text:
in: Trope, Pages with broken file links, Superhero Tropes,
Standard Superhero Suits
This Index Is Not an Example
Costume Tropes
Brought To You By The Letter S
Brought to You by The Letter "S"
File:Superman character logo 7359.jpg
"Nice 'S'."
Kari: What does the 'S' stand for?
Syndrome: For, uh... sitter. Yeah, sitter. Originally I was gonna use the initials for 'Baby Sitter' but then I'd be going around with a big ol' 'BS!' And you understand why I couldn't go with that...
—Jack-Jack Attack
Superheroes are in many ways much like athletes. Both frequently perform amazing physical feats we envy; both often collect themselves into teams with fancy names; both wear colorful, form-fitting uniforms.
And both have a tendency to adorn those uniforms with single letters of the alphabet. Stumped for a Chest Insignia? Just style up the first letter of your Code Name in sufficiently distinctive typeface, and have at it!
Examples of Brought to You by The Letter "S" include:
3 Fan Fic
7 Professional Wrestling
10 Web Animation
11 Web Comics
12 Web Original
Ichi of Ichi the Killer wears a big "1" on his back, since his name means "one" in Japanese.
Similarly, Ah! My Goddess's Keiichi, when he took part in the drag bike race, wore a jacket with "K-1" on the back. In the manga, he frequently signs his notes that way, as shorthand.
Mazinger Z: Although the original series avoided this, in later retellings and spin-offs Mazinger-Z wore a big "Z" letter in such the chest, the Hover Pilder or the Jet Scrander.
The big red R for Rocket of Team Rocket, general bad guys of the Pokémon series. Of course, there's also Teams Magma, Aqua, and Galactic - these three use a font style that's a bit more original, but there's still the 'M', 'A', and 'G'.
Team Rocket had a form of Lampshade Hanging of this in an episode. They set up a fake Pokemon Center by covering part of the letter 'R' painted on the wall with a piece of paper, making it look like the 'P' associated with Pokemon Centers.
Gai Shishioh from GaoGaiGar wears a large "G" on the right side of his chest.
"G" is for the entire Gutsy Galaxy Guard. "J", likewise, is for the J-Ark Fleet, manned by Soldat J cyborgs. In both cases, the letter appears inside their Power Crystals (the G-Stone and the J-Jewel) when they get a powerup.
"G" is for... Speed Racer, because his name in the original anime is Go Mifune (he also wears an "M" on his helmet to represent Mifune Racing). His girlfriend Trixie has an "M" on her blouse, for Michi Shimura.
The late 80's comic version of Speed Racer by NOW Comics claimed that the "G" stood for Greg, which was Speed's real name in the comic (making him Greg Racer).
Chargeman Ken has a large letter "K" on his orange sweater.
Bleach's Ichigo Kurosaki has a 15 on his room's door. It becomes kind of a pun if you realize "Ichi" is 1 and "Go" is 5. Plus he's 15.
His sister refers to him as 'Ichi-nii', which, while short for 'Ichigo-niisan' (big brother Ichigo), is also similar-sounding to ichi-ni, which translates as "1-2". Ichi-niisan itself sounds a lot like ichi-ni-san, which is "1-2-3".
The Straw Hat Pirates of One Piece periodically wear shirts featuring numbers significant to them:
Luffy wears a '01' because he is captain or a '56' which reads 'go-mu'.
Zoro, next in command wears '02'
Nami wears a '03' as well as '73' (Na-mi)
Usopp wears a '04'
Sanji sports a '05' as well as '32' (San-ji) and '56' (Ko-kuu/kokku)
Dr. Minami in Heroman has an M on his shirt. Wonder why.
In Future GPX Cyber Formula, all the cars have numbers throughout the series.
The "S" in later Asurada models stands for "Sugo", the racing team the main character, Hayato is in. Shoemacher/Osamu in 11, also has the letter "S" in his racing suit. And Kaga's racing suit has the letter "Z" in it, as he belonged to Aoi ZIP formula.
Some of the team logos also has letters in it, like the "S" for Sugo and "Z" for Aoi ZIP.
"A" is for Action Kamen, though it's on his belt only. The Spanish dub completely ignored it and called him "Ultrahéroe".
In The DCU ...
"A" is for Aquaman (and Aqualad) and Animal Man. Anarky also wears this letter, though as part of the "Anarchy-is-order" Circle-A.
"E" is for Element Lad.
"G" is for Green Arrow—some artists draw his belt buckle with a noticeable "G" shape.
When his former sidekick, Speedy/Arsenal/"Red Arrow", adopted a red version of GA's costume, it included the "G"-shaped buckle at first. When the moniker "Red Arrow" became official, the belt buckle became a distinct "R".
"GG" is for Guy Gardner, during the period when he was operating as a superhero (using Sinestro's yellow ring) with no codename other than his own name.
"Remember when Guy used to fly around with that big G on his jacket?"
"Remember what he said it stood for?"
"Yeah. 'Girl-magnet'."
"GF" is for Geo-Force.
"i" is for Invisible Kid.
"L" is for the Legion of Super-Heroes - many Legionnaires (in the post-Zero Hour Reboot, all of them) have an L-logo belt buckle. The classic Legion flight ring also has an L. Un-boot Lightning Lad even has an L-logo tattoo.
"P" is for Phantom Girl.
"R" is for Robin. The resemblance of the original "R" logo to the official "registered trademark" symbol is uncanny, and has been the source of some humor in the past.
'Registered Sidekick—all rights reserved'...
"S" is for Superman (and "family"). He may possibly have been the Trope Codifier, since he is such a prominent example. Bizarro uses a reversed (twisted in the DCAU) "S".
Oddly enough, Superman's Jewish parody Shalomman uses the Hebrew letter shin, which is the initial letter of the word "Shalom." His bizarro-equivalent had the Hebrew letter sin, which in addition to being a shin-with-a-backwards-dot also made a pun on the word "sin."
No, Superman, the "S" does not stand for Shakespeare!
"S(blank)" is for too many homages/parodies of Superman to count.
In the 1978 film they make it clear that the reason for the S symbol is that traditional Kryptonian garb always included a chest insignia with a family seal on it, and the seal of Jor-El's clan just happened to look kind of like what we think of as the letter S. This is why Superman's outfit has that symbol on it already when it was made out of the rags he was swaddled in when he arrived in the crashed spaceship from Krypton even though it wasn't until later when the media gave him the moniker "Superman".
In 52 Ralph Dibny reveals that the S is actually the Kryptonian symbol for the word "hope". Upside-down, it means "resurrection".
Superman once defeated a Proud Warrior Race Guy called Draaga in gladiatorial combat on Warworld. In the comics, Draaga wore a replica of Superman's costume, while on the Justice League cartoon he actually burned an "S" symbol onto his chest - in both cases this was so he wouldn't forget his failure.
"T" is for Tasmanian Devil (of the Global Guardians and Justice League Europe) and Red Tornado. The current Mr Terrific has a T-shaped mask. Well, unless that's just facepaint.
"W" (and occasionally "WW") is for Wonder Woman, when she's not using an eagle insignia. In a few continuities, like Kingdom Come, the two are combined: a stylized eagle that happens to resemble a W.
"Z" is for General Zod - at least the Polkistanian version.
In the Legion of Super Heroes "Z" is also for...well, the guy wearing it is named Drax, but considering Drax is a kid from the Phantom Zone, a safe guess would be "General Zod," presumably his father figure.
Depending on the costume, the Elongated Man has an E and an M.
Perhaps depending on how far his costume is stretched?
"F over A" is for The First American from Alan Moore's Tomorrow Stories, published by America's Best Comics, an imprint of Wildstorm Comics.
"Ω" (Omega) is for Omega Effect, so Darkseid's most recent costume has a Greek letter Ω as a Chest Insignia.
The Chinese character for the number "7" is for the Great Ten's Seven Deadly Brothers.
"?" is the Riddler.
In the Marvel Universe ...
"A" is for Captain America (on his head) and Apocalypse (on his belt buckle).
"D" is for Demolition Man (sometimes just called "D-Man"). Two means Daredevil... though this gets a little complicated when you realize that Daredevil's original costume really did have the one "D", and is in fact the very same costume worn by D-Man.
"F" is for Flatman, a member of the less-than-astounding Great Lakes Avengers X-Men Champions Initiative.
"G" is for Galactus (on his belt buckle in his first appearance).
"H" is for Hawkeye. And Hardball.
"I" is for Mr Immortal, the Man Who Can't Die No Matter How Much He Really Wants To, and leader of the aforementioned Great Lakes Initiative. His 'I' is in multiple places, with 'Mr.' written inside the letter itself, since it's just a big rectangle anyway.
"N" is for Nomad.
"P" is for Puck (of Alpha Flight).
"S" is for Sentry (on his oversized belt).
"T" is for Thor (sometimes — it's on his belt buckle in the Silver Age) and, by extension, Thunderstrike.
These days, Thor's belt buckle is the rune uruz (basically the letter "u"), because the Uruz rune was traditionally used to represent the god Thor. It also represents strength and virility. In addition, "u" stands for "uru", from which Mjolnir is made.
"W" is for Wonder Man (when he's not using Civvie Spandex).
"X" is for the X-Men's "x-factor" or "extra factor" in their mutated genes.
Not a letter, but each member of the Fantastic Four goes into battle with a large "4" emblazoned somewhere on their uniform.
"MM" is for Miracleman/Marvelman.
Jughead Jones typically wears a sweater with the letter "S" on it...the meaning of which is known only to Jughead.
In Johnny Saturn the Utopian, as an example, wears a stylized "U" on his chest. A variation of this would be Titanium Tom, who wears a patch on each shoulder with Ti—the symbol for titanium.
The revived Darkwing Duck comic books featured many Darkwings. If they were Darkwing versions of other heroes, they'd have a 'DW' or 'D' on them (such as the Incredibles version). One exception is a result of the entry under Western Animation; one of the infinite Darkwings took over Gosalyn's identity of Quiverwing Quack.
In Son o' God comics, Jesus wears spandex with a cape and a "JC" on his chest.
In All Fall Down, S is for Siphon and P is for Paradigm.
Fan Fic
Holographic Retro of Calvin and Hobbes The Series has an "H" on his forehead.
In The Incredibles:
"i" — distinctly lowercase with a prominent dot — is for Mr. Incredible, and later his whole family.
"EG" is for Elasti-Girl; she dropped this after the intro of the movie, for plot-explained reasons.
"S" is for Syndrome.
"G" is for G-Girl, from My Super Ex-Girlfriend. G-Girl was notable for not having just one costume but (being a hip New Yorker) a whole closetful, each distinguished only by a "G" motif.
Interestingly, she never explains what the G stands for.
"1" in an "engraved" style similar to that on the one dollar bill for U.S. Bill of The Specials.
"M" is for both Megamind and Metro Man. After Metro Man faked his death he chose to change his name to "Music Man" and pursue a career as a singer.
In Harry Potter, Mrs. Weasley gave her sons knitted sweaters with letters on them one Christmas. P for Percy (or "Prefect" if you ask Fred or George), F for Fred and G for George. On the other hand...
'You haven't got a letter on yours [Ron],' George observed. 'I suppose she thinks you don't forget your name. But we're not stupid — we know we're called Gred and Forge.'
And in the movie at least, Ron gets one with "R" on it.
The eponymous letter in The Scarlet Letter. It's a red 'A', which is supposed to stand for "adulteress", but since Hester, the woman sentenced to wear it, is so helpful to the people in her community, they start to believe it stands for nicer things, such as "admirable".
"?" is used by the Fourth, Fifth, Sixth and Seventh Doctors in Doctor Who, possibly related to the fact that his signature contains a question mark.
The Cybermen of series 2 and the 2008 Christmas Special feature a 'C' on their chests, standing for Cybus Industries, the organization that created them. The Doctor lampshades this, saying that they have been 'franchised'. The Cybermen that appeared in "The Pandorica Opens" still used this design, despite being the original Mondas Cybermen, due to budget issues.
"CH" is for Chapulin Colorado.
"G" is for Super Grover.
"V" is for Major Victory, a season 1 contestant on Who Wants to Be a Superhero?.
From Kamen Rider:
"V3" is for Kamen Rider V 3 (the 3 is tiny on his belt buckle, but it's there)
"X" is for Kamen Rider X
"S" is for Kamen Rider Stronger, with "T" used in sidekick Tackle's breast designs.
"RX" is for Kamen Rider Black RX
In a non-Latin example, the Greek letter "Phi" is for Kamen Rider Faiz.
"Chi" is for Kaixa
"Delta" is for Delta
"Rho" is for Riotrooper
"Psi" is for Psyga
"Omega" is for Orga
Kamen Rider Decade, celebrating the 10th year of the show's Heisei era, sports an "X" for 10.
"W" is for Kamen Rider Double (the Japanese often use the letter "W" as a shorthand for the word "double"). All the show's Riders and Monsters of the Week fall under this trope, as their Transformation Trinkets bear a letter made from a stylized representation of whatever power they possess.
"A" is for Accel, Anomalocaris, and Arms.
"B" is for Bird, Beast, Bomb, Bean, and Bat.
"C" is for Cyclone, Claydoll, Cockroach, and Commander.
"D" is for Death and Dummy.
"E" is for Eternal, Engine, Edge, Energy, and Eyes.
"F" is for Fang.
"G" is for Gene.
"H" is for Heat and Hopper.
"I" is for Ice Age and Invisible.
"J" is for Joker, Jewel, and Jazz.
"K" is for Key.
"L" is for Luna, Liar
"M" is for Metal, Masquerade, Magma, Money, and Memory.
"N" is for Nasca and Nightmare.
"O" is for Old and Ocean.
"P" is for Prism and Puppeteer.
"Q" is for Quetzalcoatlus and Queen.
"R" is for Rocket.
"S" is for Skull, Smilidon, Sweets, and Shinigami Hakase.
"T" is for Trigger, Trial, Terror, Taboo, T-Rex, and Triceratops.
"U" is for Utopia and Unicorn.
"V" is for Virus and Violence.
"W", besides Double, is for Weather.
"X" is for Xtreme.
"Y" is for Yesterday.
"Z" is for Zone.
Non-superhero example: In Laverne and Shirley, "L" is for Laverne DeFazio. She has a cursive "L" on every blouse, shirt and sweater she owns. This was carried over to her military uniform in the Animated Adaptation.
In the 1970s PBS children's series The Electric Company, a recurring cartoon feature, "The Adventures of Letterman", had the eponymous hero sporting a different letter on his "varsity sweater" each episode; his power was the ability to change one object into another by replacing a letter in its spelling. When his arch-enemy, the Spellbinder, fired a dart at him, Letterman replaced the 'd' with a 't', turning it into a tart, which he then ate.
