#Vertebral Fracture | Explore Tumblr posts and blogs

sun-snatcher · 4 days ago

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( credits to @winterswake for this phenomenal gifset ! )

3/? | SEAWARDS, TO YOU. ; REPENTANT!AU

summ. A continuation. Sauron learns what it means to be human— and what it takes to be one. or: Sauron experiences the best & worst of mortality. pairing. (Repentant!Mairon/Sauron) Halbrand / f!reader , ( established in #SEAWARDSTOYOU ) w.count. 4k a/n. Important tags in first chapter ! Warnings for implications to PTSD & slight horror , including Non-graphically implied Animal Death.

THE BARNACLES STARE.

They’re overgrown; marrow-white and clinging onto the cracks of the salt-licked rockface, breathing and blinking at him like the thousand, ever-watchful eyes of the Ainur.

In his dreams, every single one turns to blazing stars that wink out in an instant as he passes them. The shadow of Morgoth is a powerful darkness: it can dim them into lightlessness and nothingness. He tells them he is neither Morgoth nor Melkor nor Sauron nor Mairon, that he is something new; something different— but they can’t hear him under the sheet of waves crashing like a tempest on the shores, pulling him down, down, down, and under.

(He drowns. Rarely does he choose to fight the currents.)

In other vivid dreams, the barnacles don’t listen. They don’t because they can’t listen; because they’re dead and lifeless and the colour of their shells look eerily vertebral and bone-faced. They’re skulls, he later realises. A thousand of them. Endless. Both young and old. Their missing teeth and gaping maws, frozen in terror, roll in masses that wash in from the bloody tides and take up the shore beneath his feet. They fracture and splinter and cry out in pain when he walks on where soft sands ought to be, begging for mercy with every black step he takes.

He wakes up restless. He wakes up mortified.

A forest fire rips through Eldalondë.

It dies out as quick as it had come, however; by the grace of the Valar and their blessed storms! The Faithful cry.

“Blessed,” Galadriel hears Halbrand scoff underneath his breath. They’d both sailed down the river Nunduinë with the other locals to help with clearing out whatever the blaze had left in its wake, and the very air now is clogged with residual smoke and the stench of death. She doesn’t comment on his muttering. (He had yet to heal completely from the rope burns in his palms from when they’d been stranded at sea, after all.)

“You think it’s a sign?” asks one of the arborists.

A grave weight seemed to have sunken into Galadriel when the scent of the Mellyrn had greeted her, and she’d been brought to the heart of the massive grove, where she lay a hand on the now-sundered tree.

“These very trees were brought as seeds from Aman by the Eldar of Tol Erresëa. Elros Tar-Minyatur himself had hand in planting these.” She remembers Elrond, too, had come to sail and plant a tree of his own here. The forest had been so young then, in the early years of the Second Age. Now the woods seem unsettled— even the very winds that blow between its spaces.

“Not idly do the trees of Valinor burn,” she finally warns. “Even when ensnared by lightning.”

Halbrand had seen it from afar, coming downwind from the riverbank: the tree’s colossal trunk— thick as a Dwarven-hewn mountain pillar— torn in its center from the high canopies of branches, snaking all the way down to the spindly stretch of roots. The bolt of light had rent an ugly, gaping wound into its silver bole, hollowing out the wood and carving it out to look like a glaring crack into the Unseen World.

He can still see the gleam of red embers between the bark of the tunnelled tree.

He can still hear it crackling in its seams, even.

Or… no. That isn’t the fire—

“Galadriel!”

Mallorn branches grow great and wide, so it takes out an entire stable when it crashes down.

One of the horses get caught underneath.

They cannot move the branch. (It wouldn’t do any good, even if they did.)

Abârzî, the sea-cadet weeps, stroking the mare before he went to braid the hairs of her tail and cut it off. He chants it like a prayer.

Abârzî. Abârzî. Abârzî.

(No one has the heart to finish the job.

Halbrand does not exactly offer— but they don’t stop him either when he begrudgingly enters the stables for them.)

“What was he saying?” Sauron asks, after, in some poorly attempt to clear his mind.

“Her name,” Galadriel translates, solemn. “Abâr holds several meanings. It stands for strength, might, endurance. ‘One of Valiance’, even. Perhaps: ‘Admirable one’—”

It’s the first time Mairon ever experiences throwing up.

Galadriel sits beside him, and doesn’t say a word more.

He’s glad.

Or, maybe he isn’t.

He doesn’t understand what he feels these days.

The wine Sauron pours to the raven-haired elf in his dreams is thick.

Too thick to be wine— but just as deceptively sweet.

On other nights, he pours and it keeps going, and going, and going. It gushes down his palms and down the nameless peak he’s standing in, and cascades down the cliff- like a thundering waterfall— no, an open wound. Sometimes the elf pushes him forward from the back, and it stings like a stabbing betrayal. (Other times, Mairon simply chooses to fall.)

When he plummets, it’s into red seas. It feels like wading through molasses; exhausting a pain into his limbs more than the dull ache at his nape and the throb of his suffocating lungs. Then there’s the twinkle of starlight throwing him off every time he swims. He always mistakes them for the night sky, and he blindly reaches towards the surface— until they turn out to be the white-faces of barnacles instead, attached to the maws of a sea-wyrm deep in the ocean.

Tonight, however, he swims in the right direction.

The raven-haired elf pulls him out with a trusting, helping hand wrapped in a gauntlet; and when Sauron breaches ashore, he’s not kneeling at his feet on sands or bones, but instead on the all-too familiar cracked, black stones of his old fortress up in the bleak frigidness of Forodwaith.

Mairon is garbed in soaking red robes.

This time, Adar coronates Sauron not with Morgoth’s crown, but with a rotting horse skull named Abârz—

“You have a strange shadow, ‘Maril,” Eärien tells you, not long after you’d come down to Nísimaldar to assist in the clean-up effort. “It’s shaped like… a funny-looking man who always seems to look as if he’s rolled around in the dirt for ten hours.”

You blink, puzzled, then turn to where she’s peering over your shoulder.

Halbrand’s eyes dart away just as you meet his gaze.

“Friend,” you correct, levelling an unimpressed glare back at your table of teasing looks. “Halbrand is a friend.”

Isildur raises his brows once you begin gathering another fresh bowl of seafood. “Don’t forget the oysters. I hear they’re great for men’s libid—”

“Shut your mouth when you eat,” comes your sharp flick at his ear, going to leave as the rest of the cadets break into laughter. “Even Berek has better manners than you, airhead.”

Halbrand, shaded under a temporary forge set up by the treeline near the half-constructed stables, senses you long before he hears your voice. You’re appraising him again. He can feel it. It reminds him of the barnacles staring, and he has to actively remember not to be instinctively beset.

You’ve been kind, after all.

Frustratingly so.

And Sauron, as uncertain as he has been of everything (and by everything, he means his entire simulacrum of an existence— or, reincarnation? Re-embodiment?) of late, is smart enough to know not to bite the hand that feeds him. You’d made it clear that night in the forge, after all, that you’re a friend. And if not that, then at the very least— an ally.

