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1602: Witch Hunter Angela (2015)
In the altered realms of Battleworld, Angela and Sera are Witch Hunters, the scourges of King James' England, 1602. In a land beset by magic and monstrosity, they seek a new and seductive evil, not witchbreed, but deal-making Faustians, who bargain with ancient creatures for unnatural power! Moral ambiguity? Fancy allusions? Marguerite making the most of that English degree? Try 1602 Witch Hunte
In the tradition of BOOK OF DEATH, ARMOR HUNTERS, and HARBINGER WARS, Valiant's most ambitious crossover event yet starts here! At the dawn of the 41st century, the future of Earth will be decided in the stars. This May...the rebellion begins in 4001 A.D.! One hundred years from today, Father – the benevolent artificial intelligence that governs the island nation of Japan – will gain sentie
Adventure Time Comics
Oh My Glob! We've unleashed some of the industry's best cartoonists loose in the Land of Ooo to share their most algebraic stories in their own voices! The first issue is so math thanks to Katie Cook (My Little Pony: Friendship is Magic), Tony Millionaire (Sock Monkey), and Art Baltazar (Patrick the Wolf Boy). You're lumping welcome! This ongoing series will feature radical stories from Jeffrey Br
Archie (2015-)
Change is coming to Riverdale in this all-new reimagining of an American icon! Familiar faces return in new and unexpected ways. As the new school year approaches, you'd think Archie Andrews would be looking forward to classes and fun -- but nothing is as it seems in the little town of Riverdale. But is this a one-off or a sign of bigger changes awaiting for America's favorite teens -- and the ent
Bombshells: United (2017-)
The Bombshells are back in an all-new series! It's now 1943, and because of Executive Order 9066, Wonder Woman is called to Arizona to help two young girls named Cassie Sandsmark and Donna Troy!
Civil War II: Choosing Sides (2016)
If you knew something bad was about to happen, would you stop it? How far would you go? The line is drawn. Everyone in the Marvel Universe has to ask themselves: are you with Captain Marvel or Iron Man? Kicking off an all-new series, this first issue features Nick Fury, Damage Control and Night Thrasher!
DC Comics: Bombshells (2015-2017)
It's World War II and Batwoman's battling crime on the home front. But events in her life are about to quickly change, and she may be leaving Gotham behind for a bigger cause.
Disney Manga: Magical Dance
A young girl joins a dancing competition with her fellow students and soon realizes that she has two left feet! She spends a lot of time practicing but is discouraged by her results. Because of the young girl's passion and dedication, Tinker Bell appears to grant her a wish. When Tinker Bell casts a spell on a magical card, the young girl enters the magical world of Disney and learns the joys of d
Orphaned at a young age, Faith Herbert – a psionically gifted "psiot" discovered by the Harbinger Foundation – has always aspired to greatness. But now this once ordinary teenager is taking control of her destiny and becoming the hard-hitting hero she's always known she can be – complete with a mild-mannered secret identity, unsuspecting colleagues, and a day job as a reporter that routinely
Faith (2016)
AN ALL-NEW ONGOING SERIES! Because you demanded it...the high-flying hero that captured the imagination of the world is back with a colossal new comics milestone! In a city under siege by robots, aliens, monsters and even worse... celebrities, there is only one woman the people of Los Angeles can count on: the stratospheric superhero called Faith! Aspiring reporter by day and dedicated crime-fi
The Fall and Rise of Captain Atom (2017)
Captain Atom hasn't been seen or heard from in years-and even if you think you know what happened to him…you're wrong! But you're not alone. To this day, no one on Earth-not even the other superheroes-has an inkling of the missing Captain Atom's true fate. At last, the truth is about to be revealed in a saga that transcends not only the meaning of life and death, but the limits of time
Fearless (2019)
Collects Fearless (2019) #1-4. The fiercest ladies of the Marvel Universe — on and off the page! Straight off her silver-screen debut, Captain Marvel takes the world by storm! And speaking of the weather, Storm of the X-Men faces a problem only a goddess could solve. Add in the Invisible Woman, and you've got an unstoppable trio in a story by Hugo-nominated novelist Seanan McGuire! Alien inva
Femme Magnifique
Just in time for Women's History Month, we've curated a one-shot selection of short stories from the critically acclaimed anthology, FEMME MAGNIFIQUE: 50 Magnificent Women Who Changed the World. Part mini-biopic, part salute to their personal icons, the subjects and creative teams include: MARGARET HAMILTON by Alisa Kwitney & Jamie Coe, SYLVIA EARLE by Maris Wicks, KATE BUSH by Gail Simone & M
Fresh Romance
FRESH ROMANCE is a romance comic anthology from Emet Comics. Each anthology collection depicts a variety of forward-looking romances, some fantastical and some grounded in the reality of real world. However, at the heart of every story are the joys and complications of modern love.
Giant Days
Susan, Esther, and Daisy started at university three weeks ago and became fast friends because their dorm rooms were next to each other. Now, away from home for the first time, all three want to reinvent themselves. But in the face of hand-wringing boys, "personal experimentation," influenza, mystery-mold, nu-chauvinism, and the willful, unwanted intrusion of "academia," they may be lucky just to
Hinterkind (2013-2015)
Decades after "The Blight" all but wiped out the human race, the Hinterkind have returned. From the last, lost corners of the world they come, a myriad menagerie of myth and magic...but these aren't childhood fairytale creatures.
The Life Of Captain Marvel (2018)
Collects The Life Of Captain Marvel #1-5. She's one of the mightiest heroes not just on Earth but in the entire galaxy! Now learn exactly how Carol Danvers became the woman she is — the Avenger she is — in the definitive origin of Captain Marvel! When sudden, crippling anxiety attacks sideline Carol in the middle of a fight, she finds herself reliving memories of a life she thought was fa
Mad Max: Fury Road (2015)
Max. The warrior Max. Haunted by his past and fated to wander the brutal Wasteland in search of his better self. To do so, Max Rockatansky enters Gastown, the only source of guzzoline for thousands of miles. Here he finds the final piece that he needs to rebuild his Interceptor-the powerful Boss 351 engine. But in order to acquire the fabled V8 in a world where car parts are worth more than a man'
Marvel Comics (2019-)
THE GREATEST TALENT EVER ASSEMBLED FOR ONE STORY! THIS IS THE BIG ONE! In celebration of Marvel's 80th Anniversary, we have gathered together the greatest array of talent ever to be assembled between the covers of a single comic book! Names from the past, from the present, and even the future! Every page is filled with all-new work from this cavalcade of comic book luminaries! There is a mystery
Ms. Marvel (2014-2015)
The all-new MS. MARVEL, the ground breaking heroine that has become an international sensation! Kamala Khan is just an ordinary girl from Jersey City--until she is suddenly empowered with extraordinary gifts. But who truly is the all-new Ms. Marvel?
