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Recently a contaminated cement squeeze was performed in the Gulf of Mexico using coiled tubing. The work was performed at 18,600 ft, 326°F bottom hole temperature, 12,000 psi pumping pressure and 9,000 psi chokeback pressure in a H2S, CO2 environment. Operationally this squeeze was a tremendous success and set several new benchmarks with regards to high-pressure coiled tubing operations. This paper describes the reasons for using a contaminated cement squeeze under these harsh conditions, the standard procedure for this work, and the deviations from standard procedure made specifically for this well. The paper also discusses the importance of hydraulic modeling, fluid selection, the benefits of doing yard tests, and analyzing previous jobs to verify the models.

Altairis MCS embodies an entirely new approach to the operation of complex systems through a unique automation technology based on Finite State Modeling (FSM). Conventional mission control systems provide extremely limited automation capabilities through limit checking and command scripts written in languages such as TSTOL or its variants, or can analyze at best a handful of telemetry parameters by means of a rule-based expert system application. Such applications have proven only marginally practical due to the great deal of time and expense required developing, testing and maintaining them. FSM, in contrast, captures human expertise in models as an adjunct to the normal systems engineering process all space missions must undergo. These models provide automated analysis of the entire telemetry stream during real time operations.

The efficacy of a new pharmacokinetically enhanced formulation of amoxycillin/clavulanate (AMX/CA) 2000/125 mg, twice daily, designed to provide adequate levels of amoxycillin over the 12-h dosing interval to eradicate penicillin-resistant Streptococcus pneumoniae (PRSP) with amoxycillin (+/-clavulanic acid) MICs of/=4 mg/l, was evaluated in patients with respiratory infections caused by S. pneumoniae, including PRSP (penicillin MICs 2-16 mg/l). Data from nine clinical studies were combined (total intent-to-treat N=5531). Six randomized, double-blind studies used levofloxacin 500 mg od in acute bacterial sinusitis (ABS), levofloxacin 500 mg od in acute exacerbations of chronic bronchitis (AECB), clarithromycin 500 mg bid in AECB, AMX/CA 875/125 mg bid and tid in community-acquired pneumonia (CAP) and AMX/CA 1000/125 mg tid in CAP as comparators. The three remaining studies (two in ABS and one in CAP) were non-comparative. In the AMX/CA 2000/125 mg bid-treated patients evaluable at follow-up (Day 14-39), outcome was successful in 60/64 (93.7%) patients with S. pneumoniae infections in the comparative studies and 348/363 (95.9%) in the non-comparative studies, including 95.6% of all patients and 95.2% of patients whose isolates had AMX/CA MICs of/=4 mg/l. In the pooled comparator group, the success rate at follow-up was 86.5% (45/52). For PRSP (AMX/CA MICs of 0.5-8 mg/l), the overall success rate was 98.2% (55/56) at follow-up for AMX/CA 2000/125 mg and 50.0% (2/4) for comparators. AMX/CA 2000/125 mg shows efficacy comparable to that of the comparators evaluated against S. pneumoniae infections. Due to its favorable pharmacokinetic/pharmacodynamic profile and promising clinical success, the new AMX/CA 2000/125 mg formulation should be considered for the empirical treatment of respiratory tract infections in regions with a high prevalence of antimicrobial-resistant S. pneumoniae and in patients at high risk of antimicrobial-resistant S. pneumoniae infection as this formulation covers many PRSP that are non-susceptible to amoxycillin (+/-clavulanic acid) (MICs of/=4 mg/l) as well as common beta-lactamase-producing respiratory pathogens.

We sought to evaluate gatifloxacin in adults with acute uncomplicated bacterial rhinosinusitis.TeqCES was an open-label, multicenter, noncomparative study of the safety and efficacy of gatifloxacin. More than 11,000 adult patients with acute uncomplicated rhinosinusitis received gatifloxacin 400 mg once daily for 10 days.Moraxella catarrhalis (91% beta-lactamase producers), Haemophilus influenzae (28% beta-lactamase producers), Streptococcus pneumoniae (18% intermediately resistant and 14% fully resistant to penicillin), and Staphylococcus aureus were the predominant pathogens isolated from purulent nasal discharge. More than 99% of rhinosinusitis pathogens isolated from the nasopharynx of patients meeting the clinical criteria for rhinosinusitis were susceptible to gatifloxacin. Among 10,353 patients whose clinical response could be determined, 91.6% were cured. Clinical cure rates exceeded 90% for the major pathogens. Gatifloxacin was well tolerated; drug-related adverse events that occurred in 1% or more of patients were nausea (4.4%), dizziness (1.8%), diarrhea (1.4%), and headache (1.0%).Gatifloxacin is effective for patients with acute bacterial rhinosinusitis in the community.