So it’s no surprise he sets the horseshoes he’s working on aside, and relents to your plate of food. It is a surprise, however, when a few minutes later you go:

“Thank you, by the way.”

He shuts your train of thought down before it can take off.

“Don’t start,” Sauron says, voice a low rasp. He knows where you’re going with this: You’ll thank Halbrand for going out of his way to help, for lending a hand with the rebuilding, for putting down a boy’s dying horse. He wants nothing to do with it.

“Then I want to—”

“Don’t apologise either,” he interjects, failing to hold back the mild bite. (So much for biting the hand, huh?)

Sauron had chosen, anyway, to take it upon himself to toil away in the forge, from sunrise to sundown; Dedicating himself to aiding the reconstruction by crafting everything from bridles, stirrups and bits, to metal brackets, hinges, and nails. He’d toiled because it focused him; because he’s utilitarian at heart and so despises uselessness; because it helps blur the waking haunts of horses and the seas under the hissing and clanging of working metal.

(Besides, there’s plenty to improve in this part of the island, and Sauron is the type to not count flaws and cracks but to instead step up and fix them.)

So there’s no place for you to apologise.

“You work quickly,” you redirect instead, avoiding the urge to bicker with him. “Some might say almost tirelessly. Seems you’re getting into our good graces, from what I hear.”

“Well, you ought to listen closer.” Local gossip is difficult to not earwig, especially if the topic is about a low-man from the South; even more so that they don’t expect said low-man to have a passable fluency in Adûnaic.

You don’t bother to hide the amused look on your face. “Right. Well. They do say eavesdroppers never hear but ill of themselves. What have you gathered, jailbird?”

“That I would be their downfall,” he says, then after a mouthful, goes: “That I would squander their resources and drain their waters and steal their women,” which makes you laugh.

“Númenórean women are not so easily taken.”

He hums at that. “And are you?”

“…Am I what?”

“Númenorean.”

You blink. Halbrand levels a gaze you suddenly can’t meet. It’s a game he plays, you guess right then, between the crawl of heat up your cheeks. Of sharpening ulterior meanings into both sides of his words like one would a sword’s edge.

(“The low-man said that?” Isildur titters, much later. “What a smooth advance! I ought to give him a—”

“Beheading,” Eärien overrides, “You do know he also effectively implied your sister may be easy?”

Isildur cheers. “And he’s honest? Outstanding!”)

“I believe I am one, and that’s enough for me,” you lie. The thought has crossed your mind before— that you may very well be an orphan descendant of those who had sided with the Enemy, once upon a time. That it’s likely you’ll die long before your own foster family does.

“And if you’re wrong?” asks Halbrand. He enjoys making you squirm. “Shall that be enough?”

“Then so be it,” you wrinkle your nose, displeased yet matter-of-fact. “It doesn’t matter what type of life we’ve been chanced to be given, jailbird, so long as we live it doing the right thing.”

Until it becomes part of your nature, Sauron abruptly remembers Diarmid; of his words; the necklace he’d cruelly taken from the old man that stormy night. The advice had been unwelcome then, and now it seems to haunt him still.

“Is that your heraldry?”

Halbrand loosens his grip. His hand has been flying to the pouch out of habit, lately. “No.” Then, after you scrutinise him, cocks his head and says, “Is it so hard to believe we might quite be the same— Lost and found at sea?”

“You have a past,” you point out, the same way Elendil had chivvied you then. (If you had noticed him blink away in a flinch, he’s grateful you don’t mention it.) “But no, not so hard to believe, considering that’s precisely how my father found you too. It’s just hard for me to believe someone would be so willing to sever ties with their history.”

“I found this on a dead man.”

“Then why keep it?”

“Thought it looked fancy,” he dodges.

“A pearl is fancy,” you reflect, unconsciously flexing your fingers. The ring he’d caught the first day you two met lustres now at certain angles of the setting sun, beyond the horses grazing lazily in half-barren pastures.

Your answer is hardly a surprise to him. A bereft orphan would likely covet something as insignificant as a worn-out emblem if it meant a potential link to their true heritage, no matter how thin or nonsensical. Yours just happens to be a pearl.

“Beauty is subjective, seabird,” he comments sagely, before letting curiosity get the better of him to ask, “Is that from the tidepool, too?”

No, you want to say. I like to think my mother gave it to me. “Yes. It was in my grasp when my father found me; so came my name.”

Halbrand finishes his bowl, and doesn’t say a word more.

You’re glad.

“You know, I meant to say earlier, before you interrupted me,” you begin out of the blue, voice possessing that Nienna-esque lilt that makes him unconsciously want to shrink into himself. “…You shouldn’t have had to be the one.”

He follows your gaze to one of the Bay horses being herded away. Its body gleams; a vibrant, rich red-brown in the dusk that needles a strange grief into him. The colour reminds Mairon of his old form.

“You’re right, I didn’t,” he agrees distastefully. Needless suffering also falls under the realm of uselessness, however. Perhaps, in a twisted, roundabout way, Sauron had chosen to put down Abârzî. “…But I’ve done far worse things.”

You watch him tuck the necklace away beneath his collar, and he wonders, briefly, if you’d caught his shudder; his waver.

“To survive,” you emphasise. Surely.

He laughs under his breath. It’s neither sad nor sordid, just empty.

“Not all of it.”

Sauron opens his eyes to a crowned shadow and a blade.

Do not fear, it says. And when its hand had come away with a fistful of his long, braided hair, cut from his blazing red head— it repeats itself to him again, though this time in the commanding tongue of Black Speech.

Do not fret.

(He frets, and begs. He disobeys because he’s terrified— but it’s all happening under his skin. Black Speech cannot completely overpower the mind, you see, but it can command and seed an intent in it; a sliver of power over the flesh, if willed so. He can fret and beg all he likes; it will never translate to his body.

Now he’s just a vessel, still as a Bay horse caught neath a great tree, watching and waiting; helpless and paralysed.)

He catches the glint of the dagger but he cannot scream.

Do not fret, Morgoth commands, in that divinely, beautiful way only a Valar can make all guttural words sound. Do not fret, Abârzî.

Mairon startles awake.

When the candlelight flickers with the moon, he mistakes them for blood on his hands and a stable floo—

“Y’alright, brother?” Someone claps him on the back.

It’s noon, now. It feels like he’s woken up for the third time today.

The stables are coming up nicely (Quickly, because Halbrand works when everyone else is asleep). The clouds are thick, so the day isn’t beating down on the horses as they feed on bran and alfalfa, and there aren’t any damning signs of coming rain to hinder what little is left of the reconstruction today.

“Never better,” Halbrand says, after steadying his heavy breathing. The perfectly delivered lie is somehow miraculously seen through, however, and promptly called out, via: an insistent pint of ale into his calloused hands that’s supposedly the ‘cure to all ailments’.

He learns the old drunkard’s name is Seamus.

He learns a bit of everything to nothing, really; until the sun had sunken too far beneath the canopies of the Mellyrn, and the dappled light faded into drifting spots, and all that was left of their drinks was a final sip. Sauron had found himself both inexplicably refreshed and exhausted between the overload that managed to distract him from the cavernous feeling in his chest.

