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*PREP: Splinting a Finger? and other questions...
Hello everyone, ^^
Another question (Or three... Or seventeen... X_X) in regards to preforming the magnet implant(s, I will be doing two). I have been starting to amass my supplies, wish to double check on everything for any suggestions or red flags. D: Call me a fool if you see something wrong, please. Please!
- Any disadvantage to using an aluminium alloy full-finger splint to protect the finger (Other than inconvenience) after surgery for a week or two to isolate and protect from collisions at the worst times? REALLY want to avoid getting a rejection after doing so much study and prep to make some stupid movement that wrecks all the work. I tend to be extremely active, I don't mind looking like a dork if it means it stops me from accidentally messing all this up. `_`
- 91% Isopropyl Alcohol... Appropriate general-purpose sterilising agent for tools that need to be sterilized / immediate surgical area / final operating surface prep / anything else that needs attention/sterilization? Or is there something better / more ideal to use? I hear about Chlorohexidine a bit here, It;s not something I have worked with at all... Is it much more effective than 91% Isopropyl?
- "New Skin" Liquid bandage... Any good as an adhesive to keep the area sealed in lieu of sutures? Or is it not going to be idea compared to other adhesives. As a branching question, is there a significant advantage to using sutures over adhesives that will promote a measurable increase in success, using one to another?
- Utilization of Lidocaine... I have never used it before. Obviously, get it perfect. IF it gets into a vein, what do I do? Poison control / ER or just make sure I feel okay? Also, using the same needle from one finger to the next, is this a big No No? I will be needing to nerve block two independant fingers.
- In regards to enlarging the pocket after making the incision, the highest degree of efficiency is to use the back, blunt edge to undermine/remove the material? Or would it be best to use another modified tool/designed tool?
If you wish to help, answer any questions you wish to. ^^ Of course, I am still always doing more research, this is not my FINAL plan, this is my current position, and I am still always gathering more information, and I still have a good amount of time to engorge on what else I can find. Watching @AlexSmith's progress on his M31's, really interested on their lack of Ni coating.
I will be locating a pair of TiN M31's into my fingers, one on each hand, onto each ring finger, outer facing edge. These will be my first implants, I will ideally preforming both at once, myself, and maybe with a person or two spotting/waiting in case i make a mistake. (I don't exactly trust their ability more so than my own, but they are still extra hands should i need extra hands :D)
I kinda pride myself on being the person who's there and usually reacts to people getting injured first among my group of friends. I don't mind blood, i don't mind doing the incisions and work on myself from the intimidation standpoint. Nerve blocking should make it even easier, not feeling pain throughout it.
But I fully respect that i am in no way trained or experienced as a medical responder or surgeon. I have confidence in my abilities, but I also understand I am extremely naive. Any advice or suggestions are always appreciated. I love knowledge.
Thank you everyone, and please don't work too hard.~~ ^^
Comments
Displaying comments 1 - 30 of 33
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For the sake of argument how deep are you planning on going, and how do you plan to measure it?
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implant depth? Umm... D:>If I recall correctly, I believe 1mm to 1.5mm Is the ideal depth, just below all the layers of the skin until you break surface texture into subdermal is the ideal position. >~<My fingers are really thin, however. but I think dermal layering should still be similar to an average person.More so out of the visual appearance of the location I am penetrating into, as well as gauging with the blade on depth.I know I don't want to go too shallow, easier rejection tendency. Too deep is a loss of sense and risk of damaging something i shouldn't be, even worse.
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In regards to the splint, the next time I do a finger implant I'm going to use a splint. I'm also pretty active, mostly on my bike, and I wish I'd done it this time. I was thinking of shortening it a little so it only covers the first two finger sections, but only because it's hard to wear mittens on a bike if you've got one finger sticking straight out. Honestly, it's been about a month and I still put a bandaid on there sometimes just to remind me to be careful.
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If you're doing 2 magnets at once, you definitely want to use sutures. And make sure you plan out your procedure sequentially. Like, nerve block finger 1, incision, closure, nerve block finger 2, incision closure. Preferably on paper.
