Cerebral Palsy And Its Effects Health And Social Care Essay

What is intellectual paralysis? It ‘s a neurological upset that can happen before, during or after birth. It causes a aggregation of motor upsets from harm to the encephalon. An illustration of motor upsets is hapless coordination, hapless balance, and/or unnatural motion forms. Along with motor upsets, patients can besides hold other medical jobs. Epilepsy, mental deceleration, larning disablements or Attention Deficit Hyperactivity Disorder ( ADHD ) are sometimes seen in patients with intellectual paralysis. Cerebral paralysis is non a progressive upset, intending symptoms will non come on after clip. Congenital intellectual paralysis, intending bing from birth, is the largest figure of instances in the United States. 5 kids in every 2,000 Borns are diagnosed with intellectual paralysis. Today, 5-10 % are diagnosed with athetoid intellectual paralysis, which is characterized by slow, wrestling nonvoluntary motions. The staying 80-90 % are diagnosed with spastic intellectual paralysis. This type is characterized by rigidness in musculuss which causes stiffness and restricted motion in patient. In the 1880 ‘s, intellectual paralysis was believed to be caused by deficiency of O at birth. It has since been found to be caused by encephalon harm in early fetal development, before the procedure of birth. One possibility is an infection in the amnionic fluid environing the foetus. Infections can be rubella ( German rubeolas ) , toxoplasmosis-an infection caused by a one-celled parasite most normally acquired from contact with cats and their fecal matters. These infections are a hazard to the foetus merely if the female parent contracts the infection for the first clip during the gestation. A shot in a foetus can do neurological harm merely like every bit in an grownup. Birth asphyxia important plenty to do intellectual paralysis is uncommon in developed states, although it can still happen. There are infections that can be passed during birth that are n't passed through the placenta during gestation. An infection that causes a serious unwellness in the neonate can hold the possible to bring forth some neurological harm. Approximately 15 % of intellectual paralysis is due to a encephalon hurt sustained after birth. Infections, such as meningitis and phrenitis may do irreversible harm to the encephalon. Abuse, accidents, near drowning, or asphyxiations may do intellectual paralysis in newborns/children up to age 3. After the age of three, the neurological harm is n't classified as intellectual paralysis. A doctor will name intellectual paralysis in a kid by supervising the kid ‘s mileposts, when they sit up, start catching things and when they start walking. Besides observing musculus rigidness or unnatural leg/arm motion in the kid. Children enduring from intellectual paralysis will besides meet other neurological jobs besides the 1s mentioned and besides orthopaedic jobs. Seizures, epilepsy, ADHD, larning disablements, and mental deceleration are a few of the neurological jobs that can travel along with intellectual paralysis. Scoliosis, disagreement in leg length, contractures of articulations, and hip disruption are some of the orthopaedic jobs associated with intellectual paralysis. This is n't to state that every patient diagnosed with intellectual paralysis will see every one of these symptoms. Since it is a neurological upset, no two patients are traveling to be afflicted in the same manner. There are different types of Cerebral paralysis. Spastic is the inability to loosen up a musculus ( stiffness ) and affects approximately 80 % of those with CP. Athetoid is the inability to command a musculus and it affects about 25 % of those with Cerebral Palsy. Hypotonic is where the musculuss are really floppy due to hapless or low musculus tone and may develop spasticity. Hemiplegia is muscle stiffness in one arm and one leg on the same side of the organic structure and affects approximately 1 in every 1,000 kid born. Hemiplegia does n't ever intend your kid has intellectual paralysis. Diplegia is musculuss stiffness in both legs. Quadriplegia is muscle stiffness in all four appendages including the truck and cervix musculuss. This signifier of intellectual paralysis is caused by an hurt to the spinal cord that sends messages to the organic structure parts that control motion and esthesis. Ataxic affects coordination of musculuss, impacting all four limbs and besides the bole. A patient holding atactic intellectual paralysis will hold hapless or low musculus tone. Ataxic intellectual paralysis affects 5-10 % of those with intellectual paralysis. There are different types of therapy that can be used with intellectual paralysis to decrease or command the grade of musculus job. Physical therapy, medicines, orthotic devices and surgery are some types of therapies or interventions that can be used. Physical therapy can assist with musculus preparation, beef uping the musculuss, balance and mobility. Stretching is one manner to assist decelerate the formation of contractures ( joint scope of gesture restrictions ) . Medicines can cut down shudders, musculus cramps and can besides loosen up tight musculuss. Injected medicines can cut down countries of musculus spasticity. Orthotic devices, besides called braces, can be used to stretch spastic musculuss which can forestall loss of abilities and balance. Surgery can be used to rectify size of leg differences and besides to assist rectify any spine curvatures. Cerebral paralysis is a neurological upset caused by infections during gestation, during birth or after birth, physical injury to the caput and/or spinal column, and besides by deficiency of O although that cause has been decreased as medical progresss are made. If affects a big sum of people and can be rather hard to populate with. Since it is a neurological upset, it affects each patient in a different manner. There is no remedy for intellectual paralysis, but there are ways to minimise the effects it can hold on a patient.