Ninjak (2015- )
For the first time, Ninjak's past and future collide in the pages of an all-new ongoing series from New York Times best-selling writer Matt Kindt (Rai, Mind MGMT) and superstar artists Clay Mann (X-Men: Legacy, Gambit) and Butch Guice (Captain America, Action Comics)! Then: Meet inexperienced MI-6 recruit Colin King on his first mission in the field as he learns the basics of spycraft and coun
Red Sonja Vol. 3
Through the plains of Hyrkania, a message sweeps through the scattered peoples of the nation. Bells ring, horns blow, voices shout – the King is dying! Red Sonja rides to save the King from his doom as the powers of Hyboria crowd around to strike when the kingdom is weakest. But a dread new power rises from within Hyrkania's own borders, bent on defending its homeland – no matter the cost, no
Rise: Comics Against Bullying
Everyone has a place they belong. Some of the stories in these pages are autobiographical, some are fantastical. Some are funny, some are sad. But what they all have in common is triumph. Triumph over bullies, triumph over naysayers, triumph over self-doubt. These kinds of stories are important for people of all ages; they remind us that we are better than we often think. That we can achieve am
The Ruby Equation
On the surface, Ruby is a cynical, bored barista. Behind her facade, however, Ruby is a cynical, bored Love Emissary from another dimension. She can't wait to finish her mission so she can get to a more exciting job. Buthe regulars at the coffee shop she works at are about to teach her a lesson about love that goes well beyond logic and math.
Scarlet Witch (2015-2017)
Witchcraft is broken- and the Scarlet Witch is on a journey across the globe to fix it. From the back alleys of Manhattan, to the serene Greek Isles, to the bustling streets of Hong Kong, Wanda will have to face down her foes and find out who her true friends are. But as Wanda solves magical crimes and pieces witchcraft back together, the most important question remains: Who is the mastermind that
Sensation Comics Featuring Wonder Woman (2014-2015)
Diana Prince: Amazon warrior, ambassador to Man's world, or champion of women in need? All of the above! This anthology series will bring some of comics' greatest talents to Themyscira, and give them leave to explore Diana, her world—and ours!
Shade, The Changing Girl (2016-2017)
"Far away on the planet Meta, Loma's going nowhere fast. She's dropped out of school, dumped her boyfriend, and is bored out of her mind. She longs to feel things. That's where her idol, the lunatic poet Rac Shade, and his infamous madness coat come it. Loma steals the garment and makes a break across galaxies to take up residence in a new body: Earth girl Megan Boyer. Surely everything will be b
Steven Universe: Harmony
As Steven helps Sadie cope with quitting her job at the Big Donut and losing Lars, Steven and the Gems must work together to deactivate an old Diamond Authority artifact called the Harmony Core before it destroys Earth.
Superfreaks (comiXology Originals)
Get ready to binge read an all-new 5-issue superhero mystery debuting in its entirety with art by rising star Margaux Saltel, making her series debut, and written by Elsa Charretier and Pierrick Colinet (IDW's Infinite Loop). All the world's superheroes have disappeared overnight, and it's up to their untrained, largely overlooked teenage sidekicks to find out what happened--while dealing with
Thor (2014-2015)
Who is the new and mysterious woman wielding the Hammer of Mjolnir? Let she who is worthy possess the power of the Mighty Thunderer! Introducing a Thor that the Marvel Universe has ner' encountered before. But is this new Thor Asgardian, or from Midgard?


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Approach Considerations
Perceptual speech evaluation by a qualified speech and language pathologist (SLP) with experience and expertise in cleft pathology is the mainstay of evaluation and ongoing treatment, in that the goal of therapy is the ability to communicate successfully using speech.
In patients with cleft palate, residual articulation abnormalities associated with hypernasality should be corrected after palate closure but before secondary surgery for velopharyngeal dysfunction (VPD). Learned compensatory misarticulations must be addressed and corrected through focused intervention with a trained SLP. Early speech therapy results in increased speech accuracy and can help improve long-term outcomes. Parents can be trained to effectively deliver speech therapy to young children with cleft palate.
Van Demark and Hardin discussed the effectiveness of exclusive articulation therapy in children with cleft palate and noted less improvement and slower improvement than expected. [28] Ruscello reviewed nonsurgical palatal training procedures, such as articulation therapy, sucking and blowing exercises, electrical and tactile stimulation, speech appliances, and biofeedback techniques. [29] These techniques have never been demonstrated to be of any value, and all clinicians should make sure that their patients are not receiving ineffective speech therapy.
The prosthetic speech bulb is most useful in patients with little or no velopharyngeal motion. Velopharyngeal movement is essential to surgical success with a pharyngeal flap procedure or sphincter pharyngoplasty. Patients with little velopharyngeal movement are good candidates for prosthetic management. A velopharyngeal speech prosthesis can elevate the velum (lift), fill the residual velopharyngeal gap (obturator), or both (lift-orator). The nasal valve is another prosthetic option.
The primary indications for surgical intervention include structural defects of the velum and functional problems that result in poor or inconsistent velar closure.
One study that compared speech outcomes from prosthetic management with those from surgical management showed no difference for patients who complied with the prosthesis. [30] However, because nearly 30% of patients referred for prostheses did not comply, surgery was more efficacious overall.
Speech Therapy
Speech therapy improves velopharyngeal function in patients whose VPD is minimal or due to articulation errors and in postoperative patients. Compensatory articulation techniques secondary to VPD also can be corrected with speech therapy. However, in patients with a specific anatomic deficiency that precludes adequate closure of the velopharynx, speech therapy cannot replace surgery. Surgical management may also be necessary in cases where closure is possible but nasal speech persists with connected speech.
Upon completion of speech and language testing, the SLP determines if VPD and hypernasality are related to articulation errors or if the condition is phoneme-specific. If either is the case, the VPD usually is not related to structural abnormalities, and correction with speech therapy most likely is possible.
VPD also can be a result of decreased muscle tone in the oral musculature and soft palate. Decreased muscle tone can be observed on fiberoptic nasoendoscopy (FN) when the soft palate closes inconsistently or when closure appears slow in connected speech. A period of speech and language therapy focusing on improving overall oral motor skills and improving strength and elevation of the velum may be able to correct VPD in such cases. Speaking slowly and deliberately is another strategy to improve speech intelligibility.
Visual Feedback
In some children, especially those with hearing impairments, visual feedback can assist in therapy to improve VPD. Several devices are available to assist with this method. Simple tools (eg, a cold mirror or a paper paddle) can serve to show the patient when nasal escape occurs. Other devices are commercially available, such as the See-Scape, which is placed at the nose and causes a ball to rise when airflow is nasal rather than oral.
A more sophisticated method is the use of a nasometer, which graphically displays a ratio of oral sound energy to nasal sound energy. The visual readout can help the therapist and patient develop compensatory techniques to reduce nasalance. In older children, video-recorded nasopharyngoscopy has been used to achieve the same goals. The latter method has been shown to be effective in patients with VPD and cleft palate.
Nasal Continuous Positive Airway Pressure Therapy
Continuous positive airway pressure (CPAP) therapy is a palate-strengthening program completed 6 days a week for 8 weeks in the patient's home. It is beneficial for patients whose VPD seems to be related to oral motor issues or velar weakness rather than to structural problems of the velum.
