MakerSpaces ( by use PRINCE2 and Design Thinking method ) Term Paper

MakerSpaces ( by use PRINCE2 and Design Thinking method ) - Term Paper Example Then discuss these at your next group meeting. The forms that you are completing in the early weeks of the course, aim to foster and document your initial ideas. Later in the course you can expand on these as you develop the actual Business Case response. The most ideal use for the Makerspace would be to provide a place for students from high school level to the college or university level to be able to pull academic resources for references and be able to share technological projects ideas. This increases the productivity levels of the students by working as a team. The group is for the idea that the demographic study showed a higher percentage of the student population aged between 18 to 25 years in most of the households, than the age group between 25 to 35 years. Thus it would be most ideal if the Makerspace would favor the students’ education, technological research, discussions and projects. Design Thinking (and for that matter good project management) asks you to gather information from your demographic audience – your potential audiences / users. In a design thinking framework, you would interview or observe some of your users and then develop a narrative or story around their project need. Draft TWO stories that use demographic data to help define a user and product of your group’s potential project. For example: â€Å"Teenagers interested in electronics will be able to design and build simple iPhone apps using the provided hardware and instruction and thus develop a basic programming skill that could enhance their application for VET or university application†. The implication in this narrative is a teenage demographic and need for educational support. University students’ focus is based on technological research and projects as opposed to studying. The space will be able to provide technological tools and software tool resources to enable the innovative minds to develop new generation

A View from the Bridge Essay Example | Topics and Well Written Essays - 1750 words

A View from the Bridge - Essay Example The time setting, which is between 1940 and 1960, may not appeal to the interest of the present-day audience. But analytically speaking, the story contains more substance than many stories written by most contemporary writers. It connotes the favorability as well as the dangers one must experience and endure when living in a foreign land. [It] is a play largely concerned with discovery. As [Italian-American lawyer] Alfieri warns, no one can ever know what will be discovered. There are two secrets in the play: Eddie's incestuous desires for his niece and the two illegal immigrants hiding in the Carbone home, Marco and Rodolpho. [qtd. in Sparknotes, 18] The play, which is set to happen in an Italian-American community known as Red Hook, situated in the waterfront in Brooklyn, New York City, tells the story of Eddie Carbone, a longshoreman who feels something toward his niece other than filial love and how his life ends tragically because of it. Eddie Carbone - the center of the story - is a character who was created as an ordinary man; the type of person whom everyone will learn to love. However, Miller did not create a totally perfect character, but rather gave him flaws and weaknesses; his weakness is mainly concentrated in his love for his niece, Catherine. [] a suitable subject for a modern tragedy because the potential for self-destruction, which is in all of us, in Eddie's case has destroyed him. And apart from this improper love, Eddie is a good man; and this love has its origin in the quite proper love of father for child, and Eddie's sense of duty to his family and community. [A View from the Bridge] In a review of the play, another critic commented: Eddie sets in motion against one person rains a whole avalanche of destruction. Like many classic tragic figure (including Shakespeare's Hamlet), Eddie's effort to get rid of the one man he perceives as his enemy, cannot control fate's ripple effect on Marco, Marco's family and the hapless additional underground border - and, as importantly, his own standing in the tight-knit community. [Sommer] Despite Eddie's efforts to hide his feelings toward his niece, he is not able to do so, as shown in his actions. Although his wife Beatrice is aware of the fact of Eddie's non-paternal feelings toward her niece, she tries to ignore it and pretends that everything is just normal. Eddie's relationship with his wife and niece becomes more complex when he takes into the shelter of their home the two illegal immigrants, Marco and his brother Rodolpho, cousins of Eddie's wife Beatrice. Eddie's problem starts when one of the brothers, Rodolpho becomes romantically involved with his niece Catherine to whom Eddie harbors special feelings. Eddie tries everything in order to stop Rodolpho and Catherine from getting married, including seeking lawyer Alfieri's advice, making Catherine see Rodolpho's flaws and finally reporting the two brothers to the Immigration Bureau, an act which destroys Eddie's good reputation in the community. Eddie, however, is not able to stop the marriage from taking place. Embittered by hatred for Rodolpho and probably also driven by frustration, he refuses to reconcile with the younger man. In the end, Rodolpho becomes and American

Cultural Diversity in Organizations Essay Example for Free

Cultural Diversity in Organizations Essay Diversity has arrived as a descriptive word for the American lifestyle in the modern world. With increasing immigration of people from many countries, many races, and many cultural backgrounds to the United States, the country has become a nest of diversity. Several factors shape the fact that the workforce is becoming increasingly culturally diverse: women represent an increasing percentage in organizations; the difference in age is becoming more evident on all levels; due to continuously changing demands organizations are employing more and more people with diverse professional and specialist backgrounds; there is a growing number of immigrants having different customs, religions and cultures and finally, the ongoing globalization is causing an influx of a large number of expatriates, who comes from various countries in the world, also contributing with different values and cultures. This increasing cultural diversity is both an opportunity and a challenge. Diversity brings with it a wide range of creativity and fresh thinking into the system. Diversity is here, in the population, in the workforce and in the marketplace. Racism, discrimination in the workplace, social stratification, and conflicts in social lifestyles are all negative byproducts of diversity. Thus cultural diversity in America is a highly debated issue because of the numerous problems arising due to it. One of the most serious and explosive issues in the United States today is meeting the business goals within an environment of multicultural diversity. When companies fail to create a culture of diversity and inclusion effectively, the costs can be high – costs arising due to ‘diversity training† and settlement of discrimination lawsuits. Many well-known companies have spent millions of dollars on â€Å"diversity training,† after settling discrimination lawsuits totaling hundreds of millions of dollars. Moreover, diversity also raises issues of interpersonal relations and communications among employees. This fact is underlined by increasing discrimination and