- Incision Closure
I haven't gone and checked exactly which of the successful M31s were done with sutures rather than glue, but I know that one of the longest lasting M31 implants was done by @cassox , Who uses sutures. From the standpoint of rejection, sutures will help reduce the likelihood that your magnet rejects because of the trauma at the site. So, I suggest sutures.- Sterilization
Do use chlorohexidine. It kills a number of microorganisms that alcohol doesn't. You're better of using it and not needing to than not using it, and ending up with necrotizing fasciitis, or something like that.- Lidocaine
If you follow the procedure for administering the lido (once you've stuck the needle in, aspirate. If you draw blood into the syringe, you've hit a vein, and need to move to a new spot.), you won't hit a vein. But if you do hit a vein and actually put lido in your bloodstream, you'll know it. In short, if you do hit a vein and put some lido into it, immediately stop what you're doing, get yourself a blood pressure cuff and a stethoscope and start monitoring your heat. Or have your assistant do that. I'm not sure whether or not putting a light tourniquet on your arm would do anything to limit the spread of the lido. @Cassox could tell you. Either way, if you pass out, or start to, head to the ER. If the ER is not very close, call for an ambulance. Don't know that poison control would tell you to do anything other than call the emergency responders.If you have enough lido in a single syringe for both fingers, you can use it on your second finger too, so long as it's within a short period of time (within an hour). The whole point of not reusing needles is a microbiology thing. Your body's got its own balance of bacteria. So long as you remove anything on the surface of the injection site(since what's outside shouldn't necessarily be getting inside), putting stuff from one area of your body into another won't hurt.- Pocket formation
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Some additional notes on digital blocks with lidocaine-
- Don't use Lidocaine with epinephrine. Epi vasoconstricts and can potentially cut off the blood supply to your finger to the point were permanent damage occurs. Using Lidocaine without epi is the way to go for digital blocks.
- Some additional signs of lidocaine toxicity are: tinnitus, numbness of the tongue, drowsiness, visual disturbances, and muscle twitching.
- The best place to inject is the base of the finger, where the webbing is, not the tip of the finger. There are complications that can arise from injecting a bolus of liquid into the tip of the finger.
- 4mLs is more than enough for numbing both sides of a single finger assuming a 0.5%-1.0% solution.
- Don't use Lidocaine with epinephrine. Epi vasoconstricts and can potentially cut off the blood supply to your finger to the point were permanent damage occurs. Using Lidocaine without epi is the way to go for digital blocks.
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@TheGreyKnight, What exactly causes the stitching to heal better than the glue layering, is it the strength of which the two sides are held together with?The benefit and drawback I see to using the sutures are that it lets the wound 'breathe' a little better. I completely understand why this would be more ideal; for the prospect of letting it naturally have a little easier time expelling whatever it needed to.My biggest fear with using sutures isn't the sewing part. I don't fancy myself too afraid of needles. >~< Moreso, for a living I work as a technician on small handheld power equipment (i,e.Chainsaws). Cleaning these little units gets dirt EVERYWHERE. The combination of chemicals I use (Brake cleaners, Carburetor cleaners,Ether, Industrial degreasers, Huge varieties of oils, gasoline, etc), along with whatever miscellaneous organic or inorganic debris that they end up getting in them make it stupid messy. >~<In the interim before things heal over, when I need to hold things together, really really not keen on leaving things exposed. I am not against suturing with a stitch, but is it going to be either redundantly useless to use both, or bad for the wound to apply glues over it?I do not expect superglues or adhesives to prevent anything. But I do know from experience (This is the part you can frown on me) that This specific Loctite super glue was a monster when it came to holding together fingers that have just been torn open wide. Even under chemical exposure and mechanical use and wear. *Please note, I am not at all endorsing this as a smart idea. Just telling you the experiences and mistakes I've made regarding incorrectly treating injuries. Do not do this.Obtained Chlorhexidine Gluconate, Hibiclens. 4% concentration. The ideal stuff? ^^Duly noted on the Lidocaine. Thank you so much for the information, and you too, @Crazyivan. Really appreciate the knowledge from both of you, I intend to know everything I could possibly need to know about what I'm doing off hand before doing anything. Or at least as much as possible. :DOne last question in relationship to pocket formation. Is it best to just break the scissors in half at the rivet to have two 'tools' to form pockets with? Or just work with them open? I think I recall reading that one individual split a pair in half to produce a very ideal easy tool for it, but I'm not sure if that is intended to be the norm, or a good idea if there's a bad part of it.I'll be sure to know the whole procedure inside out and backwards before doing it. But i'll also make sure that I'm doing each one completely isolated from the other, back to back as to not cross steps over or cause complications with one or the other.Many thanks you two. :D
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I would recommend latex gloves while you have the stichs/structures in till you remove them.