Preschool Education System Essay

Ramona is a hard-working, loving, single mother of two preschool aged girls, Theresa and Rosa. She works overtime every week, just to make ends meet for her and her children. Ramona and her children are in poverty. Unfortunately, statistics indicate that Theresa and Rosa will struggle to receive the quality preschool education they need to in order to succeed throughout Kindergarten, grade school, high school and into adulthood. According to one study by Sum and Fogs, students living in poverty rank in the 19th percentile on academic assessments, while their peers who are part of mid-upper income families rank in the 66th percentile on the same assessments (Lacour and Tissington, 2011). â€Å"The achievement gap refers to significant disparity in low educational success between groups of children: low-income and minority children as compared to higher income and non-minority children† (Early Education for All). This academic achievement gap is unacceptable and every child dese rves the chance to excel to their fullest potential in school, in order to prepare for adulthood. Preschool is a pertinent part of a young child’s education, which has been proven successful many times in preparing children for grades K-12, and beyond. â€Å"Practitioners and researchers alike contend that the enrichment of preschool makes a difference especially for children living in poverty† (Loucks, Slaby, and Stelwagon). By providing all children with access to preschool programs, the educational achievement gap can be reduced. Unfortunately, since preschool is not a government mandated educational requirement, preschool must be privately funded, leaving families who are unable to pay tuition costs are. This is an opportunity that Theresa and Rosa would miss out on because Ramona cannot afford the tuition. Because of these lasting cognitive and social development benefits that preschool can provide, it should federally funded educational requirement. Quality preschool education needs to be regarded as a constitutional right, not a socioeconomic privilege. There is an increasing educational achievement gap in the United States, between children of low-income families, and their peers, due to their limited access to a preschool education. It has been proven time and time again, that underprivileged children, who are not provided with the access to a preschool education, perform lower in later academic learning, than those who were afforded a preschool education. One study in California revealed that second and third grade students of low-income families who did not attend preschool were significantly less proficient in English and Mathematics (Loucks, Slaby, Stelwagon, 2005). Another California survey illustrated that poverty stricken children entering kindergarten were six months behind their wealthy peers in pre-reading skills. (Loucks, Slaby, Stelwagon, 2005). Children of low-income families are also much more likely to encounter environmental and health risk factors. (Early Education for All). These risks can potentially impede on a child’s readiness for school. For example, children living in poverty have been proven to begin kindergarten with significantly less mathematical knowledge than their peers. â€Å"This would suggest that the preschool experience is a mechanism to level the playing field and fully prepare students to succeed in kindergarten† (Loucks, Slaby, Stelwagon, 2005). By entering the early grades without having the proper pre-requisite education and skill sets, children run the risk of falling behind in class. When a student enters kindergarten unprepared, the students risk of grade retention increases, not only in kindergarten, but also in the grade school years to follow. Catching up to the required proficiency level becomes harder and harder for the student, and in some cases, the student will simply giv e up and either fail or drop out. Access to preschool education for these children can help to close the educational achievement gap, and prevent grade retention, by providing these children with the tools and skills necessary to prepare for Kindergarten and beyond. The United States of America prides itself on its educational standards, and even has ratified educational laws which require children to meet proficiency standards in reading and mathematics at certain grade levels, as indicated in the No Child Left Behind Act. The law incentivizes those school districts which show improvement in test scores, and enforce corrective actions upon those districts who continuously fail to improve student proficiencies. Still, these underprivileged children are left behind, and find it continually challenging to catch up, as the school grades progress. A child’s odds of academic accomplishment are maximized when attending a high quality preschool program, especially within the lower-income communities. This theory has been put to the test. In New Jersey lays a group of the thirty one most poverty stricken districts in the state called the Abbott Districts. The state of New Jersey granted these districts a program which funds preschool education within the districts to their children in order to close the achievement gap for poverty stricken students. The results were noteworthy, and the funds allocated to this cause were well spent. Children who attended this program improved on their math, language and literacy skills. The kindergartners who had previously attended the program closed the academic achievement gap by a remarkable fifty percent between their own literacy scores and those of the national average (Early Education for All, 2005). These results proved the program to be a great success. Studies have been conducted all over the United States, pertaining to children in poverty and the profound effect a preschool program can have on each child’s continued education. In a fifteen year follow up study in Chicago, Illinois, children who attended preschool were proven to be significantly more academically successful than their peers who did not attend preschool. At the age of thirteen, this group of children’s academic scores was sixty percent higher than those who did not attend. By the age of twenty, this same group who had attended preschool was thirty percent more likely to complete high school, and forty percent less likely to experience grade retention or be enrolled in special education classes (Early Education for All, 2005). It is important to remember, however, that although the strongest support for the advantages of preschool education indicates that underprivileged children benefit most, all children, regardless of socioeconomic status can benefi t academically from a preschool education. When a child has had the privilege of attending a quality preschool program, that child is also much more likely to adjust socially in adulthood, than those who did not attend a preschool program. According to Loucks, Sharon, Slaby and Stelwagon, those who have attended a quality preschool program are also less likely to have long periods of unemployment or welfare, and drop out of school. (â€Å"Why is preschool essential in closing the achievement gap?† par. 1). Adults who attended preschool as a child also have been proven to reduce delinquency and crime throughout adulthood (Barnett, 2008). Preschools are not only about cognitive learning, but they give a formal education to pre-kindergarten aged children on the developmental concepts of interaction with their peers. These lessons stay with the children through the remainder of their life. Without those lessons, many do not develop the social skills needed to succeed in our society. Preschool education is not only beneficial to the individuals who attend the programs, but it also benefits community and the local economy as a whole. Funds invested into preschool programs provide a significant return to the community. The RAND Corporation, a non-profit organization which provides objective analysis through surveys and research (The RAND Corporation), recently performed a study which found that for every on dollar invested into quality preschool programs for underprivileged children, two dollars and sixty-two cents was returned into the labor force and economy (Loucks, Slaby, and Stelwagon, Fall 2005). That is a two hundred and sixty percent return on investment. The direct return on this investment alone is more than enough to warrant a universal program. This study does not even include other potential indirect financial returns. Other financial returns from a public preschool investment would also be present in the lowering of state Medicaid costs, law enforcements costs, and other low-income assistance costs, such as food vouchers, homeless shelters and unemployment pay, which cost the government and tax payers a significant amount of money every year. Preschool is a necessary business investme nt for our economy to yield a higher return rate, than the current K-12 requirements today. The concept of a universal preschool program is not unheard of, not even in the United States. Most state government funded preschool programs are targeted toward children of lower income households. These programs have been put into place in a collaborative effort to close the educational achievement gap that exists in our society. However, some states, and even entire countries have already begun governmentally funding preschool programs, not just for underprivileged children whose families cannot afford the tuition, but for all pre-kindergarten aged children. In 1998, Oklahoma legislation ruled to make all four year olds eligible for a universal quality pre-kindergarten program (Sacks and Brown Ruzzi, 2005). Of course, a program as significant as this would not go without continued research and analysis. In a study performed between 2002 and 2003, significant supporting evidence was found which indicated that the program was a success. The study showed increased academic test scor es in the subjects of reading, spelling, writing and mathematics skills (Gormley, Gayer, Phillips and Dawson). Oklahoma is not the only state to equalize education for all children, regardless of their socioeconomic status. With the revenues from a state lottery, and the leadership of, then governor, Zell Miller, Georgia was the first state in the United States to offer a publically funded preschool program (Early Education for All, 2005). Similar to the findings in the study of Oklahoma’s program, Georgia’s program was also proven to be successful. A study found that more than eight percent of students who had attended the program ranked average or above upon evaluation third-grade readiness (Sacks and Brown Ruzzi, 2005). A universal preschool program is not just a theory waiting to be tested, it is already in effect in some areas, and is proving its value in this country’s educational achievement. If we do not put into place the appropriate interventions in the society, the educational achievement gap will only widen, costing more and more tax dollars, and most importantly, costing children the equal opportunity of prosperity in this country. This gap can be diminished significantly by providing each and every child in this country with the equal educational opportunity of a quality preschool program. Such a program provides this nation’s youngsters with the skills they need in order to meet the countries educational standards throughout the span of their education. It is unfortunate that in this land of opportunity and prosperity, that in order to grown and succeed; our children are subject to exclusion of such a beneficial educational tool, because of his or her parents’ inability to afford tuition costs. With our current economic status, our children, the future of this nation, must be provided every advantage possible in order to change this economy around. An investment should be made in our future today by providing a constitutional right to a quality and inclusive preschool program to all children. Works Cited Loucks, Sharon, Slaby, Robert, and Stelwagon, Patricia. â€Å"Why is preschool essential in closing the achievement gap?† Educational Leadership and Administration Fall 2005: 47+. Academic OneFile. Web. 7 Oct. 2012. Document URL: http://go.galegroup.com.ezp1r.riosalado.edu/ps/i.do?id=GALE%7CA142874683&v=2.1&u=mccweb_riosalado&it=r&p=AONE&sw=w Strategies for Children. â€Å"Early Childhood Education: A Strategy for closing the Acheivement Gap†. Spring 2005. Web. 06 Oct. 2012. Document URL: http://www.strategiesforchildren.org/eea/6research_summaries/07_AchievementGap.pdf Marcon, Rebecca A. â€Å"Moving up the Grades: Relationship between Preschool Model and Later School Success.† Early Childhood Research and Practice 4.1 (2002). 06 October 2012. Document URL: . Gormley, William T., Jr., Gayer, Ted, Phillips, Deborah and Dawson, Brittany. † The Effects of Universal Pre-K on Cognitive Development.† National Institute for Early Education Research. 06 October 2012. Document URL: http://www.crocus.georgetown.edu/reports/oklahoma9z.pdf Barnett, W. S. (2008). Preschool education and its lasting effects: Research and policy implications. Boulder and Tempe: Education and the Public Interest Center & Education Policy Research Unit. Retrieved 10/06/2012 from http://epicpolicy.org/publication/preschooleducation Sacks, Lynne and Brown Ruzzi, Betsy (2005). Early Childhood Education: Lessons from the States and Abroad: 2005. National Center on Education and the Economy. The New Commission on the Skills of the American Workforce. Retrieved 1027/2012. Document URL: http://www.ncee.org/wp-content/uploads/2010/04/Early-Childhood-Education.pdf Lacour, Misty and Tissington, Laura D. (2011). The effects of poverty on academic achievement.. Retrieved 11/03/2012. Document URL: http://www.academicjournals.org/err/pdf/pdf%202011/july/lacour%20and%20tissington.pdf The RAND Corporation. (n.d.). RAND Corporation: Obective Analysis. Effective Solutions. Retrieved November 03, 2012, from The RAND Corperation: http://www.rand.org/

Identify the federal law that governs Protected Health Information Term Paper

Identify the federal law that governs Protected Health Information (PHI) and briefly discuss the elements of compliance. Describ - Term Paper Example In all, there are 18 identifiers that must be followed implicitly in order to avoid a breach of confidentiality. (Jones, 2009) Under HIPAA patients have the right to be educated regarding their health information and a clear definition of what will be done with that information, who has access to it; how it is stored, communicated, and distributed. They also have access to their health information with the right to amend it, obtain copies of it, and know the history of to whom it has been distributed. Before health care information can be released from the provider, the patient must sign an informed consent stating where the information will be distributed. This release must be specific and timely; health information requested for non-routine uses requires a separate consent to be signed by the patient. This authorized consent may not be forced or coerced; complaints with regards to breach of confidentiality can be filed with the Secretary of the Department of Health and Human Servic es. (Senior Health Forum, 2011) One of the largest claims filed to date involves a Seattle firm, Providence Health System.

American Constitution Research Paper Example | Topics and Well Written Essays - 2750 words

American Constitution - Research Paper Example The details of this amendment make it necessary for a search warrant to be issued before the personal life of any American citizen is subject to view. These search and arrest warrants also have to abide to certain requirements to make them plausible and usable. Not only do they require judicial approval but the warrant must also have a suitable cause initiating the search or arrest. Thus, these warrants are created according to the knowledge of a specific person, mostly a law enforcement officer, who have sworn to it and are therefore responsible and accountable for it to the issuing court. In 1885, the Murray v Hoboken land law determined that the fourth amendment applied only to criminal law and not any kind of civil law (Encyclopedia Britannica). The federal government then ensured that areas like narcotics were also included in the realm of criminal jurisdiction. However, the Supreme Court soon ruled that some searches and seizures were violating the Fourth Amendment despite the warrant carrying a probable cause and a limitation in scope (US Supreme Court 1967). Yet, at the same time the Court has also allowed innumerable seizures and searches to be carried out without any form of warrant, only because they feel a probable cause to exist that a criminal offense has been or is being committed (US Supreme Court 2004).This a clear portrayal of how the reasonableness and issuing of the warrant are often vastly different. The ACLA v NSA case relates back to the creation of a classified foreign intelligence program, now known as the Terrorist Surveillance Program. This agency could intercept international telephone and internet communications from numerous persons and organizations without needing to issue a warrant. The plaintiff in this legal case included, ACLA, the Council on American-Islamic Relations, the National Association of Criminal Defense Lawyers, and Greenpeace along with five individuals who are authors and journalists. These included Christopher Hitchens, James Bamford, Tara McKelvey Larry Diamond: a democracy scholar of Stanford University and the Hoover Institution, and Barnett Rubin: an Afghanistan scholar of New York University. All these individuals claimed to have a history of communicating with people located inside or from the Middle East. They held the opinion based on a secure belief that their communications had been targeted by the TSP. This idea was because of the public kn owledge that had been attained by the workings of this program. ACLA v NSA was one of the first lawsuits produced that challenged the Terrorist Surveillance Program (Hibbits 2006). The District Court presented its own opinion. Judge Taylor wrote a forty-four page and eleven part opinion which was responsible for examining the defendant's claims over the part played by the NSA in this movement. It was discovered that according to the Foreign Intelligence Surveillance Act the NSA violated that laws that had been decided. According to FISA, the Terrorist Surveillance Act was passed in 2006 through which President Bush gave additional power to the authorities to conduct electronic surveillance on suspected terrorists in the United States subject to the view of the Congress. Judge Taylor also felt the NSA responsible for violating not the fourth

Duty of Partner to Give Accounts Essay Example | Topics and Well Written Essays - 1000 words

Duty of Partner to Give Accounts - Essay Example In the context of the partnership agreement, the roles, responsibilities, and liabilities of partners need to be discussed. According to Sec 9 of the Partnership Act of 1963, it states that except for an incorporated limited partnership, a partner of a particular firm is considered as the agent of the firm along with the other partners present in the firm, for the reason of the business of the firm1. It also, declares that apart from an, incorporated limited partnership, an act carried out by a partner of a firm, for the reason of cont,inning in the customary method business of the type continued by the firm, connects that particular firm and remaining of the partners in the particular firm unless the partner who conducts the act has no right to act in any way for the particular firm in the specific matter and the person involved in the dealings with that particular partner either is well aware that the person is not authorized or is unknown about the factor does not consider the par ticular partner to be the firm’s partner4. According to Sec 10 of the Partnership Act of 1963 it states that a certain act or any particular instrument in relation to the nature of business of the firm apart from an incorporated limited partnership is obligatory on all the existing partners of the particular firm and also on the firm too if it is carried out by any person who has the authorization to conduct such an actor perform the instrument irrespective of the fact that whether the person is a partner of the firm or not, in firm’s name or in any such way or intention where it involves the firm4. The liability of a partner according to Sec 13 of the Partnership Act of 1963 declares that every individual partner of any particular firm except for an incorporated limited supported partnership is equally accountable along with the other partners for the duties and legal responsibilities of that particular firm which was obtained when the particular person was still an e xisting partner as per the partnership agreement which proves it to be legal and also in case of the partner is an individual, after the demise of that partner the assets of the deceased partner would be liable in the course of management for the liabilities and obligations of that firm which was acquired while the already dead partner was still a partner that stays discontented, but subject to the previous payment of the individual debts of the deceased partner4. The most important duty of a partner that needs to be mentioned in relation to this case is according to Sec 33 (1) A particular partner of a firm apart from an incorporated limited partnership is responsible for giving accurate accounts and complete information regarding all the things that might affect the firm to the other partners or partner or to the legal personal spokesperson of the other partner4.