class action lawsuits. Diversity impacts every person, every project, and every transaction in todays business world. Some companies approach it in terms of the noticeable differences among people. What many fail to realize is that diversity is really about personal interaction and emotions, and creating a corporate culture that welcomes all kinds of differences. Managing Diversity: Managing diversity is all about approaching the issue proactively as a business opportunity. There needs to be a culture of diversity within the organization. One of the major obstacles in managing diversity is that many companies view diversity as a problem that needs to be solved. They just take a reactive approach. Supposing there is a lawsuit brought under the Equal Employment Opportunity Act, they just take an initiative that would solve the problem in the short run. Though this approach seems to be successful, in the long run, there is likely to be no impact on the corporate culture in a positive way. Such reactive approaches can negatively impact the workforce morale as they don’t appear to be a genuine commitment to diversity. The path to diversity is not always an easy one. One of the most common obstacles is resentment from white male managers who see diversity as threatening to them. Since diversity is typically framed to be about white women and people of color, the focus is rarely on examining what it means to be white and male, say Bill Proudman and Michael Welp, Partners at White Men as Full Diversity Partners LLC, a consulting firm based in Portland, Oregon. White men, and sometimes others, thus conclude that diversity is not about them† (Goffney, 2005) Another obstacle that can arise in a multicultural business environment is resistance to change. When new diversity programs are introduced, it is essential that the employees view it as a genuine effort. Hence, these diversity programs should be tailored to meet the needs of the company’s workforce and integrated into the daily environment. Any diversity initiative should be tied to the company’s bottom line. Even though top management may make the commitment to diversity, if the initiative is not tied explicitly to the company’s bottom line, it does not become a priority for middle managers. The diversity initiative should be integrated into the tools and processes they use to manage employees, including orientation, training and education, and interpersonal communication. If not, existing employees will not accept the diversity initiative and new employees are likely to get disillusioned with a taste of it. Top management must ensure that the commitment to diversity has buy-in at all levels of the organization by making diversity an integral part of company success. Yet another obstacle to managing diversity is that the diversity initiatives might be restricted to training alone and is left as an ‘HR issue†. This narrow focus results relegation of diversity to a single department and companies thus miss out on opportunities to improve and integrate the diversity initiative into other areas of the company. Any corporate initiative should be feedback based, dynamic and flexible. Else, there is the danger that the initiative will remain static. Too often diversity initiatives begin and end with the first efforts undertaken. Diversity and inclusion are part of company culture, and like the culture, diversity must continue to evolve (Adams and Ruch, 2006). Managing all these obstacles require the ability to value a diverse world. This means there should be individual assessment of beliefs about work values. People from differing backgrounds having different experiences bring to work the biases and â€Å"veils† as well as the strengths that arise out of cultural differences. To work effectively with persons from diverse backgrounds, it is necessary to understand others– people from other racial, ethnic and cultural heritages, and people whose values, beliefs and experience are different. This involves learning to recognize when new competencies are needed, knowing how to develop the requisite new competencies, and implementing the competencies effectively. Companies need to assess their state of diversity: What is the state of diversity in our company? Are we making the most of diversity? Do we speak with one voice with respect to diversity? Companies that ask these questions on a continual basis, set strategic goals, measure their progress and evolve their programs in sync with their overall organizational change will be the ones to leverage the full potential of diversity (Adams and Ruch, 2006). Individual Reactions to Diversity: Diversity may be viewed positively or negatively depending on the individual reaction to diversity. In a culturally diverse workplace, there is likely to be prejudice, stereotyping and discrimination. This is because of self-fulfilling prophecies. The perceiver develops false belief about a person from a different cultural background. He then treats the person in a manner consistent with that false belief. Ultimately, the person responds to the treatment in such a way to confirm the originally false belief. Other negative reactions of individuals to diversity may include: tension among staff, distrust of anything new, gossip and rumor, open hostility or bullying, absenteeism, tarnishing of the agencys reputation, low staff retention rates, lack of response to customers and falling standards of service quality (NSW, 2006). In the positive sense, diversity that brings with it community language skills and cultural competencies can be seen as valuable assets to an agency (MSASS, 2006). Customer service improves when employees are able to tackle customers from a range of backgrounds. When employees are encouraged to learn from one another, their skills and knowledge are also enhanced. Diversity can reduce skill shortages at specific times. In a business, diversity gives the advantage of utilizing the language, international expertise and cultural knowledge of staff to identify successful export opportunities. When employees are encouraged to work in their areas of strength and capability, they are happier, more productive and more likely to stay with the agency. Productive diversity is based on the concept that there are potential economic benefits to be gained from valuing different experience, perspectives, skills and the cross-transfer and integration of these into the agency and local economy. Productive diversity makes good business sense in an environment where local diversity and global interconnectedness play a critical economic role (Muhr, 2006). Diversity effects on groups and teams: In the context of working in groups or teams, diversity seems to cause contrasting goals, miscommunication or inter-group anxiety, thereby prohibiting teamwork creativity. Miscommunication and the lack of a common language make it difficult for team members to engage in an exchange of ideas and questions, an exchange, which is essential for effective teamwork (Nahapiet Ghoshal, 1998). If individuals carry out negative stereotyping of outgroups it can prevent them from trusting and engaging with others and can threaten communication patterns within organizations. This is mainly due to a lack of common context and language usage. Anxiety in the team occurs when people identify themselves as placed among people belonging to different diversity categories. Thus, diversity will in this situation make it difficult for the individuals to identify with the team, since there is no unified perception of what values the team