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>~< I'd be tearing them up left and right day to day. I already use nitrile and latex gloves for shop work, but they don't even last too long before a saw chain cutter/felling spikes/bar burr/insert other sharp object snags it. #_# Fully intending to use finger splints for mechanical protection, but removing and replacing them and taking gloves on and off over and over again, along with the moisture that gathers in the gloves, sounds very unideal. :s
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Maybe take a few days off?
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@Johndoe I may try to do that. And I appreciate your suggestions, thank you. :3 But I'm still very much more interested in using a completely covering adhesive to prevent any contamination, and the brace to prevent physical trauma to the site, work or not. The more I look into things, glue seems more and more appealing even though stitches are still the conventional tested method with proven effectiveness. I do not at all deny that stitches are effective. >~< But for my own personal situation, I think adhesive may work better, at least with everything I know. Is there a significant downside to using both? Or does become redundant to use both?
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I don't know, by me answering you questions with what I read around the forum it helps me more than you. Glims told be there is a step curve to this, I am making a point to take it on two wheels.... Sincerely, John Doe
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Don't work with that hand if you have an open cut. Your talking about wood chips, dirt, oil, and what ever else someone happened to pick up on it. You are looking at rejection at best with that type of scenario. Let it close first after it starts toss on some glue, and use bandaids to add alittle cushion.
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Since you do physically demanding work I'm guessing you sweat a lot, if so then I think the idea of using adhesive is a better than a latex or nitrile glove. When I was doing bike delivery I ended up with a sweaty finger smelling kind of nasty from having a glove covered finger. If there's going to be a lot of debris then get work gloves or something as well, but the adhesive sounds like a great plan. Plus a splint to make sure you don't bonk it.
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Spent a little time cutting down some super long aluminum splints to the right size for the first two digits of my ring fingers. It goes slightly against it's design, but I might be wearing them sideways to put the layer of metal directly over the wound site to completely prevent and damage through the unprotected open sides. Also obtained more Loctite. One thing that I have learned is that you can apply a layer of this specific type of superglue (this variety being a thin liquid), and then layer on top/adhere a strip/piece/layer of woven material and replicate a resin/fiberglass effect. Also, it tends to be much much more resilient than almost every other type of glue I've tried. I've never ever had this stuff fall apart, even under full mechanical strain on my right index finger, without doing any cloth. I've strait cracked open shells of lower quality glue accidentally. :_: Really sucks. I may be needing to do some tests. I purchased a product called 'new skin' to try as a wound adhesive... I don't know how strong it is, if it needs to be reinforced, if it's safe to reinforce, and how it will bond if they are comparable. The nice thing about it is it's medical and not just the really good, yet... not medical... And it has antibacterial properties. Needs more research. :0 @Meanderpaul I'm going to be doing one on each ring finger, both hands well be in the same shape when I get done with them. >~< @cathasach My hands aren't just doing very hands on work. I also have hyperhidrosis... Not that like, it's really bad, but one thing I've noticed is that any time I wear nitrile/latex gloves for more than 10 minuets I begin getting moisture inside, even in 'dry' conditions. I get a lot of cuts. I've had a lot of 'waterlogged' cuts, I know not to wear these gloves with cuts unless they are sealed.
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Have you thought of doing one hand first let heal then do the other so you aren't that useless with two bum hands? Also last time I used the newskin is had a nasty habits of a sting/burn feeling on opencuts. It does end up peeling and falling off if you get it wet or use/bend that spot.
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I did think about it, quite a bit... I decided though that it might be difficult to get two isolated attempts out at two different times. I understand the uselessness that will occur, but I'd rather swallow two pills at once if I can, than two pills, one at a time. >~< Duly noted on New Skin. May just try it on completely stable, inert skin for a while and see how it holds up as an artificial callous/skin in terms of durability.
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Only thing I feel you you need to be careful of is mechanical trauma, like banging implants against anything ever. I am not aware of that has been brought to your attention or not but I do feel like you should know about that you may need to change some of your habits in the shop.