Business Law Patent Rights Essay Example | Topics and Well Written Essays - 500 words

Business Law Patent Rights - Essay Example An instrument can be protected as utility patent or even a design patent if it has any unique ornamental feature. Primarily patentability of the invention needs to be determined, which cane be dome by conducting a through patent and non patent literature (prior art) search. Once the patentability established a patent application should be drafted and filed at the respective patent office. The inventor can file a National Application in the parent country or an International Patent Application with WIPO. The international patent application is called a PCT application proves to be cheaper if the invention is desired to be protected in a number of countries. Patent application goes through examination at patent office and eventually the patent gets granted. In the present case if the safety tests conducted on the instrument enhance any feature of the instrument it should be protected. The enhanced feature of the instrument can be protected by filing a continuation in part patent application for the same. Once the patent is granted the assignee can commercialize his invention or in other case assign rights. The rights can be granted completely, by assigning the patent to a single individual/ organization, or territory specific licenses can be given out for commercialization of invention to various interested parties. Patent Infringement is said to have occurred when a patented invention is used, sold, manufactured or offered for

The History of the Pirates Research Paper Example | Topics and Well Written Essays - 2250 words

The History of the Pirates - Research Paper Example From the research it can be comprehended that, historically, civilization has developed in lands bordering the Mediterranean Sea. Civilization began in Ancient Egypt. There is evidence that peoples from different parts of the world made journeys across oceans to Ancient Egypt to partake in trade and other activities. This is because there is the mention of ships and boats in Biblical texts like Genesis 49 where Jacob blesses one of his sons to control a port. This shows that ships existed for several thousands of years. Although there are few sources of piracy in that era of Ancient Egypt, there is little evidence that also shows that there was no piracy. This therefore leaves this era of history in some kind of darkness. However, Grainger states that there is evidence that piracy was quite common in the era where Ancient Greece was at its peak. He quotes an instance the Assyrian King Sennacharib who sought to fight piracy in his time. In Grainger's assessment of Sennacharib's attemp t to fight piracy, he notes that the effort was not so successful since there were too many limitations in resources the king had. There were also clear evidence that the pirates had so many options and could evade capture. This is because in that era, there concept of nationality was not so strong and there was little co-operation between nations. This made it difficult to handle instances where ships intercepted other ships and stole the cargo and killed people on the ship. Numerous texts cite that the Phoenicians were notorious for the practice of piracy (Alberton, 2006). These Phoenicians normally operated in the Mediterranean where they attacked ships carrying trade inputs from different parts of the Known World. However, the coming of the Roman Empire saw a single government controlling a large number of nations in the region. This led to some level of naval co-operation that sought to control the activities of pirates and similar criminals (Alberton, 2006) Privateering The Am ericas were discovered by Europeans in 1492. The journey over the Atlantic presented a larger volume of ocean that ships and vessels were to cover. Unlike the Mediterranean which was a small corridor of water, the huge distance between Known World and the New world made it difficult for the waters to be patrolled and piracy controlled. This led to a new age of privateering. Privateering refers to individuals who had no national allegiance

Wk 5d2 Essay Example | Topics and Well Written Essays - 250 words

Wk 5d2 - Essay Example otocols on the wide area network (WAN) routers, then border routers and firewall devices, trailed by routers in data-centers and in last the desktop accessing routers. As most of internet is transitioned to IPv6 the network engineers may require to deploy dual-stack enabled switches on edges earlier. Though it is quite difficult for private networks to transition from IPv4 networks that easy but the growth and evolution of the over the Internet would urge organizations to move towards this transition. If it is than why not right now? IPv6 has its advantages that are making it better than IPv4. But still without the knowledge of technology and proper study it will be a quite difficult task. Things that are causing adoption of IPv6 so long is that it is not commonly not compatible with IPv4 networks. To make this transition possible number of transition technologies with tunneling facility are used to provide cross network compatibility. Two of those facilitating technologies are 6to4 and Teredo. While both of these technologies works in different ways, the simple idea is behind is that they encapsulate packets of IPv6 network inside the packets of IPv4 network. Beside the flow of the traffic the endpoints of the tunnel are required to extract and encapsulate the IPv6

Race in the study of food Essay Example for Free

Race in the study of food Essay â€Å"Local food advocacy is a political and moral discourse that is meant to provide the foundation for understanding local food networks as sites of resistance against the norms and power of globalized industrial foodways† (Daston, 2017). Daston is correct â€Å"in her philosophy because, in various and dispersed traditions, nature has been upheld as the pattern of all values, the good, the true, and the beautiful.† (Daston, 2017) â€Å"There is nothing new about the link between nature and necessity, nor with the exculpatory inferences drawn from such links. † (Daston, 2017). In the first section of the paper, she describes local food advocacy as having a political and moral discourse that is meant to provide the foundation for understanding local food networks as sites of resistance against the norms and power of globalized industrial foodways. She explores the use of the concept of â€Å"nature† and the â€Å"natural† in local food discourses with a number of examples of local food advocacy in an attempt to decipher the meaning of the â€Å"natural† in the discourse. Portman (2014) discovers that a cluster of implicit concepts which are uncritically assumed to be earth-based, family-based, and feminine-based; these bases are also assumed to be unproblematic.† (Portman, 2014 Daston asserts that â€Å"the moral dimension of local food discourse, in general, is encompassed in the conviction that there are ethical and unethical ways by which our food can be produced, distributed and consumed.† (Daston, 2017). â€Å"It is only within this modern framework that we can make sense of the naturalistic fallacy, both its confusions and its tenacity. The naturalistic fallacy and its barnacle-like accretions assume what Frankena called a â€Å"bifurcation ontology† that prohibits commerce between the two immiscible realms. Repeated efforts on the part of monists of both materialist and idealist persuasion to dissolve the dichotomy in favor of one or another realm have only reinforced its binary logic† (Daston, 2017, p.581). Portman’s (2017) decision to delve into the ethics of local food advocacy is a timely decision as words such as organic, healthy, and farm-fresh have become a part of the mainstream vernacular. While it may seem random to popular culture.† (Portman, 2017, p. 4). His ideology supports a long-held belief that humans make their food choices based on financial ability. However, it is reckless to say that a single mother of four will make â€Å"everyone’s agreed upon† morally sound decision when trying to determine how to feed her children with her last $20. While politics and economics dictate the type of food presented to various populations and demographics, morality is a luxury that only those who have the time to debate it can afford. â€Å"In this context, the concept of the â€Å"natural† is frequently and uncritically invoked to argue for the ethical significance of participating in and advocating for local food networks. This is problematic in that the dualistic framework serves to obscure many actual complexities within the â€Å"natural† and the â€Å"local† themselves, and in their relationships with their counterparts, the â€Å"cultural† and the â€Å"global.† Thus, by leaving unquestioned certain assumptions about the meaning of the â€Å"natural† and how that meaning was constructed, local food advocacy is not as resistant as it might otherwise be.† (Portman, 2014) Datson (2014), on the other hand, supposes that the idea of morality having a direct influence on decisions regarding nature is a modern phenomenon. This notion supports the theory that these philosophical examinations are only able to be discussed because humans now have the knowledge and time, thanks to modern technology, to make these assumptions. Datson (2014) defined nature as, â€Å"everything in the universe (sometimes including and sometimes excluding human beings), to what is inborn rather than cultivated, to the wild rather than the civilized, to raw materials as opposed to refined products, to the spontaneous as opposed to the sophisticated, to what is native rather than foreign, to the material world without divinity, to a fruitful goddess, and to a great deal else, depending on epoch and context† (Portman, 2014) (p. 582). The lack of a universally accepted definition of the term they are trying to define speaks to the logical flaw that we cannot discount anything that we do not yet understand. It argues that just because something is natural it must be good. We act against nature all the time with money, vaccination, electricity, even medicine. In the same sense, many things that are natural are good, but not all unnatural things are unethical which is what the naturalistic fallacy argues. Both articles show a bias for people who have a choice. A choice to choose what they eat, a choice to carefully examine what they are able to consume, both physically and mentally, and a choice to act on their desires. According to the â€Å"Center for Disease Control (CDC), Non-Hispanic blacks have the highest age-adjusted rates of obesity (48.1%) followed by Hispanics (42.5%), non-Hispanic whites (34.5%), and non-Hispanic Asians (11.7%)† (2017).† The CDC also reported that â€Å"obesity decreased by the level of education. Adults without a high school degree or equivalent had the highest self-reported obesity (35.5%), followed by high school graduates (32.3%), adults with some college (31.0%) and college graduates (22.2%)† (2016). The populations represented in these reports are often plagued by a lack of choice due to political agendas and systemic oppression. Without using these statistics to inform their theories, the authors have left out a demographic who would benefit the most from these findings. Portman (2017) and Daston (2014) have continued a discussion that has been argued for centuries. Portman (2017) provides an action-based solution to the posed questions and the stance it takes, while Daston (2014) attempts to break down a concept that has not been generally agreed upon. Both articles, when referenced wisely, can begin the movement of a positive change in the relationship between our decision-making and our food. References Daston, L. (2017). The naturalistic fallacy is modern. The History of Science Journal, The University of Chicago Press, 105(3), 579-587. doi:10.1086/678173. Overweight and Obesity. (2017). Adult Obesity Facts. Retrieved from https://www.cdc.gov/obesity/data/adult.html Overweight and Obesity. (2017). Adult Obesity Prevalence Maps. Retrieved from https://www.cdc.gov/obesity/data/prevalence-maps.html Portman, A. (2014). Mother nature has it right: Local food advocacy and the appeal to the â€Å"natural.† Ethics and the Environment, 19(1), 1-30. Doi: 10.2979. http://www.journals.uchicago.edu/doi/10.1086/678173 https://muse.jhu.edu/article/547343/summary https://muse.jhu.edu/article/547343/pdf https://www.cdc.gov/socialdeterminants/archive/