“It’s a swallow bird. We sailors tattoo it as belief it’ll lead us back home when we get out at sea,” says the old man, between a tangent on island customs and traditions beyond the primly ‘Nobody kneels in Númenor’ ones. “Why? Lookin’ to get inked yourself?”

Halbrand blinks.

He had composed as Mairon among the other Ainur in the Timeless Halls for the Ainulindalë, once upon a time; and then served, much, much later, as Sauron alongside Morgoth in the Iron mountains of Thangorodrim. Neither exactly had been something anybody would call a home— One was simply a state of Being far beyond Eä, and the other had been both a fortress and a prison.

“Don’t have a home to return to,” is all he decides.

It sounds a lot like a realisation.

“Aye, well…” The drunkard flails his hand to the chilly winds. “Swallows mate for life.”

Halbrand frowns in confusion. Seamus just laughs, mad.

He doesn’t understand what the crazy old shrimp had meant, until two days later (of which Sauron still had only understood half of what was told to him, if he’s being honest) when the stables had at last been completed and the locals put together a small feast for everyone who had come together to help.

Crab legs had been the catalyst, oddly enough.

Or, rather, how you seemed to move amongst the people-who-may-not-be-your-people, and spoke to your family-who-isn’t-actually-your-family.

“Here,” you say, and idly lay skillfully de-shelled crab legs and a lobster tail on your bright-eyed sister’s plate. Then onto your even-more-bright-eyed brother’s plate, before doing the same to those within your reach at the table, including Halbrand— sitting adjacent and at a length, because nobody quite fancied sitting next to a brooding stranger.

“I can de-shell my crabs on my own,” he had wanted to huff, put out by the way he suddenly felt impeccably small by your limitless grace and social-butterfly-ness, but one of the cadets had beaten him to it.

Your answer is a smile that’d made Mairon think of Nienna again, followed by a winsome, “I know you can.”

He lingers on what you’d told him ere a week ago, at the forge when you’d come to him saying he looked most at home with a hammer and tongs in hand, and drafts in his head something he tells you much later, which is:

“You looked different around your not-people.”

You’re wrapped in a pelerine cloak that seems to do little with the cold Mallorn-fragrant winds, here at the Bay of Eldanna, where you’ve somehow convinced him to follow you down to at the crack of dawn. (It’s not like he could sleep through the night, anyway, now that the stables are complete and there’s nothing left to busy himself with for the time being.)

It’s early enough that the carpet of stars in the sky shines the rocky shoreline a blinding silver, and only the lantern-lit trawlers far out at sea are awake to fish for teeming shoals of shrimps in season beyond the reef.

“My not-people?” you yawn, gathering up your cloak and shift dress to toe between the rocks. “Ah. I get it. Because I’m an outsider.”

He raises a tolerant eyebrow. “I’m the outsider, seabird.” To which you answer, breezily, as if it’s a simple equation:

“Not to me. If it helps though, we can both be outsiders together.”

He barely has time to wrap his head around together when you begin skipping across the tidepools.

“I meant,” he trails after you, ungainly and tender-footed to the shallows compared to your well-versed steps. He had not been raised by the sea like you. “That you looked at home; with your people. And tha— Eärmaril, why did you bring me out here with a bucket?”

You peer at the crevices of the outcrops, turning over black slabs with a trained eye. “Have you ever had soft-shell crabs? They’re active around this time of night, so watch your step. If you’re not getting pinched by their claws, you’ll get stabbed by an urchin.”

“You loon!” he exclaims. “You brought me here for a hunting trip?”

“Hush, now! Or you’ll scare the fur seals further down the coast,” you hiss over your shoulder. “And no. I brought you here because I know you won’t be sleeping, anyway.”

The blatant accusation has him slipping from a jutting rock face.

You catch his hand to steady him.

(He’s warm. Some part of you wants to pull him close.)

“I overheard the farriers. They say the only reason the stables got put up that quickly is because you worked through the night.” You inform him as delicately as you can, because there’s a recognisable, vestigial haunt in his eyes you’ve seen in your father’s, under the shimmer of Eärendil’s starlight. “Is it nightmares, Halbrand?”

“See, Amm— Mother saved Isildur when he was a child.” Nobody in the family prefers to say drowned except your father, because the word is bitter to the taste. “I was there when it happened. Couldn’t sleep for weeks after. Do you dream of the waters too?”

The defensive frown he’d put up melts away, but you can see Halbrand steel himself, still, in order to answer.

“I dream of barnacles,” Sauron allows, brusque so as to cut the conversation short as he regains his footing.

You let go and narrow your eyes at him.

After a long moment, you conclude, resolutely: “Valar, you’re a terrible liar, jailbird.”

And Mairon couldn’t help it—

He laughed.

(It sends your heart stumbling.)

“Believe me when I say, seabird, that if I were to deceive you, you would never know.”

“…Right,” you scoff, quick to turn away to hide the budding smile on your face as you carve his laugh and awfully handsome grin into memory. “Now, come and be useful, will you? Before the tide runs in with daybreak.”

He can do that. He likes to be useful.

So he does.

Sauron, however, gathers alarmingly quickly that he’s as helpful as an infant grappling the ways of the water for the first time. Some distant part of him enjoys it, though— learning. It reminds him of his long gone time with Aulë.

Learning to follow your effortless sea-nymph dance across the jagged shallows, memorising how to identify which rocks to flip and the right ways to harvest mollusks or crabs without risking a fingertip, all while unconsciously committing to mind the shanties you hum under your breath.

You tell Halbrand stories and Mairon listens despite the general inanity of it; because he’s a quiet sort, and because he likes the diluting distraction of it all.

Little things, like how your mother had bequeathed the craft of pottery to you, or that your father had preferred to teach you to fight instead of fish (“I can hardly imagine that,” Sauron muses, which earns him a sharp look and a: “Well, you don’t seem the imaginative type, anyway.”); that Eärien’s artistic strength is adapted from her uncanny skill of observation, and that Isildur is often wayward because he’s as free-spirited as the sun.

The conversation whiles and goes until the sky slowly pales awake, and the fur seals begin to bark and bay at the shorebirds and skimmers diving close to the rolling surfs. When the stretch of Eldanna’s shoreline finally raises, peaks and tidepools drowning back below the cresting of blue seas, the both of you make headway back inland.

“I was telling the truth,” he says, abruptly, which made you stop in your tracks at the beach. Your cloak is billowing from the salt gusts, edges sticking to the wet of your ankles.

“You don’t have to tell me,” comes your honest answer.

But he wants to. It feels right to. Here Mairon stands bearing witness to the intimacies of your life, while he had nothing to offer you in return beneath the veneer of Halbrand. It’s only fair to do the same. An exchange, if you will. It’s all he’s ever known.

He sets the bucket of skittering crabs on to the wet sand, and dips his feet at the lap of the tide. “I dream of the Dark,” Sauron admits. “Of a light I cannot reach. The ocean is always red— red as my hands— and the rock-faces are always white and blinking.”

Barnacles. You understand now.