Aim: Matrix metalloproteinases (MMPs), together with their tissue inhibitors (TIMPs), are responsible for the controlled degradation of collagen and other matrix substrates in bone and other tissues. This study evaluated the expression of MMPs and TIMPs in bony remodelling in a bilateral sheep mandible model up to 12 months following lengthening by distraction osteogenesis. Methodology: Sheep mandibles were harvested 3, 6, 9 or 12 months following lengthening by bilateral mandibular distraction (1 mm/day for 20 days). Undistracted sheep mandibles were used as controls. The tissues underwent routine histology and immunohistochemical staining with monoclonal antibodies specific to MMPs 1–3 and TIMP-1, 2. Matrix and cell staining was assessed using a semi-quantitative analysis. Results: Matrix metalloproteinases and their tissue inhibitors (TIMPs) expression levels were marked at 3 months and decreased thereafter becoming similar to undistracted controls by 12 months. The histologic development of mature lamellar cortical bone was similar to undistracted controls by 9 months following distraction. Conclusions: A temporal expression of MMPs and TIMPs was found in distraction osteogenesis. MMPs and TIMPS may, in part, reflect the state of bony remodelling following mandibular lengthening by distraction osteogenesis. Matrix metalloproteinases and TIMP expression were comparable to undistracted controls by 12 months, suggesting that equilibrium had been achieved and that bony relapse is unlikely. Copyright 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved.

Acute rhinosinusitis represents a condition for which educational efforts could help minimize the inappropriate use of antibiotics, particularly for children. The majority of acute rhinosinusitis cases are of viral etiology and thus, are self limiting. Although bacterial infection complicates a small number of cases, the lack of accessibility to the sinus, the limitations of diagnostic modalities and the lack of specificity among signs and symptoms often make it difficult to determine when bacterial infection occurs. Furthermore, antimicrobial resistance among the pathogens that frequently cause bacterial infection complicates the election of empiric therapy. The Sinus and Allergy Health Partnership recently developed and published antimicrobial guidelines to provide practitioners in the US with recommendations for the diagnosis and treatment of acute bacterial rhinosinusitis. The purpose of this paper is to review the rationale behind the development of these guidelines and how they apply to the management of acute bacterial rhinosinusitis in children.

Mono- and di-methyl complexes of the type (η-C 5 H 5 )Nb-(NR)(Me)(Cl) (R  t Bu, 2,6- i Pr 2 C 6 H 3 ) and (η-C 5 Me 5 )M(N-2,6- i Pr 2 C 6 H 3 )(Me) 2 (M  Nb, Ta) have been prepared by treatment of (η-C 5 R′ 5 )M(NR)(Cl 2 ) with one or two equivalents of methylmagnesium chloride respectively. Trimethylphosphine adducts are readily formed from the mono-methyl but not from the dimethyl compounds. The molecular structure of (η-C 5 H 5 )Nb(N t Bu)(Me)(Cl) is reported.

Aim: Distraction osteogenesis is a technique used to lengthen the shortened mandible. However, the long term stability of the distracted mandibular bone is not known. The aim of this study was to assess if the sheep mandible relapses following lengthening, and to assess the quality of distracted bone up to 1 year post lengthening. Methods: Twenty-four sheep had bilateral external mandibular distractors applied, with three sheep as controls. Titanium marker screws were positioned both proximal and distal to the distraction zone in all sheep. Following a 5 day latency period, the interdental gap was distracted 1 mm/day for 20 days, with a subsequent 20 day consolidation period. Ante-mortem serial X-rays were used to assess for relapse by measuring the distance between the screws. The animals were sacrificed at either 3, 6, 9 or 12 months post-distraction. At post mortem, the distance between the screws was re-measured. The distracted bone was assessed mechanically and histologically. Results: The mean mandibular lengthening obtained was 13.2 mm. There was no relapse of the mandible over 12 months. The distracted bone had attained the strength and stiffness of undistracted bone by 6 months post-distraction (p

The emergence of drug-resistant pathogens, especially Streptococcus pneumoniae and Haemophilus influenzae, has complicated empiric treatment of both upper and lower respiratory tract infections. Clinicians are now forced to reevaluate their choices of first-line antibiotics. Although some bacterial respiratory infections may resolve spontaneously, the use of antibiotics has demonstrated a faster resolution of symptoms and prevention of sequelae and recurrences, thereby improving the patient's quality of life and ability to function. Therefore, it is recommended that all diagnosed bacterial respiratory infections be treated with an antibiotic. Factors that clinicians need to consider in prescribing an antibiotic are the predominant causative pathogens, rates of pathogen resistance, patient history, the bacteriologic and clinical efficacy, safety profile, dosing regimen, and cost effectiveness of available antibiotic choices.

