European Settlements and the Decline of Indian Power in America Essay

European Settlements and the Decline of Indian Power in America What today is the province of Virginia used to be Native American grounds. The Indians guarantee that God had given them the option to possess and settle those terrains. The issue as we have found in class is the Europeans, for example, the Spanish and English came and assumed control over the Native American land for the sake of the King and/or Queen. They attacked their region, and obliterated their way of life, all for the sake of success. What I mean to show is the means by which these issues created for the English from the long periods of 1607 to 1644. Kirkpatrick Sale in his book Conquest of Paradise says that the English were simply completing the Columbian inheritance with a similar severity toward the Native American populace. The principle objective of the English just as the Spanish was to settle huge pieces of land and have military authority over a regressive (through their eyes) society. By 1610 the foe for the English was the locals, or as they called them savages, and their central goal was to take them prisioner and make them slaves. It even says in the sanction allowed to the pioneers in 1607. Which may by the Providence of Almighty God, from this point forward keep an eye on the greatness of his awesome grandness, in propagfting of the Christian religon to such individuals so far live in obscurity and hopeless numbness of all obvious information and love of God and may in time bring the unbelievers and savages living in those parts to human class and to settled and calm government (Warner 38). In addition if the local s became unfriendly they felt that it w as their entitlement to take their corn while consequently giving them pointless things of no pratical esteem, for example, globules, compasses, and mirrors. The English felt that in time the Indians would com... ...t I need or I will butcher your populace and take you prisioner. Furthermore the Indians were on English land when it truly was their acquired land from their progenitors. It resembled what Columbus did on Hispanola; he took over local terrains and did what he needed with the Indian clans, steling their property placing them in subjection and having them perceive the Spanish as unrivaled individuals. It was a fight between the Indians and the colonizers and as should be obvious the colonlists won. It truly was a conflict of societies with the last winning. Book index Campell, Charles. History Of The Colony And Acient Domion of Virginia. Philadelphia, J. B. Lippincott and Co. 1860. Deal, Kirkpatrick. The Conquest of Paradise Christopher Columbus and the Columbian Legacy. New York 1991 Warner, Charles D. Chief John Smith 1579 - 1631 New York, Harvey Holt and Company. 1881

Heraclites V. Parmenides Essay Example for Free

Heraclites V. Parmenides Essay Theory fills one need, carrying request to reason. This, on such a significant number of levels can sort out ones perspective into an organized way; along these lines rendering it a lot simpler for one to finish up strong ends, in this manner staying away from mistake. There have been numerous autonomous surges of reasoning from a few unique pieces of the world, for example, China, and India. In any case, the most famous way of thinking that has made the most effect on the United States, in actuality would need to be the antiquated Greeks (who by the way begun way of thinking in a manner of free religion). Avoiding straight ahead to two of ways of thinking extraordinary logicians: Heraclitus (540-480 B. C), and one of the most miss-got, Parmenides (515-440 B. C. ). These two rationalists took theory to another level; from attempting to comprehend our evolving world, to attempting to comprehend change itself. In the event that the quest for a central substance was to ever advance, it would need to confront the inescapable issue of progress. As such, what continues as before when everything else changes of a specific thing? Change gives off an impression of being a principal character in nature/life. Our encounters reveal to us that things are unquestionably (moving) and changing (getting unique) each snapshot of consistently. Be that as it may, in any case, the inquiry despite everything shows up, what continues as before all through this procedure? The two key arrangements (as I would like to think one) originates from these two very much idea rationalists. Like I stated, just one has a strong end wherein I concur. Parmenides talked profoundly when he stated, being is; and non-being, isn't. Parmenides base way of thinking was that change was just a fantasy. It was entirely obvious to him that the world seemed, by all accounts, to be in a steady condition of motion; all the more so however he accepted that our faculties hoodwinked us. The principal substance is being. What's more, so as to accommodate the never-ending change he saw with his detects; he contemplated that nothing originates from nothing, and that every single existing originate from something prior. Parmenides underestimated that the world had consistently existed, in this manner, being must have consistently existed, and at last will consistently exist. Being is an interminable state he said. Presently comes Heraclitus with the way of thinking that everything changes, and nothing remains the equivalent. Oppositely contradicted to that of which Parmenides represents. Heraclitus immovably had faith in his suspicion that everything changed. He thought turning out to be was the root to all things. Furthermore, one of his popular expressions was, one never ventures into a similar waterway twice. What he implied by this was, the point at which an individual intrudes on the ebb and flow of the waterway in any capacity structure or design, he/she has changed the stream from what it was to what it is. Indeed, even without intruding on the waterway and obviously watching the stream on can observer the change. Also, this can be applied to consistently life on all levels. He expresses that if the results of an unendingly changing establishment into reality are significant, and the principal components are conflicting and insecure, in what manner can there be any laws to administer them? This inclination for steady change drove Heraclitus to his hypothesis of fire being the essential component of all things, because of its reliable change in nature and its elements. When deciphering Heraclitus I consider him to be stating, since we know from our own encounters that change occurs, this is no deception by a wide margin, since one can genuinely encounter the change. Heraclitus additionally focuses to his hypothesis of fire, because of the way that in such a significant number of words theres such a plenitude gracefully of it in nature its the essential component for all things. I can't help contradicting him. His perspectives are perfect by a wide margin and one can even now contend his focuses today. Parmenides then again gets a handle on my consideration and holds such a great amount of more grounded with strong ends, to such an extent that one can just think. Parmenides says, One can just consider what as of now exists, and can appear from the previous. He contends that nobody, and I quote, nobody can talk on or even consider what doesn't exist or even appear from nothing. This is on the grounds that nothing is basically that, nothing, and in what manner can one really make something from nothing. Hence is the reason I side with Parmenides on this theme.