The Ambiguously Gay Duo have G for Gary and A for Ace. Unsurprisingly, there happened to be times when they had to stand next to something large and Y-shaped.
Betty Suarez of Ugly Betty wears an identical "B" necklace.
From Super Sentai and Power Rangers:
The members of Goranger all wear belt buckles shaped like a "5" (as in "Go" for five), while each of their helmets are individually numbered from 1 through 5.
The four main members of J.A.K.Q. wear belt buckles shaped like a "J", as well as individualized helmets and badges engraved with the first letter of their respective "rank" (Jack, Ace, King and Queen). Big One wears a belt buckle shaped like a "B1" and a helmet with a "1" engraved on it.
"BF" is for Battle Fever on the chest of the Battle Fever Robo. The individual members of the team have the first letters of their respective countries engraved on their belt buckles as well (Japan, America, Kenya, France and Cossack, who represents the Soviet Union[1]).
"D" is for Denziman, with the letters on the belts for "I [color]" (i.e. Denzi Red has "IR", Denzi Blue has "IB", ect.). The "I" is actually the left half of the letter "D" that forms the main emblem on their badges.
Sun Vulcan has a general "V" design that stands for "Vulcan". The Sand Vulcan jeep is also adorned with the letters "SV" as well.
The members of Goggle-V all wear a badge with a "V" symbol (a roman numeral five), as well as belt buckles with "GV" engraved.
"D" is for Dynaman on their badges, plus a roman numeral and "D[letter]" for Dyna[color] on their helmets.
"CM" is for Changeman on their belt buckles and gloves.
"FM" is for Flashman on their belt buckles.
Subverted by the "5" in Hikari Sentai Maskman, which doesn't stand for anything despite appearing prominently on the chest of each member (it was an artifact from when the show was going to be titled "The Fiveman").
"LM" is for Liveman on the waist of the Live Robo.
Another general costume design resembles "T" for Turboranger. We also have on their belt buckles: GT (for Grand Tourer) on Red, T (for Truck) on Black, J (for Jeep) on Blue, B (for Buggy) on Yellow and W (for Wagon) on Pink.
Another team with "V" costume designs can take it as the roman numeral for Fiveman. The symbols on their helmets are related to the Hoshikawa siblings' day jobs as school teachers: Five Red (a science teacher) has an atomic symbol, Five Blue (a gym teacher) has a figure of a running man, Five Black (a Japanese language teacher) has the kanji for 'language', Five Pink's symbol (who is a math teacher) is a combination of several mathematical signs (specifically of addition, subtraction, multiplication and division), and Five Yellow (a music teacher) has a quaver (or eighth note).
"Z" is for Zyuranger; not on the Ranger suits but on the backside of the belt buckles (visible on the civilian outfits) and on the mecha. When it shows up in Mighty Morphin Power Rangers (Season 1), it can be implied to mean "Zordon".
"D" is for Dairanger. Its counterpart, Mighty Morphin Power Rangers Season 2, dropped this but added a villainous version with "Z" for Zedd.
"N" is for Ninjaman (in Ninja Sentai Kakuranger) and Ninjor (in Mighty Morphin Power Rangers Season 3). Oddly, when Ninjaman powers up into Samuraiman he changes his emblem, yet it still resembles an "N" instead of an "S". (Power Rangers doesn't have this problem because Ninjor keeps his name in both forms.)
King Ranger had 王, the kanji for "king", on the face of his helmet and on his staff. It provides a Bilingual Bonus in Power Rangers Zeo.
"C" is for Carranger. (Power Rangers Turbo ignores this completely and it's just a generic logo.) Also (in both shows), "S" is for Signalman and Blue Senturion.
"M" is for Megaranger (again, just a generic logo in Power Rangers in Space). This also shows up on the mecha in non-logo forms, though the later ones' "MV" and "MW" (Mega Voyager and Mega Winger) do apply to Power Rangers as those names weren't changed. In addition, "N" is for Negiranger, but this also is ignored in the US as we call them the Psycho Rangers instead.
"H" is for Hurricaneger or, probably more accurately, Hayate Ninja Academy. (Once again, it doesn't stand for anything in Power Rangers Ninja Storm.)
"SPD" is for Special Police Dekaranger or Space Patrol Delta. They also have numbers on their chests, "1" to "5" for the main team and "100" and "VI" (6) for the extra members, plus the occasional One-Shot Character with a potentially odder number:
"M" (1000), which some also take in a roundabout way as 7 (M -> IVI -> VII).
One with no blatant number, but the design on the chest can be interpreted as "8", "白" (the kanji for "white" - which resembles 百, the kanji for a "hundred" minus one stroke, making her 99), or a heptagon representing seven.
Dekaranger only: "X" (10)
SPD only: A Ranger wannabe wears, appropriately enough, 0.
"M" is for Magiranger and Mystic Force. In the same series, "W" is for Wolzard and Knight Wolf and "S" is for MagiShine and Solaris Knight.
AkaRed, the living embodiment of every red ranger in history, originally wore a badge engraved with the number "30" during his first appearance in Go Go Sentai Boukenger vs. Super Sentai (which commemorated Sentai's 30th anniversary). This was updated to "35" when AkaRed returned as a semi-recurring character in Kaizoku Sentai Gokaiger (the 35th Super Sentai show).
The main Go-Ongers and RPM Rangers also have numbers 1-5 on their chests. There's also a "G" for Go-Onger in various places (including on the chests of the Sixth Rangers in place of a number), but it's another that's stylized enough to serve as a generic logo in RPM.
The Shinkengers and Samurai Rangers wear the appropriate Japanese kanji (火 fire, 水 water, 木 wood/forest, 土 earth, 天 sky, and 光 light) on the visors of their helmets.
"B" is for Basco in Kaizoku Sentai Gokaiger.
"GB" is for Go-Busters.
"A" is for Akibaranger- their logo is actually a combination of the letter A and the kanji 非, which means "non-" and is the first character in the Japanese word for unofficial, so it's sort of a bilingual example.
Seiun Kamen Machineman has "M" for the titular character, in both his superhero form and his Cool Car-Cool Plane vehicle.
"H" is for Hurricane, former resident superhero of the WWE. "R" is for Rosey, his boy (well, 300-pound Samoan who acts like a boy) sidekick.
"R" may have been Rosey's insignia once he graduated from sidekickery, but first he was a "Super Hero In Training" (S.H.I.T.).
Scott Steiner used the Superman S — actually the full Superman logo, until the expected legal action forced a change to an S in an ellipse.
In another non-superheroic example, during his WWE tenure, the number "13" was for Tazz. According to Tazz, the "13" represented the bad luck his opponents must have had to have drawn him as their opponent for the evening.
Some of Kurt Angle's singlets featured an "A" inside a Superman-esque shield, obviously standing for Angle. In his typical smartass fashion, The Rock came up with his own vulgar ideas of what the "A" stood for.
Yu-Gi-Oh!: H is for Elemental Hero, but D is for Destiny Hero and N is for Neo-Spacian (although just to be confusing, one Elemental Hero works with all Neo-Spacians). Not to mention that each of the letters of the word 'Hero' has its own card. Since one of them gets any Elemental Hero from the deck to your hand, and another Special Summons an Elemental Hero from the Graveyard, this could be a literal case of Brought To You By The Letter S (or in this case, E/O).
Akuma from Street Fighter has a winpose where the kanji for "heavenly sky" shines on his back, usually done after defeating an opponent with his Raging Demon super. It's pronounced "ten", by the way.
"M" is for Mario, "L" is for Luigi, "W" is for Wario, and logically enough, "Γ" (capital Gamma) is for Waluigi. All these symbols appear on characters' hats, rather than on their chests.
City of Heroes' ridiculously extensive costume creator gives you a choice of the entire uppercase Latin alphabet and figures 0–9. After six months of subscription, players get to access all letters of the Greek alphabet, uppercase and lowercase.
Although ironically for a superhero game, not many players follow this trope.
Klavier Gavin (Kyouya Garyuu in the Japanese version) in Apollo Justice: Ace Attorney has a G pendant.
DK! Donkey Kong! On his tie, uniquely enough, but it's also his only piece of clothing.
In Mega Man Zero, Copy-X wears a jacket that crosses over his chest like an X (as do his four Guardians) and Cyber-Elf X looks like a ball with a rainbow X around it, foreshadowing his identity. In Mega Man X 8, X's earpieces have X-shaped lights.
Marisa Kirisame's design in the 12th Touhou game, Undefined Fantastic Object, gives her an apron with a large "M" on it.
Hina Kagiyama, a curse/misfortune goddess, has a stylized kanji 厄 (yaku) on her dress, meaning "misfortune".
In Space Channel 5 Part 2, "P" stands for Purge.
Twilight Heroes features the "letter shirt" for its superheroes, which can be customized to show any capitalized letter in the English alphabet.
Picky Minch from Earthbound wears an M on his shirt, for "Minch". His clay model artwork shows a P on the shirt instead, probably for "Picky".
In Homestar Runner, "M" is for Strong Mad. Coach Z wears a medallion with a stylized letter "Z" on it.
"TH" is for Bubs' alter ego, the Thnikkaman.
In PS238, a Batman-like hero called The Revenant wears a stylized letter "R" on his chest.
Mister Mighty, of Everyday Heroes, of course wears a gold "M" in an oval.
His teammate, Dot Dash, wears a dot-and-dash on her chest; Morse code for the letter "A". This is one of the most convoluted Punny Name references ever: The dot is for her first name Dorothea, the dash is for her super-speed, the "A" is for her maiden name of Axel, and Morse code for her married name of Morse.
In The Inexplicable Adventures of Bob, after Bob very briefly becomes a Superhero and then loses his powers, he says his one real regret is that he used a permanent laundry marker to make the "B" logo on his shirt.
Evan from The Wotch always wears a shirt with a capital "E" on it. Lilly wears a dress with a lil' 'e' on it instead.
"50", as found on the back of America's jacket, stands for the 50 states, natch. This detail was removed in the anime.
Homestuck: When Kanaya imagines a troll version of Rose, she wears a dress with her initials, RL.
The actual trolls themselves are this as well, in a strange and roundabout way. The symbols the trolls wear on their shirts are twelve out of thousands which just so happen to coincide with our own zodiac symbols. Each color acknowledged by the hemospectrum has a library of hundreds of symbols associated with it; every troll is assigned one after they pupate, and they must wear it somewhere upon their person their entire lives. This symbol acts as a single-character signature for them and they may, in fact, sign documents with it.
'P' for Phase, in "Boston Brawl II" of the Whateley Universe. Since Phase is a density changer like the Vision, the 'P' starts out dense at the top and fades away at the bottom. Phase hates it.
'C' is for C the speed-of-light-octogenarian in Legion of Nothing.
'J' for Jock, a super-athlete with heightened reflexes from the Global Guardians PBEM Universe.
'E' for Embrace, a stretchable supervillain. Also for Echo, a superhero with ultrasonic powers.
'A' for Apex.
'V' for Velocity.
There's even one villain with a number: '8' for Eight-Ball.
'S' for Simon of the Yogscast in real life: He wears a distinctive blue Superman hoody. For a time in 2011, Simon's character Honeydew in the Yogscast Minecraft Series had a metallic S symbol over his chest, which Simon claimed was for Simon AND Superman.
In Neopets, most Aishas have collars with the letter 'A' on them. The Darigan-colored one has a 'D' instead, and the Snot-'colored' one has an 'S'.
"A" is for Alvin, as in Alvin and The Chipmunks.
"R" is for Richie Rich, at least as Hanna-Barbera animated him.
"M" is for Marvin White, the aspiring superhero in the first season of Superfriends.
"J" and "Z" are for Jayna and Zan, the Wonder Twins.
In the classic Bugs Bunny short "Super-Rabbit", "S" stands for Super too.
All Canadians on South Park have either the first letter of their name (T for Terrence, P for Phillip, etc.) or their position (f for fans at a football game) on their shirt.
I.R. Baboon from I Am Weasel has an upside-down "IR" scribbled on his shirt.
After fiddling around with casual outfits for José Carioca's comic book series, they eventually settled on a T-Shirt with a "Z" on it, for "Zé".
"8" is for Manic 8-Ball, a one-shot villain from The Venture Bros.
"DP" is for Danny Phantom (the "P" is inside the "D").
And Dani Phantom.
"F!" is for Freakazoid.
"H" (inside a male symbol) is for Captain Hero of Drawn Together. It's actually his real name, though (Leslie Hero).
"A?" is for a Canadian superhero appearing extremely briefly in an episode of Eek the Cat.'
"A" is for Atom Ant.
"C" is for Coil Man of the Impossibles and for Curly Howard of the Robonic Stooges.
"CR" is for Captain Rescue.
"D" is for Dynomutt.
"DM" is for Danger Mouse.
"F" is for Fluid Man of the Impossibles, for his namesake of the Super Globetrotters, for Frankenstein Jr. and for Blue Falcon.
"G" is for Gizmo Man of the Super Globetrotters; Inspector Gadget also has a few of these, most notably on his Gadget-mobile.
"L" is for Larry Fine of the Robonic Stooges (and "M" is for Moe and "C" is for Curly, of course(.
"M" is for Multiple Man of the Impossibles, for his namesake of the Super Globetrotters and for Moe Howard of the Robonic Stooges.
"Q" was (briefly) for Quiverwing Quack; Darkwing Duck's daughter really wants in on the family business.
"SD" is for Scooby Doo (on his engraved dog-tag).
"SG" for Super Goof as he appeared on House of Mouse and in the comics.
"U" is for Underdog.
"N" is for Captain N: The Game Master. It's actually a Varsity letter on a Letterman jacket, so In-Universe, it's more of a convenience that his school's name and the company that produced his favored console (and the fact that Videoland is populated pretty exclusively by characters from or inspired by that company's games) share an initial letter.
"KP" is for "Kim Possible". She doesn't wear the insignia, but it does appear on the screen of her Kimmunicator.
"M" is for the so-called Mysterious Mare Do Well of the alike-titled My Little Pony Friendship Is Magic episode, whose full-body costume includes a cloak clasp bearing the letter.
Anne Boleyn famously had a necklace with the letter B.
Many sports teams use this, particularly Major League Baseball. As of the 2012 season, only 4 teams do not have letters on their caps (Toronto Blue Jays, Houston Astros, Baltimore Orioles, Cleveland Indians) and all of those four at one point did but have since changed it.
↑ or is it CCCP?
Superhero Tropes