The CPAP equipment includes a nasal mask, which is attached to the patient. With the mask in place, the patient repeats a series of consonant-vowel combinations and sentences designed to cause the velum to open and close against air pressure from the nasal mask. CPAP pressures are increased on a regimented schedule, producing exercises similar to a weightlifting program for the soft palate.
The disadvantages of CPAP therapy are the high degree of regimentation and the need for cooperation and participation for up to 24 minutes, 6 days per week, which is difficult to achieve with young children. Wearing the nasal mask and speaking with nasal air pressure also can be frightening for some young children.
Studies of the efficacy of CPAP for hypernasality have demonstrated variable results; however, significant reductions in hypernasality are seen in some patients undergoing therapy. [31, 32] Further research is required to establish its effectiveness.
Prosthetic Management
In a small number of cases, prosthetic management may be the best solution for VPD. [33] Prostheses may be used as a temporary reversible trial; they can provide diagnostic information in cases of variable VPD where it is unclear whether surgery alone will significantly improve speech quality. They may be useful in some patients with a short, scarred velum or in other patients with a long, supple, paretic velum. Some authors have hypothesized that prostheses may stimulate neuromuscular activity, [34] though definitive proof for this hypothesis is lacking. [35]
The main types of prostheses include the following:
Palatal lift
Speech bulb/obturator
Nasal valve
Devices that include features of both lifts and obturators (so-called lift-orators) also exist.
Palatal lifts (see the images below) are used when adequate palatal length exists but dynamic motion of the palate is poor as a consequence of neuromuscular etiologies. Palatal lifts reduce the distance the palate must traverse to produce adequate closure.
An obturator is usually necessary when the velum is short and scarred, and the ratio of velar length to nasopharyngeal depth is excessive, such as seen in some patients with repaired cleft palate. Obturators can substitute for tissue deficiency and are attached to the palate or teeth. In certain cases, the obturator can be downsized gradually so that the native tissue, if adequate in bulk, can strengthen over time and compensate for the decreasing obturator size.
A combined prosthesis (lift-orator) is useful when elevation of the velum alone is not sufficient to achieve closure. Such speech prostheses are fitted under endoscopic control by an interdisciplinary team that includes a prosthodontist, an SLP, and an endoscopist.
The nasal valve is an appliance fitted to each nostril. [36] A one-way valve on either side allows the patient to breathe in through the nose, but stops nasal airflow with exhalation or speech.
Surgical Therapy
As noted previously, the primary indications for surgical intervention include structural defects of the velum and functional problems that result in poor or inconsistent velar closure. Maximum benefit can be achieved when the surgical technique takes advantage of whatever native velopharyngeal function exists in the patient.
Information obtained during the objective evaluation via physical examination, FN, and multiview videofluoroscopy (VF) can greatly aid in determining the best way to make use of remaining velopharyngeal function. Some claim that successful outcomes in fact depend on matching the functional capability of the patient with the surgical procedure. Others have disputed this claim, reporting that there is no difference in outcomes regardless of surgical technique or preoperative sphincter characteristics.
Four patterns of velopharyngeal closure (VPC) have been described on the basis of FN and VF: coronal, sagittal, circular, and circular with the Passavant ridge. (See Pathophysiology.) The type of closure pattern is determined by the relative contribution of the palate and lateral pharyngeal walls to closure of the velopharyngeal sphincter. Determination of a patient's predominant VPC pattern (see the videos below) directs the surgeon to the most appropriate treatment for the patient.
The four main surgical approaches to velopharyngeal corrective surgery are as follows [37, 38] :
Pharyngeal flap
Sphincter pharyngoplasty
Posterior pharyngeal wall augmentation
Go to Surgical Treatment of Velopharyngeal Dysfunction for complete information on this topic.
Palatal procedures most often include the Furlow palatoplasty, which involves a double Z-plasty lengthening of the palate. This technique appears to work best when the orientation of the palatal levator musculature is sagittal or when a small preoperative velopharyngeal gap size is noted.
Pharyngeal flap
The pharyngeal flap is the preferred surgical approach in patients with good lateral pharyngeal wall motion who have a persistent central gap resulting from poor palatal motion, as is common following repair of a cleft palate. The procedure aims to develop a central flap of tissue to obturate the midline of the pharyngeal port and decrease the degree of air escape into the nasal cavity. [39, 40, 41, 42, 43]
Schoenborn first reported this procedure in 1876 when he described an inferiorly based posterior wall flap sutured to the nasal surface of the soft palate. [44] He later modified this procedure by using a superiorly based flap when he found that an inferiorly based flap tended to contract and tether the palate downward over time, worsening the patient's velopharyngeal insufficiency (VPI).
The flap is raised down to the level of the prevertebral fascia, creating a tissue flap of superior constrictor muscle with its overlying mucosa. This flap is raised superiorly so that its base is at the level of the arch of C1. Typically, splitting the soft palate in the midline is necessary to provide better access to the nasopharynx during creation of the flap. The flap then is sutured to the nasal surface of the palate by incorporating it into the split repair.
Alternatively, the flap can be inset into the palate by performing a fish-mouth incision on its nasal surface. Raising a longer flap than necessary is advantageous to accommodate any future flap contracture. Red rubber nasal trumpets (4 French) are placed through the resulting lateral ports to alleviate any immediate postoperative obstructive breathing patterns.
One large series of 500 patients reported normalization or resolution of hypernasality in 90% of patients. Failure to improve is related to inadequate flap width either by design or due to contracture. Conversely, a flap that is too wide narrows the lateral ports and produces hyponasal speech. Postoperative airway obstruction is most likely to occur within the first 24 hours and in one series resolved within 2 days in more than 90% of patients.
The drawback to this surgery is the potential for prolonged postoperative obstructive sleep apnea development in up to 50% of patients. Care must be taken in the pediatric population to ensure adequacy of nasal respiration following paryngeal flap surgery. In many cases, this includes hypervigilance for obstructive sleep apnea both before and after surgery. Surgeons should definitely contemplate removal of large tonsils and adenoids prior to pharyngeal flap surgery.
Sphincter pharyngoplasty
Sphincter pharyngoplasty is advantageous when coronal or circular closure is present and lateral pharyngeal wall motion is deficient. The goal is to develop a more functional sphincter by improving the dynamics and bulk of the velopharyngeal tissues and by tightening and reducing the size of the velopharyngeal opening. [45, 46, 47, 48, 49]
Hynes was the first to describe pharyngoplasty in 1950 as the elevation of two superiorly based flaps comprising the right and left salpingopharyngeus muscles and overlying mucosa. [50] The flaps were rotated 90° and sutured to the mucosal edges of a transverse incision made across the nasopharynx just below the level of the tori tubarii.
In 1968, Orticochea described a modification of the pharyngoplasty procedure using two superiorly based flaps comprising the posterior tonsillar pillars with the underlying palatopharyngeus muscles. [51, 52] A small inferiorly based posterior pharyngeal wall flap then was elevated, and the two lateral flaps were rotated 90° and inserted onto the posterior flap.
Jackson further modified this method by sewing the lateral flaps onto a superiorly based posterior pharyngeal wall flap, allowing higher placement of the lateral wall flaps.