“When I wake up, I feel like I’m bracing for something, but I don’t know what,” he says, which he’s quick to realise had been an instinctive lie, and so he amends it with an explanation. “Like I’m charging headfirst into the abyss, and I’m bracing myself for the impact. For a fight or a— punishment.”

Halbrand kicks at a bubbling bump in the water and out pops a shell. (It’s a whelk. Lightning whelk, if Sauron is being precise. He’d listened to you listing the different kinds an hour ago.)

“Anybody home?” you peer.

“Mh.” Sauron assents and tosses the hermit back to the waves.

He looks at where the open sky meets the sea, thinks of the knee-high swathes of sea oats growing at the coastlines of Valinor if he’d set sail Westwards from Eldanna and choose not to look back. He entertains idly on the idea of home for a beast such as himself— if it’s even possible to tame savagery into such domestications.

Then he resists on asking you if there’s a difference between making a home and inventing one (those are questions for another sleepless night, he supposes), and instead glances down to where you’ve stepped into one of the remaining tidepools and back out.

A smooth pebble with a perfectly circular hole in its centre, still damp from its discovery, sits in your palm.

“What in Eru’s name is that?” he furrows, watching you wink at him through the gap.

“A hagstone,” you say, unoffended. “My other brother Anárion has one, though he prefers calling it an adder stone. Ammê told us they were naturally-occurring talismans. They ward off anything evil and protects its keeper. Catch.”

He does so with attractive ease.

(…You commit that to memory, too.)

“You don’t actually believe this little thing, do you, seabird?” he asks, tossing the piece up in his hands.

His snort makes you roll your eyes. “See! You are the unimaginative type. Halbrand, it’s the nature of a thing that matters, not its form.”

Right. He’d forgotten you are You; who built a home in the people; whose wound is your geography and history— or lack thereof— and who’s chosen to anchor to Númenor, because your foster family is where you found your true port of call.

“You Númenóreans are an odd lot,” he settles candidly, and curls his fingers around the hagstone.

“Odd?”

“Superstitious,” he clarifies.

“I prefer traditional,” you volley.

“Try paranoid.”

Your warm laugh breaks with the surf of the shore, makes him tarry on the sight and sound of you.

“Red sky in the morning; sailor’s warning…”

“Red sky at night; sailor’s delight,” Halbrand recites Seamus, scoffing humorously. “I mean… Boarding a ship right foot first? Nailing a horseshoe under the mast, laying a silver coin for Uinen or tattooing swallows to lead the way home? And no whistling on board, lest it’ll challenge the winds; Or so Isildur claims of Manwë.”

“Ah, but don’t forget—”

“—Never rename a ship,” he says in unison.

Halbrand shakes his head, but the fond look on his face is undeniable as you break out into another merry smile. Your plan to chase away his night-terrors seem to have worked perfectly. If you’d thought him handsome before, then he looks utterly divine now.

“Well, I suppose you’re right. There’s another one, though,” you hum, eyes fixated at the gulls taking wing to and fro their nests, the trawlers sailing home with their morning catch. “Never ever bring harm to a seabird.”

He cocks his head. “If I didn't know any better, seabird, I’d say you were making a threat.”

“And?” you smile. “Do you, jailbird?”

“Do I what?”

“Know better.”

Halbrand laughs again. A charming peal of a sound, canine-wide and punched out. It makes your heart sing— makes you wonder when was the last time he laughed this freely.

“You!” he exclaims once more, but there’s a thunderdrum in his ribs to reckon with all of a sudden, from the way the first break of light begins to dawn on your face and the charming, affectionate grin flowering across it, and so he couldn’t finish his insult after all.

You offer him wine in his dreams.

Soot blackens your fingers as he takes it, but the stains don’t seem to bother you.

Weighty is a hagstone in his palm.

The sea is blue and quiet—

And barnacles are just barnacles, now.

Footnotes in AO3!

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thedevilrisen · 5 months ago

Text

Hospital - 2

Nova Crosby -

10:17 pm

Luke paced the hall outside the emergency room, the silence in the bustling hospital, unnerving. The only sounds emanating throughout the hall was his heavy footsteps and frantic breathing, erratic like his heart. Anyone passing by would be highly concerned, a young man in a distressed state however clamer then staring at Nova's emotionless face as she stayed in a half conscious state of mind.

He had received a message from Sidney saying he was boarding the plane roughly twenty minutes ago, there hadn't been much update from the doctors on Nova's state as they were currently trying to figure out what's wrong and what the best course of treatment would be.

Luke was roughly on his thirtieth lap down the hall when a door crashes open and a nurse is navy scrubs peered out, when she spotted his pacing figure she moved towards him, calling out gently.

"Are you here for Nova Crosby?" she spoke quietly, hands clasping in front of her. The nurse stood like a pylon in the storm of Luke's emotions as he whipped around and practically sprinted to her, after hearing nothing for the first forty minutes of being in the hospital Luke was becoming understandably desperate.

Anticipating the barrage of questions the nurse tenderly grasped his arm and led him to a small cluster of seats adoring the side of the hall, non-verbally asking him to take a seat. News about any loved on becoming injured and hospitalised is always hard to deal with. Luke tried and failed to form words but no words from any of the 7,000 dialects of the world would accurately depict his feelings.

"Take you're time son." she murmured grazing her hand feather-lightly over the fabric of his hoodie. Luke choked out a wet, unintelligible sound before taking another few gasping breaths desperately trying to tame his mind but it felt akin to herding cats.

"H-how is she." he formed eventually, lips feeling swollen around the words. His brain was still struggling to even comprehend the fact that this situation was real, that Nova was in the emergency department with critical injuries and all he could do is watch and wait for his Nova to come back to him.

"She's going to alright.. eventually." the nurse stated, "I'm not going to sugar coat it. She has a long road ahead of her and will need lots of support but right now they are preparing for surgery to place some disk in her back to counteract the vertebrate discs from deflating."

Luke took a deep breath, "Something tells me that won't be it."

The nurse sighed, the smile lines on her face showing the many happy moments and information she would have shared but now it only sported a frown, "She has a minor concussion, however that is the least of your worries, she also has a fractured sternum but there is little we can do about that." She let out a long sigh, "We will need to keep her under monitoring though at risk of a collapsed lung."

Luke picked at the skin around his finger, taking a deep breath. "That's a lot."

The nurse smiled softly, "It could however be much, much worse too hon." she watched as Luke contemplated this notion, grappling once again with his mind before he nodded reluctantly.

"I think you should take a walk, hon. Go down to the cafe on level two, they do a wonderful banana bread." the nurse smiled gently, standing up and guiding Luke with her.

"I will, you have my phone number, her father's too but he is on a plane here currently so please, call me if anything changes." Luke begged, eyes wide and voice shaky.

"I will hon, I will personally make sure." She smiled gently, "Now go eat! Banana bread remember!"

Luke nodded to her grateful for the support in this treacherous time, as the doors to the elevator opened and he stepped in his phone buzzed.

Sidney - 11:02 I've landed, what's new? I'll be there in half an hour.