France was ruled by Napoleon Bonaparte 1799-1815 Free Essays

During the French Revolution the long stretches of 1799-1815, France was controlled by Napoleon Bonaparte. Albeit numerous individuals feel that Napoleon is one of tyranny, actually he one for the nation and did what he felt was to the greatest advantage of France. Napoleon was a popularity based pioneer for his nation. We will compose a custom article test on France was administered by Napoleon Bonaparte 1799-1815 or on the other hand any comparable subject just for you Request Now By examining his job in instruction, the political perspectives, and the social parts of France, one can see he did useful for the nation despite the fact that not all things be great, there is no ideal individual or Utopia. Napoleon set out to make France the best country of Europe, and training was one of the top needs on his rundown. Since Napoleon put stock in an arrangement of legitimacy not one of family progression, he felt everybody should have been taught. The legislature was getting various grievances with respect to the absence of schools in numerous regions, absence of polished methodology among the instructors, absence of control and participation by understudies and, in a couple of zones, absence of strict training (Markham 5). The issue with strict training was mostly settled by the Concordat among Napoleon and the Pope. Strict grade schools had opened yet for the most part for young ladies. Napoleon felt that young ladies and young men didn’t need similar training. Young ladies required local aptitudes, which will be useful once hitched. Despite the fact that he felt they expected to learn, numbers, composing, and the standards of their dialects, just as history, topography, material science and organic science. Another piece of instruction that was huge to Napoleon was the possibility of optional training. He felt that boy’s instruction ought to be isolated into 2 sections; under over the age of 12 age 12. The initial 4 classes would incorporate general subjects, when gotten done with that they would need to pick between a common vocation or a profession in the military and the remainder of their training would rely upon that (Markham 5). Right up 'til the present time the Napoleonic instructive framework is still mainstream in France. There has been some alteration in the framework, for example, the partition of chapel and state was made finished. Presently religion was not part of the open school’s educational program. The secondary schools know, as lycees are still there today and even plays a greater amount of a significant job. Graduation from a lycee is sufficient for most occupations. Napoleon likewise did useful for the political arrangement of France. He made another constitution. It comprised of three diplomats. The primary delegate expected by Napoleon, however was casted a ballot in. Napoleon endeavored to assemble France back after the unrest. He permitted a wide range of political displaced people once again into France, and furthermore named both radical republicans and royalist nobles to his legislature. (Hooker 2). While the most unbeatable act was to permit the Catholic church once again into to France, The concordat with Pope Pius VII. While in rule he likewise made The Napoleonic Code. It was a finished patch up of the French law. It depended on 2 thoughts: that all men are equivalent under the law (yet not ladies) and all individuals reserve a privilege to property. The code got rid of all benefits from the law including charge laws. The code illuminated different authoritative laws to guarantee the sacredness of private property. (Hooker 3) Many individuals imagine that what Napoleon was doing wasn't right, yet they casted a ballot him Napoleon I, Emperor of France in 1804. Napoleon likewise in everything he did annulled feudalism, which was a piece of the Code. As was expressed before Napoleon brought the Catholic Church once again into France; Bonaparte and Pope Pius VII concurred that it was fundamental for the tranquility of the nation. Napoleon additionally made the Legion of Honor in 1802. It was Nobility yet it depended on capacity. From the start relatively few individuals supported it, yet by Napoleon’s defeat everybody even the Republicans supported it. (Holtman 3) Napoleon additionally represented the improvement and better treatment of the Jews. He gave them the option to venerate in private and sometimes permitted them to turn out to be undeniable residents. Napoleon likewise made an arrangement of estimation for the entire nation currently utilized in numerous spots the decimal standard for measuring. He additionally made the bank of France. It supported the unification of the nation and made it simple for everybody. Before Napoleon came around relationships were just permitted through the congregation, he permitted relationships outside the congregation. The congregation never perceived separations however Napoleon did. Which made life significantly simpler for individuals in France. Napoleon may have needed to have command over numerous terrains, yet in particular he had improved the status of France from what it was after the Revolution to what it is currently. He has helped shape present day France. His thoughts with instruction, the legislature, and the social transformation he made were a colossal part ever. He was a law based pioneer in a wide range of perspectives. Step by step instructions to refer to France was governed by Napoleon Bonaparte 1799-1815, Papers