Theoretically, the sphincter becomes dynamic. However, one study featured selective electromyographic evaluation of the muscular pharyngeal sphincter during speech and revealed no intrinsic muscular activity. It is important to place these flaps high in the sphincter to reduce the need for revision surgery. [53] The sphincter pharyngoplasty has also been recommended for use in cases of stress-induced VPI, such as in wind-instrument players.
As noted, the need for adenoidectomy and possible tonsillectomy is determined preoperatively. (See Workup.) Adenoidectomy is performed several weeks (minimum, 6 weeks) preoperatively to allow the velopharyngeal sphincter to heal. If the tonsils are enlarged to a degree that may make raising the palatopharyngeal flaps difficult, they must be removed. Velar closure is then reassessed after adenoidectomy (and tonsillectomy) because the muscular dynamics may have changed.
Several studies have reported a success rate (ie, correction or significant reduction in hypernasality) from 78-100% with pharyngoplasty. The incidence of postoperative hyponasality is estimated to be 12-17%.
Posterior-wall augmentation
Posterior-wall augmentation is appropriate in the presence of a persistent gap in the central velopharyngeal port measuring at most 1-3 mm. It also is indicated when the patient can achieve touch closure that is not tight enough to prevent air escape with high oral pressure. Persistent postadenoidectomy VPI is also an appropriate indication for this procedure. Both autogenous tissue [54] and foreign implants have been used for this approach.
A superiorly based pharyngeal flap incorporating the superior constrictor is raised down to the prevertebral fascia. The superior extent of elevation is defined just above the point of maximal closure. It then is buckled onto itself and sutured in place. Initially good results can become less favorable as the flap can atrophy with time, and this procedure is recommended only for small gaps.
A wide variety of implantable materials have been used to augment the posterior wall. Problems with extrusion, migration, resorption, and infection have been reported. The US Food and Drug Administration (FDA) has banned silicone because of a high extrusion rate. Teflon is not approved for use in the pharynx because of concerns over the risk of injection into large blood vessels. Autologous tissues such as fat or rolled dermis have been less problematic, but they tend to resorb with time.
Subsequent reports described the use of calcium hydroxyapatite injected into the posterior pharyngeal wall. [55] This technique has been demonstrated to have a reasonably high success rate with no migration or extrusion of the injected material. Polyethylene implants imbedded into the posterior pharynx have also demonstrated success in some adult patients. [56]
Although these procedures appear to be safe and relatively easy to perform, critical evaluation of procedures for posterior wall augmentation have not demonstrated significant improvements in speech following surgery. Autologous fat injections may be of some benefit in further augmentation after either sphincter pharyngoplasty or a pharyngeal flap procedure. The use of injectable collagen materials for pharyngeal augmentation has not been reported.
Predictors of postoperative outcome
Perceptual speech assessment is a key subjective tool used to diagnose VPI in children, determine disease severity, and measure improvement after treatment. Speech intelligibility is very important to patients with VPI and can have a large impact on quality of life. It is also important to develop standardized methods for use in research and improve overall management of patients with VPI.
One study validated a new disease-specific instrument, the Velopharyngeal Insufficiency Quality of Life (VPIQL) survey. This study identified that children with VPI and their parents perceive a reduced quality of life when compared with age-matched controls. [57] Another prospective cohort study implemented the Pediatric Voice Outcome Survey, an instrument used to assess general voice-related quality of life, and showed that parents perceived at least short-term improvements in fuctional outcomes and quality of life following surgery for VPI in their children. [58]
The greatest predictor for postoperative final speech outcomes from VPI surgery is the patient's preoperative condition. Children with syndromes such as VCF are more likely to have suboptimal outcomes after surgery than children anatomic, nonsyndromic causes of VPI. The type of surgical procedure used does not seem to be as important as the experience of the surgeon. A large, prospective, randomized study from Mexico found no difference in outcomes between sphincteroplasty and pharyngeal flaps, regardless of preoperative velopharyngeal sphincter characteristics. [59]
In summary, outcomes after VPI surgery are probably dependent on a multitude of factors, including severity of preoperative VPI, gap size, presence or absence of comorbidities or syndromes, and surgeon comfort.
There seems to be no long-term effect on growth after VPC over time. The ratio of cephalometric measurements of velar length to pharyngeal depth was similar in patients with repaired clefts and their normal control subjects. This ratio remained stable with growth from age 4 years through puberty. [60]
Postoperative Care
Immediate postoperative concerns deal mainly with upper-airway obstruction. Placement of nasal trumpets overnight, while the patient is still under the effects of anesthesia, is helpful. A 2-0 suture placed through the tongue tip and used to protrude the tongue can be helpful in temporary airway management in the postanesthesia recovery area.
Patients are admitted overnight primarily for airway management and intravenous (IV) hydration. Discharge home is on the first postoperative day as long as oral diet is tolerated and pain control by mouth is adequate.
Postoperative pain management is typically limited to narcotics, such as acetaminophen with either codeine or hydrocodone. Stronger narcotics, such as morphine or meperidine, may cause increased sedation, thereby worsening airway obstruction.
Once oral fluids are tolerated and any postoperative nausea has cleared, the patient resumes a diet of thick liquids and soft foods. With pharyngoplasty, a diet similar to that for tonsillectomy patients is used and may include most foods as tolerated. Patients undergoing a pharyngeal flap procedure follow dietary restrictions similar to those for patients undergoing palatoplasty. Typically, these patients are restricted to thick liquids or soft foods (eg, mashed potatoes) until the palatal incision has healed (usually 10-14 days).
Complications after VPI surgery include persistent VPI, flap dehiscence, and obstructive sleep apnea (OSA).
Concerns about long-term OSA development after pharyngeal flap surgery led some centers to abandon this procedure all together. A study of 222 consecutive pharyngeal flap operations reported a relatively low postoperative OSA incidence and concluded that when appropriately performed, pharyngeal flap surgery was well tolerated and effective for the treatment of VPI and that there was no reason to avoid applying it to children for fears of postoperative OSA. [61] In the case of severe persistent OSA after a superiorly based pharyngeal flap, division of the flap generally results in improvement in symptoms and some persistent speech benefit.
In a sphincter pharyngoplasty, more superiorly raised palatopharyngeal flaps lead to a greater degree of velopharyngeal obturation. If this is excessive, an obstructive pattern of breathing can develop. [62, 63] However, even if the obturation is not excessive, some patients still develop some mild temporary obstructive sleep patterns in the immediate postoperative period. For this reason, most surgeons place a nasal trumpet through the sphincter intraoperatively and remove it the next morning.
Long-term considerations include shrinkage of the flaps and nasopharyngeal scarring. Over time, the flaps may shrink, reducing the bulk of the repair and altering speech results. Patients with return of velopharyngeal escape over time may be a candidate for flap augmentation with fat injection. Nasopharyngeal stenosis may also result, especially if the dissection is carried up onto the soft palate. Resultant upper airway and nasal obstruction may require revision pharyngoplasty with tissue grafts.
After a pharyngeal flap procedure, failure to improve is related to inadequate flap width, whether through faulty design or as a result of contracture. [64, 61] Conversely, a flap that is too wide narrows the lateral ports and produces hyponasal speech. Postoperative airway obstruction is most likely to occur within the first 24 hours [65] ; in one series, it resolved within 2 days in more than 90% of patients.