text:
Het arrest Chaussures Bally / België is een uitspraak van het Europees Hof van Justitie van 25 mei 1993 (zaak C-18/92),
inzake de maatstaf van de btw-heffing bij betaling met een creditcard, in verband met de commissie die dan wordt ingehouden.

Zesde btw-richtlijn

Casus en procesverloop

Deze rechter heeft het Hof verzocht om een prejudiciële beslissing.

Rechtsvraag
Moet bij een creditcard-betaling de af te dragen btw worden berekend over het brutobedrag (inclusief commissie) of over het nettobedrag (exclusief commissie)?

Uitspraak Hof
De verkoper dient btw af te dragen over de volle 100% van de verkoopprijs.

Tot besluit
Het maakt verschil als de creditcard-maatschappij, anders dan in België, geen btw-vrijstelling heeft voor de ontvangen commissies.

Chaussures Bally
Belastingrecht (Europese Unie)

redpajama_set_name: RedPajamaWikipedia


Whether you are a fresh graduate or a nurse with some experience, you can have a rewarding career in Ontario. The latest snapshot of the nursing field in Ontario shows that healthcare needs in the home and community are expanding at a fast pace. Moreover, there is now a greater emphasis on illness prevention and general well-being. It is worth mentioning here that currently, Ontario has a ratio of 72 nurses for every 100,000 people. This does not meet the required national average of 83 nurses for every 100,000.
The good news is that if you are aspiring for a nursing career in Ontario, the prospects and opportunities are now brighter than ever before.
The 'Nursing Strategy' is an initiative by the Government of Ontario that focuses on tackling any kind of instability in the nursing workforce. They look after a number of fronts including the full employment of nurses. To ensure this, the government funds a number of nursing employment programs like the Nursing Graduate Guarantee. This initiative ensures all nursing graduates, be it RNs or RPNs, work for a minimum of 12 weeks.
Due to Ontario's fabulous geography, diverse population, and world-class health care system, it has become a hub of nursing professionals, offering tremendous growth opportunities for nurses from all over the world.
Generally referred to as ONA, this nursing union represents over 55,000 registered nurses, 12,000 nursing students and allied health professionals. These professionals practice in hospitals, public health, long-term care facilities, clinics and more.
Another renowned nursing association is Registered Nurses Association of Ontario (RNAO). This association represents over 29,000 registered nurses in Ontario. It is regarded as one of the most influential associations for promoting nursing excellence. The association lobbies for public health policy, and influences decisions that affect nurses and the public they serve.
This governing body represents around 145,000 registered nurses (RNs) and registered practical nurses (RPNs) in Ontario. The association plays a crucial role in implementing standards of nursing practice, sets the requirements that define the entry criteria to the profession, and assures quality of practice and conducts continuing education of nurses.
If you want to study nursing in Canada,Ontario offers the best prospects. To know more about available nursing programs in Ontario, keep exploring our website.