#risen rambles :d #nc57 #luke hughes #sidney crosby #luke hughes blurb #luke hughes fic #luke hughes x oc #luke hughes imagine #hughes brothers #nj devils #sidney crosby fic #sidney crosby fanfic #sidney crosby fanfiction #sidney crosby imagine #pittsburgh penguins #thedevilrisen blurbs #thedevilrisen au's

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slamdunktheories · 7 months ago

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What sort of injury did Sakuragi have? An orthopaedic surgeon weighs in

Hey, gang! I stumbled upon this interesting article sometime back and have been meaning to share it. It's basically an orthopaedic surgeon (and fellow SD fan) analysing what sort of back injury Sakuragi had gotten during the Sannoh match. See article here (in Japanese). Google-translated English version is here.

In short, the surgeon thinks it was either a vertebral body fracture or a lumbar transverse process fracture, and goes on to talk about the recovery period one could expect from such an injury, how the team reacted to it in the story, etc.

His response when asked how Anzai-sensei and Ayako had handled things was pretty funny. “From the POV of an orthopaedic surgeon, it was of course a total fail.” LMAO!

But then he goes on to say something that would probably resonate with every SD fan (that if they had done the right thing and benched Sakuragi... there’d be no story).

As a fan, I'm relieved to hear that the injury seems perfectly realistic and also perfectly recoverable. Thank you Inoue-sensei for sticking to realism even in key/dramatic moments.

Have a gander at the article - it's quite interesting and much more in-depth than what I've shared here! Again, links here:

Original article here (in Japanese). Google-translated English version is here.

#slam dunk #takehiko inoue #anime and manga #スラムダンク #sakuragi hanamichi #fan analysis #mangaka

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breathing-rapture · 6 months ago

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Spine spin!!! Spin spine!!!

Everyone ignore the sacrum being offset, I didn’t notice until I rewatched the recording. It’s hard to get each vertebra to stay lined up…

Anyways this is the spine of that coyote car-hit-survivor, with the fractured and refused femur and humerus… she’s got some strangely healed ribs too, aaand a few fused vertebrae in the spine!!! I tried to get a close up here, but it’s really hard to appreciate on film… the bones developed this weird shell, one of the vertebral bodies was shattered to nothing and was anchored to the other by the sliver of body it had left. The whole mass would’ve limited her mobility I imagine. It’s a miracle she survived long enough for the bones to heal so thoroughly.

#bone collecting #bone collector #vulture culture #animal bones #dead things #bones #coyote bones #spine

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vaporwavedoggie · 4 months ago

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Ahahahah I should probably explain why I'm not on here as much atm, along with most of my other social media.

It's gonna be long but I know I have some folks on here worried about me so I'll put everything under the cut.

Alright buckle up, this will get long.

To shorten things, my chronic pain is significantly getting worse very quickly, along with heart issues.

Not to mention my shit mental health.

But here's the long story:

There's something up with my heart. I don't know exactly what the diagnosis will be, I have a few more tests including a fun little holter monitor placement or whatever it's called.

It's where I wear this monitor over my heart for a few days and press a button whenever I start having flareups. My flareups consist of my blood pressure suddenly dropping very low (I think the lowest it was clocked was somewhere in the 80s/60s range if I remember correctly), headaches, bad chest pain, limb weakness/numbness, sudden exhaustion/passing out, etc.

They did an echo on my heart but the results didn't tell me much other than I have a dialated left atrium. No idea what that means, don't know if it's even related to the shit going on with me. I won't find out until the other tests are done and looked over.

I'm going as far as to try and give up cigarettes for the time being for this. My doc gave me a ton of nicotine patches, so I'm really hoping those will help with the urges. I'm going to be going from smoking about half a pack or so a day to patches that are 7mg of nic, so uhhh yeah.

Another reason why I'm distancing myself from online spaces more other than my personal discord servers is because stressful stuff, discourse, all that makes my flareups much much worse. I'm doing it not to be a bitch, but for my own health. So for a bit I'll probably only post art I occasionally draw n what not.

Now on to the other issues. My lower back keeps me in damn near constant chronic pain. They did an xray on it, and my MyChart (fun little doctor app) said this about their findings:

"Vertebral body heights and alignment are well-maintained. No fracture or subluxation. Pedicles are intact. Mild loss of disc height at L5-S1."

I'm not entirely sure if that's anything important, again, I go to my pcp about it in the beginning of October since there's a few more issues they'd like to test me for before coming to a diagnosis and treating me.

As for my back pain though, it's to the point where it's nearly disabling me physically.

I've had it for many years. Idk exactly when it all started, but I really started noticing it around the time I was 19-20. I have a theory it's because one of my first jobs that I worked for about a year was at a warehouse. It was very physical labor.

I'd be lifting heavy boxes constantly to the point where when I got home I couldn't bend down from the pain. I'd just have to flop down on my bed and pass out. And this went on about 4 days a week for a year.

At first, it started off as a small patch on my lower back, at the base of my spine, not being able to be touched. The gentlest poke would feel like stabbing pain. And it only got worse over the years, with the area spreading.

Now it's to the point where I can't stand for long, and when I sit or lay down I have to shift my position every 10-20 minutes or it flares up. And I dread going to sleep for a number of reasons. Not just because of the night terrors I have damn near every night due to my CPTSD, but because I wake up in excruciating pain most of the time due to not being able to shift my body in my sleep.

Worst part is, when I sleep, I'm dead to the world. If the night terrors aren't too horrible that night, I'm like a rock. No one can move me. Lord knows my husband has tried. And I'll sleep for about 12-20+ hours at a time at this point.

Funny thing is? No matter how much sleep I get, even if I get the base recommended amount without under or over sleeping, I'm ALWAYS exhausted.

My doc has sent a referral for me to get a sleep study but they have yet to reach out to me. I suspect this may also contribute to my heart issues but idk for sure.

So yeah. It's not enough that I deal with shitty mental health issues on a constant, but also chronic physical health issues as well.

Worst part is my family is borderline poverty. Despite everything I'm STILL trying to get a job because my family needs the money, along with others in the house, including my oldest son and teenage son.

Yet for whatever reason, everyone claims they're hiring, yet won't hire any of us. For me, I understand. I always struggled to keep a job due to various issues. But my sons have a completely clean slate, and my roomie has a great resume with plenty of long history, yet no one will hire anyone. Not even McDonald's.

People act like it's all us. We try everything we can, from dressing up in our nicest clothes for the interview, following up with the job, being friendly, giving the interviewer our skills. Worst part is they act like they're fucking impressed, then turn around and claim they've decided to go with someone more qualified for the position, or they're not hiring anymore.

Yes, I know I'll hurt myself if I try working a job and pushing myself beyond my limits every day, but it's taking too damn long for disability to do shit. Disability is very hard to get in Texas for whatever reason and God it's stupid. It usually takes a minimum of 2-3 years for most, and we don't have that time.

The price of rent, groceries, and everything else keeps skyrocketing, yet my roomies won't get a raise on their disability, my husband won't get a raise on his job other than just a few cents once a year.

We're living by the skin of our teeth. Paycheck to paycheck. Most of our food comes from various food banks in the area we make multiple trips to a week.