After posterior-wall augmentation, problems with extrusion, migration, resorption, and infection have been reported.
A team approach is important to success in the treatment of VPD. Close communication between the SLP and the surgeon is critical to determine the appropriate treatment modalities used. As speech motor patterns are set between age 8-12 years, timely consultation is crucial to good speech outcomes.
Role of speech and language pathologist
The surgeon, the SLP, and other health care providers work closely together to achieve the goal of optimal treatment for the patient. These practitioners collaborate in their reviews of the in-depth diagnostic assessment results and the individual patient's medical history.
Consensus evaluation usually provides an appropriate course of management for affected individuals and may yield a differential diagnosis that leads to differential management. [66] Ideally, this means that care providers attempt to match the gap size, shape, and VPC pattern to the most appropriate intervention.
Surgeons, as well as lay people, are usually capable of recognizing speech "differences." Perception of a speech difference does not require a sophisticated understanding of speech physiology, but determination of the causes, severity, and magnitude of that difference and formulation of a suitable treatment plan do require such an understanding.
SLPs are particularly adept at sorting out the components of a communication disorder and their respective weights, a process that frequently dictates whether a particular component receives surgical attention, not whether it receives attention at all. This sorting ability is a skill and a talent that surgeons and lay people rarely possess.
Relationship between speech and language pathologist and surgeon
Making the distinction between velopharyngeal valve dysfunction (structural defect) and speech dysfunction is critical. For example, consider the following analogy: If a newly licensed 16-year-old driver is involved in a motor vehicle accident, differentiating between a mechanical failure of the car and a failure of the just-learning driver to maintain control of the vehicle is important.
The investigator might logically ask: Was the driver taking mind-altering drugs? Was the accident the result of a mechanical problem with the car, or was it the fault of an inexperienced or misbehaving driver? The answers to these questions are basic to the investigational algorithm. They tell the investigator where to look next, while reminding him or her that more than one party might be at fault.
The same logic holds true for the evaluation and management of VPD. Is the velopharyngeal valve (the car) at fault, or is the speech disorder (the driver) at fault? The answer to this question tells the investigator what to do next and who should do it.
Examining the velopharyngeal valve should be quite straightforward. A simple mirror test at the bedside, with a definitive yes-or-no answer, can help determine if the patient can eliminate nasal escape. Treatment may involve fixing the velopharyngeal valve (which calls for a surgeon's expertise) or teaching the patient (which calls for the expertise of an SLP).
The presence of hypernasality is much more difficult to evaluate. Using vocal, nonverbal testing can obviate such problems as phoneme-specific VPI. An astute SLP should be able to make the determination despite the confounding glottal stops, fistulae, and other factors.
The surgeon must emphasize to parents, patients, and other providers that surgical success can be anticipated with respect to nasal escape and hypernasality. The SLP must then assume the responsibility of helping patients achieve speech and language success, including articulation and other facets of verbal communication.
Long-Term Monitoring
The initial follow-up appointment is at 7-10 days, at which time the wound is examined for proper healing. A determination regarding resuming a regular diet also is made at this time. Snoring and upper airway obstruction, if present at this point, usually resolve over the next several weeks as edema decreases and flap shrinkage occurs.
At 6 weeks, healing is usually complete, and a speech and resonance reassessment is performed. Surgical correction of structural defects in the velopharyngeal port does not necessarily change function, and articulation problems may persist after surgery. On the basis of the postoperative speech and resonance evaluation findings, speech therapy may be resumed at this point as necessary.
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Protecting Brand Integrity and Increasing Revenue Through Better Forecasting Addressed in Upcoming Vistex Webinar
Hoffman Estates – August 23, 2017. Traditionally, revenue and expense forecasting has been a time-consuming effort for licensing businesses, one that yields the required numbers but doesn't always provide the insight needed to help guide brand-based programs to success.
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This last book, "Short Stories by Timothy M Nugent," was my foray into writing something other than poetry. I took some of my poetry and used them as an outline to write stories. Some are embellishments with truth, but I hope they are entertaining. I...
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I am probably the worst fisherman. I love to fish but seem to catch very few. I traveled the Western United States for the last eight years. My girlfriend took most of the pictures—when we were not able to stop, when the park traffic was packed, or w...
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It is the good life we live in Costa Rica. Yes, we have rain but a lot of sunshine and fair weather. I hope you like my little poetry book, Poems from Costa Rica. Soon I will have Travels with the Wildman 4. It will be poetry written about the pictur...
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My wife was a prodigious card giver. I put her many cards to poems for a lasting memory of her.
Soon, "Timothy M Nugent: A Collection of Poems," with personal thoughts on life. Everything from my dogs' behavior to personal tragedy. Political mayhem ...
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I wrote this poem after the death of my wife. I was alone, searching for answers.
I was lost even with family and friends around me giving me great support.
I began to write poetry on my travels. I generally rode alone. Soon after writing this poem...
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I hope you enjoy this book. I hope you enjoy it so much that you look at my other books: Odes to Life and Love, Passages from Her Cards, and Travels with the Wildman Volumes 1 and 2. I am working on two more books: Fishing in the USA and Travels with...
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Drop-In Visits
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Jake is awesome and our Rosie loves when he comes over for a drop in. We usually end up doing last minute requests and he is very accommodating. Thank you Jake!!!
Jake is always great with our puppy! Kind, trustworthy and reliable! Highly recommend.
Jake is always great with our puppy! Kind, trustworthy, and reliable- highly recommend!
About Jake
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My family adopted a young yellow lab-husky mix named Sophie when I was three years old. Through growing up with Sophie, I learned to understand dogs extremely well. I miss her very much, which is why I will treat your best friend with the love they deserve. My mother and I used to volunteer at an animal shelter where we would walk dogs and play with cats. Many of those dogs were nervous, aggressive, lethargic, ...
What Jake would like to know about your dog
Any breed is welcome! Just let me know of their tendencies. I can work around anything!


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The food scene in Brockley in South East London has always been vibrant and so we are excited to work with Nolan and Sarah at their cafe in Brockley Rise. In between nibbling on doughnuts, we asked them a few questions to find out more about the story behind Rise Cafe.
Could you tell us about the journey you have taken to open Rise Cafe? What made you choose the location of Brockley Rise?
When the site came up right next to our children's school we knew it was going to be exciting. It had been a variety of food establishments during it's lifetime, but Nolan spent 6 months stripping it back and creating what it is today. From installing heating and a new boiler, he also used YouTube to learn how to build the seating, finally white washing all of the walls to give it a Scandinavian feel.
Are there any eateries/ cafes/ restaurants etc that inspired you?
We like to eat out and are forever inspired by the sense of a place, from the plates to the lighting....the lighting is very important. We often walk on past a place when looking for somewhere to eat if is too bright for date night!
You've created a space that promotes the sense of 'hygge'. What does this concept mean to you?
It's a feeling. It's a Danish word that is very hard to translate but most people know it as cosy. It's a huge part of us (with my Danish mum) and we live our life like that; it's about being calm, and just being with friends in a nice place that is relaxed. We like it like that at home so wanted to make a space people where people could feel it too; come and relax and we will take care of you!