represents (Muhr, 2006). In a diverse work team, the values and perceptions of different diversity categories may be contrasting or even mutually exclusive, which is likely to bring about incongruence in goals. Incongruence in goals can limit communication, which is fundamental to the creation of interpersonal relationships and trust. Furthermore, goal incongruence may also prevent individuals from sharing and combining knowledge all together, if they are not able to reach agreement on common goals for pursuing such knowledge processes (Muhr, 2006). On the positive side, it has been shown that diversity in fact improves creativity by promoting variations, thinking out of the box and avoiding ‘groupthink’. Several analyses have shown that teams made up of people with different cultural and educational backgrounds, different personalities, different professional backgrounds and different skills are potentially more creative and innovative than relatively homogeneous teams. This is because diversity creates variations variations in perceptions, values, ideas, opinions, and methods, which are highly essential for developing a stimulating creative environment (Mohr, 2006). Conclusion: In the global economy today, most companies operate globally. Diversity of thought, culture, geography, race, and gender enables companies to deliver the best solutions to their customers and markets. Diversity pays off both internally and externally. A company that embraces diversity can offer a challenging and creative work environment, and as a result, can attract and retain top talent with diverse backgrounds. There is also a connection between diversity and increased productivity. Diversity also fosters organizational creativity. But despite these benefits of diversity, work teams will not truly benefit from diversity unless sufficient communication, trust and openness are nurtured in the organizational climate. The powerful advantage of embracing diversity in organizations is best brought out by the words of Ted Childs, IBM’s vice president of global workforce diversity. In a recent issue of Fast Company magazine, in a feature article was entitled: Difference is Power†, Ted Childs suggests that, No matter who you are, youre going to have to work with people who are different from you. Youre going to have to sell to people who are different from you, and buy from people who are different from you, and manage people who are different from you. This is how [companies] do business. If its (diversity) not your destination, you should get off the plane now (Meisner, 2006). Bibliography: Adams, Brandon and Ruch, Will (2006). Diversity as a core business strategy. http://www. versantsolutions. com/knowledgecenter/EB_DiversityAsACoreBusinessStrategy2. pdf NSW (2006). What is Diversity? http://www. eeo. nsw. gov. au/diversity/whatis. htm Muhr, Louise Sara (2006). Openness to Diversity –Turning conflict into teamwork creativity. Paper submitted for the 10th International Workshop on Teamworking. http://www. mau. se/upload/IMER/Forskning/Diverse/Muhr%5B1%5D. pdf Nahapiet, J. , Ghoshal, S. 1998. Social Capital, Intellectual Capital and the Organizational Advantage. Academy of Management Review, 23(2). MSASS (2006). Valuing a diverse World. http://msass. case. edu/downloads/academic/diverse. pdf Goffney, Phyllia (2005). Champions of Diversity. Essence. May 2005. http://www. findarticles. com/p/articles/mi_m1264/is_1_36/ai_n13660850 Meisner, Lora (2006). The American Quilt Workplace Diversity. http://career. thingamajob. com/general-career. aspx/The-American-Quilt-Workplace-Diversity. aspx

Mycobacterium Marinum Treatment Literature Review

Mycobacterium Marinum Treatment Literature Review Abstract Background Mycobacterium marinum is an atypical mycobacterium that can be found in water environment. It is the agent of a characteristic skin disease known also as fish tank granuloma. In some occasions it can spread as a nodular lymphangitis, extend to deep structures as well as in exceptional cases disseminate systemicaly . The infection is adquired after contact with fish or contaminated water mainly from aquaria or swimming pools. Although the real incidence is understimate, it is a uncommon infection that needs high clinical suspicion to be diagnosed. As a consequence, delay in the diagnosis is common. Mycobacterium marinum is intrinsically a multidrug resistant mycobacterium.There is no clear consesus in the management of this infection. Usually it is managed either with monotherapy or with combination of antibiotics plus surgery in selected cases. Methods Retrospective study of cases of fish tank granuloma collected from 2000 to 2009 in the dermatology surgery of The Hospital of Tropical Diseases (HTD) of the University College London Hospitals. Systematic review of the literature with the terms Mycobacterium marinum and fish tank granuloma from 1999 to 2009. Results From the HTD dermatology surgery were collected 7 cases. Identification of M. marinum was possible only in 5. The response to treatment was good at least in 5 of them. In the literature review there were reported a total of 516 cases. From those 133 could be analyzed as individual cases. Identification was possible in 89.5% of the cases. Cured was reported in 82% of the cases. Conclusion The key of the diagnosis is to collect accurately the history of exposure. Histology, although no pathognomonic, will rise the suspicion if granuloma formation are found and will facilitate the differential diagnosis. Identification is done after culture with classical biochemical tests. Molecular biology techniques have the advantage of accelerate the procedure. There is not enough evidence to propose any specific treatment. Currently, recommendations are based in experts opinions. A prospective, randomized controlled clinical trial would be valuable to propose a base evident treatment. Contents Pages Introduction M. marinum is an environmental atypical mycobacterium ubiquitous in fresh, salt, and brackish water. It is known that infects temperate and tropical species of fish of at least 150 species, including ornamental fish. But also affects frogs, eels, oysters, aquatic mammals, toads and snakes [2, 11]. It cause tuberculosis-like disease in fish, its natural host [129]. The infection in fish has an average incubation period of 3 months. It affects viscera and produce anorexia with emaciation, skin defects, distension of the abdomen, being cause of sudden death [11, 12, 66]. In 1904, Alexander described for first time lesions in a cod fish that were associated with acid fast bacilli. But it was Aronson in 1926 that isolated the bacteria from tubercles of fish that died in an aquarium of Philadelphia. He described the bacilli as acid fast, chromogenic, pleomorphic and growing best at 18 º-20 ºC. Aronson suggested the name of Mycobacterium marinum [130]. M. marinum is as well the causative agent of the human disease called fish tank granuloma, also known as swimming pool granuloma or fish fancier ´s finger syndrome. In 1951 Norden and Linell reported for the first time the human disease in a swimming pool outbreak in ÃÆ'–rebro, Sweden. They described the lesions as chronic papulous ulcerations, usually located in the elbows. The pathogen was isolated from the walls of that swimming pool as well as from the lesions of the patients. They called the pathogen isolated Mycobacterium balnei [131]. It was not until 1959 when Bojalil demonstrated that M. marinum and M. balnei were in fact, the same mycobacterium [132]. M. marinum is the most frequent cause of