A decreased ability to arouse from sleep in response to arterial hypoxemia may lead to severe asphyxia and has been proposed as a mechanism of sudden infant death syndrome. Based on previous observations that nicotine exposure, a major environmental risk factor for sudden infant death syndrome, may impair hypoxic defense in neonates, we hypothesized that a short-term infusion of nicotine could impair hypoxic arousal through interference with oxygen-sensing mechanisms. Seven chronically instrumented unanesthetized lambs were studied at the age of 4.6 +/- 1.3 d during normoxia and acute hypoxia (0.1 fraction of inspired oxygen) for 5 min. Ventilation, transcutaneous Hb oxygen saturation, blood pressure, heart rate, and time to arousal were compared during a control saline infusion and during a 0.5 microg x kg(-1) x min(-1) nicotine infusion. Activity states, i.e. wakefulness and quiet sleep as well as arousal, were defined by EEG, nuchal electromyogram, and electrooculogram. Each lamb acted as its own control. Arousal from quiet sleep occurred significantly later during nicotine infusion compared with control (177 +/- 93 versus 57 +/- 41 s, p0.01) and at a lower transcutaneous Hb oxygen saturation (60 +/- 12 versus 79 +/- 12%, p0.01) (paired t test). The ventilatory response to hypoxia in wakefulness was similar during both conditions but was significantly attenuated in quiet sleep during nicotine infusion (p0.001, 2-way ANOVA repeated-measures design). Blood pressure and heart rate responses were similar during both conditions. These results suggest that a brief nicotine exposure blunts oxygen sensitivity in young lambs, a finding of potential relevance for sudden infant death syndrome.

The aim of this study was to evaluate and compare the parameters for mechanical respiration in pediatric patients undergoing controlled ventilation with a laryngeal mask (LM) and an uncuffed orotracheal tube.The study examined 100 ASA 1 patients undergoing general anesthesia with myoresolution and mechanical ventilation using a Servo Ventilator 900 (constant flow, 25% insufflation, 10% teleinspiratory pause, tidal volume 10 ml/kg). All patients were divided into 2 groups matched for age and weight. An uncuffed orotracheal tube was used in one group (Group T) and a laryngeal mask (LM) in the other (Group M). The following parameters were measured: peak and pause pressure in the respiratory passage (Paw), total inspiratory resistance (R tot), compliance (C) and air loss expressed as a fraction of inspired volume (Vi-Ve/Vi). The statistical analysis of results was performed using Student's "t"-test and the level of significance was p0.05.Peak pressures were comparable in the two groups and were lower than the pressure needed to open the lower esophageal sphincter. These values could be further reduced by the extension of insufflation time achieved by abolishing the teleinspiratory pause included in the study to measure air resistances and compliance. Air losses were also similar in both groups, being respectively 13 and 11%. This means that environmental pollution using LM was not greater than with the uncuffed tube and confirms that, even with the latter, the protection of the airways cannot be regarded as absolute. Total inspiratory resistances were respectively 16.1 cm H2O/l/sec in group T and 15.1 cm H2O/l/sec in group M. This occurred in spite of the fact that the latter showed an in vitro capacity to oppose lower resistances compared to the corresponding tubes given that it was shorter with a larger diameter. Studies using the mechanical model did not include the laryngeal mask--larynx connection which may cause increased resistance owing to the variable position of the epiglottis, although this cannot be identified clinically.The laryngeal mask allows mechanical ventilation with low pressure in the respiratory passage and reduced air losses compared to the uncuffed tracheal tube. The risk of gastroesophageal insufflation is therefore minimal and artificial ventilation is reliable, if correctly performed. Lower levels of inspiratory resistance might be an advantage in spontaneous breathing owing to the consequent reduction of respiratory effort, but they do not appear to be significantly lower than with the tracheal tube.