What excites you about the London cafe and food scene?
The variety (obviously) but generally we love the fact you can get anything, anywhere and there is always something new to try.
You are busy parents; how do you juggle the demands of running a business with family life? Do the children get involved with the cafe?
It's all very busy! Nolan is at the cafe all of the time (which is why Sundays are still our day of rest....for now) and I do my 'normal job' alongside cafe life. Our two kids are very much involved - our daughter Tess loves being the 'toy waitress' and giving their old books and toys to the children that come along, but she has been known to serve a plate or two. She is only 4 so we have to make sure she doesn't drop the plate! Dylan is 6 and loves telling his friends his cafe is next door, but tends to want to eat and drink everything in sight...
What made you decide to stock Borough 22 doughnuts?
We heard from a friend how amazing they are for vegans and those who are gluten-free. When Ryan came along with some sample we were sold. We also love the branding and ethos; quality but fun. Life is too short to eat bad food!
Rise Cafe 108 Brockley Rise SE23 1NH London, United Kingdom . Follow the behind the scenes on instagram @rise_cafe.


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Wine Club Members mark your calendars! We will be hosting our Summer Food & Wine Pairing. This quarter as part of your Wine Club allocation we will be releasing the following wines, 2018 Pinot Gris, 2018 Rosé of Pinot Noir and 2015 Cabernet Sauvignon, and all of these wines will be paired with a small yummy food pairing. Watch your email for details!
Back to All Events
Earlier Event: August 25CLOSED FOR A WINE CLUB MEMBER EVENT
Later Event: August 28Visit us at the Downtown Farmer's Market


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- 5 beds
- 3 baths
- $445,000 price
- 321353 mls id
- Year Built: 2015
- Status: Active
Gorgeous! & Move In Ready in Popular Grayhawk of Madison!! 3253 sqft. 5/3 with an Office area. You will see the quality of this home as soon as you walk in...the Foyer, Dining Room and Great Room all have beautiful wood flooring, quality trim and 12' ceilings. DOWNSTAIRS: Large Master Suite with wood floors and a Huge walk in closet that includes plenty of built ins, Master Bath with attractive tile, a double vanity, jetted tub, and a large separate shower. You will find 3 more good sized Bedrooms, all with hardwood floors and walk in closets. One Bedroom is very private with its own full Bath, the other 2 Bedrooms share a spacious guest Bath with double vanities. The Great Room features a gas fireplace, convenient built in shelves and cabinets. The Chefs Dream Kitchen has granite counter tops, tile back splashes, slab granite center island with breakfast bar and plenty of seating, 5 burner gas cook top, gorgeous custom vent hood, double wall ovens, and a spacious Breakfast/Keeping Room. Dining Room is open and boasts a beautiful wood trey ceiling. Laundry Room and Office Space located by the Master. UPSTAIRS: features an Awesome Bonus Rm/5th Bdrm with, sliding barn doors for access to storage, perimeter up lighting, large walk in closet, and an unfinished bath all plumbed and ready to be finished, you will also find tons of attic space for storage. OUTSIDE: wait until you see this Unbelievable HUGE fully fenced in Backyard featuring, gorgeous landscaping, wooden children's playset and covered screened in Patio with TV hook up and electrical outlets, great for entertaining. This has to be one of the biggest, level lots in all of Grayhawk. Other great features include, security system, irrigation system, epoxy painted garage floors, gated access to the community pool and amenities and so much more!! Grayhawk is located in Award Winning Mannsdale/Germantown Schools!! Call to schedule an appointment to see this lovely home today.
- Site Link
- Property SubType Single Family Detached
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Courtesy of: Real Estate Professionals
48 Pictures
3D Virtual Tour Available - Be sure to click on the virtual tour link. Floors Recently Refinished! New Roof & Kitchen Counters! Fresh Paint & New Carpet Throughout! Gorgeous Living Space! This beautiful 5 bedroom, 4.5 bathroom home is nestled on a quiet eyebrow cul-de-sac in Madison's...
509 SILVERSTONE DR Madison, MS
5 beds, 4 baths, $425,000
Listing Agent: Mark Metcalf
Courtesy of: eXp Realty
Courtesy of: mcintosh & associates
Office Phone: 601-936-2007
Listing Agent: Cheryl Yetter
Updated: 15th October, 2019 10:03 PM.
111 PINNACLE CV Madison, MS


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New Zealand police evacuate neighbourhood amid mosque attack probe
Police said the property, located some 350 kilometres from Christchurch, was 'of interest' in relation to the mosque attacks which left 49 dead.
CHRISTCHURCH - New Zealand police investigating Friday's mosque massacre in Christchurch have evacuated residents living near a property in the city of Dunedin that they believe is linked to the attacks, officials said.
Police said the property, located some 350 kilometres (220 miles) from Christchurch, was "of interest" in relation to the mosque attacks which left 49 dead.
"Evacuations of properties in the immediate area have taken place as a precaution," police said in a statement. They did not provide further details.
Police earlier reported that two explosive devices had been found in a vehicle used by the gunman who carried out the attacks on the two mosques which also left 48 injured. The devices were disabled.
The gunman was arrested by police, who also took two other men into custody. It was not immediately known what their link may have been to Dunedin, about a four-and-a-half hour drive south of Christchurch on New Zealand's South Island.
The Australian gunman involved in attacks published a racist manifesto on Twitter beforehand then livestreamed his rampage, according to an AFP online analysis.
The New Zealand government said it could be illegal to share the video, which showed the gunman repeatedly shooting at worshippers from close range.
"Police are aware there is extremely distressing footage relating to the incident in Christchurch circulating online," New Zealand police said in a Twitter post.
"We would strongly urge that the link not be shared. We are working to have any footage removed."
AFP analysed a copy of the Facebook Live video, which shows a clean-shaven, Caucasian man with short hair driving to the Masjid al Noor mosque in central Christchurch, then shooting as he enters the building.
AFP determined the video was genuine through a digital investigation that included matching screenshots of the mosque taken from the gunman's footage with multiple images available online showing the same areas.
The manifesto detailing motivations for the attack was posted on Friday morning onto a Twitter account with the same name and profile image as the Facebook page that streamed the attack.
VIDEO: 40 killed in New Zealand terror attack
Entitled The Great Replacement, the 74-page document said the gunman had wanted to attack Muslims.
The title of the document has the same name as a conspiracy theory originating in France that believes European populations are being displaced in their homelands by immigrant groups with higher birth rates.
The manifesto said the gunman identified himself as an Australia-born, 28-year-old white male from a low-income, working-class family.
He said that key points in his radicalisation were the defeat of the French far-right leader Marine Le Pen in 2017 elections, and the death of 11-year-old Ebba Åkerlund in the 2017 Stockholm truck attack.
Australian Prime Minister Scott Morrison on Friday confirmed the attacker at the Masjid al Noor mosque was an Australian.
"We stand here and condemn, absolutely the attack that occurred today by an extremist, right-wing, violent terrorist," Morrison told a press conference.
