#i do appreciate arcane because it’s one of the biggest shows of the year with an unapologetically lesbian couple at the forefront!

[hyperfixationstation128]

Chapter Six: Dinner and a Show

Rating: E (fluff/romance)

Summary: Gale treats Arcane to a much-needed meal and a private magic lesson, but the newfound connection they share feels far more powerful than any gift Mystra could bestow.

Word Count: 8,373

Once more, this is a longer chapter. I really appreciate y'alls patience with me as I worked. I think this chapter came out really nicely, so I hope you enjoy! Continue reading beneath the break!

There was a soft silence that surrounded Gale and Arcane as they made their way to his tower. The lights now snuffed out in the many shops and homes that lined their path, a few lone stragglers roaming about as they made their ways back home to rest for the night, awaiting the morrow’s ambling workday. Arcane fidgeted with the amulet in her hands as they ambled, her thumb gently stroking over the smooth-cut purple gemstone, fingers fumbling with the silver chain from which it hung.

She wasn’t quite sure why she needed it so badly. Sure, she wanted it because it was her grandfather’s and he had abandoned her with nary a note to remember him by, but whenever she thought about the boiling rage she felt at the prospect of never having it again, she was astounded by just how angry she had been. Something about getting his belongings back, the amulet especially, called to her; sang in her blood like some mighty need.

The sound of Gale’s voice beside her snapped her out of her thoughts. “I take it that stone means a great deal to you, yes? You mentioned it was your grandfather’s?”

Arcane glanced up at him, noting his inquisitive look. “Yes. He, uh, left rather suddenly, close to five years ago.” She felt her breath catch in her throat, the painful memories threatening to pull tears from her eyes. She shook her head slightly and sighed. “I haven’t heard from him in a long time, so when I heard my papa was sellin’ his things to make ends meet, I set out to find them. This is just one of his myriad of little trinkets.”

“Ah, I can see how you might think it’s just a trinket, but it is, in fact, imbued with magic.” He held up a finger to solidify his point. “You don’t feel that slight tingle in your hand? The dull pulse in your teeth? It’s faint, but powerful.” He drummed his fingers against his cheek.

Arcane’s teeth instinctively grinded against each other. “I suppose I shouldn’t be too surprised that grandda owned several magical items. He was always fond of secrets.” Her eyes squeezed shut for a moment. “Nor should I be surprised that he kept all of them from me, even if I did think I was special in his eyes.” A distant bang followed by drunken roarous laughter made Arcane jump, a memory of the rowdy pirates seared her mind. She recalled the feeling of their filthy hands on her body, groping her as she passed.

“Such is the way of those who are in tune with Mystra’s gifts.” Gale chimed in,  offering her a kind smile, one which crinkled at his eyes. “You are quite the mystery, yourself. I must confess, since I saw you during the storm, I’ve had this near overwhelming need to learn more about you. There’s something… indecipherable about you.”

“‘Indecipherable’, eh?” She chuckled wryly, shaking her head to clear it of the flashback. “You certainly know how to charm a woman.” She pocketed the amulet, considering his words for a moment. “What do you mean you saw me in the storm?”

The rosy flush painted his cheeks once more. “Ahh, well, I was having a relaxed day in my tower; partaking in a particularly lovely cup of tea, when all of a sudden, I heard a jarring roar of thunder.” His hands gesticulated in the air as he spoke; she liked that about him. “But this was no ordinary thunder, I thought to myself. The sheer resonance with which it crashed simply had to be magical in nature. I looked out onto the horizon, aided by my enchanted spyglass, where I saw it: a conjured, localized storm, the biggest I’d seen in a while, making a victim of a pirate ship.”

“My, quite jarring, indeed…” She trailed off, the flash of swords, the roar of thunder, the scent of rain mixed with blood flashed in her mind. She squeezed her eyes shut, but the images were burned behind her eyelids, inescapable, even in darkness. The fighting, the shouting; gods, the blood…

He continued on, his eyes glittering with what Arcane assumed to be amazement as he did so. “As previously stated, I recognized this storm to be magical in nature, and thus, had to find the source.” His hands stopped moving, and he paused to look at her. His eyes made Arcane’s heart flutter. “And there I saw it. A woman - you - standing in the eye of this monumental storm, surrounded by pirates; fighting with such ferocity, such capability, it was a near devastating blow to my ego! I couldn’t just stand by and watch. I had to help.”