Quest For Vengeance And Distorted Personalities Essay

Journey For Vengeance And Distorted Personalities - Essay Example This article looks at the unfriendly impacts retribution has had on the focal figure of Paulina in Death And The Maiden, and Claire Zachanassian in The Visit. Demise And The Maiden, consolidating easily components of anticipation, puzzle and ethical quality, interweaves them with profoundly fascinating bits of knowledge into the mental openings of a casualty, compelled to live with the open injuries of her oppression. The play, occurring in an anonymous nation, is set in the occasions when the nation has quite recently gotten away from a fierce fundamentalist system. Paulina lives with her better half Gerardo, who was previously a dissident neutralizing the autocracy and is currently an individual from an advisory group alloted to research human-rights infringement. A couple of years back, Paulina was hijacked and ruthlessly assaulted and tormented while blindfolded, by a perverted specialist who played Franz Schubert's group of four Passing And The Maiden. She accepts that the more peculiar that her significant other has now brought into their house is the specialist answerable for her horrible experience. She detains the specialist, sepa rates a constrained admission from him but then, rather than murdering him, releases him at long last. The play gives the peruser abundant opportunities to peer inside the tormented soul of Paulina and comprehend the degree to which her character has been mutilated by her past encounters. Paulina demands furiously that the detainee be put being investigated and resolutely will not hear the moderate voice of her better half, indicating that she has lost all soundness and reason and is blinded by a horrible anger. By portraying this, Dorfman has demonstrated how hunger for vengeance stays lethargic, covering up underneath the layers of a victim's, for this situation Paulina's, character making a dream of regularity, hushing the casualty's friends and family into a misguided feeling of smugness. In any case, when Paulina is demonstrated to remember a horrendous encounter from quite a while ago, her disdain reemerges again with such savagery that it stuns. When Paulina ties the specialist to a seat, she chokes him utilizing her underwear. This activity of hers is exceptionally quick as it shows that the specialist's all out corruption is her principle point and that's it, and just the most embarrassing treatment dispensed to her detainee will fulfill her. She does this in light of the fact that unwittingly she wants the specialist to experience the equivalent mental and enthusiastic torment that she experienced. Seeing him defenseless, truly bound and choked, squirming miserably and even incapable to take care of himself, gives her a profound, unreasonable fulfillment. Staying discreet exercises against the extremist system of her nation and her fortitude during her imprisonment in see, we can securely to accept that Paulina is a not too bad individual with a high good sense and confidence in grand standards, for example, opportunity and equity, however with regards to Dr. Roberto Miranda, she callously tosses each one of those standar ds to the breeze and turns into a tigress, hungry for blood. Dorfman successfully features the internal unrest of Paulina's spirit by comparing her tormented mind with physical confirmation of the amount she endures. The peruser can really feel her nerves tight with pressure because of her cut exchanges and her similarly touchy revilement. The accompanying tirade of hers, fills in as an away from of her enduring under a spell of scorn, as she says, And why