New Zealand authorities said that three people had been arrested, but their identities were not made public.
They later announced one man, aged in his late 20s, had been charged with murder and should appear in court on Saturday.
AFP confirmed the authenticity of the livestreamed video partly by matching the distinctive features at the mosque seen in the footage with images available online.
These included a fence, postbox and doorway at the entrance to the mosque.
Inside the mosque, the gunman's footage showed distinctively patterned green carpet that also matched images tagged on Google Maps as being at the same location.
Satellite navigational audio could also be heard in the video as the gunman drove to the mosque, which AFP tracked on Google StreetView showing his route for the two kilometres (1.2 miles) leading there.
The gunman spoke only occasionally while in the car, speaking in what sounded like an Australian accent.
Distinctive writing on the gunman's weapons seen in the footage also matched images posted on the Twitter account using the same name that posted the manifesto.
The manifesto was the final tweet on the account before it was suspended.
Photos of weaponry with distinctive writing on them were posted on the Twitter account on March 13. AFP took screenshots of the weapons shown in the Facebook Live video, which showed some of the exact same writing.
Scrawled in English and several Eastern European languages were the names of numerous historical military figures -- many of them Europeans involved in fighting the Ottoman forces in the 15th and 16th centuries. A few took part in the Crusades, centuries earlier.
The Facebook account that posted the video was no longer available shortly after the shooting. The Twitter account of the same name was quickly suspended.
AFP downloaded the video and took screenshots of the Twitter account before they went inactive. AFP is not publishing any of the images.
A spokesman for New Zealand's interior ministry said the video is likely to be classified as objectionable content under local law, and could be illegal to share.
"The content of the video is disturbing and will be harmful for people to see," the spokesman said. "This is a very real tragedy with real victims and we strongly encourage people to not share or view the video."
More in World
Spain jails Catalan separatist leaders, protesters take to streets
Johnson repeats Brexit vow as EU talks reach critical point
Trump demands whistleblower testify, as ex-aide talks to Congress
Ramaphosa: Africa the best place to invest
US trio win Nobel Economics Prize for work on poverty
Japan searches for survivors as Typhoon Hagibis death toll hits 56
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150 to 250 guests
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Post your for sale and want to buy items for the 100, A6, UrS4, & UrS6 (C4) parts in this forum.
WTB: Urs4 Front Bumper
Post your for sale and want to buy 100, A6, UrS4, & UrS6 (C4) cars in this forum.
FS Audi 100CS quattro NJ
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Seahawks tackle Willis battles for spot
Thu., Aug. 6, 2009
RENTON, Wash. – Ray Willis is not smiling, which constitutes a potential problem.
This is 315 pounds of potential malice we're talking about here, and he has just been asked why so many people tend to fight him in practice. The big man is not amused by this line of questioning.
"I don't know," said Willis, an offensive tackle. "It's just that coach Jim Mora runs a tough camp, and I think that sometimes tempers just kind of run a little high."
That's probably true, but it doesn't answer why Willis is the one Seahawk who tends to cause those tempers to boil over more than any other. In fact, Mora forecast that he would be involved in the first skirmish of training camp.
It came, in fact, in the first practice. Defensive end Lawrence Jackson was locked up with Willis in a 1-on-1 drill last Friday, and Willis held on a little too long for Jackson's taste. That elicited an open-handed smack from Jackson – and just like that it was on. The two had to be separated.
"It happens," Willis said. "It's football. It's a man's game."
Still no smile.
Let's ask someone else. Why does it seem that everybody wants to fight Willis in practice?
"Well, I don't think they want to fight him," said center Chris Spencer, his teammate on the offensive line. "I think they just fall into it. They wake the demon up in him, and then they've got no choice."
Willis is a fifth-year player, a social-science major from Florida State and the father of twins who practices hot yoga twice a week in the offseason. Put him in cleats and a helmet, though, and he has some menace to him.
"When he gets on the field, everything else just shuts off," Spencer said.
"You gotta' love him," Seahawks defensive tackle Craig Terrill said. "It's his fifth year now, usually a guy is a little calmer at practice. But it's like it's his first training camp."
The Seahawks drafted Willis in the fourth round in 2005, the year Sean Locklear established himself as the starting right tackle. That left Willis waiting his turn in line. That came last year after injuries opened the way for him to start seven games at right tackle, three at right guard.
He played well enough that many expected the Seahawks to lose him in free agency over the offseason. He visited the Raiders, but teams weren't spending this year like they had in previous years, which made it possible for the Seahawks to re-sign him to a two-year deal.
Now Willis is a consideration as Seattle tries to configure its offensive line with a new blocking scheme. Left tackle Walter Jones has practiced only once in training camp so Locklear has moved to the left side, leaving Willis to play right tackle with the first string. Willis gets time off every couple of days to rest his knee, too.
But when Willis practices, he doesn't hold anything back. In fact, he usually cinches in a block and refuses to let go.
"Sometimes, it gets on your nerves a little bit is a nice way to put it when you're on his team and he's doing it in camp," Terrill said. "But on Sundays during the season, you like that he's out there doing it to his opposing team."
Simmons signed
The Seahawks waived reserve linebacker Tony Taylor and signed former Western Washington University linebacker Shane Simmons.
Simmons, a Kentlake High graduate, was in Seattle's minicamp in April for a tryout.
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Valley Fog
Feb 25, 2010
|We woke up to very heavy valley fog this morning, visibility was down to about twenty feet. When our neighbors across the street tried to pull out with their fifth wheel this morning he couldn't even budge it. The guys from the fairgrounds maintenance crew showed up with medium sized John Deere tractor that didn't have too much of a problem pulling out his pickup but couldn't handle his fifth wheel trailer. Next they brought out the big gun, one of those large four wheel drive front end loaders, that big boy manhandled the trailer up onto the pavement so they could hook up and head back home to Arkansas.


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Description : Bryson tiller type loop. Comment if you want the MIDI file.
Trap Soul Vibez by dripchord has received 10 comments since it was uploaded.
If you have used this loop leave some feedback or say thanks and post a link to the track you made. Apart from being the right thing to do it also encourages artists to upload more loops.
cbrmnk @gmail.com thank you
ancnano @gmail.com i really appreciate it man!
Thanks in advance for the MIDI file!
hey man I want to say thank you for posting this loop it inspired me to make this
Hi Dripcord,
Excellent job on this loop. It's got that old skol vibe but its also modern
at the same time. This is the perfect foundation for a good song.
Thanks for sharing your talent.
Description : There's a simple loop I made with Fl Studio and DSK Asianz Dreamz Vst.
Root Note: G
Post what you came up with.
Tags: Drake, Travis Scott, Scarlxrd, 21 Savage, lil pump, Smokepurpp.
Description : made this on flstudio 11 split the 8bars into 4.
Description : Travis Scott, Quavo, Gunna type loop
comment the link if you use it!
Description : Pretty straightforward pluck, good for chill, trap maybe hip hop. EQ used to soften it a bit, Reverb added to make it feel more "Airy"
Description : Cool)
Description : Comment if you want the MIDI file.