text:
Elements Massage South Mesa features exceptional staff
Elements Massage Features Exceptional Staff
A big part of the program excellence at Elements Massage South Mesa is finding and training exceptional massage therapists and team members to become an integral part of their client-centric mission. Franchise owners Ron and Troy Suzanne Gatza have put together a focused team that includes studio manager, Amanda Hartline and massage therapist Stephanie Rodriguez.
Studio manager Amanda Hartline has been with Elements Massage since shortly after the location opened in 2015. "At the time, I was just leaving a big corporation," she explains. "I was looking for something that was more comfortable. Troy had called me to do an informal interview, and after our conversation I felt like we were best friends." It is that kind of warm, upbeat and professional style that permeates every facet of Elements Massage.
As the studio manager, Hartline handles all customer feedback and concerns. "We have what is called, 'Listen 360' where feedback is sent and service is rated from 1 to 10. Anything 8 or below, we will reach out to that person. I reach out and find out what we can do differently." She also handles staff scheduling, client booking and vetting potential employees and training. "I totally love what I do," says Hartline, who received much of her management training at a well-known local salon and spa. "I love that clients are put first. Every decision that is made here – it isn't 'What can we do to make more money?' it's 'What can we do to make the client happy?" The owners also highly value their staff at Elements Massage South Mesa, which now counts 13 massage therapists on its staff, including Stephanie Rodriguez who began working at Elements Massage seven months ago.
"I became aware of Elements through my massage school," says Rodriguez, who received her education at Cortiva Institute of Massage Therapy. "The franchise representatives used to come in and talk to the students. To me, Elements sounded like a place where the employees were appreciated and valued and that's why I was interested. I had seven job offers before I took this one!"
Rodriguez does several different massage modalities. "I mostly do deep tissue, but I do a variety of things - deep tissue, Swedish, myofascial, trigger point therapy, pain management and injury treatment. A lot of my training is more medically massage based. I like to work here because we get to customize everything that we do. When a person comes in and they have a problem, I like that I can solve it for them."
Hartilne adds, "We always say, 'Here at Elements, we customize our massage to best suit you.' So they kind of have a heads up about why we ask them questions." When someone calls or comes in to book a massage, they are asked what type of massage they would like, if they've had massage therapy before, what kinds of issues they are having and if they would prefer light, medium or firm pressure. "We work as a team," states Rodriguez. "If I can't give someone exactly what they need but I know that another therapist can, I will refer them."
Elements values and requires ongoing training and education for its therapists. Rodriguez states, "We are doing training sessions monthly in-house and the franchise requires us to do six of them per year. Then we have continuing education credits, so every therapist is offered 24 hours of continuing education credit a year when they start."
With more than 222 locations throughout the United States and 13 in the Valley, Elements Massage is an upscale and professional establishment that welcomes its clients in like family and offers the finest in massage therapy treatments. The Greenfield location includes 13 massage therapists that offer sports massage, couples, deep tissue, Swedish, pre-natal, oncology, Reiki, trigger point, hot stone and energy work. Regardless of how you need your massage therapy, the trained, licensed and caring professionals at Elements Massage will have you feeling relaxed and rejuvenated with each visit. As an added bonus, for clients who are pregnant or who have had surgery, there is a special table that includes strategic "cut outs" to allow for the highest level of comfort and convenience.
Elements Massage is located at 1705 S. Greenfield Rd., Mesa. To book an appointment, visit http://elementsmassage.com/south-mesa or call (480) 719-7199.

redpajama_set_name: RedPajamaCommonCrawl


text:
<?php

namespace common\models;

use Yii;
use \common\models\base\Pago as BasePago;

/**
 * This is the model class for table "pago".
 */
class Pago extends BasePago
{
}

redpajama_set_name: RedPajamaGithub


text:
The Sadism of American Power
It was just a couple of weeks ago that President Trump was both inciting and praising anti-lockdown protesters around the country. These included armed white militia men who stormed state capitol buildings demanding an end to public health measures to curb the spread of the deadly Covid-19 virus. Many of them were filmed harassing nurses and blocking ambulances from reaching hospitals, but to Trump they were all just "good people." He did this all while the deaths in the US from the pandemic lurched toward the 100,000 mark, the highest recorded death toll for any nation on the planet.
But in just the span of a few days Trump's rhetoric shifted. After the sadistic murder of George Floyd by a police officer in Minneapolis, he labeled the protesters against police brutality "thugs" and tweeted "once the looting starts the shooting starts." A clear call for state violence. Floyd was a Black man who was accused of using a $20 counterfeit bill. For this he was handcuffed and pinned to the ground by several white officers. One of them, Derek Chauvin, kneeled on Floyd's neck for an agonizing 8 minutes and 46 seconds, as he gasped for air, begged for his life, and called out for his late mother. At no time did Floyd appear to be resisting and bystanders pleaded with the officers to stop their assault. Chauvin continued to kneel on Floyd's neck for 2 minutes and 53 seconds after he lost consciousness.
Trump's shift in tone regarding the protests of this horrific act of brutality shouldn't come as any surprise. One of his most consistent traits has been to incite violence. At his rallies he has reveled in ridiculing the most vulnerable and has encouraged his feckless fans to "beat the crap" out of those who oppose him. "The man who once said that he "could stand in the middle of Fifth Avenue and shoot somebody and I wouldn't lose any voters" was not kidding. More recently, Trump threatened protesters against police brutality outside the White House:
"The front line was replaced with fresh agents, like magic. Big crowd, professionally organized, but nobody came close to breaching the fence. If they had they would have been greeted with the most vicious dogs, and most ominous weapons, I have ever seen. That's when people would have been really badly hurt, at least. Many Secret Service agents just waiting for action. 'We put the young ones on the front line, sir, they love it, and … good practice."
But Trump is the odious symptom of a grave disease. One which has inflicted far more damage than any virus. The systemic violence of the American project has always been rooted in sadistic racism. For instance, the demonstrations that formed after the footage of George Floyd's killing was released were largely non-violent. Despite this, they have been met with the full force of state violence. Police used tear gas, pepper spray, flash grenades, and rubber bullets, not only at protesters but also members of the press. One Black reporter for CNN was arrested while his white colleagues were not despite them being together. There were also many credible reports of agents provocateurs among the protesters. One video shows a white man in a gas mask smashing windows. The US Customs and Border Patrol even flew one of its predator drones around Minneapolis amidst the protests. Like the tanks used at Standing Rock, this is an ominous sign that America's war machine, that has made life a misery for millions abroad, is being turned inward.
There were no such police responses to the anti-lockdown protests which were composed mostly of white people. On the contrary, multiple videos show cops gently dealing with unruly white protesters despite many of them wielding assault rifles. It is a textbook example of structural racism at work. Given the armed nature of these demonstrations, one would guess that had there been a forceful approach by the police they would have been far more destruction than the "I Can't Breathe" protests in Minneapolis and other US cities.
Trump's blatant racism and belligerence are not anomalies to American culture. And those tempted to say "this is not us," yet again, should pause before doing so. At a certain point there must be a reckoning to what America started out as and what it has become. The United States was founded upon white supremacy and violence. And it is not something of the distant past. Its tendrils reach deep into the very fabric of American society today.
Like all colonial empires, sadism has always been the driving force of American power. Not freedom. Not liberty. From genocide of the native population to centuries of slavery, from Jim Crow and the internment of Japanese citizens, from the carpet bombing of Vietnam, Laos and Cambodia to drone strikes in Afghanistan and Somalia, from Wounded Knee, to the Trail of Tears, to the Tulsa Massacre, to My Lai, to Abu Ghraib, to Guantanamo, the message has always been one of coercion through sadistic cruelty and violence. It explains how 48% of Americans can justify torture. It explains how so many Americans can easily forgive their war criminals. It explains how the US military could use Agent Orange, and white phosphorus, and depleted uranium in its warfare. It explains how immigrant children can be separated from their parents with nearly 70,000 of them held in squalid detention camps. And it has always thrived on supremacy. This is demonstrable in its abysmal response to the pandemic. Most of the victims in the US are people of color, immigrants, Native Americans, and the poor. It is no accident that they are being forced back to work in many states and abandoned to die should they become ill.
The knee that mercilessly crushed the neck of George Floyd is the same knee that has crushed the global south everywhere, both in the US and abroad. The US is not alone in this, but it surpasses every one else in terms of capital and brute strength. To think that Trump is some kind of glitch is both ahistorical and ludicrous. Indeed, there have been scores of Trumps throughout the bloody history of the US and before. There are scores of them now, and many in positions of power, from the military, to ICE, to the CBP, to the judiciary, to the police, to correctional officers, to corporate executives. Trump has definitely emboldened them. But, in truth, they do not need much encouragement to begin with, because there is a long legacy of barbarism for any of them to draw from.
Kenn Orphan May 2020
This entry was posted in Archived on May 30, 2020 by Kenn Orphan.
← A Pandemic and a Plague of Absurdity Preaching Non-Violence from a Legacy of Violence →
3 thoughts on "The Sadism of American Power"
Raymond McConnie Sapater June 3, 2020 at 4:07 pm
After his long stay in the SouthWest of the USA, D.H. Lawrence concluded that every of American white male is a muderer at heart. The other literary figure to cast aspersions on the USA after a cross country trip almost one-hundred years ago was George Bernard Shaw – it is revelatory to see a nation go from barbarism to decadence without any intervening period of civilization. And, that's a mild putting off of their own British ancestors and cultural legacy in North America.
Mankh June 1, 2020 at 11:55 am
Article sharply highlights the hypocrisy and the systemic roots of the problems. And speaking of roots, the Minnesota police officer's last name is Chauvin; so maybe his whole family isn't like this but…. here's what the etymology says "1840, "exaggerated, blind nationalism; patriotism degenerated into a vice," from French chauvinisme (1839), from the character Nicholas Chauvin, soldier of Napoleon's Grand Armee, who idolized Napoleon and the Empire long after it was history, in the Cogniards' popular 1831 vaudeville "La Cocarde Tricolore." The meaning was extended to "excessive belief in the superiority of one's race" in late 19c. in communist jargon, and to (male) "sexism" in late 1960s via male chauvinis".
catherine doucet June 1, 2020 at 11:50 am
It's the sad truth in America, but elsewhere, the same dynamic proliferates. Violence to legitimize power through dissimulation, unification/fragmentation and reification. Thompson's modes of operation of ideology are in play around the world but certainly the US takes center stage.


This is where it all began for Chrome Unboxed. Years ago, we existed simply as a Chrome OS device review channel on YouTube. After expanding our reach, we still remain dedicated to offering timely and thorough reviews of the latest Chrome OS devices. Here you'll find a review of every piece of Chrome OS hardware we've been able to get our hands on.
Lenovo Smart Display: Is Google Home Better With A Screen?
Back at CES in January of this year, Google unveiled the Smart Display initiative. With brands like Lenovo and JBL on board, we were treated to a walk-through and sample use of the Lenovo Smart Display and what Google's vision for Google Home with a display could be.