Then when it comes to my mental health issues, I'm handling it the best that I possibly can.

My CPTSD has been flaring up. Then there's the other shit going on with my head I won't get into.

I'm nearly constantly haunted by trauma and I'm so fucking tired of it. I have to keep myself busy or it creeps into my mind. And I have somnophobia because every time I sleep I'm almost guaranteed to have a night terror. No, prasosin won't help.

Anyways that's a small portion of the shit im going through and why I probably won't be online much until I get shit sorted out.

Is it weird to be the happiest you've ever been in your life, yet also the most miserable??

#vent kinda #tw #cptsd #physical health #spoonie

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etapereine · 5 months ago

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vertebral fractures for nicolas debeaumarché, but that was a really scary crash so good to hear an update.

#hope there are no other issues and recovery goes well for him 🤞#i don’t think poland was the best race to try out the limited radio idea to be completely honest #seems like he crashed and then no one could see him so it took a while for him to get help #saw some clips of official race radio telling the few riders with radios about the area where he crashed #but they didn’t even mention him - presumably bc they couldn’t see him and didn’t know he’d crashed?#today and tomorrow is two radios per team and friday is no radios at all

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sassenach77yle · 1 year ago

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Here, Dr. Randall.” Joe leaned over and carefully placed the skull in my hands. “Tell me whether this lady was in good health, while I check her legs.” “Me? I’m not a forensic scientist.” Still, I glanced automatically down. It was either an old specimen, or had been weathered extensively; the bone was smooth, with a gloss that fresh specimens never had, stained and discolored by the leaching of pigments from the earth. “Oh, all right.” I turned the skull slowly in my hands, watching the bones, naming them each in my mind as I saw them. The smooth arch of the parietals, fused to the declivity of the temporal, with the small ridge where the jaw muscle originated, the jutting projection that meshed itself with the maxillary into the graceful curve of the squamosal arch. She had had lovely cheekbones, high and broad. The upper jaw had most of its teeth—straight and white. Deep eyes. The scooped bone at the back of the orbits was dark with shadow; even by tilting the skull to the side, I couldn’t get light to illuminate the whole cavity. The skull felt light in my hands, the bone fragile. I stroked her brow and my hand ran upward, and down behind the occiput, my fingers seeking the dark hole at the base, the foremen magnum, where all the messages of the nervous system pass to and from the busy brain. Then I held it close against my stomach, eyes closed, and felt the shifting sadness, filling the cavity of the skull like running water. And an odd faint sense—of surprise?

“Someone killed her,” I said. “She didn’t want to die.”

I opened my eyes to find Horace Thompson staring at me, his own eyes wide in his round, pale face. I handed him the skull, very gingerly. “Where did you find her?” I asked. Mr. Thompson exchanged glances with Joe, then looked back at me, both eyebrows still high.

“She’s from a cave in the Caribbean,” he said. “There were a lot of artifacts with her. We think she’s maybe between a hundred-fifty and two hundred years old.”

“She’s what?” Joe was grinning broadly, enjoying his joke. “Our friend Mr. Thompson here is from the anthropology department at Harvard,” he said. “His friend Wicklow knows me; asked me would I have a look at this skeleton, to tell them what I could about it.” “The nerve of you!” I said indignantly. “I thought she was some unidentified body the coroner’s office dragged in.” “Well, she’s unidentified,” Joe pointed out. “And certainly liable to stay that way.”[...]

“Oh, de headbone connected to de…neckbone,” Joe sang softly, laying out the vertebrae along the edge of the desk. His stubby fingers darted skillfully among the bones, nudging them into alignment. “De neckbone connected to de…backbone…” “Don’t pay any attention to him,” I told Horace. “You’ll just encourage him.” “Now hear…de word…of de Lawd!” he finished triumphantly. “Jesus Christ, L. J., you’re somethin’ else! Look here.” Horace Thompson and I bent obediently over the line of spiky vertebral bones. The wide body of the axis had a deep gouge; the posterior zygapophysis had broken clean off, and the fracture plane went completely through the centrum of the bone. “A broken neck?” Thompson asked, peering interestedly. “Yeah, but more than that, I think.” Joe’s finger moved over the line of the fracture plane.

“See here? The bone’s not just cracked, it’s gone right there. Somebody tried to cut this lady’s head clean off. With a dull blade,” he concluded with relish.

Horace Thompson was looking at me queerly. “How did you know she’d been killed, Dr. Randall?” he asked. I could feel the blood rising in my face. “I don’t know,” I said. “I—she—felt like it, that’s all.” “Really?” He blinked a few times, but didn’t press me further. “How odd.” “She does it all the time,” Joe informed him, squinting at the femur he was measuring with a pair of calipers. “Mostly on live people, though. Best diagnostician I ever saw.” He set down the calipers and picked up a small plastic ruler. “A cave, you said?” “We think it was a…er, secret slave burial,” Mr. Thompson explained, blushing, and I suddenly realized why he had seemed so abashed when he realized which of us was the Dr. Abernathy he had been sent to see. Joe shot him a sudden sharp glance, but then bent back to his work. He kept humming “Dem Dry Bones” faintly to himself as he measured the pelvic inlet, then went back to the legs, this time concentrating on the tibia. Finally he straightened up, shaking his head. “Not a slave,” he said. Horace blinked. “But she must have been,” he said. “The things we found with her…a clear African influence…” “No,” Joe said flatly. He tapped the long femur, where it rested on his desk. His fingernail clicked on the dry bone. “She wasn’t black.” “You can tell that? From bones?” Horace Thompson was visibly agitated. “But I thought—that paper by Jensen, I mean—theories about racial physical differences—largely exploded—” He blushed scarlet, unable to finish. “Oh, they’re there,” said Joe, very dryly indeed. “If you want to think blacks and whites are equal under the skin, be my guest, but it ain’t scientifically so.” He turned and pulled a book from the shelf behind him. Tables of Skeletal Variance, the title read. “Take a look at this,” Joe invited. “You can see the differences in a lot of bones, but especially in the leg bones. Blacks have a completely different femur-to-tibia ratio than whites do. And that lady”—he pointed to the skeleton on his desk—“was white. Caucasian. No question about it.”

Cap 20 diagnosis ~VOYAGER

#outlander #outlanderedit #the frasers #outlander series #outlander starz #outlander fanart #outlander books #claire fraser #dr claire randall #claire beauchamp #caitrionabalfe #outlander season 3 #outlander 3x05

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forgotten-retrouvaille · 9 days ago

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File!

THE FOLLOWING IS FOR INTERNAL DISSEMINATION ONLY . LEVEL 4 CLEARANCE REQUIRED . HIGHLY CLASSIFIED . ONLY FOR THE VIEW OF AUTHORIZED PERSONNEL.

PATIENT NAME : JILL VALENTINE .

D.O.B/AGE/SEX : 03.22.1974 / 32 / FEMALE .

CASE # : #208-63-001

COLLECTED : [CLASSIFIED]

RECEIVED : [CLASSIFIED]

DELIVER TO : [CLASSIFIED]

STATUS : UNVIABLE .