There were few things that set Arcane’s heart aflutter, few words spoken to her that had managed to bring a flush to her cheeks. But the things he said, the way in which he talked about how he viewed her magic, the way he used his hands to signify his points… It left a warm glow soaring across her skin and pulled her from the harrowing thoughts. She smiled at him, soft and flirtatious, taking a step closer to him, her fingers dancing on the lapels of his waistcoat. Hoping that if he continued to compliment her, it would wash away the feelings of being back there, back on that ship.

“Well? Don’t stop there, tell me more.” Her words trailed off into a breathy sigh, her eyes softening.

Gale only beamed at her, continuing on. “Happily! Thankfully, due to my keen eye, I identified this ship to not only be a pirate ship, but a slave ship! Knowing there’d be poor souls trapped below, I called forth a Knock spell. With a Weaving of words and a flick of my hand, I managed to successfully unlock their cells. Freeing the slaves, who rushed to your aid!” Once more, his hands waved in the air, demonstrating the movement he’d done. “And thus, the day was saved!”

Arcane’s smile fell and her brow furrowed. Was he… was he really trying to take credit for her efforts? Her hands released his waistcoat (perhaps pushing him back a little harder than she meant to) and she stepped away, continuing along the streets in silence, irritation biting at her burning ears.

The memories came back. The glint of Cutler’s blade raised high in the storm. The chorus of devilish shouts as she was swarmed by the crew. Her nerves stood on end, her eyes burned with unshed tears.

“Did I say something wrong? I promise you, I was merely recounting what I witnessed!” Gale caught up to her, his eyes wide and apologetic.

“Oh, no, not at all!” Arcane sneered, her arms folded over her chest. “I must’ve only imagined fighting through a wave of pirates, getting stabbed, and killing my first man. Far be it from me to think all those poor souls were rescued by my effort. I merely ‘conjured a storm’.”

The clap of thunder. The feeling of warm blood rushing through her fingers. The sting as a blade met her flesh.

Gale stepped in front of her, hands raised to halt her steps and eyes now darkened by his displeased frown. “If I said something impertinent, I’d rather you tell me outright. I’m not one for playing these childish games.”

The loss of breath as she was thrown against the mast. The soft splatter of blood on her face. Cutler’s words ringing in her ears. ‘The one thing a woman is good for, and you’re so bad at it!’ Her father’s words:

‘What a waste of magic’

‘What a waste of magic’

‘What a waste of magic!’

Arcane bristled, her fingers digging into her arms. “Childish?! You just took credit for almost everything I did. Blatantly ignoring the danger I was in and recounting it as if it were some childhood fairytale!” Her voice raised, but caught in her throat as the memories came flooding back. “It wasn’t some heroic deed. It was mortifying! And I wasn’t some valiant knight in shining armor. I was scared.”

She watched as Gale’s eyes softened, his brow unfurrowing and his mouth slightly gaping at her words. He paused a moment, his eyes now scouring the ground beneath them, as if the cobbled streets held his next words. His shoulders rose and fell as he sighed, offering her a sympathetic look.

“I’m sorry. Really, I am. And you’re right, I wasn’t thinking about what it must have been like during the altercation.” He placed a hand on her shoulder. “I’m afraid I was a tad… exuberant when I recalled it. I was safe in my tower, meanwhile, you… you were right in the thick of it! Fighting for your life, trying to control the storm around you. I hope you can forgive my unthoughtful words.”

She felt the tension in her shoulders ease at his touch. Gods, he was warm. Not quite like a roaring fire, but like the soft flicker of candlelight - bright and endearing - a welcome reprieve from the cold. Despite his apology and soft touch, Arcane gently shifted herself, letting his hand slip off her shoulder.

“I forgive you.” She muttered, averting his gaze lest she burst into flame, her fingers picking at her cuticles. “And I’m sorry for raising my voice. That was… unkind.”

“Ha! Believe it or not, that’s not the first time I’ve been shouted at for speaking without further thought. Though, I’m sorry to say, it probably will happen again.” He chuckled. “I remember this one time as a boy, I- Well, that’s probably a story best paired with a glass of wine. What say you to finally heading to my tower and cracking open a bottle, yes?”

A soft smile found its way back to Arcane’s lips, glancing back up at him. Wordlessly, she nodded, and wordlessly, they continued on.