skin infection among the environmental mycobacterium that affects humans [86, 133]. Nowadays the frequency of human infections is mainly sporadic. But in the past, outbreaks related with swimming pools were not uncommon [134]. As an example, one of the biggest epidemics was in Glenwood springs pool, Colorado in 1956 with 262 cases reported [135]. That was before chlorination became a common practice. Chlorination makes water safer. As was seen recently in Bologna, were water from swimming pools were free of M. marinum. But still could be isolated in 4.5% of the samples from the shower floor of the same [136]. The real global incidence of the disease is not know because the number of cases are underreported, due probably to the difficulties in the diagnosis [94]. It is world wide distributed but with a tendency to aggregate geographically [137]. Like in Chesapeake bay, Maryland, where there is an incidence of 4 cases per 100000 population per year [138]. Meanwhile in California was estimated in 0.27 cases per 100000 adults [139]. Or in Satowan, Micronesia, with an estimated prevalence of 10% of the population [115]. Apparently the global annual incidence remains small and stable [140]. Even though an increase number of reported cases has been noticed in The United States, going from an average of 40 cases per year in the 80s to an average of 198 cases per year in the 90s [141]. What seems clearer is that differing from other atypical mycobacteria the prevalence of M. marinum has not increased with the HIV epidemic [140]. Opposite to humans, the incidence in fish is increasing in hatchery fish, probably due to the high population density of fish. Transmission is possible fish to fish and between fish and amphibians. In addition it has been proposed transmission through eggs and through practice of feeding fish with fish carcasses [140]. There are 2 groups or clusters of M. marinum with different pathogenicity. Cluster I is characterized by producing acute disease and death in fish and also for affecting humans. On the contrary, cluster II only affects fish producing the classical chronic disease with granuloma formation [9]. This is also supported by a study done in Israel were it was seen that only certain strains of M. marinum affected humans. They also demonstrate that in Israel strains affecting humans came from ornamental fish and not from local fish for consumption [5]. The mode of transmission to humans is mainly waterborne and fish borne. Person to person transmission has not been documented [137]. However, It has been described indirect transmission via fomites in at least 3 cases. Two very small children and one infant who acquired the infection after bathing in containers that were previously used to clean the family fish tanks of tropical fish [27, 40, 142]. As other environmental mycobacterium, M. marinum has commonly low pathogenicity. For this reason in normal conditions only affects disrupted skin [8]. The main risk factor to contract the infection consists in having lesions or abrasions in the skin with exposure to non chlorinated water or marine animals infected [140]. The most frequently nowadays is the exposure to private aquaria. But some times the source of exposure is unknown. As a consequence, after the description of cases following injuries with plants, it has been suggested the possibility that could be other reservoirs different from water and fish. Although at the present moment this possibility has not been demonstrated [30, 43]. The incubation period is usually 3 to 4 weeks [135]. Following, the most common manifestation is a cutaneous lesion at the site of inoculation. It initiates as a solitary nodule or pustule that eventually evolutes to an ulcer , abscess or verrucous plaque [143]. It affects more frequently the extremities, probably because the pathogen grows better at low temperatures [144]. The severity of the disease depends, among other factors, on the number of microorganisms inoculated [134] In 20% of the cases the cutaneous lesions spread along ascending lymphatic vessels. This is called sporotrichoid spread or nodular lymphangitis [143]. As a result of direct extension invasion of deep structures as tendons, articulations and bones occurs in 29% of the cases [144]. Systemic dissemination is unusual but has been described in immunocompromised patients [140]. Spontaneous resolution , usually with scaring , has been documented from months after the infection up to 2 years [133, 135]. The diagnosis is based on the history of exposure and risk factors along with the characteristic clinical features. It is supported with histopathology, culture and bacteriological identification that in some cases require molecular biology techniques [94, 120]. The fact is that the diagnosis is not easy and in most of the cases is either delayed or remain being presumptive based in the history and response to treatment. The objective of the treatment is to increase the speed of resolution and prevent progression of the disease [1]. With this purpose different combinations of antibiotics plus the support, in selected cases, of surgery are the common practices in the treatment of this infection. Although the election of the drugs still depends of the preference of individual authors and is not based on controlled evidence [143]. Aims and Objectives The overall aim of the project is to determine the current state of evidence for the diagnosis and treatment of M. marinum infection. Being the specific objective to review the literature and the series of HTD cases with the purpose of suggest appropriate diagnosis and case management of Mycobacterium marinum infection. Material and Methods Cases with diagnosis of fish tank granuloma were review. The cases were diagnosed and treated from 2000 to 2009 in the dermatology surgery of The Hospital of Tropical Diseases of the University College London Hospitals. There were included patients with either culture positive for M. marinum or clinical diagnosis plus response to appropriate treatment. The files of those patients were reviewed and data were collected in a questioner that included: anthropological data, past medical and drug history, risk factors and exposure, description and location of the lesions, spread or deep extension of the infection, incubation period , delay in diagnosis, diagnosis, treatment and evolution (see questioner in annex). Additional information considered relevant was as well collected. A literature review in Medline and Cochrane databases was done. The review included the combination of the following terms: Mycobacterium marinum or fish tank granuloma. It was limited to papers from 1999 to July 2009, English and Spanish literature and humans. The papers obtained in the search were divided in 3 categories. First, case reports in which it was possible to collect data from individual cases. Information of those papers was collected in the questionnaire previously mentioned. Second, case series of 14 or more cases in which data from individual cases was not reported. And finally, a miscellaneous category of papers that were considered relevant for the diagnosis and treatment of this infection. The information gathered in the questioners was computerized in Microsoft Excel 2007. No statistical analysis was done in view of the cases were publish not with this purpose. As a consequence probably important reporting bias would invalidate any statistical outcome. Simple description of the results was done. Results Cases of The Hospital of Tropical Diseases From 2000 to July 2009 there were