VIROLOGY EVALUATION :

POST PHYSICAL EVALUATION AND TREATMENT , SEVERAL EXPERIMENTS DONE ON BLOOD SAMPLES PROVIDED BY PATIENT . UNUSUALLY HIGH RESISTANCE TO CERTAIN MEDICATIONS . DETECTED AMOUNTS OF TYRANT AND SLIGHT TRACES OF EXPOSURE TO BOTH PROGENITOR AND TYRANT ABYSS . BOTH REPORTED TO CURRENTLY BE DORMANT . DETECTED UNIQUE ANTIBODIES RESISTANT TO PROGENITOR AND TYRANT . UNVIABLE FOR PROJECT [CLASSIFIED] . POTENTIALLY VIABLE FOR [REDACTED] . STANDBY ON REPORT FOR FURTHER EXPERIMENTATION - PATIENT MAY REMAIN VIABLE FOR RESEARCH REGARDLESS .

PHYSICAL EVALUATION :

SEVERAL ACUTE FRACTURES REPORTED IN REGIONS INCLUDING BUT NOT LIMITED TO : CERVICAL , ABDOMINAL , UPPER EXTREMITIES , LOWER EXTREMITIES , PELVIS , BRACHIAL , FEMORAL , VERTEBRAL.

RECORDED SYMPTOMS OF SHOCK , BOTH SPINAL AND HYPOVALEMIC.

CHANCES OF SURVIVAL UPDATED TO POSSIBLE AFTER TREATMENT PROVIDED .

REPORTED EXCESSIVE LOSS OF BLOOD . SEVERAL ACUTE LACERATIONS REPORTED IN MULTIPLE REGIONS OF THE BODY . SEVERAL PUNCTURE WOUNDS LOCATED IN MULTIPLE REGIONS OF THE BODY . REPORTED EXCESSIVE PERIOD OF TIME SPENT UNCONSCIOUS .

TREATMENT GIVEN :

PATIENT PLACED IN MEDICAL WING . PROVIDED DRIP IV OF REQUIRED NUTRIENTS AND SEDATIVES . PATIENT ALREADY REPORTED TO BE UNCONSCIOUS FOR SIGNIFICANT AMOUNT OF TIME AND SUBSEQUENTLY PLACED INTO A MEDICALLY INDUCED COMA . FRACTURES SET BY MEDICAL PROFESSIONALS .

O BLOOD TRANSFUSED INTO PATIENT AND EMERGENCY SURGERY DONE TO PREVENT FURTHER DAMAGE AND INFECTION . SEVERAL STITCHES DONE . ANTIBIOTICS PRESCRIBED AND GIVEN TO PREVENT INFECTION. PATIENT REMAINING IN MEDICAL COMA UNTIL FURTHER TESTS ARE CONCLUDED AND VIABILITY DEDUCED.

INVESTIGATION RESULT

TYRANT VIRUS DETECTED

TYRANT VIRUS - NEa DETECTED

TYRANT-ABYSS DETECTED

PROGENITOR SLIGHT TRACES

INTERPRETATION :

1. DETECTION OF DORMANT TYRANT VIRUS .

2. DETECTION OF DORMANT TYRANT VIRUS - NEa .

3. DETECTION OF DORMANT TYRANT ABYSS VIRUS .

4. DETECTION OF ANTIBODIES AND FURTHER PROPERTIES CORRELATING TO VACCINE ADMINISTRATION .

5. DETECTION OF SLIGHT TRACES BELONGING TO PROGENITOR .

COMMENTS :

1. INFECTION REPORTED TO HAVE REMAINED DORMANT FOR SIGNIFICANT AMOUNT OF TIME DUE TO CELL MARKERS, SATURATION , AND ANTIBODIES . SIGNIFICANTLY POTENT STRAIN OF TYRANT .

2. SEE ABOVE . STRAIN TESTED AND REPORTED TO MATCH MARKERS WITH EXPERIMENTAL TYRANT-NEa . CAUSE OF HEIGHTENED IMMUNE RESISTANCE : LIKELY

3. SIGNIFICANTLY LESS TRACES IN THE BODY COMPARED TO THE TWO ABOVE . EXPOSURE LIKELY , FULL INFECTION UNLIKELY .

4. SIGNIFICANT AMOUNT OF UNIQUE ANTIBODIES UNSEEN BEFORE . PROPERTIES AND BEHAVIOUR CORRELATE TO BOTH PAST INFECTION AND VACCINE ADMINISTRATION . VACCINE ADMINISTRATION LIKELY TO BE THE CAUSE OF DORMANCY . USEFUL?

5. LIKELY A RESULT OF EXPOSURE TO SEVERAL STRAINS OF TYRANT. SEVERAL BLOOD MARKERS BELONGING TO TRACES OF PROGENITOR . ANTIBODIES INVOLVE TRACE AMOUNTS. USEFUL?

NOTES :

Patient to remain in Tricell's security wing . Patient to remain in medically-induced coma until injuries fully recovered and possibility to begin proper research arises . This is to remain fully classified from all personnel with the exception of those already outlined.

SIGNED BY : ALBERT WESKER ; CHIEF OF STAFF , HEAD RESEARCHER.

#✦𓂅 you hover like a hummingbird haunt me in my sleep ╱⠀ answered #[ 𝟎𝟏 ] ── * 𝗛𝗘𝗔𝗗𝗖𝗔𝗡𝗢𝗡𝗦 { to tear the stars from the heavens }#✦𓂅 with her sweetened breath and tongue so mean ╱ drabbles .#this was really fun to write out thanks for sending it in !

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pathologising · 4 months ago

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why my grandfather has a 25% vertebral fracture can we stop the aging process PLEAAAASE I can't do this rn

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mcatmemoranda · 7 months ago

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Lifestyle measures – Lifestyle measures to reduce bone loss include adequate calcium and vitamin D intake, exercise, smoking cessation, fall prevention, and avoidance of heavy alcohol use. In general, women should achieve 1200 mg of elemental calcium daily (total diet plus supplement) and 800 international units of vitamin D daily. If dietary calcium intake is inadequate, we suggest calcium supplementation.

●Low bone mass (osteopenia) – In postmenopausal women with low bone mass and without fragility fracture, we calculate absolute fracture risk using the Fracture Risk Assessment Tool (FRAX). For most patients with low to moderate fracture risk, we suggest not using pharmacologic therapy to prevent bone loss or fracture. (See 'Our approach' above.)

●Patient selection for osteoporosis pharmacologic therapy

•For postmenopausal women with a diagnosis of osteoporosis based on bone mineral density (BMD; T-score ≤-2.5) or fragility fracture, we recommend treatment with pharmacotherapy (algorithm 1) (Grade 1A).

•For postmenopausal women with low BMD (T-score between -1.0 and -2.5) and high fracture risk, we also suggest pharmacologic therapy (Grade 2B). In the United States, a 10-year probability of hip fracture or combined major osteoporotic fracture of ≥3 or ≥20 percent, respectively, is a reasonable threshold for pharmacotherapy.