It didn’t take long for the pair to make it back to his tower in the Docks Ward, only about 16 or so minutes. But when they did, Arcane could only stare up at it. The tower loomed over them, casting dark shadows onto the street below. She’d never seen a wizard’s tower before, at least, not one like this. With its stalwart stone foundation - built to withstand the crashing waves - and its aged, yet handsome wooden walls, it was quite the sight to behold! Not to mention, the grand foyer that greeted them. Paintings lined every wall, stacks of books littered the floor; it was cluttered with the kind of organized mess one would expect a young scholar living on his own to have.

To say Arcane was in awe would be an understatement; she was downright gobsmacked! Never before seeing such an incredible home in all her years!

“Ye, gods… You live here?” She gaped at the view before her, mindlessly working her coat off her shoulders. “It’s incredible! How can you live with so much space?”

Gale chuckled behind her, taking her coat and hanging it on the coat rack nearby before she could drop it to the floor, trying his best to not let his eyes linger on the tears in her shirt that revealed her tan skin. “Yes, I suppose it is rather generous in its size. A wizard can’t be expected to live in a hovel, after all.”

“Pfft, tell that to my grandda. He preferred smaller spaces.” Arcane snickered.

“Mr. Dekarios? Is that you?” A voice rang from up the stairs. Arcane turned to look back at Gale, trying not to giggle.

“Who was that, your housekeeper?”

Gale grinned in response, excitedly taking her by the hand and leading her up the stairs. “You’re going to love this. Follow me!”

Arcane followed suit, the two quickly bounding up the stairs and into a lovely seating room. Rows upon rows of books lined the far wall, their inlaid golden leaf spines illuminated by dozens of lit candelabras. On the floor, there lay an ornamental rug, upon which sat a plump cozy couch. There were no words to describe just how she felt, taking in the gorgeous sight before her.

“Now, this is something I could get used to!” Pangur chirped beside them, paws outstretched as he arched his back. “We’re definitely gonna have to get ourselves a home like this some day.”

“Aye, you could say that again…” Arcane’s eyes wandered around the room, taking in as much detail as she could, until a striking flash of orange, black, and white caught her eye. There, atop the back of the couch, green eyes stared at the group. A cat? No… surely it couldn’t be…

“Arcane, I’d like you to meet Tara. Who is decidedly not my housekeeper, but in fact, my friend.” Gale strode over to her, giving her a soft scratch behind her ears, into which she leaned, a wide pair of impressive wings spanning out from her shoulders. “Tara, this is Arcane and her companion, Pangur. They’ll be joining us for the evening.”

“By Greatshout's handlebar mustache! A Tressym?!” Arcane rushed over to get a closer look, kneeling down to be eye level with the creature. “Oh, Gale, she’s gorgeous! Tara, was it? By the gods, I’ve never seen such a beautiful creature in all my life!” She presented her hand to her, offering her scent.

Tara’s eyes widened at the sudden closeness and recoiled from her hand, giving Gale a pensive look. “Mr. Dekarios, you know I’ll always encourage you to make new friends, but to invite them over while the tower is in such disarray!” She ruffled her feathers before settling them back at her sides. “Without even a thought to send word ahead so I might make myself presentable.”

“Come now, Tara, you’re positively radiant!” Gale chuckled, continuing to pet her.

“Aye, and the prettiest wee birdie I ever did see...” Pangur made his way over to the group, his blue eyes staring unblinkingly at the Tressym.

Tara bristled, her wings fanning out to make her appear larger, and hissed. “Good heavens! What in Mystra’s name is that foul creature doing here?!”

Pangur stretched up on his hind legs, his forepaws resting on the couch as he leaned in closer. “Oh, there’s no need to be so ruffled, birdie.” He purred, licking his lips. “I may be half Cath Shee, but I’m no monster… unless the lady prefers it that way.”

Tara growled, swiping her claws at Pangur, striking him on the nose before retreating onto Gale’s shoulders, her fluffy tail lashing from side to side.

“Pangur! Don’t be vulgar!” Arcane chastised him, her arms scooping under his chest and lifting him into her arms, stepping away. “Miss Tara, I’m so sorry! Please, you’ll have to forgive my companion. He likes to pretend I never taught him any manners.” She glared pointedly at the cat-creature in her arms. He smiled haughtily as he dangled.