An Analytical Biography of The Catcher in the Rye Essay Example for Free

An Analytical Biography of The Catcher in the Rye Essay Critic Jonathan Baumbach explores the significance of innocence in J.D Salinger’s Catcher in the Rye. He claims that the novel is not only about innocence, but actively for innocence-as if retaining one’s childness were an existing possibility. Not only that, but he states that Holden wishes to be a saint: the protector and savior of innocence by preventing them from falling into the cruel adult world of corruption and fickleness. Although he also wants someone to prevent his own fall since he is in fact still a child himself. Baumbach states that this is Holden’s paradox, saying that he must shed his own innocence to protect innocence. These statements are what send Holden off into the three day soul-searching quest that dooms Holden to sinking into insanity in our novel. The critic opens with a rather descriptive insight about how others view and critique Salinger’s first and only novel, as well as pointing some of the flaws that Catcher has: â€Å"The novel is sentimental; it loads the deck for Holden and against the adult world, the small but corrupt group that Holden encounters is not representative enough to permit Salinger his inclusive judgments about the species.† Baumbach claims that Holden does not have enough information to comment on the phoniness of humanity as a whole based on his observations of only a select few. As the critic investigates further, he makes a few interesting points. Some of which regard Mr. Antolini: Holden’s former English teacher. Baumbach claims that Antolini’s kindness to Holden is triggered by a homosexual interest that he has in the protagonist. Pointing  out the flaws in his teachers marriage, as well as ambiguous actions that he had done while with Caulfield. Based on Baumbach’s misguided interpretation the reader could be lead to think that of Mr. Antolini’s gesture as one of a perverted old man rather than as one of concerned mentor. Additionally, the critic moves on to discuss Holden’s concern of where the ducks go during the winter. He claims that what Holden really wants to know is whether there is a benevolent authority that takes care of the ducks; for if there is one for the ducks, there is must be one for people as well. Next, Baumbach switches focus to Holden’s prayer to Allie, which takes place before he goes to visit his family’s apartment. The critic postulates that Holden’s prayer to Allie is not so much an act of anguish as an act of love. However, if one closely examines the scene in the novel, the reader will realize that Holden’s prayer is actually the act of one wallowing in self-pity, of one that has truly hit rock bottom. After examining Jonathan Baumbach’s critique I can gather that he is a wonderful writer, he uses a colorful vocabulary and his sentences are perfectly structured. Although a line should be drawn when using more complex vocabulary; for while reading the critique the reader will likely find themselves having to look up several words to understand the points the critic is trying get across. Not only that, but the critic makes several assumptions based on very little information or goes out on a limb to make a point. Moreover, Baumbach’s points regarding Mr. Antolini’s homosexual nature, the significance of the Central Park ducks, as well as Holden’s prayer to Allie are not entirely concrete, and leave themselves open for dispute. When a reader goes through a book more than once, they find things they never caught while reading it through the first time. One would realize that Holden views Mr. Antolini as a father figure and a role model and comes to him looking for all the answers to the questions no one has figured out yet. For example, during the story when Holden arrives at Mr. Antolini’s apartment, He knows that Holden is spiraling downward and is basically aiming to fall into that insanity he has been drifting towards throughout  the novel, he warns him of this and eventually the two head to sleep. Now the controversial action that causes some of the audience to believe that Mr. Antolini is sexually interested in Caulfied, is that he awoke to find him stroking his hair. Holden misunderstood and made such a rash decision to put everyone into that Phony corrupt persona that he believes humanity is composed of, and storms off out of his home. If Holden was thinking more clearly he would’ve probably been able to handle the situation more responsibly, realizing that Antolini was only stroking his hair in more of a concerned fatherly way. The reader can tell by the way Holden refers to Mr. Antolini they have a strong relationship and he views him as a surrogate father, and not some perverted old man that Baumbach has painted him out to be. Additionally, As far as the Central Park ducks are concerned†¦Holden’s obsessive curiosity about what happens to the ducks during the winter shows the more child-like side to his character. Although Baumbach believes that Holden is searching for a higher power, instead helps him relate to that child innocence he is so fond of. It gives him the hope that change isn’t always permanent. It also helps the reader compare Holden’s perfect world in which time stands still (Like in the Museum of Natural History), to the real world which is constantly changing. Proving that he isn’t searching for some sort of â€Å"higher power† in the ducks, but it was a way to keep in touch with his innocence of his childhood. Lastly, when Holden hits rock bottom in the novel he says a prayer to Allie, in which Baumbach claims that it is an act of love and anguish. Although, this isn’t entirely true. Holden is actually wallowing in his own self-pity, how could he pray to Allie for help when while Allie was alive he wouldn’t even allow him to go on his bike with him and a friend? Sure, he feels regret for it now that he is dead and no longer with him, but it happened yet again when Phoebe wanted to run away with him and Caulfied turned her down the same as he had done with Allie. Proving that after hitting rock bottom Holden is desperate enough to pray although he doesn’t actually believe in God, but is hoping that there is one to not only save him but the soul of his deceased brother as well. In conclusion, Baumbach as a critic did write a well-written review of J.D Salinger’s Catcher in the Rye although it was a bit difficult to understand at times, he made a clear point and backed up his point with facts from the novel. He had colorful vocabulary and his critique flowed well together. Although the critique was a bit on the longer side I did enjoy reading it. The Catcher in the Rye which is believed to be J.D Salinger’s most famous work, had been an everlasting favorite of teens and tweens of the literary scene. This novel known for its stylized prose and focus on themes of angst, alienation, and rebellion has received wide acclaim for its extraordinary sense of originality. This novel will endure as a lifetime favorite of adolescence everywhere because it has life and is probably the most original piece of its time.

