#papm

[chubbydino]

In honor of the completion of HLS, the most hopeful and heart wrenching piarles and maxiel narratives ever, what inspired you bring phantoms and la madrague together and continue their stories?

How long did you imagine the events of HSL before you began writing it?

originally i was going to publish a different maxiel fic but the story just wasn't working and it wasn't sad enough imo. i started daydreaming about PAPM but i didn't want to be entirely in pierre's POV again and i felt like going into charles's would be cheating, since a lot of what i love about PAPM is that we're never in charles's head.

the original arc of HLS had a much darker ending, and the fic was going to be very piarles focused. more under the cut (+ spoilers)

i don't remember exactly what spurred me to bring the two stories together, but once i started thinking about it, it really worked. of course, PAPM has a chapter where max is married to a woman with a daughter, but that was the only retcon i really needed, and it wasn't the important part of that story. i didn't want to develop a whole new maxiel, and then the parallels between max and pierre started showing and i dove in.

originally, pierre was going to regain his memories like he did, but then the side effects would get so bad (essentially his brain never turned completely off so even while sleeping he would be burning his brain and exhausting himself) that eventually he would have to choose between being bedridden but with memories, or choose to forget himself every few months and start over each time. it was going to end with pierre waking up after making that decision, once again not knowing who charles was.

but every time i thought about max and what he was going through, it hurt so much more. pierre's memory loss isn't painful for him, just confusing and frustrating. max was just surrounded by pain and grief and his worldview is so fucked up, and his family is so fucked up, there was just so much to explore. so, i gravitated toward that story. max took center stage and i decided not to add more angst with pierre's original arc--it just didn't work the way i planned, and max's role took on a new life.

i said it in the discord, but max was also supposed to go through with the suicide attempt on the houseboat. i planned for him to wrap the anchor chain around his neck, slip on the deck, then get up and jump in and go to "heaven"... only for us to figure out that when he slipped on the deck, he hit his head and went into a coma and never actually jumped in the water. but one night while i was playing the story out (i "watch" the next chapter before i go to sleep lolol) i thought about mack truck and the accident took shape. that fit a lot better with the story, especially for daniel, who would never have forgiven himself if he found out max actually tried to kill himself (daniel still doesn't know max was planning to, the same way max doesn't know his family went after his money).

the museum scene with daniel was heavily inspired by What Is And What Should Never Be aka S2 Ep30 of Supernatural aka the Djinn episode, when Dean realizes his perfect world is fake and he's actually dying in real life. That episode hit me so hard and every time i watch it, it still hits. I wanted the same type of scene with Daniel finally appearing in Max's world and making him realize what was really going on.

the supernatural elements of HLS aren't particularly supernatural to me. many people i know have seen or experienced something they can't explain. there are plenty of weird happenings in my own extended family that aren't scary, just strange and maybe unsettling. kids also see the world differently and i feel like theo seeing marshmallow or the kids seeing squalo goes along with that. maybe max only sees it because of his grief, or maybe that's the part of the boys that's always with him.

overall, i wanted to end HLS with the understanding that there is no way to completely heal from what max went through. he'll always, always grieve for his babies, but he doesn't have to hold space for that grief anymore. it will always be there, but he's living life despite that. he's carefully choosing daniel, over and over, and now he knows it's okay to do that. his love for daniel doesn't have to detract from his love for his boys. i don't think he ever would have learned that without the supernatural element at play.

camp bluefin is the purest form of max's love for his daniel, not only because he's allowing children back into their lives, but because he's allowing himself to enjoy having a "family" again. <3

[teamfortresstwo]

young ares. probably somewhere between 6 and 8.

yes he always looked like that. boy why are you so small. why are you so tiny. what is up with him?

HES SO SMALL I COULD CRADLW H IN THE PAPM OF MY HAND ??? World’s smallest guy ?? Built like a jerboa

[bunniibones]

🍀 with byte? though if you want to answer this about all your ocs I won't complain 👀

🍀 - What originally inspired the OC?

I won't answer with all of them bcus I have over 50 but I can answer with the main ones :D!