Gale stifled a chuckle, lifting Tara from his shoulders and placing her on the floor. “They’re our guests, Tara. And they’ve both traveled a long and hard road, so let’s try to avoid any further confrontation, shall we?”

“That depends entirely on the behavior of said guests. Oh, how you like to vex my nerves with your antics, Mr. Dekarios.” Her tail continued to swish back and forth. “But I shall endeavor to persevere. Now, let us not forget our manners. The poor girl is clearly in need of a bath!”

Arcane’s face flushed red. She hadn’t considered just how dirty she looked or how badly she must’ve smelled, but now that Tara had mentioned it, the grime that clung to her skin seemed weighed down on her.

The Tressym began to lead the pair across the room. “Come now, miss Arcane. Let’s see if we can’t wash away the toils of what clearly must have been a terrible ordeal.”

It didn’t take long for them to reach the washroom. It was unlike anything she’d seen before! A porcelain, clawfoot tub sat before them, with brass piping snaking up the wall. Arcane wondered for a moment just how well off this Gale character seemed to be. Perhaps a family fortune? She supposed it didn’t matter, all she wanted was a hot bath.

Tara shooed Pangur out the door before returning to hop onto the bathtub’s edge, explaining the concept of running water to her before hopping to the floor and sitting down, watching her. Arcane reached for the hem of her torn shirt, slowly peeling it from her skin, sucking in a sharp breath as it dragged across the nasty gash that hadn’t fully healed.

“Good gracious, child! How have you been walking around with such cuts and bruises?” Tara exclaimed, her tail flitting from side to side as she reached up to sniff at the wound, her lips curling in disgust. “Ugh, they’re positively rank!”

Arcane glanced at her wounds, shrugging slightly. “I had other things to take care of, I guess. They didn’t start hurting until I got to the tower.” She pulled at her skin, trying to get a better view of the damage, and dragged her finger lightly across the gash. “Ahh! But, I suppose they’ve grown tired of being ignored.” she winced, speaking through clenched teeth.

“Indeed! You’d better wash up quickly before an infection sets in.” She trotted off towards the door, which cracked open upon her approach. “You try and relax, miss Arcane. I’ll see if Mr. Dekarios has any healing potions amidst this disorderly tower of his.” The flickering of her multicolored tail was the last thing she saw before the door shut behind her.

Turning to the bathtub, she ran the water - as hot as she could stand it - and disrobed before stepping in. She hissed and panted as she tried to acclimate her body to the heat, finally sinking into the water with a deep, relieved sigh that left her dizzy. The warm water stung at her wounds as they were submerged, the stinging eventually dulling to a numb, throbbing pain. She pulled her knees to her chest, wrapping her arms around them.

‘I thought I told you to undress completely, wench!’

The crack of the leather belt.

Arcane buried her face in her knees, the memory echoing in her mind.

‘Now what will your dear betrothed think of you? Now that you're spoiled goods!’

Her fingers found themselves pulling at her hair, pain coursing through her head as she yanked the knotted stands tightly against her scalp. As if doing so would block away all memory of the trauma.

His icy blue eyes, his hellish smile, his rough hands. Hands, her hands, covered in blood. Her blood, his blood. The wheezing gasps he took as he strangled on his last breath.

The memories continued to plague Arcane’s mind, pulling herself into a tighter ball, pulling at her hair harshly. She couldn’t believe she had been so stupid! She couldn't believe she had ever allowed such a despicable, rotten man to ever lay hands on her. Not to mention the disbelief at her ignorance to Cutler's deception. She was disgusted with herself. She should’ve seen it coming.

Arcane grabbed the sides of the tub, the water splashing over the sides as she did so, and began to lift herself out of the bathtub. She didn't deserve to be clean.

The door opened, Arcane slipped, falling back into the water. Her eyes shot to the door, wide with panic. To her relief, it was only Tara, returning with a small vial, a sponge, and a bar of soap trailing behind her in the air, suspended by her magic.

     “I certainly hope you're not leaving! You've barely even scrubbed the mud from your face!” She once again hopped on the edge of the tub, folding her tail over her paws. “Here you are, drink this. It won't stop your wounds from scarring, I’m afraid, but it should heal them.”

Arcane stared at Tara, tentatively taking the vial and inspecting it closely. Tiny remnants of rogue's morsel salts sloshed around in the red liquid. Good. She uncorked the bottle and downed the liquid, feeling the gashed skin of her wound tightening and contracting to form deep, scarlet scars.