Interest in craniofacial osteodistraction has increased in recent years parallel with the growing attention given to the role of growth factors in tissue healing and regeneration. This study was embarked upon to investigate the expression of bFGF, TGF-β and IGF-1 in the distraction zone of the mandible. Fourteen growing sheep were allocated to three experimental groups. Six animals were allocated to Groups A and B ( n = 12) and underwent bilateral mandibular corticotomies with fixation of an external lengthening device. The distraction protocol consisted of a rate of 1.0 mm/day (twice daily) for 20 days followed by a consolidation phase of 20 days after which the sheep were sacrificed. Group C comprised of age matched sham operated animals ( n = 2). Bone histochemistry for growth factors were performed in the harvested mandibles. A strong staining of bFGF was seen in the osteoblasts, osteocytes and osteoid matrix following 20 days of distraction and 20 days of consolidation compared to the control group. TGF-β and IGF-1 demonstrated mild but clear staining in osteocyte and osteoblast cells and TGF-β stained positively in the osteoid seam in the experimental groups. These finding suggest that bFGF, IGF-1 and TGF-β may play different roles in the remodelling phase of distraction osteogenesis.

Chronic cough is a side effect of the angiotensin-converting enzyme (ACE) inhibitor class of antihypertensives. The cough is thought to be a result of inhibition of the enzymes that break down some of the mediators of inflammation, such as the bradykinins and tachykinins. We report 20 patients with chronic cough caused by ACE inhibitors and some of the characteristics of the cough. The cough is typically dry, nonproductive, and worse at night. Interference with sleep is common and was severe in three patients. Women outnumbered men in this series: urinary stress incontinence developed in five, rectal and vaginal prolapse developed in one. Three patients felt they were incapacitated by the cough. Most had been on multiple medications; only oxycodone was reported to be effective in controlling the cough, and four patients thought they were addicted to that. All coughs resolved with withdrawal of the ACE inhibitor. Chronic cough is common among individuals taking ACE inhibitors. It may be severe and associated with complications. The incidence and potential severity is understated in drug information sources, and patients and physicians often fail to recognize cough as a drug side effect.

We hypothesize that excyclorotation of the globe and extraocular muscle cone associated with external orbital rotation around each orbital axis in craniofacial conditions could be at least partially corrected by leaving the anterior periorbita (periosteum lining the orbit) attached to the surgically rotated portion of the orbit. This hypothesis was tested by comparing the degree of rotation of the globe in response to internal rotation of the anterior orbit, leaving the periorbita attached to the rotated portion of the orbit on one (study) side, and stripping the periorbita on the opposite (control) side, in nine fresh cadavers. There was a highly significant difference (P0.0001) between the study and control sides. The possible extrapolations of this finding to the clinical situation are discussed.

The major features of three catalyst systems for ‘acetyls’ processes developed by BP Chemicals are described: 1. the homogeneous, promoted iridium methanol carbonylation system for acetic acid manufacture recently commercialised in the USA and Korea (CATIVA), 2. a non-commercialised ruthenium promoted rhodium system, also for methanol carbonylation, 3. a vapour phase reaction of ethylene with acetic acid over silicotungstic acid supported on silica giving commercially viable activity and catalyst lifetime for the manufacture of ethyl acetate. All three examples illustrate the importance of exploring process conditions to reveal the advantages of new catalyst systems, or transform known catalysts into commercial viability.

Clinical failure of ototopicals is not related to antibiotic resistance per se but is most often attributable to poor drug delivery, [which is]related to failure to adequately remove copious amount of ear canal purulence.

Even though osteodistraction has been well established in the extremities, the parameters used in craniofacial distraction have been essentially borrowed from orthopaedic experience. Latency is widely practised but its relevance has not been fully investigated. The purpose of this study was to establish the role of latency in mandibular distraction osteogenesis. Twenty-two growing Wethers sheep were allocated to four experimental groups. Six animals were allocated to each of Groups A, B and C and underwent bilateral mandibular corticotomies and attachment of an external lengthening device. Latent periods of 0, 4 and 7 days respectively were observed prior to beginning distraction. The distraction protocol consisted of a rate of 0.5 mm twice daily for 20 days, followed by a consolidation phase of 20 days after which the sheep were killed. Histology, bone densitometry and 3-point mechanical testing were performed on the harvested mandibles. Group D formed the control group (n = 4). Histologically, the distracted bone exhibited bone formation primarily via intramembranous ossification with scattered islands of cartilage. The regenerated bone had mechanical properties significantly weaker than the undistracted control group (P0.05), but between the experimental groups no statistically significant differences were demonstrable either in mechanical strength or DEXA density. These data indicate that a change in latency does not alter the properties of the regenerated bone in mandibular distraction osteogenesis and indeed no latent interval may be necessary at all in craniofacial distraction. This has implications for the duration of device fixation in distraction procedures.