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@Johndoe This is why I'm going to be utilizing a set of aluminum finger braces. I've cut them down to only cover the first two digits in length, they wrap all the way around the finger, with only small amounts exposed through the sides. I may wear it on it's side, so the top and bottom are exposed and the sides are shielded, to physically shield the site with a direct layer of foam padding and then a layer of metal. That's... kinda in the title, silly. :p And the first question I asked, if there was any reason to not split it for secondary armoring. ^^ Very aware of the need to shield my finger when the active life style I have. The main thing that's going to suck is typing. >~<If you mean in regards to when everything is completed, I am specifically locating thesee magnets on to the side of the finger, closer to the nail than the pad, or perhaps equidistant, rather than directly underneath the pad to keep them positioned out of the way. They should not be close to anything specific at any point, around my fingertips this is a very low traffic area.But yes, hammers etc will be watched around them. And no karate chopping like a moron. I can live with that. <~>
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@crazyivan Reading up a smidgen on everything. The Lidocaine I am looking at appears to be 2%. 4mL still holds true, or would one expect to be using less? 2mL because of concentration? Or does it not scale directly with concentration? Again, will be doing more research. I've been reading multiple different sources for preforming digital nerve blocks, so still getting needle placement down to exactly where. I understand the basic method of hypodermic injection, I understand needle aspiration. I just need to do more intimate study of the anatomy of the hand and know exactly where I am aiming,. ^^' Open general question, does the needle need to intersect with a very specific nerve, or will the lidocaine move inside of the tissues a little bit to get where it needs to go should it 'miss' by a tiny bit? Sorry for being such a novice on all of this I know there are a few things that I am looking to do differently than the convention, but it's good to hear the standard method to know what I am working with. And thank you much for the contributed information everyone. :D
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Thanks for this thread. It's been handy. I'm into the equipping phase as well, intending to self-cut. I'd like to also ask whether anyone has any strong opinions on foregoing the use of lidocaine. I don't care for needles if I can avoid it, but I don't mind knives. I think I will also avoid stitching in favor of glue/splint/fiberglass reinforcement? Thought I'd throw this up and see if anyone thought this was especially idiotic before trying.
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@Rytcd I really have been doing a ton of investigation into using/not using Lidocaine. I'm not especially afraid of needles, but what scares me about it is the introduction of it into a vein. which again, is easily avoidable. it would be a somewhat... Stupid... Mistake to make. Anesthetic will generally make everything much easier, however. Your nervous system isn't enflamed. The site isn't transmitting a trauma signal to you, it will make. I fancy myself with enough will to do it without the anesthetic, but really there isn't any reason to not utilize it unless you either have an intense phobia of needles, cost is a HUGE deal (which in such case you shouldn't be doing this), or you are allergic to Lidocaine. Even if all it means is your hands are shaking less, that's your hands shaking less. that's cleaner cuts and easier implanting. less trauma. Higher success rate. IF you can feel pain, and pain will have an effect on your senses, and it can be removed to make things go better, I do not see any reason to not isolate it, especially since it seems to be pretty basic and effective in regards to Lidocaine. Personally, even starting from the same position, I am vying to use it after doing the research I have, I would suggest it unless one of those three conditions overrides. In contrast, however, Sutures are far more tested and successful than adhesives, so far. I am vying against using sutures myself, but that's because I have a bit of a unique condition with being forced to guarantee complete seal. If I did not work in an industrial environment with so many factors being ideal as vectors of failure, I would go with a stitch or two. I'm also willing to contribute in the field of trying to use adhesives rather than stitches, seeing if it's something that can be made successful/ideal, but I know I'm gambling against procedure there. If you are looking for stability, and have the luxury of no special conditions, Really would suggest stitches if you are going for success. From what I've read around, combining them can go horribly wrong. But don't quote me on that. Please correct me if I'm wrong, anyone who is very familiar.
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I would vote for Tegaderm/generic occlusive dressing over those liquid skin preparations. Transparent dressings allow for moist wound healing by preventing scab formation. It's most common for burns and road rash sort of wide area disruptions to the skin, but I have found it to be an unparalleled success in most dermal healing situations, including piercings gone wrong/rejecting, deep scratches, tattoos, etc. When I have my implant done, I expect to use dissolvable stitches and then seal it up with generic Tegaderm. You have to wait for the bleeding to stop of course.