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Division of the N2 Stage According to the Multiplicity of the Involved Nodal Stations May be Necessary in the N2-NSCLC Patients Who are Treated with Postoperative Radiotherapy
Hong In Yoon, Yong Bae Kim, Chang Geol Lee, Ik Jae Lee, Songyih Kim, Jun Won Kim, Joo Hang Kim, Byung Chul Cho, Jin Gu Lee, Kyung Young Chung
DOI : https://doi.org/10.3857/jkstro.2009.27.3.126
J Korean Soc Ther Radiol Oncol > Volume 27(3); 2009 > Article
The Journal of the Korean Society for Therapeutic Radiology and Oncology 2009;27(3): 126-132. doi: https://doi.org/10.3857/jkstro.2009.27.3.126
1Department of Radiation Oncology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea. ikjae412@yuhs.ac
2Department of Medical Oncology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea.
3Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea.
We wanted to evaluate the prognostic factors for the pathologic N2 non-small cell lung cancer (NSCLC) patients who were treated by postoperative radiotherapy.
We retrospectively reviewed 112 pN2 NSCLC patients who underwent surgery and postoperative radiotherapy (PORT) From January 1999 to February 2008. Seventy-five (67%) patients received segmentectomy or lobectomy and 37 (33%) patients received pneumonectomy. The resection margin was negative in 94 patients, and it was positive or close in 18 patients. Chemotherapy was administered to 103 (92%) patients. Nine (8%) patients received PORT alone. The median radiation dose was 54 Gy (range, 45 to 66), and the fraction size was 1.8~2 Gy.
The 2-year overall survival (OS) rate was 60.2% and the disease free survival (DFS) rate was 44.7% for all the patients. Univariate analysis showed that the patients with multiple-station N2 disease had significantly reduced OS and DFS (p=0.047, p=0.007) and the patients with an advanced T stage (> or =T3) had significantly reduced OS and DFS (p<0.001, p=0.025). A large tumor size (> or =5 cm) and positive lymphovascular invasion reduced the OS (p=0.035, 0.034). Using multivariate analysis, we found that multiple-station N2 disease and an advanced T stage (> or =T3) significantly reduced the OS and DFS. Seventy one patients (63.4%) had recurrence of disease. The patterns of failure were loco-regional in 23 (20.5%) patients, distant failure in 62 (55.4%) and combined loco-regional and distant failure in 14 (12.5%) patients.
Multiple involvement of mediastinal nodal stations for the pN2 NSCLC patients with PORT was a poor prognostic factor in this study. A prospective study is necessary to evaluate the N2 subclassification and to optimize the adjuvant treatment.
Key Words: Non-small cell lung cancer, Mediastinal nodal metastasis, Postoperative radiotherapy, Multiple station involvement


Undergraduate Commencement Exercises Program, August 8, 1941.
Bryant University Undergraduate Commencement Exercises Program, August 8, 1941.
University, Bryant, "Undergraduate Commencement Exercises Program, August 8, 1941." (1941). Bryant University Commencements. Paper 173.


text:
Alison Pullen
Alison Pullen has exhibited with Quantum Contemporary Art since 1999. She studied at the Norwich School of Art and then the Royal College of Art, graduating in 1993. She has been commissioned by the Royal Mail, the St Helier Opera House in Jersey, Transport for London and the Ionian Bank. She has also painted interiors of the Museum of London and several rooms inside the V & A. After completing a commission of the interior of the Throne Room in Buckingham Palace, Alison Pullen went on to become Artist in Residence at the National Trust's Osterley Park House. She has also painted the interiors of the Bodleian Library and Christchurch Cathedral in Oxford, Peterhouse at Cambridge University and the Royal Hospital, the Guards Chapel, the Merchant Taylors Livery Company and Fulham Palace in London. Her interiors are achieved by painting onto the pages of magazines, often World of Interiors. The result is an image of the room which is dominant, but coexists with a foundation of photographs of totally different rooms beneath. Quantum exhibits her work at the major art fairs in London, New York, Brussels, Toronto, Palm Beach Florida, Amsterdam, Chicago, Hong Kong and Singapore.
The Week says of her "Her accomplished, idiosyncratic interior views have that rare capacity to conjure up the atmosphere of a particular time and place."
Leeds Castle, Dining Room
Mixed media on magazine pages
46 x 42 ins (117 x 107 cm)
£ Please enquire
Osterley Park House, Entrance Hall (visionnaire)
West Horsley Place, Morning Room (mirror)
43 x 35 ins (110 x 90 cm)
Vinery, Fulham Palace (ordered)
Vinery, Fulham Palace (assets)
West Horsley Place, Entrance Hall (urn)
West Horsley Place, Entrance Hall (twist)
Merchant Taylor's Hall, Cloisters (column)
35 x 45 ins (92 x 115 cm)
Merchant Taylor's Hall, Great Hall (chandelier)
Royal Hospital Chelsea, State Room (chandelier)
36 x 38 ins (92 x 97 cm)
Royal Hospital Chelsea, Great Hall (antiques)
Ashmoleon Museum, Oxford, Randolph Gallery
Ashmoleon Museum, Oxford, Randolph Gallery I
London Interior (it's all greek)
45 x 37 ins
Alison Pullen-Hertfordshire Interior I
Hertfordshire Interior II
47 x 39ins
Alison Pullen-Hertfordshire Interior II
Fulham Palace ( all things…)
The Guards Chapel (verde)
Royal Hospital Chelsea, Chapel (pink windows)
£ SOLD
London Interior (window seat)
West Horsley Place, Entrance Hall (three windows)
London Interior (west one)
Ashmoleon Museum, Oxford (so white)
Royal Hospital, Chelsea, Great Hall (high and low)
£SOLD
Bodleian Library, Divinity School (accents)
Royal Hospital, Great Hall, Chelsea (concrete)


text:
Chatal may refer to:
Chatal, Afghanistan
Chatal, Iran
Ceatalchioi, Romania


text:
import React, { Component } from 'react';
import $ from 'jquery';
import WorkDetails from './workDetails';
import Projects from '../data/projects';

export default class Work extends Component {

  constructor(){
    super()
    this.state = {
      currentWork : ''
    }
  }

  workBelt(project){
    $('.work-belt').css('left','-100%')
    $('.work-container').show()

    let projectInfo = Projects[project]
    this.setState({currentWork: projectInfo})
  }

  renderWork(){

    let projects = [];

    for(let work in Projects ) {
      projects.push(

{this.workBelt(work)}}
          style={{ backgroundImage: `url(${Projects[work].img})` }}>

            {work}

      )
    }

    return projects;
  }

  render(){

    return (

work

              {this.renderWork()}

          <WorkDetails projectInfo={this.state.currentWork}/>

    )

  }
}


"AMi is the perfect one stop shop for direct marketing. Quick turnaround, great prices, and everything else you would want. They have been great to work with."
You know how to sell your product, but how do you produce an eye-catching piece that will get you noticed? AMi will develop or enhance your company's image and increase brand identity.
We have a staff of creative designers as well as a network of freelance direct mail designers, photographers, and copywriters. We focus on creating a mail piece that will be looked at and acted upon by the recipient.
Our designers will work one on one with you to make sure that the tone of the mailer represents your brand ideals. They ask questions about the goals you want to achieve, getting more customers into your store, soliciting larger donations for your non-profit agency, or brand awareness and then they work with you to find the best path that will eliminate the problems that are holding you back from achieving that goal.
Our print services team can then make your vision a reality by putting your design on a high-quality stock.
We strive to get you the highest response rate possible with the best return on investment (ROI). By identifying the message your business wants to send, we're able to create a design that presents your brand effectively.
We will sit down with you and get to know your brand, your goals and your vision. We will offer design requirements and a timeline that will help you accomplish your goals and stay within your budget.
We will sit down with you and create digital designs that meet your vision and help you communicate your campaign's goals.
We will help you flesh out your production schedule for your mailers, from design to creation to completion.
We will help you interpret your results and identify areas of improvement, as well as successes that can be repeated.
With our design support, you can get the designs, production and results you need and deserve.
Need Customized Prints and Graphics? No Problem!
It's a statement we hear from clients often, and it's a problem that we commonly solve!
We had one particular case where a client came to us with an announcement they wanted to make to a team of employees who had worked to reach a monumental achievement. They wanted something that was special, not just an email that went out recognizing the efforts their team had made.
After tossing around a few ideas with our creative team, we were able to present an elegant concept and piece to the customer's Marketing Department. They loved it!
We then selected the card stock and a perfectly matching envelope for them. We enhanced it even more by using our clear print technology.
This allowed for the message to be imbedded within the announcement of the card. The card was then placed in the envelope and closed with ribbon and a seal, adding a touch of sophistication to the piece.
Together, both teams worked with diligence on the project to produce a piece that will forever be remembered by all of those who were involved.
Start working with the AMi team to get your message on paper, or wherever else you imagine it.


text:
100 YEARS NOVEMBER REVOLUTION IN GERMANY – The International Conference of Marxist-Leninist Parties and organisations
by APK
Leave a comment on 100 YEARS NOVEMBER REVOLUTION IN GERMANY – The International Conference of Marxist-Leninist Parties and organisations
Message of CIPOML – The International Conference of Marxist-Leninist Parties and organisations – to Arbeit-Zukunft, Germany, on the occasion of the centennary of the 1918 November revolution
In the great epic of the struggles of the international working class the November revolution 1918 of the German workers and revolutionaries holds its own prominent place as a heroic attempt to realise the ideals of the working class and socialism of a society, and indeed a future, without exploitation, exploiters or exploited.
Protesting the barbarous imperialist war going on since 1914, the hunger and misery, and intent on ending it by establishing another social system, the call for revolution sounded from Kiel. Workers' and soldiers' councils were established in many places. Only days later, on November 9th 1918, the socialist republic was proclaimed in Berlin.
The German workers chose the road of revolution having experienced the blatant betrayal of the old Social Democratic party that sided with its own bourgeosie, its own capitalists, during the first world war. The conditions for revolution were ripe, the revolutions of 1917 in Russia set the example. The defeat of the Emperor in the war signalled the end of the monarchy itself.
The times at the end of the world war and the first years after the victorious October revolution in Russia were dramatic. The war redrew the map of Europe and brougt an end to four empires – Russia, Austria-Hungary, Germany and the Ottoman empire. Great workers' movements and socialist revolutions were knocking on the doors of capitalism.
A new page in German history was opened when the sailors in Kiel refused to continue the imperialist war, raised the red flag and turned their weapons against the officers.
The November revolution, that engaged millions in the struggle to overthrom the rulers and the ruling class, would – If succesfull – mean a mortal threat to the entire capitalist world order. It showed that revolution and socialism was not only a question raised in more backward countries, but directly in the heartlands of capitalism and imperialism.
Along with the great lessons of the succesfull October revolution in Russia the revolution in Germany inspired and assisted the formation of the revolutionary labour, socialist and communist movement at the time. The study of the unfolding and the fate of this revolution still provide important lessons for the revolutionaries.
The defeat of this great attempt at revolution came about not as a result of lack of support of the workers or from lack of popular support in general. It was a genuine workers' revolution, a popular uprising with the support of the class and the popular strata – and evidence of the proletariant revolutionary character and aspirations of the German working class. It was brutally repressed, also by murdering its two outstanding leaders Karl Liebknecht and Rosa Luxemburg.
Social democracy, opportunism and reaction would exploit its weaknesses to prevent its victory. But the November revolution provided a valuable heritage of the German working class in its struggle throughout the last century untill now and deserves to be studied also today.
One major reason why the objectives of the revolution were not achieved and of its suppression was the lack of a strong revolutionary workers' party, of a leninist party able to lead it. The struggle to create and sustain such a party is an ongoing struggle and the first condition for the victory of the revolution and the construction of socialism.This is rightly also at the center of the struggle of the communist revolutionaries today. The heroic November revolution of 1918 in Germany remains a valuable lesson.
The International Conference of Marxist-Leninist Parties and Organisations greets the celebration of this centennary, organised by the German member of the Conference – Arbeit-Zukunft. We wish you new successes in the building of a genuine Marxist-Leninist Party in Germany, upholding an carrying on further the red banner of the great revolutionary struggle in Germany, continuing the work of Marx and Engels, Karl and Rosa, and countless other revolutionaries.
LONG LIVE THE STRUGGLE OF THE GERMAN WORKING CLASS FOR REVOLUTION AND SOCIALISM!
GLORY TO MARXISM-LENINISM!
The message in danish
100 ÅRET FOR NOVEMBERREVOLUTIONEN I TYSKLAND – Til Arbeit-Zukunft, Tyskland
The International Conference of Marxist-Leninist Parties and organisations in Europe
Arbejderpartiet Kommunisterne is a member of CIPOML
GREETINGS TO THE 7TH CONGRESS OF PCM(m-l)