Alcohol, Violence and Crime in America :: essays research papers

Liquor is a predominant instrument that controls the human’s body when it assumes control over its significant frameworks. Furthermore, liquor hugy affects people’s practices so their practices leave their control and could prompt things rather increasingly genuine. As an outcome of the effect of liquor, crime percentage increments drastically affected by liquor. On reason that underpins this end is that individuals who are dependent on liquor yet can’t manage the cost of purchasing would act forcefully to gain admittance to liquor by unmannered practices that a few times could prompt genuine violations. When all is said in done, religions establish the lifestyle people should live regardless of what sort of religion is that, and since the utilization of liquor is either totally precluded or not suggested, liquor ought to be disposed of from any general public to agree to god’s law’s similarly as individuals regard their government’s laws. In any case, the end of liquor from a general public immediately is practically inconceivable and could bring about serious episodes that could go outside the ability to control of the specialists. The most ideal approach to get individuals far from liquor is to make it hard enough for individuals to get liquor; cause them to endure to get the liquor they need. A portion of the manners in which an administration could restrain the utilization of liquor is to build its cost significantly by including extra assessments and charges the individuals who sell liquor with the goal that its cost will increment and wont be reasonable for the greater part of the individuals. The salary of this augmentation ought to be spent on national mindfulness through media which would spread out the word about liquor to individuals and caution them about the utilization of this shrewd item. Another limitation would be expanding the lawful period of liquor purchasers from 21 to a higher age at which individuals would be dependable and mull over the utilization of liquor; a sensible age would associate with 25 I accept. Expanding the necessities of giving liquor licenses would constrain the quantity o f stores that sell liquor with the goal that individuals will require more of time to get liquor from a far spot. Furthermore, restricting the amount of liquor offered to one individual would make him burn through bunches of time each time he needs to purchase liquor. Restriction isn't generally the key of dispensing with something from a general public, yet training is fairly a superior thought.

Jean Piagets Greatest Words of Wisdom

Jean Piaget's Greatest Words of Wisdom Theories Developmental Psychology Print Jean Piaget Quotes By Kendra Cherry facebook twitter Kendra Cherry, MS, is an author, educational consultant, and speaker focused on helping students learn about psychology. Learn about our editorial policy Kendra Cherry Updated on May 06, 2019 Keystone/Hulton Archive/Getty Images More in Theories Developmental Psychology Behavioral Psychology Cognitive Psychology Personality Psychology Social Psychology Biological Psychology Psychosocial Psychology Jean Piaget was a Swiss developmental psychologist and genetic epistemologist. Through his studies of his own three children, Piaget developed a theory of cognitive development that described a series of stages of intellectual development that children go through as they mature. Prior to Piaget, people tended to think of children as simply small versions of adults. His work introduced the idea that childrens thinking was fundamentally different than that of adults. On Genetic Epistemology What the genetic epistemology proposes is discovering the roots of the different varieties of knowledge, since its elementary forms, following to the next levels, including also the scientific knowledge. The fundamental hypothesis of genetic epistemology is that there is a parallelism between the progress made in the logical and rational organization of knowledge and the corresponding formative psychological processes. With that hypothesis, the most fruitful, most obvious field of study would be the reconstituting of human historyâ€"the history of human thinking in prehistoric man. Unfortunately, we are not very well informed in the psychology of primitive man, but there are children all around us, and it is in studying children that we have the best chance of studying the development of logical knowledge, physical knowledge, and so forth. On Education The principal goal of education is to create men who are capable of doing new things, not simply of repeating what other generations have doneâ€"men who are creative, inventive, and discoverers. The second goal of education is to form minds which can be critical, can verify, and not accept everything they are offered. Children have real understanding only of that which they invent themselves, and each time that we try to teach them something too quickly, we keep them from reinventing it themselves. On Cognitive Development Chance... in the accommodation peculiar to sensorimotor intelligence, plays the same role as in scientific discovery. It is only useful to the genius and its revelations remain meaningless to the unskilled. Every acquisition of accommodation becomes material for assimilation, but assimilation always resists new accommodations. Knowing reality means constructing systems of transformations that correspond, more or less adequately, to reality. They are more or less isomorphic to transformations of reality. The transformational structures of which knowledge consists are not copies of the transformations in reality; they are simply possible isomorphic models among which experience can enable us to choose. Knowledge, then, is a system of transformations that become progressively adequate. If a baby really has no awareness of himself and is totally thing-directed and at the same time all his states of mind are projected onto things, our second paradox makes sense: on the one hand, thought in babies can be viewed as pure accommodation or exploratory movements, but on the other this very same thought is only one, long, completely autistic waking dream. Mixture of assimilation to earlier schemas and adaptation to the actual conditions of the situation is what defines motor intelligence. But â€" and this is where rules come into existence â€" as soon as a balance is established between adaptation and assimilation, the course of conduct adopted becomes crystallized and ritualized. New schemas are even established which the child looks for and retains with care, as though they were obligatory or charged with efficacy. The relations between parents and children are certainly not only those of constraint. There is spontaneous mutual affection, which from the first prompts the child to acts of generosity and even of self-sacrifice, to very touching demonstrations which are in no way prescribed. And here no doubt is the starting point for that morality of good which we shall see developing alongside of the morality of right or duty, and which in some persons completely replaces it. On Intelligence Furthermore, intelligence itself does not consist of an isolated and sharply differentiated class of cognitive processes. It is not, properly speaking, one form of structuring among others; it is the form of equilibrium towards which all the structures arise out of perception, habit and elementary sensori-motor mechanisms tend.