Long Bone Fractures in Children: IN Fentanyl Treatment

Long Bone Fractures in Children: IN Fentanyl Treatment Introduction The clichà © that states children are just small adults is certainly not true in the case of long bone fractures. A childs experience of long bone fractures is dramatically different from that of an adult on account of their rapidly developing physiology (Wood et al 2003). This rapid development results in biochemical and physiological differences between a childs and an adults skeleton, the mechanisms of fracture and healing, are an important component of their treatment needs and consequently crucial part of emergency care management (Bonadio et al 2001). In addition, children, from infancy through to adolescence, have common fracture patterns related to their stage of development. The structural differences between the bones of a child and an adult enable childrens bones to endure greater forces and to heal quicker a childs remodeling potential supports full recovery with limited or no long term side effects from long bone fractures (Lane et al 1998). Injuries of all types are the second leading cause of hospitalization among children younger than 15 years (Landin 1997). Musculoskeletal trauma, although rarely fatal, accounts for 10% to 25% of all childhood injuries (McDonnell 1997, Landin 1997, Lane et al 1998). Boys have a 40% risk and girls a 25% risk of incurring a fracture before the age of 16 years (Landin 1997, Ritsema et al 2007). The most common site of fracture is the distal forearm which accounts for 50% of paediatric fractures. The rates of fracture increases with age as children grow; peaking in early adolescence. Fortunately, most fractures in children are minor greenstick and torus fractures constitute approximately 50% of all fractures in children (Landin 1997, Lane et al 1998, Gasc Depalokos1999, Richards et al 2006) and only 20% require reduction. Thus, the management of paediatric fractures is often straightforward. Without exception children will experience pain at the time of injury, attending the accident and emergency department and during recovery. The most common pain management strategies involve a multi-modal approach that includes both pharmacological and non-pharmacological components delivered via the least invasive technique (Worlock et al 2000). In practice this includes oral medication, such as oramorph, paracetamol, and NSAIDs, inhaled entonox, intranasal diamorphine (IND) or intravenous opioid where necessary and distraction with age appropriate devices, such as interactive books, bubbles, music and computer games in older children. Notably, IND is currently embraced as the key route of opioid delivery for children attending AED with fracture pain in the UK British Association for Accident and Emergency Medicine (BAAM E 2002). Parents and guardians of children frequently seek care in AED for the relief of pain from traumatic injuries and as a result the field of emergency medicine has assumed a leadership role in paediatric pain management. However, despite this the literature suggests the provision of pain relief for children attending AED remains suboptimal when compared to adults with the same injuries. Further discrepancies are reported between paediatric accident and emergency departments (PAED) and district general accident and emergency departments (DGAED) (Emergency Triage 2004). One reason suggested for these differences is the geographic distribution of specialised services, which are predominantly located in large cities where they are affiliated with universities. However, a recent audit by the British Association for Emergency Medicine (BAAEM 2005) of their guideline for the management of pain in children shows inconsistencies in provision of analgesia particularly for fracture pain throughout the country with no measurable difference between PAED and DGAED. A key feature of this guideline is the algorithm which advocates the use of IN diamorphine for acute moderate to severe pain in children over the age of one year (see appendix 1). The whole topic of analgesia in the paediatric population is complex and still imperfect especially in acute moderate to severe pain requiring urgent treatment in the emergency department (Schechter et al 2002). The road to pain free suffering is still paved with impediments such as failure of pain recognition and methods of delivery of analgesia (Murat et al 2003). Oral administration can be inadequate in an emergency situation with particular limitations in potential choice of drug and delay in gastric absorption and gastric emptying. Intramuscular (IM) and intravenous (IV) administration can be distressing to children and have been shown to influence future response to painful procedures (Gidron et al 1995, McGrath et al 2000, Fitzgerald et al 2005, Walker et al 2007). Rectal administration has limited acceptability given unpredictability of onset together with occasional problems of consent (Mitchell et al. 1995). By contrast, the efficacy and safety of the IN route has been well documented for desmopression acetate (DDAVP), insulin, antihistamines, midazolam and calcitonin (Jewkes et al 2004, Loryman et al 2006). In contrast, intranasal administration has a number of advantages. It is technically straightforward, socially acceptable and demonstrably effective. The nasal mucosa is richly vascular and administration by this route avoids the first-pass metabolism phenomenon Summary Studies in the 1990s such as Yearly Ellis (1992) have also demonstrated the efficacy of administration of intranasal medication via a nasal spray rather than drops in adults, although the efficacy of this application in the paediatric population remains to be proven. Intranasal administration is possibly the ideal route of analgesic administration in children. Currently, within the accident and emergency department (AED) of Bristol Royal Hospital for Children (BRHC) intranasal diamorphine is used as the first rescue analgesia in the paediatric population presenting with acute moderate to severe pain, most frequently in patients with long bone fractures who do not require intravenous access for resuscitation. Diamorphine is a semi synthetic derivative of morphine with a number of properties that render it a desirable analgesic agent for administration via the nasal route. It is a weak base with a pKa of 7.83 and is water soluble allowing high concentration to be administered in small volume (Rook et al 2006). Unfortunately the legal use of diamorphine is limited to two European countries i.e. United Kingdom (UK) and Sweden. Furthermore periodic problems with its availability during the past few years (with further shortfalls in availability predicted by the NHS purchasing and supply agency) have resulted in an alternative efficacious analgesia being sought for this population. Fentanyl, however, is a short rapidly acting opiate has several qualities that render it useful as an IN analgesia and a potential candidate to replace IN diamorphine in the AED for acute facture pain management in children. It has a very high lipid solubility, potency and diffusion fraction, and unlike diamorphine it is not a prodrug and does not cause histamine release (Reynolds et al 1999). Assessment of a patients pain experience is not directly accessible to others, collecting and analyzing information about the processes of pain relief and pain prevention is not straightforward and presents significant challenges to health care professionals. In children, this task is further complicated by their varied stages of physical and cognitive development. Recent research by Bruce Frank (2004) however, has shown that the ability to measure pain in the paediatric population has improved dramatically and that today there now exists a plethora of age appropriate pain assessment tools for acute pain in children ranging from pre-term infants to adolescents, the majority claiming validity (strength and robustness) and reliability (consistency). However, most clinical research into pain management strategies continue to rely on the gold standard self report and visual analogy score tools (mostly 0-10) (Chalkiadis 2001, Walker et al 2007). Although these tools are reliable they are not always adapted appropriately for a childs stage of development. Childrens understanding of pain and their ability to describe pain change with increasing age in a developmental pattern consistent with the characteristics of Piagets preoperational, concrete operational and formal operational stages in cognitive development (Smith et al 2003). The quality or int ensity of the pain can be difficult to determine in children, as most tools rely upon a patients relative judgment between the intensity of present pain versus a patients worst pain experience (Murray et al 1996). These tools can therefore be unreliable where a childs age of development means they have limited or no memory of pain experience. Stevens et al (2002) recently described a conflict of understanding that resulted in a study bias and an insignificant reported power of (p=0.6). In the study an 8 year old boy had chosen the VAS (0-10) but frequently reported his score as 10, although he understood the increasing value of the scoring system further questioning identified he perceived 10 of 10 to be a good score and 0 of 10 to be poor. The boy was at a stage of development that limited his understanding of less is more. This case highlights the importance of utilizing a pain assessment technique that reliably accounts for a childs age of development. A preliminary search of literature suggests there is currently exists limited research to support for the use of intranasal diamorphine or intranasal fentanyl for the management of acute pain in long bone fracture in children as evidenced based medicine. Despite this lack of evidence it remains a key strategy within paediatric AED for the pain management of long bone fractures and is anecdotally reported as a gold standard for paediatric pain management. Therefore; its lack of availability could profoundly compromise pain management for this population. Thus, this extended literature review will examine the efficacy of intranasal fentanyl as an alternative to intranasal diamorphine for traumatic fracture pain in children attending accident and emergency departments. However, in these days of evidence based medicine, it clearly needs to be established beyond all reasonable doubt. In view of that only research into paediatrics will be included increasing the credibility of its applicat ion to practice. SEARCH STRATEGY A range of complimentary search techniques were used to capture key research including a systematic electronic literature search of the Cochrane library, Embase, CINAHL, Proquest, Medline, PubMed since 1990 up to 2009 (this has to be to year of submission). The scope of the search was extended beyond the recognised five years of current research so as to include the empirical work into the development of IN analgesia in children. Key words used included the following: pain, acute pain management, intranasal diamorphine, intranasal fentanyl, procedural, accident and emergency, emergency department, child, pediatric, paediatric, child and fracture pain, as well as various combinations. In addition, in order to ensure the completeness of the search, an internet search was completed using the Google search engine, IASP, Pain Journal, Paediatric Nursing, BAAEM, NICE, Medline, EBM; the RCN was also utilised. Backward chaining of references found was also performed to ensure all relevant papers were identified. Although this review identified twenty seven citations it should be noted that historically there are fewer Randomised Controlled Trials (RCT) in children compared to adults possibly due to problems gaining ethical approval and consent. Additionally even experienced researchers will be unable to find all relevant papers and much research is not submitted for publication. The studies identified were divided into the three modalities of IN route, IN diamorphine and IN fentanyl with the majority presenting evidence for the IN route. All papers were critiqued using a tool published by the Learning and Development Department within the Public Health Resource Unit of the NHS (www.phru.nhs.uk/casp). The tool facilitated critiquing different forms of quantitative research and is based on work by Sackett (1986), Sackett et al (1996) and Phillips et al (2008) (see appendix 2). The results of the critique process for each paper and level of evidence applied in line with the modalities they address informed understanding of current practice and development of a research proposal. STRUCTURE OF THE LITERATURE REVIEW This literature review will focus on determining whether IN fentanyl is an effective alternative to IN diamorphine for the management of long bone fracture pain in children attending an AED. The scope of the literature review considers literature from 1990 onwards although occasionally earlier research has been referenced. Given the limited available evidence on the topic the following review structure has been selected. Chapters 1, 2 3 will present the evidence sourced on each theme intranasal route, intranasal diamorphine and intranasal fentanyl with a short summary to conclude each chapter. Chapter 4 will present an in-depth discussion and conclusion on the utility of the evidence, its application to practice and the requirement for a multi-centred comparative randomised control trial to improve the credibility of the evidence base for this field of treatment. Finally chapter 5 will present a research proposal for a comparative study of these modalities. Intranasal (IN) route of medication delivery in children. Nasal administration of drugs has been reported as having several significant advantages over current practice which are predominately oral, IM, IV and rectal (Williams Rowbotham 1998). It is emerging as a low-tech, inexpensive and non-invasive first line method for managing either pain or other medical problems (Wolf et al 2006). Nasal medication delivery takes a middle path between slow onset oral medications and invasive, highly skilled delivery of intravenous medications. The nose has a very rich vascular supply, IN facilitates direct absorption to the systemic blood supply due to increased bio-availability of the drug by missing first pass metabolism, It avoids the potentially technically difficult of sterile intravenous access, is essentially painless and is considered acceptable to children when compared to other routes of administration (Shelly Paech 2006) (see table 1). a theory which will be considered when reviewing the studies within this chapter Therefore suggesting th e IN route will result in therapeutic drug levels, effective treatment of seizures and pain without the need to give an injection or a pill, furthermore; it is quite inexpensive, an advantage in this era of increasingly expensive medical technology (Shelly Paech 2006). Additionally given the complexity of the developing child and the known consequence of poorly managed pain on the future responses to pain the IN route does, if it is as efficacious and as safe as suggested offer one of the most acceptable, definitive forms of analgesia delivery in children. The degree of accuracy of the previous statements will be established within this chapter by critically reviewing the 16 studies identified on IN medications other than intranasal diamorphine or intranasal fentanyl in the paediatric population (see table 2) as these agents are considered individually in later