Cluster A schedules PDP Workshops throughout the school year. At these workshops, initial educators as well as teachers seeking license renewal by writing a PDP, can attend. The first workshop provides information on completing the documentation of the PDP. This class will review procedures for documenting completion of the PDP, examine examples of quality evidence for professional growth and student learning, map PDP activities to collect examples of specific evidence, and receive guidance materials to assist with PDP verification. The second workshop is for educators nearing their license expiration date, and this class reviews the verification process, reviews what to expect from PDP Review Team members, and receives individual time with experienced coaches to ensure all components of the PDP are completed. Final drafts of the PDP are created and a PDP review team is provided by Cluster A for goal approval and for verification.


text:
Posts About "Michael Latta"
What Would Forsberg Do?
March 16th, 2017 Heading into tonight's game against the Washington Capitals, the Nashville Predators are sitting a healthy six points within the playoff bubble, camped out in the third Central Division spot. With 13 games to go, that is not an insurmountable cushion, but it is a cushion nonetheless. Offensive Escalation This comfortable positioning...
Latta Trade Pushes Capitals in a New Direction
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Robbie Hindman takes on new CNO role at Tenet's Brookwood Baptist Health
Kelly Gooch - Tuesday, September 15th, 2020 Print	| Email
Birmingham, Ala.-based Brookwood Baptist Health selected Robbie Hindman, BSN, RN, as CNO of Brookwood Baptist Medical Center, the organization announced Sept. 13.
Ms. Hindman is a 20-year veteran of the health system.
Most recently, she was CNO of Princeton Baptist Medical Center in Birmingham, Ala. She has also served as CNO of the Brookwood Baptist Health System since 2017 and will remain in that position in addition to her new role.
Before joining the system, Ms. Hindman worked for Druid City Health System in Tuscaloosa, Ala.
Brookwood Baptist Medical Center, a 645-bed facility, is part of the Brookwood Baptist Health system, which is operated by Dallas-based Tenet Healthcare.
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Blood purification therapy for severe sepsis: a multicenter, observational cohort study in northern Japan
Kasumi Satoh ORCID: orcid.org/0000-0002-2182-31081,
Kyoko Nomura2,
Hajime Nakae1,
Daisuke Kudo3,4,
Shigeki Kushimoto3,4,
Masatsugu Hasegawa5,
Fumihito Ito6,
Satoshi Yamanouchi7,
Hiroyuki Honda8,
Kohkichi Andoh7,
Hajime Furukawa4,
Yasuo Yamada9,
Yuta Tsujimoto10 &
Manabu Okuyama1,11
Sepsis is associated with life-threatening organ dysfunction caused by a dysregulated host response to infection. However, no specific therapy has been shown to improve mortality in patients with sepsis. We conducted a study to clarify the utilization status of various BPTs and the clinical characteristics of patients who received BPTs in northern Japan. In addition, the association of various BPTs with clinical outcomes was examined.
This is a sub-analysis of the Tohoku Sepsis Registry, a multicenter, prospective, observational cohort study. To determine whether BPT was independently associated with in-hospital mortality in patients with severe sepsis, the following analyses were performed. Differences between survivors and non-survivors were assessed using Wilcoxon rank sum tests for continuous variables and Chi-square tests for categorical variables. Univariate logistic regression analysis was used to evaluate the factors associated with in-hospital mortality. In the multivariate logistic regression analysis, adjustments were made for the variables that were significant in the univariate logistic regression analysis. Clinical factors associated with mortality were analyzed.
We enrolled 616 consecutive patients (≥ 18 years) with median Sequential Organ Failure Assessment scores of 8.0. During median of 22 days hospitalization, 139 patients died (mortality 22.6%). 20.7% of patients with severe sepsis received any type of BPT (mortality 38.6%). BPT consisted of 65.1% continuous renal replacement therapy (CRRT) with renal indication (mortality 48.8%), 26.0% CRRT with non-renal indication (mortality 21.2%), 22.2% intermittent renal replacement therapy (mortality 32.1%), and 33.1% polymyxin B-immobilized fiber column-direct hemoperfusion (mortality 42.9%). Meanwhile, no BPT group (mortality 18.5%) showed a significantly lower mortality than any BPT group. Besides, in multivariate analyses, all BPT modes were not independently associated with all-cause mortality.
This study suggested the clinical status of BPTs for severe sepsis patients in northern Japan. Among all types of BPT, continuous renal replacement therapy (CRRT) for renal indication was most frequently selected. Severe sepsis patients received BPT had a higher mortality and severity; however, the BPT implementation may not be associated with mortality.
Trial registration UMIN-CTR, UMIN000010297, Registered on 22 March 2013, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000012055).
Sepsis is associated with life-threatening organ dysfunction caused by a dysregulated host response to infection [1]. In the USA, mortality rates have been reported to be > 15% [2]. Radical treatments include the administration of antimicrobial agents and surgical source control. However, no specific therapy has been shown to improve mortality in patients with sepsis.
Acute kidney injury (AKI) is strongly associated with poor prognosis in patients with sepsis [3]. Renal replacement therapy is recommended for sepsis patients with AKI [4]. However, it is unclear whether renal replacement therapy improves survival or renal recovery after sepsis-induced AKI [5]. Along with renal replacement therapy, blood purification therapy (BPT) has been proposed as a treatment for modulating the inflammatory response in sepsis, even in patients without renal dysfunction [4, 5]. The in-hospital mortality rate in sepsis patients undergoing BPT is reported to be high, ranging from 41 to 79% in patients with renal and non-renal indications [6,7,8,9]. However, mortality rates are highly variable, and the number of reports is limited. There is little detailed information on the use of BPT modes in septic patients and mortality rates for each BPT mode.
Several studies have shown the potential of BPT in modulating the immune response. Two meta-analyses [10, 11] of small, randomized controlled trials evaluating the effects of hemoperfusion, plasma exchange, and hemofiltration with hemoperfusion demonstrated favorable results. However, the quality of these studies was not adequate. Even is the focus if only on renal replacement, the optimal timing and implementation remain unclear [12]. Thus, the benefits of BPT in terms of sepsis outcomes remain unclear. Mortality-related factors, such as age [13] and hepatic disease [14], have been reported in sepsis patients. However, there is no literature examining whether BPT is an independent clinical factor associated with survival.
We conducted a study based on prospective and continuously collected database to clarify the utilization status of various BPTs and the clinical characteristics of patients who received BPTs in northern Japan. In addition, the association of various BPTs with clinical outcomes was examined.
This is a sub-analysis of the Tohoku Sepsis Registry, a multicenter, prospective, observational cohort study conducted across 10 sites in the Tohoku district of northern Japan, including 3 university hospitals and 7 large community hospitals with > 300 beds. The protocol of the Tohoku Sepsis Registry has been registered at the University Hospital Medical Information Network Clinical Trials Registry (UMIN000010297). It is described in detail elsewhere [15]. The study design was approved by the Institutional Review Board of each institution and conforms to the provisions of the Declaration of Helsinki (as revised in Fortaleza, Brazil, October 2013). The need for informed consent was waived due to the observational nature of the study.
Study setting and participants
The Tohoku Sepsis Registry included consecutive patients admitted to intensive care units (ICUs) with severe sepsis or those presenting with severe sepsis after admission to ICUs or general wards in the 10 included hospitals between January and December 2015.
Participants were eligible if they were diagnosed with severe sepsis according to the 2012 International Sepsis Guidelines: sepsis-induced tissue hypoperfusion or organ dysfunction, including sepsis-induced hypotension, elevated serum lactate levels, low urine output despite adequate fluid resuscitation (< 0.5 mL/kg/h for > 2 h), acute lung injury with a ratio of arterial oxygen pressure to fractional inspired oxygen (PaO2:FiO2) of < 250.0 in the absence of pneumonia as the source of infection or a PaO2:FiO2 ratio of < 200.0 in the presence of pneumonia as the source of infection, elevated serum creatinine levels (> 2.0 mg/dL), elevated serum total bilirubin levels (> 2.0 mg/dL), low platelet counts (< 10.0 × 104/mm3), and coagulopathy with an international normalized ratio of > 1.5 [16]. Patients aged < 18 years were excluded.
The registered information includes that on age, sex, preexisting comorbidities, and medications before admission, in addition to the unit where sepsis was diagnosed, the presence or absence of septic shock, severity as assessed using the Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores, and primary site of infection. Other information includes physiological data, testing results, and treatment details, including drugs, source control interventions, and BPTs. The lengths of ICU and hospital stay and outcomes at 28 days post-diagnosis and at discharge were documented.
AKI was diagnosed according to the AKI Network criteria [17], which are used for classifying the different stages of AKI (stages 0–3) based on serum creatinine levels and urine output. AKI stage 1 is defined as an elevated serum creatinine level of ≥ 0.3 mg/dL or an increase of 150.0–200.0% from the baseline serum creatinine level or a reduction in urine output of < 0.5 mL/kg/h for > 6 h. AKI stage 2 is defined as an increase of 200.0%–300.0% from the baseline serum creatinine level or a reduction in urine output of < 0.5 mL/kg/h for > 12 h. AKI stage 3 is defined as an elevated serum creatinine level of ≥ 4.0 mg/dL with an acute increase of ≥ 0.5 mg/dL or > 300.0% from the baseline serum creatinine level or a reduction in urine output of < 0.3 mL/kg/h for 24 h or anuria for 12 h.
In this study, BPT consisted of continuous renal replacement therapy (CRRT), including CRRT with renal and non-renal indications, intermittent renal replacement therapy (IRRT), and polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP). The indications for BPT were based on the clinical judgment of the attending physicians at each institution. The equipment used and operational settings were determined by the clinician based on resources available at the institution. No uniform protocol was followed.
Participants were divided into the no BPT and different BPT groups. Patients were included in the BPT group regardless of the frequency or duration of BPT. If multiple BPTs were administered, patients were classified into more than one BPT group.