Byte!

For Byte my main inspiration was myself! Byte was my Sonicsona, so they were basically "What would I be in Sonic's world?" but with my personality exaggerated and villainized.

The rest under the cut~

Angel!

For Angel it was bcus I saw a picture of a character working in a flower shop, so I kinda felt like making a gardener. Angel is not my first gardener character but I still wanted another LOLOLOL Windmill Village was also a huge inspiration factor, since most of his concept was inspired from Tinker and what happened in that village

Ampere!

For Ampere it was a RP I was doing in 2020. A friend roleplayed Tinker and I roleplayer Angel, both living in Windmill Village, so when Tinker found an eggpawn and Elder Scruffy wanted to make sure that the robot wasn't harmful, I realized we needed a mechanic that was an expert in Eggman tech but algo hero aligned, so that's how Ampere was born! As a rp npc lol

Cipher!

There was an owl background character in a Sonic IDW cover and I was like "I want an owl oc" lol, their design is inspired in a concept prototype I had made years ago based on a Rowlet + an old oc of mine who was a mechanic

Cyani!

I just wanted a crazy nurse character -papming-

Wrench!

For Wrench it was my BATIMsona Joseph, I wanted to turn him into a sonic character so that's how Wrench came to be. Winry Rockbell is also a huge inspiration for them since they're basically an automail mechanic hahaha

Fortune!

This is silly, but... I wanted an Eggman Empire oc to interact with Kimmy's oc Vino, so that prompted me to create Fortune ;v;

Sprout!

I wanted Angel to have an apprentice in the mainline of the story since he was lonely after Tinker was turned into Eggman, that's how Sprout came to be :3

Chamber!

... I wanted a boyfriend for Starline LOLOLOLOLOLOL

[hackfuel]

🚀 Unlocking Business Success with SAP Profitability and Performance Management (PAPM) 🚀

In today's dynamic business landscape, staying competitive requires more than just financial management. To truly excel, organizations need precise insights into their profitability and performance. Enter SAP Profitability and Performance Management (PAPM), a powerful tool that helps businesses make informed decisions, optimize profitability, and drive growth. Let's explore its key features and differences from other SAP solutions.

Understanding SAP Profitability and Performance Management (PAPM): SAP Profitability and Performance Management (SAP PAPM) goes beyond traditional financial management, offering advanced analytics and insights into profitability drivers. It allows organizations to gain a comprehensive view of their financial performance.

Key Features:

Advanced Profitability Analysis

Performance Optimization

Integration with SAP Modules like SAP S/4HANA

Differences Between SAP S/4HANA and SAP PAPM: While both SAP S/4HANA and SAP PAPM are valuable tools, they serve different purposes. SAP S/4HANA is a comprehensive ERP suite, while SAP PAPM focuses specifically on profitability and performance analysis.

Implementing SAP PAPM: Implementing SAP PAPM requires careful planning and configuration. SAP provides an installation guide and documentation to assist organizations in setting up the system effectively.

🌐 For more information on SAP PAPM and how it can benefit your organization, refer to Noshtek.com to learn how our solutions can complement SAP PAPM and help your organization achieve even greater success.

[lyx92]

Wala man papm dyan bro!

[referindiaofficial]

Kaar Technologies Hiring for #SAP #PaPM #Consultant Location : Saudi Comment if you are interested and stay connected with Fresher & Experience Jobs - ReferIndia for more job updates. #hiring #kaartechnologies #jobs #SAP #PaPM #Saudijobs #kaartech #referindia (at Saudi Arabia) https://www.instagram.com/p/CVhQFBGt3I5/?utm_medium=tumblr

[oddballskateandsnow]

【PAPM NEW DECK】入荷！

詳細はblogをご覧下さい！

[fabfoxly]

Meghan, Duchess of Walmart Lookbook: part 3

Hiking in the woods, all alone with just your dolly, a couple borrowed dogs, and some security? No problem! Grab the attention of paps shivering in the nearby shrubbery with these super-basic looks that include black leggings and a vomit-coloured beanie! After all, who needs LuLuLemon when you’ve got Great Value?