     “Thank you, Miss Tara. I feel better already.” she sighed, taking the sponge and lathering herself in the soap.

Sandalwood, spiced, sweet, and creamy, with hints of coconut.

After her bath, she wrapped herself in a bathrobe and followed Tara to, quote, “Wear something more acceptable than tattered rags.”. She felt cleaner than she had in what felt like years. Her skin smelled delightfully sweet, finding herself rolling up her sleeves just to press her nose to her arm and get another whiff.

While Arcane took her time getting changed, Gale was at work in the kitchen. If he guessed correctly, she wouldn’t have had much to eat in the past few days save for the dried rations they handed out in the Castle’s prisons. Besides, his mother would be most dissatisfied with him if he neglected to feed his guest. He stood there, his sleeves rolled up to his elbows to avoid staining them, slicing away at some limes while a pot of rice sat bubbling on the stove. A fragrant - and the had to admit, ambrosial - smell filled the air, combining into an amazing mixture of spiced fish, lime, and cilantro.

It was no secret to anyone that he loved cooking. It gave him something to focus his thoughts on, something he could control. When all the world seemed to drown in chaos, cooking a meal for either himself or loved ones was just one of the few things he could do to quiet the noise. But tonight… he found his mind wandering.

‘That poor girl.’ he thought to himself, ‘She must be petrified having gone through what she did. Surviving the wreck, getting locked away for a crime she didn’t commit… no wonder she’s so on edge.’ He was so lost in his thoughts that he didn’t hear the door to the kitchen open.

“Need some help?”

Gale turned his head, his fingers losing their grip on the knife, falling to the cutting board with a clatter. Arcane stood in the doorway, her fingers fumbling with the tasseled ties that held a sheer, floor-length robe to her form. The iridescent green silk complimented her sun-kissed skin and matched her eyes near perfectly, and it flowed behind her like water, exposing her lithe, bare legs, and over her ample hips as she meandered over to him. Her dark hair draped freely over her shoulders, finally clean of all the filth that dared to touch her, and framed her face perfectly.

She was a vision - a downright exquisite sight to behold. Gale blinked hard, as if doing so would pull illusion from reality, but yet there she still stood in front of him. The prettiest picture he’d ever seen.

“I, uhh, suppose it couldn’t hurt.” He shook his head, trying his best to ignore the unconscious tightening of his pants as excitement built within him. “I’m just about finished, but you could help me plate the fish.”

“It smells divine! A Waterdhavian dish?” She stood next to him, eyes scanning the food on the counter.

Gale could hardly breathe, lest he take in the succulent notes of sandalwood that blended perfectly with the scent of her skin. He nodded, silently averting his eyes to focus back on slicing the limes.

She chimed in once more, her sweet, velvety voice continued to send shivers down his spine. “This is incredible! Back in Daggerford, we mostly ate things like clam chowder or fried, breaded fish. Which, mind you, is good if you’ve the stomach for it, but the smell certainly doesn’t compare to what you’ve made here!”

He felt her eyes boring into him. Gods, how she made him burn. Gale mentally lectured himself over the sudden effect she had. She was simply a woman! An attractive woman, make no mistake, but just a woman nonetheless. He kept himself busy, eyes fixated on his work as he stirred the rice, squeezing the lime juice over it before topping it with roughly chopped cilantro leaves. He reached for the plates he’d set aside, handing them to Arcane so she could help. Her fingers brushed against his, lingering far too long and far too quickly before he swiftly moved out of her way.

Gale’s hands found themselves pushing back his hair, his eyes wandering unabashedly over her form as she arranged the food on the plates. He recognized this robe - a shameless gift left over from Merletta after a particularly regrettable drunken visit. It didn’t nearly suit her as much as it suited Arcane. She turned to him, plates in hand, and she smiled. The color had returned to her face, painting her freckled cheeks and full lips with a warm, peachy glow. He swallowed thickly, reaching for the plate, but she pulled away from him, smirking.

“Ah, ah!” She tutted, a playful twinkle in her eyes. “You’ve done far too much for me already. The least I can do is help bring dinner to the table.”

Gale couldn’t help the smile that mirrored hers, a stifled chuckle exhaling through his nose. “As you wish, my lady.” He gestured to the side, silently leading her into the dining room where she set the table - his plate on one end, hers on the other - and sat down.