●Choice of initial therapy

•Most women with osteoporosis – For the initial treatment of osteoporosis in most postmenopausal women, we suggest oral bisphosphonates (algorithm 2) (Grade 2B). We prefer these agents based on efficacy, cost, and long-term safety data. Oral bisphosphonates are contraindicated in those with esophageal disorders (eg, esophageal stricture) or known malabsorption (eg, Roux-en-Y gastric bypass) (algorithm 2).

Algorithm 2:

25(OH)D: 25-hydroxyvitamin D; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate; GI: gastrointestinal.

* Refer to additional UpToDate content on evaluation of hypercalcemia and hypocalcemia.

¶ Very high risk of fracture: No consensus exists on the definition of very high fracture risk. Examples may include: T-score of ≤–3.0 even in the absence of fractures, T-score of ≤–2.5 plus a fragility fracture, severe or multiple vertebral fractures.

Δ Patients most likely to benefit from anabolic therapy are those with the highest risk of fracture (eg, T-score ≤–3.5 with fragility fracture[s], T-score ≤–4.0, recent major osteoporotic fracture, or multiple recent fractures).

◊ Increased risk of vertebral fracture is evident after discontinuation of denosumab; the need for indefinite administration of denosumab should be discussed with patients prior to its initiation.

§ Anabolic agents include teriparatide, abaloparatide, romosozumab.

¥ Oral bisphosphonates are poorly absorbed and must be taken on an empty stomach first thing in the morning with at least 240 mL (8 oz) of water. After administration, the patient should not have food, drink, medications, or supplements and should remain upright for at least 1 half-hour.‡ Denosumab is an alternative to intravenous zoledronic acid for women at high risk for fracture who have difficulty with the dosing requirements of oral bisphosphonates or who prefer to avoid intravenous bisphosphonates due to side effects. However, increased risk of vertebral fracture is evident after discontinuation of denosumab so the need for either indefinite treatment or transition to another osteoporosis medication should be addressed with patients before denosumab initiation.

We typically prefer alendronate as our choice of oral bisphosphonate due to efficacy in reducing vertebral and hip fracture and evidence showing residual fracture benefit after a five-year course of therapy is completed. Risedronate is a reasonable alternative.

•Very high fracture risk – For postmenopausal women with very high fracture risk (eg, T-score of ≤-2.5 plus a fragility fracture, T-score of ≤-3.0 in the absence of fragility fracture[s], history of severe or multiple fractures) (algorithm 1), we suggest initial treatment with an anabolic agent (Grade 2B). Patients most likely to benefit from anabolic therapy are those with the highest risk of fracture (eg, T-score ≤-3.5 with fragility fracture[s], T-score ≤-4.0, recent major osteoporotic fracture, or multiple recent fractures). Options for anabolic therapy include teriparatide, abaloparatide, or romosozumab. For patients with very high fracture risk who cannot be treated with an anabolic agent due to cost, inconvenience, contraindications, or personal preference, a bisphosphonate or denosumab may be appropriate (algorithm 2). Patients should be under the care of a provider with expertise in treating osteoporosis to facilitate shared decision-making.

●Contraindications to bisphosphonates

•Oral bisphosphonates contraindicated – Patients who cannot take oral bisphosphonates can be treated with an intravenous (IV) bisphosphonate instead (algorithm 2). Zoledronic acid is our agent of choice, as it is the only IV bisphosphonate with demonstrated efficacy for fracture prevention. Denosumab is a reasonable alternative. (See 'Gastrointestinal malabsorption or difficulty with dosing requirements' above.)

●Oral and IV bisphosphonates contraindicated

•Most women with osteoporosis – For most patients who cannot tolerate any bisphosphonate, we suggest denosumab rather than an anabolic agent (Grade 2C). Increased risk of vertebral fracture develops after discontinuation of denosumab, so the need for indefinite administration should be discussed with patients prior to denosumab initiation.

Anabolic agents may be used in patients with less severe osteoporosis when bisphosphonates are contraindicated. For patients with no history of fragility fracture(s), particularly those at high risk for breast cancer, raloxifene is a reasonable alternative.

•Very high fracture risk – For patients at very high risk of fracture (eg, T-score of ≤-2.5 plus a fragility fracture, T-score of ≤-3.0 in the absence of fragility fracture(s), history of severe or multiple fractures) who were not treated initially with anabolic therapy, we suggest switching to an anabolic agent (Grade 2C). Denosumab is an alternative. (See 'Contraindications or intolerance to any bisphosphonates' above and "Parathyroid hormone/parathyroid hormone-related protein analog therapy for osteoporosis", section on 'Overview of approach'.)

After initial therapy with an anabolic agent is discontinued, patients should be treated with an antiresorptive agent (typically a bisphosphonate) to preserve the gains in BMD from anabolic therapy. For individuals who are unable to tolerate oral or intravenous bisphosphonates, alternatives may include denosumab or raloxifene. (See "Parathyroid hormone/parathyroid hormone-related protein analog therapy for osteoporosis", section on 'Management after teriparatide' and "Parathyroid hormone/parathyroid hormone-related protein analog therapy for osteoporosis", section on 'Management after abaloparatide'.)

●Monitoring – For patients who initiate osteoporosis pharmacotherapy, we obtain a follow-up dual-energy x-ray absorptiometry (DXA) of the hip and spine after one to two years (algorithm 3). A change in BMD is considered significant only if it exceeds the least significant change (LSC) for the specific densitometer used. If LSC is not available, a threshold change of ≥5 percent has been suggested as an alternative. (See 'Our approach' above.)

•Bone mineral density stable or increased – If BMD is stable or improved, we continue therapy and remeasure BMD less frequently (eg, two to five years based on the clinical setting).

•Bone mineral density decreased or fracture during therapy – After at least one year of osteoporosis pharmacotherapy, a BMD decrease greater than the LSC or new fragility fracture should trigger additional evaluation, including assessment for treatment nonadherence or interim development of a secondary cause of bone loss (table 8). Whenever possible, patients should be under the care of a clinician with expertise in osteoporosis management.

If a remediable secondary cause of bone loss is identified, it should be treated. If the secondary cause of bone loss cannot be mitigated, or no secondary cause is identified, management depends on BMD and whether an interim fragility fracture occurred.

-Interim fragility fracture or T-score ≤-2.5 – For postmenopausal women who experience a fragility fracture or have a T-score ≤-2.5 on bisphosphonate therapy, we suggest discontinuing the bisphosphonate and switching to anabolic therapy (Grade 2C). Teriparatide and romosozumab increase BMD after previous bisphosphonate treatment. (See 'Interim fragility fracture or T-score ≤-2.5' above and 'Selection of anabolic agent' above.)

-BMD decreased but no interim fracture and T-score >-2.5 – In the absence of interim fragility fracture or T-score ≤-2.5, we use bone turnover markers and clinical assessments to evaluate the likelihood of treatment effectiveness. If treatment is unlikely effective, we stop the oral bisphosphonate and switch to IV zoledronic acid. If treatment is likely effective, we typically continue oral bisphosphonate therapy and remeasure BMD with DXA in one to two years. (See 'BMD decreased but no interim fracture and T-score >-2.5' above.)

#osteoporosis #osteoporosis tx

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