Knockoffs of nearly ALL of the clothes and accessories featured on M and “Archie” in the pap shots are available at your local Walmart! You, too, can dress just like the soon-to-be-ex-royal Duchess of Whatever!

LOOK 3

ALL ITEMS ARE FROM WALMART.COM

They even have the baby carrier! (Pro tip: to copy M’s style, add a few of these):

Don’t forget the accessories:

Who says costumes are just for Halloween, right?

For when they’re too slow jumping out of the bushes:

In case they don’t get the hint:

And later, a bedtime story for our girl:

[chewybitart]

I was gifted a bunch of beauties last week and decided to do a big pot swap and move everyone outside to enjoy the cool weather

[chubbydino]

I never read wips but after reading the amnesia fic I needed to read hook line and sinker, and it's sooo good. I never read maxiel either but I had to know Max's backstory. Thank you for this great piece of angst and the regular updates. In the past three days I've reread all of them like three times (I haven't slept much but keep finding new lil parallels each reread). The way you write Pierre's pov is so convincing, and my heart bleeds for Charles (I would love a Charles pov at some point cause that man is enduring a lot, but piecing his thoughts together through Pierre's lil flashbacks is so fun (would also love to read the prequel before Pierre's accident but I would read anything set in this universe)). If Pierre really gets his memory sorted I'm really interested how Charles will deal with it, he has endured so much from Pierre which he couldn't really talk to him about, but if he finally can??? Omg the drama

Max's decent into depression is so recognizable, at the same time I just want to reach through the screen and shake him till he snaps out of it, which I reckon is a testament to your writing. And how Daniel talks?? So on point.

The parallel with Pierre and Max is wonderful. They hate each other and can't accept themselves and see the other as the monster but really they are so alike. I hope they get the opportunity to talk it out if they get their heads in order.

Lastly, Theo is so well written as a child, which is really hard to do.

Keep up the good work and thanks for helping me through the exam season.

thank you for the kind words. HLS kind of writes itself in a lot of ways--i just let it flow so it gets away from me sometimes, but oh well. i kind of enjoy the slice of life aspect to it. the most recent chapter felt WAY long for what it was, but it didn't feel write to chop up an important therapy session.

and thanks for the comment on theo--i joke that he purposely doesn't have an age because i write him however i see fit lol. he's loosely based on some of the little kids in my family. i think my favorite scenes with him so far are the one with mon moth and the burbulence. ❤️

[leorjo]

ok i feel really fucking stupid but it's just two people holding pinkies?

palms are naturally lighter than someones skintone but theyre lighter esp on black/brown ppl so. the person who made that image just colored one hand brown and went with it LMFAO

[deborahchapinstudio]

As Part of my opening up my studio/gallery I'm doing a Countdown to Opening on Saturdays. To celebrate I'm offering 21% discount through the 2021 season to those who subscribe to my newsletter at https://gallery.deborahchapin.com/subscribe Opening May21st, 2021 - Coming Up: I'm finishing up one of my little piece as part of set I'm working on this week from #NewHarbor , I'm also finishing up a dawn piece from #PemaquidHarbor so I think this must be a harbor week. - On Wednesday I'm joining the #PAPME for a #paintout at Cozy Harbor in Southport ME. - #maineartists #maineart #marineart #mainegallery #openingstudiogallery #americanartist #amwomenartists #mainemarineartists #deborahchapin #coastalmaineart #tourmainewithart #midcoastmaine #CoastalMaine #deborahchapin #mainemarineartist #newharbor #seascapes #seascapepainting #pemaquidpoint #sandbeachacadia #floralart @deborahchapinfineart (at Deborah Chapin Fine Art) https://www.instagram.com/p/COvxWd5HDqD/?igshid=2irluf7eltn7

[myarlert]

Congrats on 900 followers! Imagine if you will, calling Reiner sweetie. That man would melt in your papms.

thank you sweetheart! AND YES, he would get so blushy n shit, his tummy would get all warm when you say it, literally every single time. it makes him wanna curl up in your arms and listen to your breath while he falls asleep <3