He watched as she sat across from him, resting her elbows on the table as she folded her hands and bowed her head, muttering a hushed prayer. “I didn’t take you as the religious sort.” He fanned out his napkin before placing it in his lap.

“I’m not. I don’t hold enough faith in the gods to pray to them on a daily basis.” She matched his movement, placing her own napkin over her legs. “But tonight is a special occasion. I’m giving thanks for the stroke of luck I seem to have stumbled upon.” Soft fingers danced on the edges of her plate, hungrily eyeing the meal.

“Ah, all thanks to a certain handsome wizard who saw it fit to offer you shelter for the evening, no doubt?” Gale shot her a playful smirk.

She laughed, her smile scrunching her nose. “Well, I certainly didn’t add the ‘handsome’ part, but I’ll be sure to correct myself later if you wish.” Her fork lightly prodded at the fish. “Though, I have to admit, I don’t feel overall deserving of the kindness you’ve shown me thus far.”

Gale was taken aback by this, his first bite stopping short at his open lips. How could she say such a thing? He set his fork back on the plate. “Why not? Forgive me for bringing what must be a hard topic for you back to light, but was it not you who freed an entire vessel of slaves whilst simultaneously fighting off waves of pirates? They would have died - or worse - had it not been for your selfless actions!”

He watched as her eyes fell to the table, her brow knitting together. “I hardly did anything.” She mumbled, lifting her eyes back to him, soft and contrite. “I’ve had some time to think it over since being here and… you were right to take credit for their freedom. Had it not been for you, your well-timed spell, they’d have gone down with the ship! I’m… I’m so sorry for how I acted, Gale. You didn’t deserve that.”

The pair stared at each other, a silent exchange of sympathetic glances, before Gale smiled softly at her. “I forgive you, Arcane.” The forgiveness seemed to be enough, the two finally turning to their meals.

“Gods, this is amazing! You’ve a real talent!” She exclaimed, covering her chewing mouth as she spoke.

“I’m glad you’re impressed! Not to boast, but I do know my way around the kitchen.”

She eagerly took another bite. “Don’t be so humble. This is, without a doubt, the best supper I’ve had in a while!” She barely took the time to chew before swallowing, humming her enjoyment. “Whoever manages to lock you down in the future won’t go hungry, that’s for certain!”

Gale’s heart jumped at the mention of marriage, his cheeks warming at the thought. He cleared his throat. “I, ahem, I don’t necessarily think of myself as one for matrimony. Least of all with anyone I’ve met thus far. I’m… not particularly well-liked by my peers.”

Arcane halted to look up at him, her brow quirked in confusion. She looked him over, as if doing so would reveal just what exactly he was talking about. Given his action since their introduction, she found it rather strange that he wasn’t at the very least talking to someone special.

“So, no long-lost lovers? I shouldn’t expect to see an angry man or woman storming through the doors to catch their partner sharing a meal with a strange woman?” That delightful playful smirk returned to her lips.

“Ha! Certainly not.” He felt the soft pang of disappointment tug at his heart as he continued. “To be perfectly honest with you, I’m afraid I’m seen as something of a pretentious ass, if you’ll excuse my language. I have… a certain reputation that people tend to cling to, rather than who I am at heart.” It didn’t go without mentioning that he deeply craved affection. The only kind one would get from a lover, not the familial, motherly love he’d grown accustomed to from Tara and his mother.

Arcane hummed, considering his words for a moment before reaching across the table to get his attention, their eyes meeting as she smiled. “Well, for what it’s worth, I think you’re lovely.”

“Truly?” His voice raised slightly in surprise at her confession.

“Truly,” She echoed. “Far lovelier than any of the horrid men I’ve had the misfortune of meeting, anyway. And I don’t think you’re an arse, I think you’re passionate.”

Her words struck him like an arrow to the heart and warmed him from head to toe. She was one to talk. It wasn’t difficult for him to admit to himself that he found her lovely, too. Quite lovely, in fact. She was audacious, ambitious, funny… soft. A far cry from the other men and women he’d had in his life, who only saw him for the status that came with his inherent talents, rather than who he was at his core. It was comforting to meet someone who claimed to enjoy his company.

His eyes fell back to his plate, finding it hard to focus clearly if he kept staring at her. His mind raced as he looked for another topic to speak of. “So, ahem, your name…” he trailed off.