chapters. The rigour of the studies will be addressed within this chapter and reflect the level of evidence applied according to Sackett (1986) criteria (see appendix 3). Most studies reviewed were randomised clinical trials and in some cases compared against a placebo Conversely, this does not concur with the trials discussed earlier (Lahat et al 1998, Al-rakaf et al 2001, Fisgin et al 2002, Mahmoudian and Zadeh 2004 and Holsti et al 2007) where significant dosing was applied or in Wilson et al (2004) who retrospectively studied 30 children age 2-16 years receiving 0.3mg/kg at 5mg/1ml INM and 13 patients receiving rectal 0.2mg/kg diazepam for seizures. The authors report equal efficacy for both routes. Success of these agents was considered on cessation of seizures, no reported complication and not needing to attend A+E. A total of 27/30 families who had used INM found it effective and easy to use. Although 20/24 (83%) who had previously used rectal diazepam still preferred it mostly due to the coughing and the volume of liquid administered via the IN route. Given it is generally considered that the optimum IN dose as stated above is 0.1- 0.2 ml per nostril, all but the studies discussed so far were using drug concentration and dosing regimes whic h resulted in large volumes of liquid being dripped in to the nasal cavity. This is particularly poignant in Wilson et al (2003) who compared buccal to IN midazolam in 53 children aged 3-12 years experiencing seizures lasting > 5 minutes attending AED. A key feature of this study is the mean age of the children (age 9 years), mean weight (24kg) the study drug concentration as with previous studies was of 5mg /ml. IN dosing was at a dose of 0.3mg/kg. Given these figure the average dose would have been 7.2mg = a volume of 1.4ml being administered. Since the comparative route of administration for this study was buccal there is a possibility that part of the IN dose was buccally absorbed therefore creating a flaw in this study methodology, raising questions over why this comparative route was chosen and suggesting the only real conclusion to be taken from this particular study is buccal midazolam is effective and safe in children. Furthermore although this is described as a blind RCT and the authors claim the time to cessation of seizure was quicker for the INM group 2.43 (SD 1.67) to 3.52 (SD 2.14) for buccal route there is little detail on the blinding process or data collection procedure suggesting the rigour of the study maybe flawed therefore the efficacy and safety claimed for the IN route should not be embraced without further study. On the other hand Fisgin et al (2002) and Hardord et al (2004) compared the INM with rectal diazepam. In Fisgin et al (2002) in an unblinded RCT equivalence study the authors compared INM with rectal Diazepam to ascertain the safety and efficacy of INM for the development of a clinical protocol in the management of prolonged seizure in children attending the AED. Forty five infants and children age 1 month -13years experiencing prolonged seizures > 10 minutes were either given INM 0.2mg/kg or rectal diazepam 0.3mg/kg. The authors report proven efficacy (p Intranasal Diamorphine (IND) The delivery of opioids via the IN route is perhaps one of the most valuable indications for IN medication delivery. Acute pain is a frequent experience for children whether attending an AED, hospital and hospice setting (Hamer et al 1997). Furthermore it is not unusual for them to experience frequent episodes of breakthrough pain which requires additional support from fast acting analgesic agents. Owing to the developmental and physiological difference in the paediatric population there is a need for a variety of effective treatment option from which to select and individualise the patients therapy to meet their needs. IN opioid is simply one such option available which may be useful in children. It has been suggested that the delivery of medications via the IN route results in rapid absorption with medication levels within the cerebral spinal fluid (CSF) being comparable with (IV) administration (Chien and Chang 1997). Diamorphine hydrochloride is a semi-synthetic derivative of morphine. It is extremely hydrophilic, which makes it ideal to use when preparing in high concentrations in solution, thus allowing high doses to be administered in smaller volumes via the intranasal route (Kendall Latter 2003). However, this route of administration can be a painful process as reported by adults (Henry et al 1998). Despite this the intranasal route is considered more acceptable to children and their parents and is thought to lessen the opioid side effect profile seen in IV administration (Stoker et al 2008). This concept has been well recognised throughout the UK and many centres already use intranasal diamorphine for acute pain in children, following the guidelines by the British Association for Accident and Emergency Medicine Clinical Effectiveness Committee (2002) (BAAEM). Although the administration of intranasal diamorphine is now a first line choice for moderate to severe acute pain for children atten ding AED, as is the case within our institution, there is very limited research to substantiate this practice although as noted above it has been readily accepted by the BAAEM for acute pain management in children and very successfully used within our institution A recent shortage of diamorphine evoked the search for an equally effective and acceptable alternative. Early research in animals and adults reported pharmacokinetics of nebulised inhalation and intranasal administration of diamorphine as detected morphine in plasma at six minutes (Masters et al 1988, Kendall 2001). Despite the age of this research and the fact that the later study was in adults, it is still quoted as creditable evidence to support this practice in paediatrics. However the legitimacy of this should be questioned, due to children not being just small adults but have physiological differences intrinsic to their age and stage of development which may affect the bodys absorption and level of toxicity in different ways to adults. The extensive literature search highlighted four randomized controlled trials (RCT) that demonstrate IND to be clinically superior to intramuscular morphine and inferior to IV morphine particularly in the management of acute pain in children, a case study of an 8 year old boy and clinical audit of IND for pain relief in children attending AED (see table 3). The key methodology in the RCTs by Wilson et al (1997), Kendall et al (2001), Brennan et al (2004) and Brennan et al (2005) suggest these are superiority studies where the authors hypothesised improved pain management with the IND when compared to a variety of routes. The rigour of the studies will be discussed later in the chapter. Although while the critiquing process takes place it is fundamentally accepted that RCT are considered level 1 or 2 evidence as opposed to case study or audits at Level 3b and therefore generally sourced to Latest published clinical evidence to support the use IND in the paediatric population is presented in an audit by Gahir Ranson (2006) of 54 children whose care was managed by the use of an integrated care pathway for acute pain management while attending the local AED. This integrated care pathway focused strongly on the use of IND. Data collection was on a one page performa and included consent, date, patient demographic, pain score and side effect profile. Data collection was retrospective and data analysis illustrated limited recording of side effect profile but improved pain scores. However only 60% of patients have this information documented so data collection was difficult. Despite this lack of hard evidence no clinical incident, including the side effect profiles, were reported. Thus suggesting the practice of IND for acute fracture pain management in children could be safe, effective and more acceptable to children than the more painful alternative of IM or IV administration. However there is limited strength in an audit, other than a review of practice (Bowling Ebrahim 2005) and in this case a key feature for review should be the documentation process in the department as there were facets in the care pathway administration documentation missing. Therefore this audit suggests that IND is safe and effective pain management for children, but this conclusion can not be categorically drawn from the limited data available. The potential outcome of this audit could be education on documentation, to do a more rigours prospective audit of practice. Unfortunately at this point it only offers an insight to their clinical practice which is favourable for this agent and route. Albeit as noted before IND has improved childrens pain management and over all experience of acute care in our PAED additionally as with the results of the audit we have experienced no side effects or complications, further highlighting the importance of seeking an alternative to IND which offers equally efficacy. Intranasal Fentanyl (INF) Monitoring of the usual observations and pain scoring in the child was recorded prior to the administration of fentanyl (20 micrograms for 3-7 year olds and 40 micrograms for 8-16 yrs) and continued at 5 minute intervals for the 30 minute period. Additional doses of fentanyl (20  µg) were available if required at 5 minute intervals. Pain assessment was achieved with two validated pain assessment tools, the visual analogue scale (VAS) in older children and the Wong-Baker Faces (WBF) for younger children. Both are reliable and known to support consistency in pain assessment. Though there was no mention of training for those assessing this primary end point using these tools in the paper therefore this should be considered in the overview of the standard of evidence produced by this study. Additionally although forty five patients were randomized following consent unfortunately no details on the randomization process was disclosed in the paper either. This may not be significant, but when reviewing the credibility of the authors claims these obvious omissions could be responsible for a flaw in this study and remains to be established. On the other hand, the methodology that has been disclosed in the paper appears sound as it addresses key areas of sample calculation (power of the study) as a superiority study with the sub groups size adequate to detect a significant difference (Greenhalgh 2004); demographics, blinding of the drugs, assessors and appropriate statistical analysis of the data therefore supporting the validity of the results claimed and the application of the results to the age of patient targeted that this literature review is aiming to find an analgesic alternative to IND for. The results concluded by Borland et al (2002), are a reduction in pain score at 10 minutes to 44.6 mm (95% confidence interval) 36.2-53.1 mm from 62.3 mm 53.2-69.4 mm (95% confidence interval) at assessment using the VAS and 2.2 (95% confidence interval 1.3-3.1) at 10 minutes from 4.0 (95% confidence interval 3.3-4.7) at assessment in 16 children using WBS. Visual analogue pain scores demonstrated clinically significant reductions in pain scores by 5 minutes that persisted throughout the entire study (up to 30 minutes) for both INF and IV morphine. The second primary end point of this study (side effect profile) showed no significant change in physiological parameter of the childrens pulse or respiratory rate, blood pressure or oxygen saturations, interestingly the side affect profile chosen for monitoring such as pulse and blood pressure are not considered to be one of the primary side affects of morphine, however nausea and vomiting which are was not assessed. Ultimately, there wer e no negative side-effects and the sizeable reduction in pain scores (compared to baseline assessments) was accomplished in children using INF by 10 minutes and maintained throughout the 30 minute period with the mean INF dose at 1.5 µg/kg and ranging from 0.5-3.4  µg/kg. Interestingly 35.5% of children in the INF group only required one dose. Given the clinical equivalency of these two agents and routes the authors conclusion that INF offers the benefits of a simple painless technique for treating acute pain is substantiated. These benefits suggest that the IN route could be a valuable technique not only in an AED but also for breakthrough pain by offering a fast onset of pain control in moderate to severe painful conditions. It could also provide pain relief and allow topical anaesthetics to take effect on the skin prior to IV establishment. Therefore this may be a suitable alternative to IND. A similar and more recent double blinded RCT trial by Saunders et al (2007) claimed efficacy of a larger dosing regimen with a mean dose of 2 µg/kg INF (50 µg/ml) for pain reductions in paediatric orthopaedic trauma compared with IVM at 0.1mg/kg in 60 3-12 year old children. This study reports positive outcome for INF following both patients and carers reporting very effective pain management and satisfaction using this treatment method. However there is little information in the paper of methodology and results are given in percentages rather than a P value or NTT which should be expected in a rigorous creditable RCT of two agents (Bowling Ebrahim 2005) reducing the level of evidence applied to the paper to L3. Even supposing the results are an accurate reflection of the efficacy and safety of INF, particularly the fact that no significant difference in pain score or side effect profile and INF is a way forward, the lack of detail the randomisation process and analysis of data in the study methodology merely implies that these results maybe flawed. Interestingly given the concentration of fentanyl 50 µg/ ml a dosing volume for a 25kg child would have required one ml = 0.5ml per-nostril therefore suggesting some of the administration may have been oral rather than IN and present the issues of bad taste which is put forward as a possible study limitation by the authors. Then again there are no complications or reports on taste presented in the results and the authors conclusion on the efficacy of INF for acute pain management in children may be founded. However, without sourcing more details from the authors it cannot be considered evidence to inform this dissertations aims but merely an ex ample of poor research or appropriate omission by publishers. Further suggesting there remains a requirement for more research on the topic within double blind, equivalence, RCT focused on INF efficacy and dosing with sound methodology that is transparent in publication to answer the dissertation question. Conversely an older and more rigorous study which also looked at dose related analgesic effect between routes of administration is by Manjushree et al (2002). The authors demonstrated the clinical efficacy of INF in a cohort of 32 children (aged 4-8 yrs) in a postoperative situation and with a double blind level 1 RCT. The study design gives the impression of sound methodology as blinding, assessment and analysis of data was appropriate and available for scrutiny in the paper, particularly the analysis of both nonparametric and nominal data. The only weakness is possibly the sample size of 32 patients. Although the authors performed a power calculation which identified 40 patients to show a significant affect, they only recruited 32 patients, furthermore, this appears to be an equivalency study where the authors hypothesised INF would be equal to and not inferior to IVF therefore would have needed a larger sample to de