The primary outcome of this study was in-hospital mortality. Secondary outcomes included 28-day mortality, ICU-free days, length of ICU stay, and length of hospital stay. In-hospital mortality and 28-day mortality were defined as all-cause mortality at discharge or 28 days after the diagnosis of sepsis, respectively. ICU-free days represented the number of days on which ICU admission was not required within a 28-day period following the diagnosis of severe sepsis. The number of ICU-free days for patients who died within the 28-day period was 0.
Baseline patient characteristics (age, sex, preexisting comorbidities, worst physiological data on day 1 of diagnosis, and treatment modalities) were compared between the two groups of BPT (BPT vs. no PBT) by using Wilcoxon rank sum tests for continuous variables and Chi-square tests for categorical variables. Continuous variables were tested for normality with the Shapiro–Wilk test, with all continuous variables showing the skewed distribution (p < 0.05), thus summarized by median and interquartile range.
To determine whether BPT was independently associated with in-hospital mortality in patients with severe sepsis, the following analyses were performed. Differences between survivors and non-survivors were assessed using Wilcoxon rank sum tests for continuous variables and Chi-square tests for categorical variables. Univariate logistic regression analysis was used to evaluate the factors associated with in-hospital mortality at a significance level of 5%. Odds ratios and 95% confidence intervals were calculated. The results of univariate logistic regression analysis were used to select variables for multivariate logistic regression analysis. In the multivariate logistic regression analysis, adjustments were made for the type of BPT, as well as variables that were significant in the univariate logistic regression analysis. Since SOFA and APACHE II scores were correlated (Spearman's rank correlation coefficient, r = 0.687; p < 0.001), only SOFA score was included in multivariable logistic regression analysis. SOFA score includes the Glasgow Coma Scale, mean arterial pressure, PaO2:FiO2 ratio, and platelet counts, which were also excluded from the multivariate logistic regression analysis. Eventually, type of BPT, SOFA score, lactate level, AKI stage, primary site of infection, mechanical ventilation use within 24 h, inotropes or vasopressors use were included in the multivariate logistic regression analysis. There were six BPT types included in multivariate logistic regression analysis: BPT, CRRT with renal indications, CRRT with non-renal indications, IRRT, and PMX-DHP. We performed six multivariate logistic regression models for each of the BPT types, and clinical factors associated with mortality were analyzed. The goodness of fit was assessed using the Hosmer–Lemeshow test. All statistical analyses were conducted using Stata® software, version 15.1 (StataCorp, College Station, Texas, USA). Significance was defined as a two-sided p value of < 0.05.
In total, 616 patients in the Tohoku Sepsis Registry were enrolled. The median (interquartile range [IQR]) age was 75.0 (65.0–83.0) years. The proportion of male patients was 61.5%. The median (IQR) APACHE II and SOFA scores were 20.0 (15.0–26.0) and 8.0 (5.0–11.0), respectively. Patient characteristics are shown in Table 1. Detailed patient characteristics are provided in Table 5, according to the type of BPT. The proportions of patients treated with any BPT, any CRRT, IRRT, and PMX-DHP were 20.7%, 17.4%, 4.6%, and 6.9%, respectively.
Table 1 Characteristics of the patients
Comparison of variables between the no BPT and any BPT groups showed the following results: the BPT group was a younger (median 76 [IQR 66–84] vs. 71 [63–81], p = 0.016) and a more severe disease group with higher APACHE II score (19 [14–25] vs. 25 [20–30], p < 0.001) and SOFA score (7 [5–10] vs. 11 [8–14], p < 0.001). Chronic kidney disease (5.9% vs. 25.2%, p < 0.001) and malignant disease (10.0 vs. 17.3%, p = 0.022) are more frequent comorbidities with BPT, and AKI (31.1% vs. 83.5%, p < 0.001) is more frequent as its complication. The proportion of patients receiving mechanical ventilation within 24 h (39.2% vs. 71.7%, p < 0.001), proportion of patients receiving inotropes or vasopressors (45.5% vs. 73.0%, p < 0.001) was higher in BPT group comparing with no BPT group.
Clinical outcomes according to the type of BPT
Table 2 reports the clinical outcomes according to the type of BPT. During a median hospitalization period of 22 days, a total of 139 patients died (mortality rate, 22.6%). The in-hospital mortality rates in patients treated with no BPT, any BPT, any CRRT, CRRT for renal indications, CRRT for non-renal indications, IRRT, and PMX-DHP were 18.5%, 38.6%, 41.1%, 48.8%, 21.2%, 32.1%, and 42.9%, respectively. Significant differences in in-hospital mortality rates were observed between patients treated with any BPT (p < 0.001), any CRRT (p < 0.001), CRRT for renal indications (p < 0.001), or PMX-DHP (p < 0.001) and those treated with no BPT. The number of ICU-free days differed significantly between the no BPT and any BPT groups (22.0 vs. 12.0 days). According to the type of BPT, only the IRRT group exhibited no significant difference in the number of ICU-free days. Patients in the other BPT groups had significantly fewer ICU-free days than those in the no BPT group. The number of ICU days was significantly higher in BPT groups other than the PMX-DHP group than in the no BPT group. The number of hospital days was also significantly higher in the any BPT, CRRT for non-renal indications, and IRRT groups than in the no BPT group.
Table 2 Differences in clinical outcomes between those treated with BPT and without BPT
Factors associated with in-hospital mortality
Significant differences in the following variables were observed between survivors and non-survivors: APACHE II (p < 0.001), SOFA (p < 0.001), and Glasgow Coma Scale (p < 0.001) scores, heart rate (p = 0.030), mean arterial pressure (p < 0.001), serum lactate levels (p < 0.001), PaO2:FiO2 ratio (p < 0.001), serum creatinine levels (p < 0.001), platelet counts (p = 0.020), AKI (p < 0.001), AKI stage (p < 0.001), and primary site of infection (p < 0.001), mechanical ventilation use (within 24 h of diagnosis) (p < 0.001), use of inotropes or vasopressors (p < 0.001), any BPT (p < 0.001), any CRRT (p < 0.001), CRRT for renal indications (p < 0.001), and PMX-DHP (p = 0.005). In the univariate logistic regression analysis, the same variables were significantly associated with mortality at discharge, except for serum creatinine levels (Table 3).
Table 3 The differences between survivors and non-survivors
Effects of BPT type on mortality
In the multivariate logistic regression analysis of BPT type, all BPT types were not associated with in-hospital mortality. Instead, SOFA score, serum lactate levels, and AKI stage 3 were significantly associated with in-hospital mortality (Table 4).
Table 4 Factors influencing in-hospital mortality in multivariable logistic regression analysis
Based on the prospective and continuously collected database of severe sepsis patients recruited from the Tohoku Sepsis Registry in northern Japan, 20.7% of patients with severe sepsis received any type of BPT. The in-hospital mortality rate for patients who received any BPT was 38.6%. Among all types of BPT, CRRT for renal indication was most frequently selected. BPT consisted of 65.1% CRRT with renal indication (mortality 48.8%), 26.0% CRRT with non-renal indication (mortality 21.2%), 22.2% IRRT (mortality 32.1%), and 33.1% PMX-DHP (mortality 42.9%). Meanwhile, no BPT group (mortality 18.5%) showed a significantly lower mortality than any BPT group. According to BPT type, the CRRT for non-renal indications group and IRRT group exhibited relatively low mortality rates. Besides, any BPT was not independently associated with all-cause in-hospital mortality. To our knowledge, this is the first study based on prospective cohort focusing on the effectiveness of BPTs for severe sepsis.
Compared to previous Japanese study [18] that aggregated BPT patients in critical care, our PMX-DHP utilization rate is comparatively lower (33.1% vs. 43.4%) and our CRRT utilization rate is apparently higher (84.3% vs. 46.3%). While that previous study did its patient collection in 2013, ours in 2015. At international society of intensive care and emergency medicine conference in 2014, a randomized controlled trial reported did not confirm mortality benefit of PMX-DHP in patients with septic shock due to peritonitis [19], which was published early in 2015 [20]. This turn of the tide against PMX-DHP may have affected the results. The cohort in the previous Japanese study was sepsis patients, but severe sepsis was selected in this study; thus, CRRT may be selected more frequently for unstable hemodynamics.
In previous studies, the 28-day and in-hospital mortality rates of sepsis patients treated with BPTs ranged from 21 to 67% [6, 8, 9, 20,21,22,23,24,25,26,27] and 41% to 79% [6,7,8,9], respectively, and the lengths of ICU and hospital stay ranged from 7 to 26 days [6, 9, 20, 24, 26, 27] and 23 days to 59 days [6, 9, 21, 24], respectively. In this study, the 28-day and in-hospital mortality rates were 34.5% and 38.6%, respectively. This 28-day mortality rate is comparable to those in previous studies [6, 8, 9, 20,21,22,23,24,25,26,27]. The in-hospital mortality rate is lower than those in previous studies [6,7,8,9], although the severity of illness in the patients in this study receiving BPT was not particularly low in terms of APACHE II and SOFA scores. The lengths of ICU and hospital stay were shorter in our study but were broadly comparable to those reported elsewhere [6, 9, 20, 21, 24, 26, 27].
The mortality rates at 28 days and at discharge were significantly higher in the any BPT group than in the no BPT group (34.5% vs. 18.3% and 38.6% vs. 18.5%, respectively). We consider that this result may have been influenced by the high severity of illness in patients requiring BPT. On analysis according to BPT type, similarly high mortality rates were observed in the CRRT for renal indications and PMX-DHP groups. In contrast, the CRRT for non-renal indications group may have exhibited relatively low mortality rates and differed from other modalities in terms of other characteristics (e.g., low APACHE II scores and less renal impairment). The IRRT group also did not exhibit a significantly higher mortality rate. The IRRT group was also the only group to not exhibit significant differences in the number of ICU-free days. From this group, 50.0% of patients were also included in the CRRT for renal indications group, and in 57.1% of patients, treatment commenced > 48 h after diagnosis. It is possible that IRRT may have been administered to a patient population with stable circulatory hemodynamics. This may have been responsible for the lack of significance in mortality rates and the number of ICU-free days in the IRRT group compared with those in the no BPT group.
Our findings also suggested that none of the BPTs was independently associated with all-cause in-hospital mortality. Although the BPT groups tended to have higher mortality rates, there was no evidence to suggest that BPTs contributed to adverse effects on the outcomes of this study. There is no clear evidence that a particular BPT (CRRT for renal indications [6, 7, 23, 24, 26], CRRT for non-renal indications [8], or PMX-DHP [21]) is associated with better clinical outcomes, and our data support this. It may be difficult to expect significant improvements in prognosis with current BPTs. The establishment of a new method of BPT is eagerly awaited. Novel methods, including methods using the AN69 surface-treated hemofilter (sepXiris®) [28], modified AN69 surface-treated hemofilter (oXiris®) [29, 30], and extracorporeal cytokine adsorption device (CytoSorb®) [31], are currently being investigated. Further, large-scale studies are needed to evaluate the prognosis associated with the use of these methods.