collected 7 cases with diagnosis of Mycobacterium marinum infection. The 7 cases included 6 males and 1 female and their ages ranged form 31 to 65 years. All the cases admitted to have had contact with an aquarium. In two cases the exposure was occupational. One of them worked in the London Zoo being responsible of the management of the aquaria. The second was a cook in a restaurant that store crustacean in an aquarium. All the cases presented nodular lesions located in one of the upper limbs, six of them with sporotrichoid spread and one with a solitary nodule (see photos is annex). One patient that was taking oral prednisolone due to severe atopic eczema presented with tenosynovitis of the left hand, sporotrichoid spread and palpable regional lymphonodes. The rest of the patients were not immunosuppressed. Biopsy of the lesions was performed in all the cases. However AFB were found just in one case. Whereas cultures were positive in 5 cases for M. marinum. In the other two cases the diagnosis was done based on history of exposure, clinical characteristics and positive response to treatment. Different combinations of antibiotics were used with no clear advantage of any regimen in particular. In 4 patients it was need to change the regiment. The reasons were drug intolerance in one case and lack of improvement in the rest. There was also one case that initially was improving with a regimen of rifampicin plus minocycline. But after simplification of the regiment to clarithromycin monotherapy presented worsening of the lesions. This case was eventually controlled switching to minocycline plus ethambutol. There was one patient who presented a relapse after one year of the previous infection. Finally it was cured with 6 months of rifampicin plus clarithromycin. Susceptibility test was done in 3 cases. It was detected resistance to trimethoprim-sulfamethoxazole and rifampicin in one case and susceptibility to clarithromycin, ethambutol and doxycycline in 3 cases. The average time of duration of the treatment was 6 months with a range of 2 to 9 months. Surgery was not required in any patient. The final outcome was good in 5 patients being the other 2 lost of follow up (see table 1). Case No Age(y) /Sex Medical history Drug history Exposure Location Clinical characteristics Histology AFB results Culture Treatment Duration (months) Evolution 1 9/M No Aquarium Upper limb Multiple nodules sporotrichoid spread Granulomatous inflammation AFB + 1-RIF+DOX 2-RIF+EMB+DOX 3-RIF+EMB+CLR 7 Cured 2 61/F Psoriasis Chronic paronychia Aquarium Upper limb 3 nodules Sporotrichoid spread AFB + 1-MIN 2 Improving Lost of follow up 3 64/M No Aquarium Upper limb Multiple nodules Sporotrichoid spread Noncaseating granuloma 1-EMB+TET 2-RIF+EMB+INH 9 Relapse after 1year 3(*) 65/M Fish tank granuloma Aquarium Upper limb Multiple nodules Sporotrichoid spread 1-RIF+CLR 6 Cured 4 59/M Severe atopic eczema Systemic steroids Aquarium Upper limb Multiple nodules Sporotrichoid spread Tenosynovitis AFB + 1-DOX 2-RIF+EMB 3-RIF+EMB+CLR 4-ERI+MIN ? Lost of follow up 5 44/M No Aquarium Upper limb 5 nodules Purulent discharge Sporotrichoid spread Necrotizing granulomatous inflammation AFB- + 1-RIF+MIN 2-CLR 3-MIN+EMB 3.5 Cured 6 31/M No Aquaria (London Zoo) Finger Solitary nodule AFB + 1-CLR+EMB 4 Cured 7 49/M No Aquarium (Restaurant) Upper limb 5 nodules Sporotrichoid spread + 1-RIF+EMB 5 Cured (*) Notice that case number 3 is repeated. It belongs to the same patient that the one above but one year later. The patient presented a relapse after one year of being cured. Results from the literature review From 1999 to July 20009 there were found 233 results in Medline database and zero In Cochran Library. From those, 127 were considered relevant and consequently analysed in this review. From the 127 papers reviewed, 108 contained case reports and the 19 remaining were a miscellaneous of reviews or original articles covering issues related with diagnosis and treatment. No clinical trials or randomized control trials were found. In those years the literature reported a total of 516 cases of M. marinum infection. From those cases reported only 133 could be analyzed as individual cases. The rest of cases were reported as series of cases (See figure 1). The number of cases reported per year since 1999 up to July 2009 have been variable with a minimum of 6 cases per year in 2004 to a maximum of 88 cases in 2000. No clear tendency to increase neither decrease has been notice (see Figure 2). The majority of the cases have been reported in Europe, North America and South East Asia. No cases have been reported in Africa and only one case in South America (see Figure 3). Results from papers that could be analyzed as individual cases The reports included 82 men and 51 women. The average age was 46.7 years with a minimum of 18 months and a maximum of 87 years (see Figure 4). 70% of the patients had no relevant past medical history. 9% of the patients were immunosuppressed: 5 patients had HIV infection, 4 were recipients of solid organ transplant, 1 patient had a myelodisplastic syndrome, 1 had Non-Hodking Lymphoma and 1 had Chronic Lymphocytic Leukaemia. Among other relevant pathologies were reported 12 diabetic patients, 11 with rheumatic diseases and finally 5 that were suffering from other problems as: asthma, bullous pemphigoid, myasthenia gravis, Cronh ´s disease and sarcoidosis. The majority of the patients were not taking any relevant drug. However, 20 of them were on systemic steroids, 12 had received steroids as local injection, 10 took methotrexate and 9 TNF-blockers. The most frequent exposure referred was the contact with an aquarium usually of tropical fish, it was reported in 51% of the cases. It was followed in 26 cases (20%) by other kind of contact with fish mainly referred as contact while cooking or cleaning fish. Finally 16 cases (14%) had other kind of contact with water environment. That included mostly fishermen or recreational sailors. Opposite to papers from the 60s, only in 2 patients referred contact with swimming pools. In 15 cases (11%) the source of exposure was not recall or reflected in the papers. Injury related with plants was reported in 3 cases. In one case the exposure was a bucket. The bucket was used to bath a child of 18 months after being used to put fish from an aquarium. As a result the child got infected [40]. History of trauma with skin barrier impairment was referred in 46 cases (71%) of the patients. Among those, 18 cases (39%) recall direct injury with either fin fish, fish hook or crab bite. Occupational exposure was reported in 20 cases (15%). The most frequent occupational risk was to be cook and have injuries while cleaning fish. Another common job of high risk was to work in a pet shop, with the duty of cleaning aquaria. Finally fishermen are evidently in direct contact with water and fish and prone to suffer injures with fish hooks. The incubation period was documented only in 30 patients. It went from 1 day up to 4 months with and average of 48.9 days. The cases that presented an incubation period less than two weeks had in common to have suffered penetrating injuries with fish (figure 5). The upper limbs were affected in 120 case (90.2%), being the fingers the most frequent location. The lower limbs were affected in 11 cases (8.3%). The face in 7 cases (5.3%) and that included delicate locations as nostrils, eyelid and cornea. Finally, cutaneous dissemination was reported in 7 cases (5.3%). Sporotrichoid spread was found in 53 cases (39.8%). Lymphonodes affectation was recorded