[nyssasorbit]

“Mademoiselle? Who are you?” “Why do you not answer?” “You are beautiful, like an angel. Are you an angel?” “Do you mind if I refer to you as Blanche?” “Mademoiselle Blanche, my angel. It’s a pleasure to meet you.” ~ Marius Cadieux

[yourmekan-blog]

Hipertrofia ventricular derecha en relación a la concentración eritrocitaria en nativos A

uso de CEC Universidad Peruana Los Andes 

Autor:  Purificación Pérez Terán

OBJETIVOS

1 OBJETIVOS GENERALES: 

El objetivo común que llevó al diseño de esta Tesis Doctoral ha sido investigar el posible papel que podría tener la FVD en el desarrollo de DPI en el postoperatorio inmediato del TP. Así como, explorar la utilidad del strain-2D en la valoración del VD en los pacientes candidatos a TP. 

2. OBJETIVO DEL TRABAJO 1 

El objetivo principal del primer trabajo fue explorar de forma retrospectiva la posible implicación de la FVD en el desarrollo de DPI grave. 

3. OBJETIVOS DEL TRABAJO 2 

Objetivo Principal:

El objetivo principal fue realizar una confirmación prospectiva del papel del VD en el desarrollo de DPI, tanto de forma invasiva mediante el índice cardíaco (IC) como no invasiva mediante strain-2D. 

Objetivos secundarios: • Realizar una validación prospectiva del SLB, como subrogado del IC, como un predictor precoz y no invasivo del desarrollo de DPI grave.

• Proponer un modelo de estratificación del riesgo de desarrollo de DPI grave basado tanto en el SLB como en el IC 

MARCO TEÓRICO

Epidemiología y Factores pronósticos  Según el registro de la International Society for Heart and Lung Transplantation (ISHLT)9 hasta junio de 2013 se habían realizado 47647 trasplantes pulmonares y 3772 trasplantes cardio-pulmonares en adultos en todo el mundo. La mediana de supervivencia de los pacientes trasplantados es de 5.6 años con una tasa de supervivencia del 88% a los 3 meses, del 79% al año, del 53% en los primeros 5 años y del 30% al cabo de 10 años12. Las causas fundamentales de fallecimiento tanto dentro de los 30 primeros días como durante el primer año postrasplante son la disfunción del injerto (DPI) y las infecciones12. Existen una serie de factores de riesgo asociados a una mayor mortalidad en el primer 

La hipertrofia ventricular también llamada hipertrofia cardíaca es una enfermedad que consiste en un aumento del grosor del músculo cardíaco (miocardio) que conforma la pared ventricular, tanto derecha como izquierda, secundaria a una alteración en la que el ventrículo debe esforzarse más para contraerse por tener que vencer un obstáculo como por ejemplo en la estenosis pulmonar valvular (estrechez de la apertura de la válvula que regula el paso de la sangre hacia los pulmones).

Sola, o en combinación con la dilatación, es causa común de cardiomegalia o crecimiento anormal del corazón.

En principio, su finalidad es mantener la tensión de pared, que, en virtud de la Ley de Laplace, es igual al producto de la presión intracavitaria por el radio de la cavidad dividido por el doble del espesor. El mantenimiento de la tensión de pared es necesario para evitar una dilatación progresiva de la cámara, y constituye uno de los principales mecanismos por el que el corazón se enfrenta a un aumento de la carga; este mecanismo es particularmente evidente en la sobrecarga de presión, como la que sigue a una hipertensión arterial o una estenosis aórtica. Pero también en casos de sobrecarga de volumen se produce cierto grado de hipertrofia ventricular, aunque en estos casos es «excéntrica», esto es, acompañada de dilatación de la cavidad. Por el contrario, en la sobrecarga de presión la hipertrofia es «concéntrica». 