Summary The rabbit model has been used to study the effects of different rates of distraction upon mandibular bone. Bilateral distraction was performed at two different rates anterior to the molar teeth. Both experimental groups were significantly inferior to sham operated controls in terms of bone density (DEXA) and mechanical testing. No difference in new bone formation between the two distraction rates was detected by these modalities. However, histological examination revealed non-union to be more common in the rapidly distracted group. This suggests that attempts to shorten the duration of external fixation in clinical mandibular distraction osteogenesis should be by methods other than more rapid distraction.

Objective: To study the effect of day care and tube type, as well as other risk factors related to ventilation tube insertion and reinsertion. Design: A case series of 456 consecutive cases with 162 controls from a well-baby examination group evaluated for age, sex, smoking history and day care attendance. Setting: Private practice in a mid-sized, southeastern university town. Patients and controls: This was a referred sample of patients who were entered consecutively in a private-practice setting. All children were age five or less at entry into the study. Interventions: Children underwent ventilation tube insertion with or without adenoidectomy, using standing indications. Main outcome measures: The primary outcome measures were whether or not a child had the need for a second set of tubes, and also determining the status of the child's ears for at least 1 year after tubes had extruded. Results: Day care and young age were both identified as risk factors associated with initial ventilation tube insertion. Only 11% (seven out of 63) of home care children, as compared with 31% (108 out of 346) day care children, had the insertion of ventilation tubes ( P =0.000). Day care children who had tubes inserted and adenoidectomy (with or without tonsillectomy) had a significantly lower rate of reintubation than children who had tube insertion alone ( P =0.00). Day care and young age are significant risk factors for any child, both with a first set of tubes and for ventilation tube reinsertion. Children in day care had a reintubation rate of 36% as compared to 11% for those in home care. Parents should be aware that day care can represent a two-fold hazard-both in the observed connection between day care and tube insertion and the demonstrated increased probability of reinsertion. Any studies looking at ventilation tube outcomes need to make certain to monitor for day care attendance.

Rational antibiotic therapy for sinusitis is a difficult goal, made difficult by few satisfactory comparative trials with sufficient clinical power, the large numbers of therapeutic options, prescribing pressures from the pharmaceutical industry, and rapid changes in bacterial resistance patterns. Controversies exist about the relative need of antibiotics for uncomplicated disease, duration of therapy, and relative efficacy of various agents. Nonetheless, limited data support the notion of superior efficacy of more potent antimicrobials, and an analysis of in vitro activity versus tissue concentrations of the various antibiotics can predict efficacy of eradication of causative bacteria. Multidrug-resistant pneumococci render any algorithm for empiric antibiotic use problematic and prone to fail.

Accuracy and errors in judges' attempts to differentiate facial expressions that displayed genuine pain, no pain or were dissimulated (i.e., masked and exaggerated) were examined. Judges were informed that misrepresentations in the facial expressions were present and were asked to rate their confidence in classifying these expressions. Detailed, objective coding of the patients' facial reactions (e.g., brow lowering, mouth opening) were related to judges' decisions. Judges' classification decisions were better than chance, but there were many errors. Extreme expressions (i.e., no pain, and exaggerated expressions) were identified more accurately than genuine and masked expressions. Judges level of confidence was consistent with their level of accuracy. Judges consistently used rules of thumb based on specific facial cues when making judgments. Certain cues were effectively discriminative. Systematic training in the use of specific cues or the use of articulated decision rules may be helpful in improving judges' accuracy.

Autoantibodies may cause severe hemolytic anemia, but only rarely are they the cause of a hemolytic transfusion reaction due to the destruction of transfused allogeneic blood. In two patients, autoantibody was detected shortly after blood transfusion. The first case was a D-negative patient who produced an autoanti-Ce and subsequently developed hemoglobinuria and hyperbilirubinemia. The second case was a patient who developed an autoanti-Wrb that caused severe hemolysis that resulted in death.

We describe the case of a 4-day-old girl who presented with an epiglottic cyst that was later identified as a rudimentary pinna attached to the soft palate.