in only in 7 cases (5.3%) of the cases. The lesions were described as nodules in 63 cases (7%), plaques in 23 (17.35%), papules in 13 (9.8%) and ulcers in 22 (16.5%). There was purulent discharge in 32 cases (24.1%), as well as swelling and tenderness in 37 (27.8%) and 42 (72.4%) cases respectively. Involvement of deep structures was referred in 45 cases (33.8%) of the cases being the most frequent tenosynovitis with 34 cases (75.6%), followed by arthritis with 12 (26.7%) and osteomyelitis with 6 (13.3%). Systemic dissemination with documented bacteraemia was reported in 3 cases. The 3 of them were males from 66 to 87 years. In 2 cases the patients were on systemic steroids, due to myasthenia gravis[103] in one case and polymyalgia rheumatica[62] in the other. Sadly the third case that initially was not taking drugs, after being misdiagnosed as rheumatoid arthritis was put on systemic steroids, infliximab (TFN blocker) and methotrexate [59]. From the patients with invasive disease, including involvement of deep structures or systemic dissemination, 21 (46.6%9 were taken some kind of immunosuppressive drug. Meanwhile only 13 (15.5%) of the rest of the patients were taken them (see figure 6). Other interesting characteristic of the patients with invasive disease was that 15 (33.3%) of them referred direct fish injury. Only 3 (3.4%) of the rest had this exposure (see figure 7). Patients that for any reason were taken immunosuppressive drugs presented different characteristics from the rest of the patients. More than half of them presented invasive disease compared with only 20% of the rest (see table 2). Patients taking immunosuppressive drugs (*) Patients no taking any drugs Number of patients 36 91 Average age (years) 53.2 44.9 Female % 14 / 38.9% 36 / 39.6 % Sporotrichoid spread 13 / 36.1% 39 / 42.8% Involvement deep structures 21 / 58.3% 19 / 20.8% Systemic dissemination 3 / 8.3% 0 AFB positive 19 / 52.7% 33 / 36.3% Culture 33 / 91.6% 75 / 82.4% Bad evolution 2 / 5.5% 3 / 3.3% (*)Immunosuppressive drugs including: TNF-Blockers, systemic steroids, local injectable steroids, methotrexate and azathioprine. The time of evolution until the patients presented for consultation was as short as 4 days and as long as 18 years with an average of 8.6 months. The time until the diagnosis was finally done was only reflected in 17 patients. However the delay went from 21 days to 2 years with an average of 6.3 months. Tuberculosis skin test was only done in 19 patients. From those 86.4% were positive. Biopsy of the lesions was done in 120 cases (90.2%). Aspirate was reported only in 19 cases (1 4.3%). Histology characteristics suggestive of mycobacterial infection with granuloma formation were found in 45.5% of the biopsies. However, only 21% of those were described as caseating granulomas. Other frequent finding reported was mix infiltrates with chronic and acute inflammatory cells. In some cases a wrong diagnosis was done due to confusion with rheumatoid nodules, Sweetà ¢Ã¢â€š ¬Ã¢â€ž ¢s syndrome, foreign body granuloma or interstitial granuloma annulare (See table 3). Table 3: Histology Findings Histology description Number of patients Non caseating granuloma 19 Caseating granuloma 12 Granuloma( type not specified) 26 Infiltrates of chronic and acute inflammatory cells (lymphocytes , neutrophils, histiocytes) 18 Granulation tissue 6 Abscess formation 9 Necrotizing folliculitis 1 Focal dermal necrosis 3 Fibrinoid degeneration 1 Necrotizing paniculitis 2 Cystic degeneration 1 Pseudoepitheliomatous hyperplasia 4 Acute suppurative paniculitis 1 Fibrinous exudates 3 Lichenoid inflammation 1 Acanthosis in epidermis 2 Necrotic Corneal Stroma 1 Dermal fibrosis 2 à ¢Ã¢â€š ¬Ã‚ ¢ Pseudocarcinomatous hyperplasia of follicles à ¢Ã¢â€š ¬Ã‚ ¢ Nodular and perifollicular infiltrate of neutrophils and histiocytes à ¢Ã¢â€š ¬Ã‚ ¢ Dermal fibrosis à ¢Ã¢â€š ¬Ã‚ ¢ Collections of neutrophils within follicles 1 patient with lesions of 18 years evolution Confusion with other pathologies Rheumatoid Arthritis ( rheumatoid nodule) 2 Sweet ´s syndrome 2 Foreign body granuloma 2 Interstitial gra nuloma annulare 2 In the samples collected AFB was found in 41.7%, was negative in 34.6% and was not reported in 23.6%. In total identification of M. marinum was possible in 119 cases (89.5%). Culture was positive in 114 cases (85.7%). The time until the cultures grew went from 8 to 56 days, with an average of 23.3 days. Identification with PCR was done in 19 cases (14.2%). The imaging techniques were useful to diagnose extension of the infection. Radiographies were used in 25 cases (18.7%) to rule out bone involvement. Magnetic resonance imaging was used in 16 cases (12%) resulting in the diagnosis of tenosynovitis, abscess, join effusions or osteomyelitis. About the treatment, 126 patients were treated with antibiotics; in the rest of the cases the management is not mentioned. Surgery was need in 38 patients (84.4%) with affectation of deep structures and in 21 patients (25%)with cutaneous lesions. Monotherapy was used in 54 cases (42.8%), bitherapy in 38 cases (29.4%), triple therapy in 20 cases (15%) and combination of 4 or more drugs in 5 cases (4%). Finally combinations of drugs that included classical tuberculosis treatment were used in 10 cases (8.7%). In 41 patients the regimen of drugs needed to be change, either for non effectiveness or non tolerance. The regiment was change one time in 29 cases (21.8%), two times in 10 cases (7.5%), and up to 3 times in 2 patients (1.5%). The drug more frequently used as monotherapy was clarithromycin, followed by minocycline, doxycycline, ciprofloxacin and trimethoprim-sulfamethoxazole. The combinations of drugs more frequently used were rifampicin + ethambutol followed by clarithromycin + rifampicin and clarithromycin + ethambutol. (Effectiveness of the different regimens depending of the extension of the disease can be seen in table 4) Susceptibility test were reported in 34 patients. Rifampicin was susceptible in 86.4% of the test, ethambutol in 91.3%, clarithromycin in 95% and minocycline in 62.5%. Isoniazid was resistant in 100% of the tests done and streptomycin in 66.6% (see table 5). The average time of duration of antibiotic treatment was 5.4 months, with a range of 12 days to 15 months. After completion of the treatment the final evolution of 109 patients (81.9%) was reported as good outcome or cured. Only in 8 patients (6%) the evolution was reported as bad outcome. No mention about the evolution was done in the rest of cases. Among 12 patients in which long follow up was reported, only one patient presented recurrence of the infection after 3 months course of doxycycline. (Characteristics of the cases with bad outcome are resumed in table 6. Table 4:: Antibiotic Combinations Used Depending On The Extension of The Disease Patients with only cutaneous lesions Patients with Invasive disease Number of patients Effectiveness Number of patients Effectiveness Monotherapy 38 52.5% 16 75% CLR 8 75% 5 100% MIN 10 70% 1 100% DOX 8 50% 1 100% CIP 4 25% 2 50% CTX 2 100% 3 33.3% AZI 3 0% 0 AMK 1 0% 0 ERI 0 1 0% LEV 0 1 0% MOX 1 0% 0 OFL 1 0% 2 50% Combinations of 2 drugs 26 92% 11 83.3% CLR + EMB 6 100% 2 100% CLR + CIP 1 100% 0 CLR + MIN 1 100% 0 CLR + RIF 5 80% 0 CLR +CTX 1 100% 0 RIF + EMB 9 100% 5 60% RIF + CTX 0 1 100% RIF + INH 0 1 100% CIP +DOX 1 100% 0 CIP + EIR 1 0% 0 DOX +CTX 0 2 100% CIP + EMB 1 100% 0 Combinations of 3 drugs 13 72.7% 7 66.6% CLR + EMB + CIP 0 1 0% CLR + EMB + RIF 2 100% 5 100% CLR + EMB +RFB 0 1 0% CLR +CTX + CIP 1 0% 0 EMB + AZI + MIN 1 0% 0 RIF + CLR + AMK 1 100% 0 RIF + INH + CLR 1 0% 0 RIF + EMB + CTX 5 100% 0 RIF + EMB + DOX 1 0% 0 RIF + EMB + MOX 1 0% 0 Combinations of > than 3 drugs 2 100% 3 33.3% CIP+RIF + EMB + CLR + RFB + AMK 0 1 100% CLR + DOX + RIF + EMB 0 1 0% RIF + EMB + CLR + AMK + IMP 0 1 0% RIF + EMB + AZ I+ CTX 1 100% 0 RIF + EMB + CLR + CIP 1 100% 0 Combinations with TB treatment 1 100% 9 55.5% INH + RIF + EMB + CLR 1 100% 1 0% INH + RIF + EMB 0 3 100% INH + RIF + EMB + PZA 0 4 50% INH + RIF + EMB + PZA + CLR 0 1 0% TABLE 5: PATTERN OF SUSCEPTIBILITY Drug Number of patients Susceptible Resistant Indeterminate Isoniazid 9 9 Rifampicin 22 19 3 Ethambutol 23 21 2 Pyrazinamide 1 1 Streptomycin 6 1 4 1 Rifabutin 2 2 Azithromycin 4 1 3 Clarithromycin 20 19 1 Minocycline 8 5 1 2 Doxycycline 6 6 Tetracycline 2 1 1 Trimethoprim-sulfamethoxazole 6 5 1 Ciprofloxacin 11 6 1 Levofloxacin 1 1 Moxifloxacin 4 4 Gatifloxacin 1 1 Amikacin 9 9 Linezolid 1 1 Imipenem 2 2 Erythromycin 2 1 1 Cefotaxime 2 1 1 Kanamycin 3 3 Ethionamide 3 3 Ansamycin 1 1 The table reflects in how many patients each drug was tested and in how many it resulted as susceptible, resistant or indeterminate. TABLE 6: CHARACTERISTICS OF CASES WITH BAD OR POOR OUTCOME References Age Sex Past medical history Type of infection Treatment Duration treatment (months) Evolution [25] 67/M DM Cutaneous disseminated RIF+EMB+CLR+CIP 3.7 Deceased Secondary bacterial infection [26] 50/M No Tenosynovitis RIF+EMB Synovectomy 3 Dysfunctional index finger [46] 62/F No Tenosynovitis CLR 4 debridements 6 Amputation index finger [46] 26/M No Tenosynovitis DOX+CTX 4 debridements 3.5 Persistent infection Need of grafting [73] 56/M No Tenosynovitis Local gentamicin Synovectomy 3 drainages ? Deformity [83] 47/M HIV infection Osteomyelitis 1-INH+RIF+EMB+PZA 2-Avobe + Fluoroquinolone 3-RFB+EMB+CIP 4-RFB+CIP ? Amputation Knee [88] 60/F NHL Systemic steroids Cutaneous disseminated 1-Ofloxacine 2-RIF+EMB+LEV+CLR 3-Above+STR+IG 4-CTX+MOX ? Continue with signs of active infection [103] 81/M Myasthenia gravis Systemic steroids Cutaneous and systemic dissemination 1-CIP 2-Hyperthermia 3-DOX intravenous 5 Deceased Bone marrow infected by M.marinum Results from papers that contain series of 14 or more cases There were 14 papers that contained series of cases with no available information of individual cases. As a consequence, individual cases could not be analyzed separately. There were 2 papers that reported the same series of cases in different years, the cases were counted just once. The principal characteristics of the papers are described in the table 7. There were 363 cases reported, 68% were males with an average of 44.3 years. In most of the cases the past medical history was not relevant; only 4 cases of HIV infection were reported. The most frequent exposure was to own an aquarium in 134 cases (37%). There was other kind of contact with fish in 37 cases (10%), swimming pool contact in 7 cases (2%) and other kind of contact with water in 58 cases (16%). In the rest of cases exposure was not mention. Finally occupational exposure was referred in 68 cases (19%). The incubation period was not reported. The upper limbs were affected in 245 cases (67%), the lower limbs in 78 cases (21%), the face in 3 cases (0.8%) and there was cutaneous dissemination in 10 cases (3%). Sporotrichoid spread was reported in 46 cases (12%). The lesions were described as plaques in 92 cases (25%) and nodules in 54 cases (15%). Deep structures were affected in 45 cases (12%): 41 tenosynovitis (91%), 8 arthritis (18%) and 3 osteomyelitis (6%). There were no cases of systemic dissemination described in any of the series. The average in the delay until the diagnosis was done was 3.8 months. The drugs more commonly used as monotherapy were doxycycline, minocycline, trimethoprim-sulfamethoxazole and clarithromycin. The combinations more prescribed were rifampicin plus ethambutol, rifampicin plus clarithromycin and clarithromycin plus ethambutol. The effectiveness of the treatments were not frequently reported. Consequently is not possible to point the advantage of any concrete regimen (see table 8). The average duration of the treatment was 5 months. Surgery was reported in 73 cases (20%). The evolution was good in 225 cases (62%), poor in 15 cases (4%) and not mention in the rest. There were 5 papers that contained series of cases of atypical mycobacterial infecti

Alas Babylon Critique :: essays research papers

Critique Alas Babylon, by Pat frank, is a story that revolves round the actions of a single idea, survival. This is reflected in his choice of the title in itself. It is a phrase that is repeated several times in the book, and brings a sense of uneasiness each time. These words come from a part of the â€Å"Revelations of St. John, which describes the decadence of Babylon and the evils that surrounded it at the time (Pg.14-15).† The characters in this book, Mark, and Randy Bragg, began using this phrase from a preacher that they used to listen to as kids. â€Å"Randy and Mark never forgot preacher Henry’s thundering, and from it, they borrowed their private synonym for disaster, real or comic, past or future (Pg.15).†   Ã‚  Ã‚  Ã‚  Ã‚  There is such a great pattern of impending death and destruction that awaits each character, which a city like Babylon is a perfect comparison to their world in which they live in. Babylon was once a city of many achievements and wonders, proving that they were far ahead of their time. This makes one wonder if it is possible that we are on the same path. â€Å"Sometimes Preacher Henry made Babylon sound like Miami, and sometimes like Tampa†¦(Pg.14)†   Ã‚  Ã‚  Ã‚  Ã‚  The phrase in its self could mean that we have at last reached our point of no return, and that there is no way back, it seems like such a solemn and definite statement that there can be no way out, when Mark says to Randy, ‘But if you hear â€Å"Alas Babylon,† you’ll know that’s it,(Pg.16)’ he means it as a last resort for help or great destruction is coming. Mark knows that there is no choice but to prepare for war, and a message that strong can only be expressed by words that significant.   Ã‚  Ã‚  Ã‚  Ã‚  There couldn’t have been a better way to describe what the brothers were feeling at the time, two words ‘Alas, Babylon.’ The title was taken from a text that had been read and reread, and had given many interpretations. In the bible, the name Babylon comes with a association of power and strength. Pat Frank wanted to convey that same feeling to the readers, so he used a city that couldn’t be mistaken for anything else. Only few other events in history were as memorable as the fall of Babylon, so this means it has to be notorious.

James Baldwins Fifth Avenue, Uptown Essay -- Nobody Knows My Name, Ja

In his collection of essays in Nobody Knows My Name, James Baldwin uses â€Å"Fifth Avenue, Uptown† to establish the focus that African Americans no matter where they are positioned would be judged just by the color of their skin. Through his effective use of descriptive word choice, writing style and tone, Baldwin helps the reader visualize his position on the subject. He argues that â€Å"Negroes want to be treated like men† (Baldwin, 67). Baldwin gives a vivid sketch of the depressing conditions he grew up on in Fifth Avenue, Uptown by using strong descriptive words. He makes use of such word choices in his beginning sentences when he reflects back to his house which is now replaced by housing projects and â€Å"one of those stunted city trees is snarling where our [his] doorway used to be† (Baldwin...