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The biggest reason why sutures are so handy is because you can close the wound, and then use liquid bandage if it suits your fancy. with just liquid bandage, you may as well dump the bottle on your finger and let it dry. It's going to be a mess as a solitary closure.The few times I've used liquid bandage, I've ended up with some scarring in the area (I probably should've gotten stitches, but it was more trouble than it was worth sitting in the ER. So, the trauma in the are probably was partially responsible). You also kinda have to push the edges together and hold 'em while the glue dries, which might be... troublesome if there's a lot of blood.
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I see I see :o@TheGreyknight It's safe to use both at once? I've seen a few places saying it's a disaster to combine sutures and adhesives. I'm not convinced they knew what they were doing, but It's still imput people said for a reason.@JuniperToxic, how does Tegaderm stand up to wear and tear?Now I know that i keep revisiting the Loctite brand glue... X_X Reason being because it has seemed to counteract strength issues well. It's pretty well established to me as an ideal adhesive. I am not especially afraid of scarring, and it seems to adhere extremely well in regards to getting it to seal. The blood definitely makes it a little tougher, but I've been able to even kinda layer it over that on some cuts I just didn't care about looking pretty while they healed.I have never had any problem with any of the cuts I've gotten getting infected when using this glue. I am not afraid to use it in terms of bacterium/irritation of the glue itself, it seems to be relatively inert. Usually, I'm using this stuff in a far from sterile environment without any issues. I recognise this situation is a bit different than an innocent cut.I've also just completely ripped the tip of one of my fingers apart with a small steel hook while trying to do clutch springs on a chainsaw before. Imagine getting a 12 gauge steel wire, folding it with a u shape about 7mm running parallel, and maybe being a 1-2mm longer before tapering into a spiked point. i had this little thing hook into my finger, loop around, and then tear out. >~<Tore my fingerpad apart. I cant remember which one, but it was left hand, I could probably at the time, if I cut away all of the torn skin pieces, fit a 1/4" ball bearing into the hemisphere cleanly.I cleaned it all up with 70% isopropyl and then coated it in a normal layer of Loctite, backfilling what wasn't present. Proceeded to put it under mechanical load for the day, it did not come apart at all with slightly less than normal use, and continued to use it until it healed up. There have been dozens of dozens of times I have used this, but one of the more colorful 'Cuts'.What I fear from any medical grade super glues is their strength factor. Different glues have different strengths. This glue does not fall apart even with mild exposure to Brake Cleaner (primarily methanol and acetone) and industrial grade degreasers, Gasoline, nor from regular hand washing or even mechanical use or putting it under moderate load. I don't think the same can be said with Liquid Skin, @Meanderpaul mentioned that it fell apart under water exposure or simply bending. This stuff doesn't really bend, which is okay where it's going.It's glue I trust for most injuries I get, personally. I have never had any adverse reactions to it. Should I not use it in lieu of liquid skin? I know on it's MSDS(This may take a while to open, open it in a new tab) It's labeled as an irritant (Never had any problem with that, however) and if large amounts are applied thermal reaction can cause burns (also never experienced). Is there any significant reason that this should not be used, barring lack of medical testing giving it proper labeling for medical use, irritation factor and burn factor? Does Ethyl 2-cyanoacrylate pose health issues?Just not medical-y enough to know these things. v-v I specialise in Chainsaws, not bodies. >~<
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I personally can attest to failure with the liquid skin in salt water which was the primary times I used it on cuts. It lasts a little longer in freshwater. Gurilla glue is almost identical in the durability with liquid but is much less flexible. I used gorilla glue on my RFID hole. I know I already mentioned that but I figured I could elaborate on my experience with it. I used gorilla a lot while working but also mixed it with electrical tape to help keep it together or I would just use the tape.
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http://forum.biohack.me/discussion/29/stitching-alternativessI'm going cross eyed right now, Need to go sleep. Digging a few of these up for myself and others to read on when i get time to tomorrow/later to see if these reveal further information that makes or breaks things. >~<
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@Aviin http://forum.biohack.me/discussion/comment/7111#Comment_7111 Thank you, first hand account appriciated! ^^Condensing useful stuff here...http://forum.biohack.me/discussion/comment/418#Comment_418 - Nature of Cyanoacrylates for skin closure.http://forum.biohack.me/discussion/29/stitching-alternativess - ..And just a whole thread. It's useful.