Factores de riesgo La importancia de conocer qué factores se asocian a un mayor riesgo de desarrollar DPI radica en poder realizar una detección precoz que permita un tratamiento dirigido agresivo y temprano. Y lo que es más importante, una mejor estratificación del riesgo de los receptores que permitiría prevenir el desarrollo de DPI o disminuir su gravedad. En la literatura publicada al respecto, existen una serie de factores de riesgo consistentemente relacionados con el desarrollo de DPI. Dichos factores se pueden categorizar en factores del donante, del receptor y de la técnica quirúrgica. 

Factores del Receptor

Existen varias características del receptor que se han asociado con el desarrollo de DPI, pero en muchos casos la evidencia existente era inconsistente e incluso contradictoria. Recientemente, se ha publicado un metanálisis con la intención de precisar, incluso de forma cuantitativa, cuales son las características del receptor que se asocian a un riesgo aumentado de desarrollar DPI en el postoperatorio inmediato del TP37. En dicho metanálisis se han incluido 13 estudios, lo que supone un total de 10042 pacientes. Los resultados de este estudio muestran que el sexo femenino, la raza negra, el índice de masa corporal, el diagnóstico de FPI, sarcoidosis o HAP primaria y una presión de arteria pulmonar media (PAPm) elevada, se asocian significativa y consistentemente a un mayor riesgo de desarrollar DPI37. Se desconocen los posibles mecanismos que explican estos hallazgos. Alguna de las teorías sobre los resultados diferentes en función del sexo abogan por la influencia de factores inmunitarios y hormonales. 

Factores del Donante

Factores de la Técnica Quirúrgica

El tipo de trasplante (unilateral vs. bilateral) no ha demostrado tener ninguna relación con el desarrollo de DPI. Sin embargo, en estudios con tamaños muestrales pequeños puede existir confusión ya que el uso de circulación extracorpórea (CEC) o el porcentaje de pacientes con HAP es mayor en los trasplantes bilaterales. Sí son factores de riesgo el uso de CEC, probablemente en relación a la activación de la cascada inflamatoria con liberación de citoquinas y activación del complemento, y la politransfusión.

Prevención y Tratamiento

El Óxido Nítrico Inhalado (ONI )

Uso de CEC

La reintroducción progresiva del flujo sanguíneo.

Uso de una estrategia de ventilación protectora.

membrana de oxigenación extracorpórea (ECMO)

CONCLUSIONES El VD, con su compleja geometría y sus mecanismos de adaptación únicos en las CC, continúaplanteando un verdadero reto a los cardiólogos deadultos. El mantenimiento de una función adecuada del VD y evitar la dilatación excesiva de esteson esenciales tanto si se encuentra en una posiciónsubpulmonar como si tiene una posición sistémica,e influyen en la capacidad de ejercicio y la morbimortalidad a corto y largo plazo. Aunque las intervenciones hemodinámicas para reducir la sobrecarga de volumen producida por la IT o la IPparece que aportan una mejora hemodinámica y dela clase funcional, continúan produciéndose cambios en cuanto al momento adecuado para practicarla cirugía valvular. En estos pacientes, lo más adecuado es que cardiólogos expertos en cardiopatíascongénitas en el adulto realicen evaluación y seguimiento en centros experimentados. Los nuevos tratamientos como los DAI y la TRC parecen prometedores en los casos de insuficiencia del VDsistémico, aunque son necesarios más estudios alrespecto. 

REFERENCIAS

1. González-Fernández C, González-Castro A, Rodríguez-Borregán JC, et al. Pulmonary venous obstruction after lung transplantation. Diagnostic advantages of transesophageal echocardiography. Clin Transplant. 2009; 23:975-80. 

2. Fadel BM, Abdulbaki K, Nambiar V, et al. Dual thrombosis of the pulmonary arterial and venous anastomotic sites after single lung transplantation: role of transesophageal echocardiography in diagnosis and management. J Am Soc Echocardiogr. 2007; 20: 438. 

3. McIlroy DR, Sesto AC, Buckland MR. Pulmonary vein thrombosis, lung transplantation, and intraoperative transesophageal echocardiography. J Cardiothorac Vasc Anesth.

[ssta2]

#흉터커버업 #당일타투 가능 https://www.instagram.com/p/Cdr-_y-paPm/?igshid=NGJjMDIxMWI=