Isobelle Carmody’s “The Gathering” Essay

The book â€Å"The Gathering† by Isobelle Carmody explored the theme of â€Å"Good VS Evil† in such an intricate manner that every aspect of the text, the characters, themes and her own message portrayal, all become involved. This means that the reader can understand the plot of the book, and will be able to clearly read the message being revealed by the three main aspects of it. Other minor things, such as the title of the book itself, contribute to the feelings of the reader, all of which are designed by Carmody to make the book exactly what it is. By using the characters to develop the readers understanding of â€Å"Good VS Evil†, the themes to allow the reader to grasp the message being sent by Carmody and her style of writing, and the purpose of Carmody’s presence in the text itself, â€Å"The Gathering† has proven to be one of the most fascinating book of its kind. The characters in the book â€Å"The Gathering† help us to grasp the message which is being sent by the author, that is, â€Å"Good VS Evil†. Nathanial (Nat) Delaney, who stars in the novel as the main character, depicts the image of the good character. One who has found his place, and has managed to establish himself as a crucial role in the development of his own life, and that of those around him. In the fight against the current Kraken, Nathanial, as a character in the text, has helped the reader understand who the people around him are fighting for, whether it is good or evil. His relation to the book outside the Chain would be very minimal, as most of the text’s relation to him is connected in some manner. His study on Anna Galway as a veteran of Cheshunt exposed the truth about her past, that is, that she was part of a previous Chain, one which failed to do its job. Carmody uses these â€Å"two separate† issues in Nathanial’s life to create a feeling of hope and understanding, but also confusion, as to why that Chain had failed. The characters around Nathanial, although star a very important role in the progression of the story, are not focused on in the same way as that of Nathanial, and therefore are only know through the Chain. They, being Nissa, Indian, Nathanial, Danny and Seth, all relate to the â€Å"Good† side of the story, and the true meaning of being â€Å"Good† is developed in a very intriguing way by Carmody. The use of making these main characters â€Å"Good† rather than â€Å"Evil† creates a connection between the reader and the text. When this connection is made, through a series of hardships and moments  which make the reader realize just what role they are playing in the plot, the reader then begins to feel the same things as are being described by Carmody, the emotions, the desire for everything to turn for the better. The â€Å"Evil† side of the book â€Å"The Gathering† is also shone through the characters, particularly those fighting against what the reader and the Chain desire. While there is â€Å"Evil† present in a physical way through characters like Mr. Karle and Buddha, â€Å"Then the Kraken stepped forward and slapped her across the face. A trickle of dark blood ran from the corner of her mouth†¦Ã¢â‚¬  , â€Å"The match landed on his tail and flames swept forward up over him.† , there is still an ever strong emotional, physiological evil. For example, when the final fight between â€Å"Good† and â€Å"Evil† was set up at the abattoir, Mr. Karle uses his advantage of knowing each of the members of the Chain’s mental weakness. By picking at their weaknesses, the reader feels the sympathy and sorrow felt amongst the characters. â€Å"(Nissa) No one could ever love such a creature except out of pity† , â€Å"(Indian) you would recognize the signs of concussive brain damage.† , â€Å"†¦ (Nathanial) her only begotten son is going the way of the father. So terribly sad. So ironic.† , â€Å"(Danny) I think you truly must have damaged your brain in that field. The dogs must have bitten into it† . This makes the reader fully understand how the â€Å"Good VS Evil† is present within the text, as they are fully taken in to the emotions of their own understanding as to what is being done by the Evil. The themes in the book â€Å"The Gathering†, namely love, friendship, suspense, and believability, allow the reader to grasp the concept of â€Å"Good VS Evil†. The theme of love is explored and expressed through the characters of Nathanial and Nissa. Nathanial, throughout the text, has started to develop a fond affection toward Nissa. Although Nathanial initially regarded her as â€Å"†¦a girl up the far side with odd spiky red hair sticking up in all directions.† ,as the story progressed, the Chain was re-created, and issue arose which (to lay to rest) depended on the support and encouragement of one another, Nathanial fell more and more in love with Nissa. This ploy by Isobelle Carmody is an attempt to create a relationship between both them as a couple, and the reader with them as a couple. The reader then feels more for the success of the side in which this couple is committed to. This  connection between reader and characters is then played on by Car mody as they face struggles, and almost an absolute failure as the Chain. Another theme in the text is friendship. This ever strong theme is present throughout the whole book, one which supports the structure and plot of the text. The friendship and trust which is needed to create and hold the Chain was immense, and was evident throughout; â€Å"†You’re not one of us† Nissa was saying to Seth.† â€Å"†Nissa, we’re the Chain,†Ã¢â‚¬ ¦ â€Å"†The five of us make up the chain and he’s trying to break Seth away from us!†Ã¢â‚¬  . This shows that through hardship and times of struggle, friendship will bond one another together, and will prevail. Though not as clichà © as love, suspense plays the most important role in the story. Carmody uses suspense throughout the story, specifically when the text is nearing a rise in tension, a chapter conclusion, or a climax. This is so that when the reader has reached any of these points in the text, they do not want to put it down because there is a hook, te lling the reader that more information will be revealed, or leaving them on a â€Å"cliff-hanger†. Suspense is also used in the description of important scenes in the plotline. To do this, Carmody would, momentarily, leave the dialogue to give a description of the surroundings, or such, so that the reader can grasp the importance, or the feeling trying to be sent by her. â€Å"It was a grim joke, considering why I had come. She hummed to herself as she emptied the blackberries into a double boiler.† This shows us how something so irrelevant, as blackberries, can give an effect, and the effect in said situation was the fact that she was just an old woman, a genuine person. The last, but as important as all other themes, is believability. Carmody uses the technique of believability to connect the reader to the text, so that we feel what the characters are feeling, and we feel for them. She does this by making the reader understand the position they are in, and how each character depends on one another. Also, by influencing the reader to love the â€Å"Good† characters of the text, there is then a vile hatred for that that is evil, as with the characters. The contrast is then able to become more evident, between â€Å"Good VS Evil†. Throughout the book â€Å"The Gathering† by Isobelle Carmody has proven to explore the theme â€Å"Good VS Evil† in a very detailed manner, that is, by using things like the themes, characters, and Carmody’s own message, which seeps into the  text all through the story. This is the message of â€Å"Good VS Evil†, it is the message of the superior themes within the story, which help dictate everything from emotion to decisions. The text â€Å"The Gathering† by Isobelle Carmody has, in no doubt, managed to explore and enlighten the reader of the theme, â€Å"Good VS Evil†.