children are just small adults - Free Essay Example

Introduction The clichÃÆ'Â © 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 Me dicine (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 (I V) 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 straightf orward 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 intensity 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 und erstanding 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 cl early needs to be established beyond all reasonable doubt. In view of that only research into paediatrics will be included increasing the credibility of its application 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 releva nt 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 the 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 a ccording 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 th at 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 which 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 c onclusion 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 eith er given INM 0.2mg/kg or rectal diazepam 0.3mg/kg. The authors report proven efficacy (p 0.05) for INM stating time to cessation was faster INM 2-5 minute Vs rectal diazepam 5-7 minutes. Additionally, only 3 patients in the INM group compared with 10 in the rectal diazepam group needed a second dose. Statistical analysis applied to parametric and nonparametric values, respectively was SPSS Inc, The Mann-Whitney U-test, Wilcoxon rank sum test and Pearson chi-square test. Interestingly group stratification was almost identical, further supporting the study outcomes claimed. However it is worth noting that the sample size is small considering this is an equivalence study and without detail on the process of powering the study the possibility of a false positive result should not be ignored. As power for a study increases the chances of a false negative result decreases, therefore, appropriate powering is a vital component of clinical trials and should be preformed early in any study d evelopment 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 o f 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 attending 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 Ra nson (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 c ase 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 ÂÂ 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 significan t, 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 were 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 1.5ÂÂ µg/kg and ranging fr om 0.5-3.4 ÂÂ 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 2ÂÂ µg/kg INF (50ÂÂ 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 50ÂÂ 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 t he 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 example 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 postopera tive 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 detect reliable differences (Bowling Ebrahim 2005). Additionally the short fall in patients recruited is not explained suggesting this is a significant failing of this study lowering the level of strength applied to it to L3a Nevertheless the study by Manjushree et al (2002) demonstrates that, although the results were comparable between groups in terms of both analgesia obtainable and incidence of side effects, the IV group required slightly less of the drug to produce the same clinical effect and also obtained comparable analgesia about 5 minutes earlier than the intranasal group. The INF group required (1.43ÂÂ ±0.39ÂÂ µg/kg) fentanyl compared to (0.8ÂÂ ± 0.3ÂÂ µg/kg) intravenously. One particularly interesting feature of the study was the dosing regime used. Children either received INF+IV placebo or IV fentanyl + IN placebo. Dosing commenced at 0.5 ÂÂ µg /kg and was titrated to comfort for both routes. The total dose of fentanyl needed to establish comfort was 21.43 ÂÂ ± 10 ÂÂ µg intranasal compared to 14.6 ÂÂ ± 6.35 ÂÂ µg intravenously (p 0.01) and onset time was slower for the IN route 13 minutes compared to 8 minutes in the intravenous group therefore supporting the theory that intravenous medication needs to be prescribed in larger doses when administered intranasally to achieve equal efficacy to the more invasive IV route (Williams Rowbottom 1998). Additionally this may suggest that if a large dose had been used for the IN route to begin with, and then time to attaining comfort may have been equal between the groups. Conclusion here does not appear to be any significant work directly comparing the efficacy of IN fentanyl with IN diamorphine as an appropriate agent for producing similar analgesia effect in children. There is a substantial body of literature which attests to the fact that the IN route of administration is both effective and appropriate for both of these agents Wilson et al (1997), Kazin et al (1998), Finkel et al (2001), Kendall et al (2001), Larkin et al (2001), Borland et al (2002), Manjushree et al (2002), Borland et al (2005), Brennan et al (2005), Borland et al (2006). However; the difficulties arise when trying to make an informed assessment of the reliability of the evidence base, considering the guidelines that dictate clinical practice. As already highlighted, there are a number of methodological shortcomings in the studies of INF in children discussed, which has meant the evidence from these trials could not be extrapolated to the wider paediatric population. In contrast, two stud ies of sound methodology provide some evidence of a dosing regime that may be therapeutic and reduce clinical risk but these alone do not provide enough evidence on which to change clinical practice. The challenge still remains to find a replacement for IN diamorphine in the AED for acute pain in children. In these days of evidence based medicine it clearly needs to be established beyond all reasonable doubt that IN fentanyl is such an alternative, unfortunately there is a large gap in the currently available literature. To address this problem further research in the form of a multi centre RCT comparative study between IN diamorphine and fentanyl is suggested (see chapter 5) from which a rational decision could be made