Images Of Control Propaganda Essay -- essays research papers fc

One of the greatest revolutions in the twentieth century was not political in nature. It however aided in many different political revolutions. This revolution was the communications revolution. The twentieth century has experienced one of the greatest changes in mean of communication including technologies such as radio, television, motion pictures, advanced telecommunications and the Internet. These technologies have been used to fulfill the purposes of many. Some who wished to use this technology to influence other people. A term commonly used to describe the use of media to convince or persuade other people of a certain idea or cause is propaganda. Political leaders often use techniques of propaganda, as the goal of politicians is to convince people that their ideas supercede those of others. Two examples of propaganda being used extensively during the twentieth century is by the National Socialist German Workers Party (Nazi) in Germany from 1933 – 1945 and by the Communis t government led by Josef Stalin in the Union of Soviet Socialist Republics from 1929 – 1953. In examining these two states and their use of propaganda, it can be seen that although both state had radically different ideologies, certain trends in their use of propaganda can be found to be in common. These primarily being: the glorification of individuals or groups as heroes, the glorification of the leader of the state, and the dehumanizing of the state’s enemies. After Adolf Hitler was proclaimed Chancellor of Germany in 1933 he started to establish a Nazi government. It became immediately apparent that the new government would have to get the people’s unquestioned support. Although the Nazi party had been relatively popular before Hitler became Chancellor, there was still opposition to be found in some people. One tactic that was used by the Nazi propagandists was to use a hero to symbolize all that could be accomplished under the new National Socialist government. A hero is also useful to rally the people behind something that they can relate to and have sympathy for. The obvious example of this is the Nazi glorification of Horst Wessel. Considered a Nazi martyr, he was in reality murdered and was not really a hero at all. He was however used by Nazi Propaganda minister Goebbels to be seen as a National Socialist hero who was murdered by Communists (Welch, 1983, p. 75). Horst Wes... ...es from both nations can reveal certain common themes including the glorification of heroes, an all-powerful leader and the degradation of the nation’s enemies. It can be concluded that since two separate nations used the same themes and media that there must have been some degree of success. As one looks back at these two regimes one may wonder how people could have supported these radical and often horrific forms of government. Propaganda is defiantly one of many answers.   Ã‚  Ã‚  Ã‚  Ã‚   Works Cited Bonnel, Victoria E. Iconography of Power: Soviet Political Posters under Lenin and Stalin Berkeley:  Ã‚  Ã‚  Ã‚  Ã‚  University of California Press, 1997. Britain Alone. Videotape. London: BBC TV [1980]. 20min. Hitler, Adolf and Anton Drexler Programme of the NSDAP, 24 February 1920, 1999, Hiter Historical  Ã‚  Ã‚  Ã‚  Ã‚  Museum, Retrieved 07 Nov. 1999. Maltin, Leonard â€Å"Triumph of the Will† Leonard Maltin’s Movie and Video Guide 1995 [CD-ROM]. Dutton Signet, 1994. Triumph Des Willens. Dir. Leni Riefenstahl Berlin: NSDAP – Reichspropaganda Abteilund, 1934 Welch, David Propaganda and the German Cinema: 1933 – 1945 Oxford: Clarendon Press, 1983

Kafka Essay -- essays papers

Kafka Franz Kafka was born in Prague, Bohemia, July 3, 1883 and died June 3, 1924 of tuberculosis at the age of 40. He came from a middle-class Jewish family. His father was a shopkeeper and tried to climb up the social ladder by working hard at his shop and sending Franz to a prestigious German high school. He went on to get a law degree and worked for two insurance companies (not at the same time) When his .tuberculosis got bad in 1917 he was put on temporary retirement with a pension. German was the language the upper class spoke and by sending Franz to German schools his father tried to disassociate from the lower class Jewish who lived in the ghetto. They were always moving from apartment to apartment advancing as the business grew. Franz had a very strained relationship with his father that traumatically affected his whole life. This is apparent in a letter to his father he wrote, â€Å"What was always incomprehensible to me was your total lack of feeling for the suffering and shame you could inflict on me with your words and judgments. It was as though you had no notion of your power† (Letter). Max Brod and Franz met in college and became life long friends. It was Max who persuaded Franz to publish some of his work and it was Max who was responsible for most of the Kafka writings that are available today. Franz had entrusted his manuscripts to Max and in his last will and testament specified that all his work was to be destroyed. Instead Max had them published after Franz’ death. Although he never married, he was engaged several times but always broke the engagement as the wedding day would approach. Most of the biographies about him tell of his problem with women and repulsion from sex and say that it was ... ... http://members.xoom.com/danielhornek/. 1 Mar. 2000. Kafka, Leni. Biography. Hp. 2000 [last update]. Online. Available: http://victorian.fortunecity.com/vermeer/287/biography.htm. 2 Mar. 2000. Letter to His Father. Hp. 2000 [last update]. Online. Available: http://www.fortunecity.com/victorian/vermeer/287/lettertohisfather.htm Magil, Frank N. ed. Franz Kafka. Vol. 4 of Critical Survey of Short Fiction . Pasadena: Salem Press, 1993. Novels for Students Vol. 7 Farmington, MI: Gale Research, 1999. p281-297. Pawel, Ernst. The Nightmare of Reason: A Life of Franz Kafka. NY:Noonday Press, 1992. Spann, Meno. Franz Kafka. George Prior Publishers, 1976. Times Literary Supplement, Aug. 22, 1997 n4925 p15(2). World Literature Criticism 1500 to Present. Vol. 3. Detroit: Gale Research, 1992.

Ludwig Von Bertalanffy

History : Ludwig V. Bertalanffy was born in September 19, 1901, and grew up in the little village of Atzgersdorf near  Vienna. He was  known as one of the founders of general systems theory  (GST). Von Bertalanffy grew up in Austria and subsequently worked in Vienna, London, Canada and the USA. In 1972, he died from a sudden  heart attack. Theory ( Open System ): Ludwig developed open system theory between 1930 and 1956. By the early 1960s, theoretical psychologists applied the theory to organizational structures such as governments, universities and businesses.Any time an individual organization uses resources from its environment–including personnel–in its production, its system is open to outside forces. System Characteristics: When a business regularly interacts with its environment, and exchanges and processes feedback, it is an open system organizational structure. Open systems have open, or porous, boundaries that allow feedback exchanges from inside and outside the business.The controllers of open systems pay attention to their external environment, internal environment and customer needs and reactions. Open systems tend to devise more than one way to accomplish goals or reach similar results with different conditions and operations–what von Bertalanffy called â€Å" equifinality . † This is in direct contrast to closed systems that function under the assumption that there is only one way to achieve a result: a direct relationship between cause and effect. Open Systems in Business:Businesses depend on employees, suppliers, customers and even the competition for research, development and profit. Because the business doesn’t have control of all the environmental forces, it relies on predictions and contingencies to cope with unexpected input. For example, an influenza epidemic can affect suppliers, personnel and even customers, causing lost production and lost profit. Benefits: Open system organizational structur es promote effective problem solving by clarifying the big picture.Continuous feedback and response results in better understanding, by leadership and management, of the organization’s structure within the environment and the interactive dynamics between them. That opens the door for better communication and more feedback. When the system and subsystems have enough feedback, the results can produce more clearly directed planning, intelligent design, useful products and necessary services.