Arcane chuckled. “Haha, I knew this would come up sooner or later. It always does.” She took a sip of the white wine in front of her. “Grandda named me. I used to beg him to tell the story over and over again as a girl.” Her shoulders rose and fell as she sighed.

“It must have been an enthralling experience, if it warrants a story. Would you care to share it?”

A wry snicker crinkled her nose once more, frowning slightly. “If you insist, though I assure you, it’s hardly the tall tale grandda made it out to be.” She straightened in her seat and cleared her throat, dotting the napkin at the corners of her mouth. “It was an especially rainy time. In the wee hours of the morning, on the second tenday of Kythorn, a baby girl was born. The thunder heralded her delivery, the waves cheered her arrival. Aloft in my arms, I held her to the heavens and thusly, I cried, ‘Arcane! Daughter of the Weave!’” Arcane imitated her grandfather’s voice as best she could.

Gale watched as she acted out the scene, listening intently, engrossed as she recounted the tale.

“Arcane, I called her. Blessed, she was. Consigned to be my apprentice. My light, my love, my darlin’ little dove.” Arcane’s voice waved slightly at the pet name. Her heart sank with the fond memory. She gripped the edge of the table, steadying her breath before she continued. “‘Little dove’. That’s what he called me. He’s the one to credit for my magic, teaching me all he knew. Before he disappeared…”

Gale’s heart ached for her. His abandonment clearly affected her deeply. He felt a sense of… well, he wasn’t quite sure what to call it. Compassion? No, he felt far too heated for that. Protectiveness? The thought baffled him! For only a few short hours, had he known her, and yet, he still felt the soft burn of a need to protect radiating in his arms. He knew the pain of abandonment from a father figure all too intimately. To see a similar experience reflected in someone who was most undeserving of it… well, it made him angry.

“I’m so sorry, Arcane.” Was all he could manage.

She shrugged slightly, dropping the napkin over her plate. “It was five years ago. I imagine the pain of losing his daughter to sickness clouded his judgment. Perhaps he left to seek out a cure for death. Maybe he grew tired of our quaint home on the waterfront.” A hand raised to wipe away a tear that damped her lashes before it fell. “It wasn’t uncommon for him to just up and leave out of nowhere. But his most recent departure seemed decidedly final and… sudden.”

“Your mother passed?” He caught himself grasping his chest. The mere thought of losing his own mother made his blood run cold. He would never be able to relate to such a devastating loss. Arcane merely nodded, silently sipping her wine as she averted her gaze.

Gale stood, taking their now empty plates and setting them in the sink. He wasn’t sure what to say in this situation; he only knew that he felt for the poor girl. A distraction, perhaps? Something to turn their thoughts away from the bleak conversation. He turned to face her, leaning against the counter and rubbing his hands together.

“You mentioned it’s been five years? That’s far too great a time to go without your grandfather’s guidance.” He ambled over to her, offering his hand. “What do you say to a private lesson from an accomplished Wizard?”

Arcane scrutinized his hand for a moment, gazing up at him with a cocked brow. Surely, he wasn’t being serious. But the look he held on his face, that soft smile, those warm eyes, that gentle tone. She bit down on her knuckle, hesitating before slipping her hand into his. He was soft, his fingers wrapping gently around her own as he guided her to her feet.

“I thought you were impressed by my magical prowess?” She spoke, finding herself quite breathless.

Gale let out another breathy chuckle, shaking his head slightly. “Make no mistake, my lady. Seeing you in action was certainly extraordinary, but you lack a certain… discipline.”

The corners of Arcane’s lips fell and she slightly clenched her jaw, her eyes half-lidded as she made an unimpressed face. Gale held up a hand, sensing the impact his words had on her nerves.

“No, no, don’t mishear me! You’re rapturous! Invigorating, even! But you’re lacking in self-control. That isn’t necessarily a bad thing, it just needs correcting.” His eyes glanced to her hand in his, thumb mindlessly dragging across her knuckles. “I’d… be honored to teach you.”

He certainly had a knack for making someone feel both inadequate and flattered all at the once. If Arcane was in her right mind, she’d decline after some harsh words. But the way he held her hand, the way his honeyed, erudite tone warmed her heart… She found herself entranced, unable - no, unwilling - to say no. She hesitated for another beat, but finally relented and followed where he led.

