, 2012). The manager is ineffective in communicating to this section of the work force as they have trouble reconciling their traditional roles and their new found duties. Communication is a very critical