Succubus on Top CHAPTER 18

â€Å"That's not funny,† I said. â€Å"Seems like a reasonable question.† I looked at him and then wrapped my arms around myself. â€Å"Is that all you're going to say?† â€Å"I†¦I don't really know what else to say.† â€Å"This is the part where you yell at me.† His eyebrows rose. â€Å"Oh, I see. I didn't know this was already scripted out. â€Å" â€Å"That's not what†¦look. I slept with someone else. And not just slept. I didn't have to do it†¦not the way I have to with humans. You get that, right?† â€Å"Yes,† he said, still dead calm. â€Å"And I wasn't drunk or anything. Tipsy maybe, but still in control of my senses.† â€Å"Yes.† â€Å"So aren't you mad?† â€Å"Stunned is the dominant emotion at the moment. Finding out someone impersonated you is almost more troubling than the sex part.† â€Å"He didn't impersonate you, perse†¦I mean, I knew it was him.† â€Å"I know. But it's still weird.† When he fell silent again, I could only stare with incredulity. He caught my look and retuned it. â€Å"What do you want?† This time he did sound annoyed, almost angry. â€Å"Do you want me to be mad? Will that like†¦punish you or something? Is that what you want?† I said nothing and realized that was exactly what I wanted. I had read a book once where a guy accidentally killed a girl while driving drunk. His powerful family had managed to keep him out of jail, and he'd hated it. He'd wanted the cleansing catharsis of real punishment, of paying for his crimes. Right now, I needed the same thing. â€Å"I deserve it,† I told Seth. His voice was cold. â€Å"Well, I'm not going to give it to you right now. You can't dictate what I feel. Sorry.† My mouth started to drop open, unsure what to do with this turn of events. The ringing of my cell phone interrupted my rumination. I glanced at my purse, then let the phone go to voice mail. A moment later, it rang again. â€Å"You should answer it,† Seth told me. I didn't want to talk to anyone. I wanted to crawl into a hole. But I got the phone and read the display. No one I recognized. Sometimes that was Jerome. If I didn't answer, the demon was likely to teleport on over, and that was quite possibly the only thing that could make this scenario worse. â€Å"I'm sorry,† I said softly to Seth, just before I answered. I didn't know if I was apologizing for the interruption or what I'd done with Bastien. â€Å"Hello?† â€Å"Hey, Georgina. This is Wyatt.† It took me a moment. From Doug's band. â€Å"Hey, how's it going?† â€Å"Bad. I didn't know who else to call. I'm at the hospital with Doug. â€Å" My heart stopped. â€Å"Oh my God. What happened?† â€Å"He, uh, took some pills.† â€Å"What kind of pills?† â€Å"Not sure. But he took a whole bottle of them.† Wyatt's news spurred Seth and me to action. It was funny how tragedy could override anger. Whatever unresolved issues ensnared us, we put them on hold as I drove us downtown. Wyatt had briefly told the rest of the story as I'd left my apartment at a run. Alec hadn't come through with his latest shipment. Doug had crashed again, plunging into that frightening darkness I'd observed before. Wyatt didn't entirely know what had triggered the overdose. He blamed everything from a suicidal urge to a desperate attempt at recapturing the high through other means. The emergency room had pumped his stomach, and the doctor said he was okay for now, but he hadn't yet regained consciousness. Wyatt had called me because Doug had no family here, and no one knew how to contact the ones who lived out of town. Corey and Min were there when we arrived. They elaborated a bit more for us and said there was no change in Doug's condition. Seth stayed silent, but I could tell he was as concerned as I was. I asked if I could see Doug, and a nurse told me I could. I entered the room alone and found him asleep, hooked up to tubes and a bleeping machine. I had watched medical technology change over the years, from leeches to defibrillators, but that didn't mean I felt comfortable with any of it. Machines that kept people alive rubbed me the wrong way. They weren't natural, even if they did good. â€Å"Oh, Doug,† I murmured, sitting at his bedside. His skin was pale, his hand cold and clammy. The bleeping machine registered a steady heartbeat, so that was something. None of the other readouts meant anything to me. I watched him, feeling helpless. Mortals, I thought, were fragile things, and there was nothing I could do about that. Many, many years ago, Bastien and I had worked at a dance hall in Paris. Dancers in those days were almost always prostitutes too, but I hadn't minded. The opportunity had provided me with both succubus energy and monetary income. Bastien had been a bouncer and ostensibly my lover. This allowed him to sing my praises, bolstering my reputation and sending me a large clientele. â€Å"There's a young man who shows up every night,† the incubus told me one day. â€Å"He has ‘virgin' stamped all over him, but he's rich too. I've talked to him a few times. He doesn't like the idea of paying for sex, but he's completely obsessed with you.† The news pleased me, and when Bastien pointed out the gentleman, I made a lot of eye contact with him throughout the performance. Sure enough, a manservant of his discretely solicited me on behalf of his employer afterward, and I hurried to prepare myself backstage. â€Å"Josephine,† called a voice beside me. I turned and saw another dancer, an especial friend of mine named Dominique. â€Å"Hey,† I told her, grinning. â€Å"I have a nice prospect I've got to get to.† Her grim face made me pause. â€Å"What's wrong?† Dominique was small and blond, with an almost waifish appearance that made her look like she wasn't getting enough to eat. That wasn't a surprise, however. None of us in that profession ever got enough to eat. â€Å"Josephine†¦Ã¢â‚¬  she murmured, blue eyes wide. â€Å"I need your help. I think†¦I think I'm pregnant.† I stopped in my tracks. â€Å"Are you sure?† â€Å"Pretty sure. I†¦I don't know what to do. I need this job. You know I do.† I nodded. From the wings, Jean – the man who took cuts from our liaisons – yelled at me to hurry up and meet my young man. I gave Dominique a quick hug. â€Å"I have to go do this. I'll find you later, okay? We'll figure something out.† But I never really got a later. The young man, Etienne, proved to be adorable. He was much younger than my apparent age, and engaged to be married. He was torn on the issue of sex. Part of him felt he needed to be pure for his bride; the other part wanted to be experienced on his wedding night. That was the part that won out, the part that brought him to my bed and gave me the succubus bonus of both a moral corruption and an energy yield. He resented me for both my lifestyle and my hold over him, but that didn't stop him from coming back every day for the next few weeks. â€Å"I hate you for this,† he told me one day after we'd been together. He lay back against the sheets, in a sweaty, postcoital repose. I stood near the bed, putting my clothes on while he watched. â€Å"Marry me.† I laughed out loud, tossing my hair – then honey blond and curly – over one shoulder. He flushed angrily. He had dark eyes and hair and a perennially brooding look. â€Å"Is that funny?† â€Å"Only because you hate me in one breath and love me in the other.† I smiled as I laced up my undergarments. â€Å"I suppose there are a lot of marriages like that.† â€Å"Not everything's a joke,† he said. â€Å"Maybe not,† I agreed. â€Å"But this comes pretty close.† â€Å"Are you turning me down?† I pulled my dress over my head. â€Å"Of course I am. You have no idea what you're asking. It's ridiculous.† â€Å"You treat me like I'm a child sometimes,† he declared, sitting up straighten â€Å"You're not that much older than me. You have no right to act so wise†¦especially since you're a†¦Ã¢â‚¬  I grinned at him. â€Å"A whore?† He had the grace to look embarrassed. â€Å"And that, sweeting, is the problem. Never mind your family's scandalized reaction. Even if we managed to pull it off, you'd never get over that. You'd spend the rest of our marriage – which would probably be short-lived – obsessing about all the men I'd been with. Wondering if one of them had been better. Wondering if I'd done something with them that you thought was new and novel with you.† Angry, he stood up and pulled on his pants. â€Å"I would have thought you'd be grateful.† â€Å"Flattered,† I said coldly, â€Å"but nothing more.† That wasn't entirely true. The truth was, despite his youthful certainty and mood swings, I liked Etienne. A lot. Something about him appealed to me. Maybe it was because all that emotionality and pride came from an artistic nature. He painted as a hobby. There it was again, my unfortunate obsession with creative men. Luckily, at that time in my life, I had enough sense to avoid deep entanglements with humans. â€Å"I wish you could choose who you love,† he said bitterly. â€Å"Because I wouldn't choose you, you know. But, here we are. I can't stop thinking about you. I feel like there's some pull to you I can't fight.† â€Å"I'm sorry,† I said gently, surprised at the small ache in my heart. â€Å"Wait until you're married. Your wife will make you forget all about me.† â€Å"No. She doesn't even compare.† â€Å"Plain?† Egotistical of me, perhaps, but I heard it a lot. â€Å"Boring,† he replied. Then I'd heard a scream, a bloodcurdling, horror-filled scream. I forgot all about Etienne and tore out of the small, dank room. Down the hall I ran until I found a congregation of people and the source of distress. It was Dominique. She sprawled over a narrow pallet, lying in blood. â€Å"My God,† I gasped, kneeling beside her. â€Å"What happened?† But I already knew. I didn't need the forthcoming explanation from the other dancers. I had neglected her pleas for help a couple weeks ago, caught up in my own whirlwind romance. So she had sought her own solution, as so many lower-class women often did. Unfortunately, there were no machines or sanitizing in those days. An abortion was a dangerous, often deadly, business. â€Å"Oh God,† I said again. I had never lost the need to appeal to my creator, despite my theoretical renouncement. I clutched her hand, not knowing what to do. A half-dressed Etienne appeared in the crowd. I looked up at him desperately. â€Å"You have to go get a doctor. Please.† Whatever injured pride he harbored over my rejection, he couldn't refuse me in that moment. I saw him make motions to leave, but Bastien grabbed his arm. â€Å"No, it doesn't matter.† To me he said: â€Å"She's gone, Fleur .† I looked at Dominique's young face. Her skin was pale, eyes blank and glazed over as they stared at nothing. I knew I should close them, but suddenly I didn't want to touch her. I dropped her hand, slowly backing up, staring in horror. It was by no means the first time I'd seen a dead body, but something struck me about it then I'd never really considered with such shocking clarity. One moment she was here, the next she wasn't. Oh, the difference one heartbeat could make. The stink of mortality hung in the air, painting the awful truth about humans. How short their lives were. And fragile. They were like paper dolls among us, turning to ash in the blink of an eye. How many had I seen come and go in over a millennium? How many had I seen pass from infancy to a gray-haired death? The stink of mortality. It threatened to overwhelm the room. How could no one else sense it? I hated it†¦and I feared it. Feeling suffocated, I backed up further. Both Bastien and Etienne reached for me in some fumbling attempt at comfort, but I wanted none of it. Dominique, barely out of childhood, had just bled her life away in front of me. What fragile things humans were. I had to get out of there before I became sick. I turned from those who would console me and ran away. â€Å"What fragile things humans are,† I murmured to Doug. The feeling that welled up within me now as I sat beside him was not sorrow or despair. It was anger. White-hot anger. Humans were fragile, but some of them were still in my care. And whether that was foolish or not on my part, I could not shirk my duty. Doug was one of my humans. And someone had nearly cut his time short. I stood up, gave his hand a last squeeze, and strode out of the room. From the shocked glances Corey, Min, and Wyatt gave me, I must have looked terrifying. I hit the pause button on my righteous fury when I noticed something. â€Å"Where's Seth?† â€Å"He said he had to go,† said Corey. â€Å"He left you this.† He handed me a scrap of paper with Seth's scrawled writing. Thetis, I'll talk to you later. I stared at it, suddenly feeling nothing. I went numb. My mind would not allow me to focus on Seth just then. I crumpled the paper up, said good-bye to the band, and left the hospital. When I reached the lobby, I took out my cell phone and dialed. â€Å"Alec? This is Georgina.† â€Å"Hey, Georgina!† I heard the anxious note in his voice. Almost desperate. â€Å"You were right,† I began, hoping I sounded anxious too. â€Å"You were right. I need more. Now. Tonight. Can you do it?† â€Å"Yes,† he said. There was palpable relief in his voice. â€Å"Absolutely I can do it.† We set up a meeting spot immediately. It couldn't be too soon for me. I'd been on an emotional roller coaster in the last twenty-four hours, and I was about to take it out on Alec. I couldn't wait. The fact that he seemed so eager for it was icing on the cake. â€Å"Oh, hey, Georgina?† he asked, just before we disconnected. â€Å"Yeah?† His voice sounded strange; I couldn't decipher the emotion. â€Å"You have no idea how glad I am you called.†