This study has several limitations. First, the protocols of the various types of BPTs were based on the clinical judgment of the attending physicians at each institution and were not standardized. Thus, there was potential for variability in the application of BPT (e.g., indication, blood flow rate, dialysate flow rate, replacement flow rate, ultrafiltration rate, type of anticoagulation, and type of membrane). To address this, we included the institution as a variable in the multivariate logistic regression analysis. Second, this study did not have an adequately large sample size and may not be well adjusted for confounding variables. These limitations may affect the external validity of this study. Therefore, these findings should be interpreted with caution.
Our study showed that 20.7% of patients with severe sepsis received any BPT, and the mortality rate of patients who received any BPT was 38.6%. Among all types of BPT, CRRT for renal indication was most frequently selected. Patients who received BPT showed higher severity of illness, and the mortality of any BPT group was significantly higher than that of no BPT group. According to BPT type, the CRRT for non-renal indications group and IRRT group may have exhibited relatively low mortality rates. BPT may not be independently associated with all-cause in-hospital mortality, although patients with severe sepsis who were treated with BPTs exhibited higher mortality rates. More detailed analyses adjusting for potential confounding variables are needed in additional cohorts in the future.
The data that support the findings of this study are available from the principal investigator of the Tohoku Sepsis Registry, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are, however, available from the authors upon reasonable request and with permission of the principal investigator of the Tohoku Sepsis Registry.
AKI:
BPT:
Blood purification therapy
ICU:
PaO2FiO2:
Ratio of arterial oxygen pressure to fractional inspired oxygen
APACHE:
Acute Physiologic Assessment and Chronic Health Evaluation
SOFA:
Sequential Organ Failure Assessment
CRRT:
Continuous renal replacement therapy
IRRT:
Intermittent renal replacement therapy
PMX-DHP:
Polymyxin B-immobilized fiber column direct hemoperfusion
IQR:
Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315:801.
Rhee C, Dantes R, Epstein L, Murphy DJ, Seymour CW, Iwashyna TJ, et al. Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009–2014. JAMA. 2017;318:1241.
Alobaidi R, Basu RK, Goldstein SL, Bagshaw SM. Sepsis-associated acute kidney injury. Semin Nephrol. 2015;35:2–11.
Ankawi G, Neri M, Zhang J, Breglia A, Ricci Z, Ronco C. Extracorporeal techniques for the treatment of critically ill patients with sepsis beyond conventional blood purification therapy: the promises and the pitfalls. Crit Care. 2018;22:262.
Monard C, Rimmelé T, Ronco C. Extracorporeal blood purification therapies for sepsis. Blood Purif. 2019;47(Suppl 3):1–14.
Zhang P, Yang Y, Lv R, Zhang Y, Xie W, Chen J. Effect of the intensity of continuous renal replacement therapy in patients with sepsis and acute kidney injury: a single-center randomized clinical trial. Nephrol Dial Transpl. 2012;27:967–73.
Albino BB, Balbi AL, Abrão JMG, Ponce D. Dialysis complications in acute kidney injury patients treated with prolonged intermittent renal replacement therapy sessions lasting 10 versus 6 hours: results of a randomized clinical trial. Artif Organs. 2015;39:423–31.
Ghani RA, Zainudin S, Ctkong N, Rahman AFA, Wafa SRWSH, Mohamad M, et al. Serum IL-6 and IL-1-ra with sequential organ failure assessment scores in septic patients receiving high-volume haemofiltration and continuous venovenous haemofiltration. Nephrology 2006; 11:386–93.
Cruz DN, Antonelli M, Fumagalli R, Foltran F, Brienza N, Donati A, et al. Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA. 2009;301:2445–52.
Putzu A, Fang MX, Boscolo Berto M, Belletti A, Cabrini L, Cassina T, et al. Blood purification with continuous veno-venous hemofiltration in patients with sepsis or ARDS: a systematic review and meta-analysis. Minerva Anestesiol. 2017;83:867–77.
Zhou F, Peng Z, Murugan R, Kellum JA. Blood purification and mortality in sepsis. Crit Care Med. 2013;41:2209–20.
Bellomo R, Kellum JA, Ronco C, Wald R, Martensson J, Maiden M, et al. Acute kidney injury in sepsis. Intensive Care Med. 2017;43:816–28.
Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29:1303–10.
O'Brien JM, Lu B, Ali NA, Martin GS, Aberegg SK, Marsh CB, et al. Alcohol dependence is independently associated with sepsis, septic shock, and hospital mortality among adult intensive care unit patients. Crit Care Med. 2007;35:345–50.
Kudo D, Kushimoto S, Miyagawa N, Sato T, Hasegawa M, Ito F, et al. The impact of organ dysfunctions on mortality in patients with severe sepsis: a multicenter prospective observational study. J Crit Care. 2018;45:178–83.
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39:165–228.
Arimura T, Abe M, Shiga H, Katayama H, Kaizu K, Oda S. Clinical study of blood purification therapy in critical care in Japan: results from the survey research of the Japan Society for Blood Purification in Critical Care in 2013. J Artif Organs. 2017;20:244–51.
Ronco C, Klein DJ. Polymyxin B hemoperfusion: a mechanistic perspective. Crit Care. 2014;18:309.
Payen DM, Guilhot J, Launey Y, Lukaszewicz AC, Kaaki M, Veber B, et al. Early use of polymyxin B hemoperfusion in patients with septic shock due to peritonitis: a multicenter randomized control trial. Intensive Care Med. 2015;41:975–84.
Dellinger RP, Bagshaw SM, Antonelli M, Foster DM, Klein DJ, Marshall JC, et al. Effect of targeted polymyxin B hemoperfusion on 28-day mortality in patients with septic shock and elevated endotoxin level: the EUPHRATES randomized clinical trial. JAMA. 2018;320:1455–63.
Quenot JP, Binquet C, Vinsonneau C, Barbar SD, Vinault S, Deckert V, et al. Very high volume hemofiltration with the Cascade system in septic shock patients. Intensive Care Med. 2015;41:2111–20.
Joannes-Boyau O, Honoré PM, Perez P, Bagshaw SM, Grand H, Canivet JL, et al. High-volume versus standard-volume haemofiltration for septic shock patients with acute kidney injury (IVOIRE study): a multicentre randomized controlled trial. Intensive Care Med. 2013;39:1535–46.
Park JT, Lee H, Kee YK, Park S, Oh HJ, Han SH, et al. High-dose versus conventional-dose continuous venovenous hemodiafiltration and patient and kidney survival and cytokine removal in sepsis-associated acute kidney injury: a randomized controlled trial. Am J Kidney Dis. 2016;68:599–608.
Cho AY, Yoon HJ, Lee KY, Sun IO. Clinical characteristics of sepsis-induced acute kidney injury in patients undergoing continuous renal replacement therapy. Ren Fail. 2018;40:403–9.
Liu H, Liu Y, Sun JK, Xu QL, Yan Y, Chen YM, et al. Extravascular lung water monitoring of renal replacement therapy in lung water scavenging for septic acute kidney injury. Int J Clin Exp Med. 2015;8:18907–16.
Barbar SD, Clere-Jehl R, Bourredjem A, Hernu R, Montini F, Bruyère R, et al. Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. N Engl J Med. 2018;379:1431–42.
Kobashi S, Maruhashi T, Nakamura T, Hatabayashi E, Kon A. The 28-day survival rates of two cytokine-adsorbing hemofilters for continuous renal replacement therapy: a single-center retrospective comparative study. Acute Med Surg. 2019;6:60–7.
Pickkers P, Vassiliou T, Liguts V, Prato F, Tissieres P, Kloesel S, et al. Sepsis management with a blood purification membrane: European experience. Blood Purif. 2019;47(Suppl 3):1–9.
Schwindenhammer V, Girardot T, Chaulier K, Grégoire A, Monard C, Huriaux L, et al. oXiris® Use in Septic Shock: experience of Two French Centres. Blood Purif. 2019;47(Suppl 3):1–7.
Hawchar F, László I, Öveges N, Trásy D, Ondrik Z, Molnar Z. Extracorporeal cytokine adsorption in septic shock: a proof of concept randomized, controlled pilot study. J Crit Care. 2019;49:172–8.
The other Tohoku Sepsis Registry investigators also contributed to the collection and analysis of data at each institution: Tohoku University Hospital, Hachinohe City Hospital, Ohta Nishinouchi Hospital, Osaki Citizen Hospital, Niigata University Medical and Dental Hospital, Sendai City Hospital, South Miyagi Medical Center, Sendai Medical Center, Yamagata Prefectural Central Hospital, and Akita University Hospital. We would like to thank S. Osaki for data management and administrative support.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
Kasumi Satoh, Hajime Nakae & Manabu Okuyama
Department of Environmental Health Science and Public Health, Akita University Graduate School of Medicine, Akita, Japan
Kyoko Nomura
Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
Daisuke Kudo & Shigeki Kushimoto
Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Sendai, Japan
Daisuke Kudo, Shigeki Kushimoto & Hajime Furukawa
Medical Emergency Center, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Japan
Masatsugu Hasegawa
Department of Emergency Medicine, International University of Health and Welfare, Narita, Japan
Fumihito Ito
Emergency and Critical Care Department, Sendai City Hospital, Sendai, Japan
Satoshi Yamanouchi & Kohkichi Andoh
Department of Advanced Disaster Medicine and Emergency Critical Care Center, Niigata University Medical and Dental Hospital, Niigata, Japan
Hiroyuki Honda
Department of Emergency and Critical Care Medicine, Sendai Medical Center, Sendai, Japan
Yasuo Yamada
Department of Emergency and Critical Care Medicine, Yamagata Prefectural Central Hospital, Yamagata, Japan
Yuta Tsujimoto
Department of Critical Care Medicine, Akita University Hospital, Akita, Japan
Manabu Okuyama
Kasumi Satoh
Hajime Nakae
Daisuke Kudo
Shigeki Kushimoto
Satoshi Yamanouchi
Kohkichi Andoh
Hajime Furukawa
KS designed the study and wrote the initial draft of the manuscript. KN contributed to analysis and interpretation of data and assisted in the preparation of the manuscript. HN contributed to the conception of the study and critically revised the manuscript. All other authors have contributed to data collection and interpretation, and critically reviewed the manuscript. All authors read and approved the final manuscript.
Correspondence to Kasumi Satoh.
All data were retrieved from a database named Tohoku Sepsis Registry (University Hospital Medical Information Network Clinical Trials Registry No. UMIN000010297). The Institutional Review Board of each institution approved the study. All Institutional Review Boards waived the need for informed consent due to the observational study design requiring no treatments beyond the daily clinical practice, according to the Japanese guideline (Ministry of Education, Culture, Sports, Science and Technology, and Ministry of Health, Labor and Welfare, Japan; Ethical Guidelines for Medical and Health Research Involving Human Subjects. March 2015).
See Table
Table 5 Detailed baseline characteristics of the patients
Satoh, K., Nomura, K., Nakae, H. et al. Blood purification therapy for severe sepsis: a multicenter, observational cohort study in northern Japan. Ren Replace Ther 7, 47 (2021). https://doi.org/10.1186/s41100-021-00366-4
Received: 30 November 2020
Hospital mortality