- It seems that costs can go either way for the medical grade variants, doing a bit of research into it. Looking at you, Dermabond.~_~
- Success or failure rates with either method don't appear to be so closely related in terms of the methods used to seal the cut, rather than the general following of aftercare procedure or surgical procedure itself.
- Either method appears to be a reasonable solution to keeping the wound shut If done correctly and following the respective wound care procedures. They don't share the same sets of instructions.
- STOP PLAYING WITH MAGNETS BEFORE THEY HEAL...RAAAAA...
General shoutout to @Cassox for just being awesome all around and feeding out information. :D -
SUTURES:- Strong interconnection between two halves of a wound being joined together via 'internal reinforcement' by a 'thread'. This Internal tensioning can be messed up and made too tight or too loose, and there is a pattern of knotwork that should be well understood and ideally practiced before implementation.- Allows for a wound to 'breathe', or the exchange of allowing unideal material to be forced from the semi-opened wound. The material itself can act as a wick to draw in bacteria/moisture/contamination, This gets worse over time. The wound itself is also still 'opened' in a sense, until the skin has healed back together.- To be left in for a 'short' period of time, ALL discussed timeframes being no less than 3 days and no more than 10, with 3-5 days being the most ideal, and varying between person to person. Longer usage promotes higher chances of contamination.- Removal is rather easy, clip one end and pull through the other side.- Use of sutures may be more difficult for a single individual and should be practiced well before hand. An incorrectly preformed suture is worse than no suture at all. Trypanophobia goes here, too.- Will provide no protection to a wound on it's own, only serve to help it healing. The wound can be easily damaged or exposed to contamination and requires strict attention.- Seems to manage scarring well, leaving little/none if preformed correctlyADHESIVES- Serves as an exterior support to bring two halves of a wound together via 'External reinforcement'. This bridge needs to anchor the two halves togetheras closely as possible, ideally with no gap, or healing will become much more difficult. Backfilling the area with the adhesive is rather undesirable.- Completely seals a wound, keeping it 'shut' and preventing any contaminationfrom entering. ALSO prevents any contamination from exiting, and can trap unideal material into the wound, causing complications.- Can be used longer than sutures. And may be required to do so. Some cases have demonstrated people only needing to utilise adhesives for a day and no longer, while the longest seen required little over a week. Depending on what's being contained under the adhesive, or the formation of scar tissue, or condition of other skin tissue, this may be something that gets less and less ideal over time.- Removal risks damage to the scar tissue formed underneath and irritation of the wound where the adhesive has attached. May create a worse wound to heal if removed incorrectly because of introduction of scar tissue having damage.- Implementation of adhesives is much more simple than sutures, and does not invoke the same 'fear response' from those afraid of needles. Requires extremely little 'training'. Should still be practiced to prevent the wound from being improperly closed, and a presence of any debris (blood) or other contaminants (bacteria) may hinder or compromise the adhesive's bonding, or trap infectants into the wound.- Provides a degree of protection to the wound from the native environment of the world, and provided it remains intact, can act as a shield and protection from contamination into the wound. Can create a very bad situation of trapping bacteria should this barrier fail and trap material INSIDE the wound.- Seems to be more varied on scarring patterns than sutures, appears to be more prone to leaving evident scars than sutures. This is not always the case, depending on quality of the joint between the two halves.As always, call out anything that doesn't match or reflect what's accurate, please, or if something has been missed. ^^
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I'd like to submit a brief followup to my earlier postings regarding my intention to do without lidocaine.So last night I attempted to implant my magnet without any anesthetic. The attempts I made involved long periods of respite between what were in reality increasingly small cuts, until finally my fortitude ran out and I decided to call the night a failure. The finger will heal up just fine and quickly I imagine by looking at it, so no harm done there. Wasted a couple bucks in supplies, took a few hours (yes, this attempt took hours), but gained a bit of wisdom.I've seen videos of people who have done this using just an ice cube as I did, but I have not found this an easy feat. Maybe it was the fact that I was cutting with my off hand, or the location of my cut, or maybe I simply lacked the willpower/pain tolerance. I don't regret the attempt, and may even try again the same way (probably not), but for anyone considering trying this, this was my experience.
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I don't remember if you said it and there is a good amount to read through but why did you choose no lido?
Displaying comments 1 - 30 of 33