Description : using the NI Reaktor vst (form ensemble)
Description : I managed to make a horn sounding synth so I threw this together to share with you. Should sound nice in a Big Room House song, enjoy and let me hear if you come up with anything
Description : Mellotron Flute Riff in G minor. Delayed
Description : Synth Loop in G - MINOR; Hope you find this useful. If you use one of my loops in your song, I'd love to hear it. -> GET A PERSONAL LOOP NOW. More INFO on my PROFILE PAGE! Contact me only via facebook please! Thanks
Description : This is a good foundation for a building techno track
Description : lead synth
Description : ENJOY
Description : send me the work you did.go Krazy!!!
Description : This is the supporting part ..a cool grungy synth patch


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Africa (Sub-Sahara) Petroceltic International said that the first of up to 24 new development wells planned in Algeria's Ain Tsila gas and condensate field was successful. The AT-10 well, situated about 2 miles from the AT-1 field discovery well, reached a total depth of 6,578 ft. Wireline logs indicated that the expected initial offtake rate would be comparable to the AT-1 and AT-8 wells, both of which test-flowed at more than 30 MMcf/D. Petroceltic is the operator with a 38.25% interest in the production-sharing contract that covers the Ain Tsila output. The remaining interests are held by Sonatrach (43.375%) and Enel (18.375%). Sonangol reported that it has found reserves in the Kwanza Basin of Angola that could total 2.2 billion BOE, including reserves in a block jointly owned with BP. Block 24, operated by BP, holds an estimated 280 million bbl of condensate and 8 Tcf of gas, totaling 1.7 billion BOE, Sonangol said in a statement seen by Reuters.
Ashraf, Qasim (Weatherford International Ltd) | Khalid, Ali (Weatherford International Ltd) | Ali, Farhad (Weatherford International Ltd) | Luqman, Khurram (Weatherford International Ltd) | Mousa, Ayoub (Weatherford International Ltd) | Babar, Zaheer Uddin (Pakistan Petroleum Limited) | Hussam Uddin, Muhammad (Pakistan Petroleum Limited) | Ullah, Safi (Pakistan Petroleum Limited)
An operator has drilled more than 32 wells to date in Adhi field, a gas and condensate field in northern Pakistan. The majority of these wells produce from depleted sands and some also produce from limestone reservoirs. The wells range in depth between 8,366 and 11,483 ft (2,550 and 3,500 m).
The operator was in the process of drilling the 8 1/2-in. hole section with the least possible mud weight to minimize the overbalance across the lost-circulation-prone limestone formation. While drilling the section, an unexpected gas pocket was encountered and subsequently required an increase in mud weight. To further add to already challenging drilling conditions, a fault was expected in the middle of the section. This fault was expected to produce total losses. The resulting loss of hydrostatic head would have caused a troublesome well-control scenario.
The above conditions led to an inherently tight drilling window. The operator thus made precise management of wellbore pressures a prime objective. However in conventional drilling, relying on the mud weight and pumping rate for accurate management of wellbore pressures proves highly inefficient, if not impossible.
A managed pressure drilling (MPD) and underbalanced drilling (UBD) hybridized system was devised to enable drilling the 8 1/2-in. hole section. An MPD system that applies constant bottom hole pressure would enable drilling the section with the least possible mud weight and as close as possible to the pore pressure line. In the event that heavy to total losses were encountered because of the predicted fault, the system could be switched over to UBD flow drilling. By switching over to UBD, the equivalent circulating density (ECD) would be reduced further and allow the well to flow while drilling and mitigating losses.
An MPD and UBD system was also expected to offer numerous benefits in drilling, including reduced chances of differential sticking, reduced formation damage, increased rate of penetration and bit life, less washouts in the drillstring and pumps, reduced nonproductive time, and enhanced abilities to execute well control with the pipe in motion without fear of getting stuck.
The MPD and UBD hybrid system was deployed to the location. The operator was able to drill the 8 1/2- in. section to the target depth. The operator commenced drilling with an MPD system but, as expected, heavy losses were encountered. Drilling then proceeded with UB flow drilling until reaching target depth. The hybrid system enabled the operator to achieve target depth, eliminate an entire casing string, and substantially reduce NPT. This paper discusses the planning, design, and execution of the MPD and UBD hybrid system.
The explosive growth of shale gas production in the US has sparked a global race to determine which other regions from around the world have the potential to replicate this success. One of the main areas of focus is the Asia Pacific region, specifically Pakistan.
In this paper, real results from seven different US shale basins- Marcellus, Eagle Ford, Haynesville, Barnett, Woodford (West-Central Oklahoma), Fayetteville and Bakken- have been used to develop a comprehensive sequence of shale exploitation strategy for emerging shale plays. The study involves integration of shale gas exploitation knowledge reinforced by a decade of experience across most of the North American shale gas basins, with published data. Different reservoir properties have been compared to develop a comprehensive logic of the effective techniques to produce from shale-gas reservoirs. We have validated the sequence with real results from US shale production ventures, published case histories, and by global experts who have been directly involved in shale reserves evaluation and production.
Subsequently, several different reservoir attributes of Pakistan shale plays have been compared with US basins, in an attempt to identify analogues.
It is the intent of this paper to diminish the difficult and often expensive learning cycle time associated with a commercially successful shale project, as well as to attempt to illustrate the most influential factors that determine optimum production. A very few papers in the petroleum literature that provide an extensive and systematic approach towards shale exploitation strategy for given shale-reservoir conditions
Encouraged by the U.S. successful experience with shale plays, many Asia Pacific countries including China and India - having 1275 & 63 TCF of technically recoverable Shale gas respectively - have already started off with aggressive plans to exploit their vast shale reserves.
Pakistan is currently suffering an energy shortfall of 2.3 BCF and the energy demand is expected to increase further by 245% until 2022, as compared to 2008. As its conventional reserves deplete, there is a need to work on new frontiers of energy sources. Unconventional gas resources, such as shale gas, tight gas and coal bed methane, are the avenues that should be focused on, in the current scenario.
According to EIA estimates, Pakistan's total Risked Gas in Place is 206 TCF, while its Technically Producible Shale Reserves are 51 TCF. It is interesting to compare these postulations with the Sui gas field serving the energy needs of Pakistan for decades, and having an estimated original recoverable reserve of 12 TCF. However, efforts to develop this potential resource have been lacking perhaps due to the economic and technological challenges.


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Huh. Already found something useful at Falafel Blogs:
If you're like me and working at a client site that does not allow access to news readers from behind their firewall, you should take a look at:
This a really cool site for searching through newsgroups. You limit your search to MS or Borland newsgroups and can filter to a specific newsgroup using the "^" character like s "^csharp localization" Be sure to look at the "Advanced search" links, my choice is to get the results organized by "Thread".


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help with my biology essay
Personal Essay: ú Discuss your reasons for pursuing this degree. ú Discuss your academic strengths and weaknesses as they pertain to your intended program. ú Describe how you plan to balance the time commitment required for the program (about 10 hours per week per course and 15-20 hours for dissertation) with your personal and professional responsibilities. I have attached my CV an old personal essay and I want you to edit it and rewrite to make it better and has better quality. The personal essay for an admission for PhD in an information system.