The two of them eventually made their way to the impressive library Gale had previously mentioned. And impressive, it was! From wall-to-wall, the room was practically made of books! Small, marble statues were scattered about the floor, and a heavy wooden desk sat in the far corner upon which a multitude of magical items, crystals, and scribbled parchment littered its surface. Sextants, globes, maps, and tomes littered the floor in an organized mess, and along the left hand wall, was a roaring hearth; two comfortable armchairs lay before it, separated only by an ornate coffee table.

It was the perfect picture of comfort and safety. The perfect place for a Wizard to unwind after a long day of… whatever it is that they do. Arcane gaped at the room before her, eyes widened with wonder, her hands mindlessly tracing across the nearby bookshelf.

“You have got to be kidding me!” She gasped, turning to scan the multitude of books next to her. “Have you actually read all of these?”

Gale chuckled beside her, moving to stand by her side while he admired his collection. “Oh, yes. I have carefully curated quite the extensive collection.” His finger hooked over the spine of a book, pulling it free and running his hands along its cover. “I have found that when you lack a social circle, it’s nice to find companionship among written words.”

Arcane continued to browse the books, tucking her hair behind her ear, eyes scanning the multitude of titles before landing on a familiar sight. Etched into the black leather cover and inlaid with silver leaf was a rather crude depiction of a woman in the arms of a hulking man, his lips at her chest, her hands in his hair.

“Hey, I have this one!” She pulled it free from the shelf, a smile spreading across her lips. It was a romance novel; a badly written one, at that. She smirked at Gale, wondering to herself how such a well-spoken, gentlemanly scholar like himself could read such filth. “Gale! I never expected one such as yourself to own something so… dirty.”

Gale’s face flushed red and he reached for the book, but Arcane pulled back. “Ah! That’s, uhh, that’s just something a fellow classmate lent to me years ago. It’s nothing really, just a terribly written excuse of a romance novel.” He rubbed the back of his neck, eyes darting around the room apprehensively. “I haven’t even-”

Arcane interrupted him, pressing her fingers to his lips and stepping closer. “Gale, you don’t need to explain yourself to me. I was only teasing you.” She saw him relax under her touch. “And you don’t need to tell me that this book is terrible. As I said before, I’ve read it. Actually, I quite enjoyed it!” Her hand moved to his shoulder.

Gale’s eyes widened in surprise. He never expected anyone to say they enjoyed such lascivious works. Arcane was turning out to be quite the surprise. His eyes softened, his hand reaching to cover hers. “That’s… quite a relief. To be perfectly honest with you, I have many more books that cover a wide range of topics pertaining to…” he shifted uncomfortably and cleared his throat. “Pleasures of the flesh.”

Arcane giggled, moving her hand from shoulder to his chest, where she gave him a placating pat, before turning to return the book to its place on the shelf. Gale tried his best to ignore the fire she ignited under her touch, but with the warmth of her touch heating through his clothes, he couldn’t deny the excitement she brought out in him. His mind wandered, imagining what she must feel like under that silk robe. Imagining how much sweeter his name on her tongue would sound if only he could touch her. A vision of her on top of him, eyes drunk with desire, her voice crying out his name, pert breasts heaving with every shaky pant that fell from those perfect lips flashed in his mind. It made his blood roar in his ears.

Catching himself staring at her for far longer than was appropriate, he blinked hard and shook his head, taking her hand in his once more and leading her to the balcony doors. “Well! Now that I’ve sufficiently embarrassed myself. Shall we proceed to your lesson?”

Arcane nodded and followed after him. Gale made a show of using his magic to open the doors, slowly revealing the world outside, the docks below them, the dark sea that glittered in the moonlight. He silently thanked the gods for making it so lovely tonight. He wanted to astound her. He watched as her eyes flew wide, her mouth hanging open, gaping in pure awe at the view that lay before them. She became a work of art in the night, the moonlight dancing across her skin, the stars sparkling in her seafoam eyes.

“Oh, Gale..” She whispered. Her amazement was like music to his ears. “It’s… it’s incredible! I-I don’t have the words!” She turned to him, a wide smile pulling at her lips.

He hummed in agreement, walking to stand beside her, gazing out at the gentle waves. “This is my favorite place in the world. I’ve spent many a night out here beneath the stars, captured by books, enthralled by my studies… or merely enjoying the view.” He side-eyed her, her eyes still taking in the sight, and he felt his hands clench at his sides. He swallowed, continuing. “Although, I must say, I’ve never had the pleasure of enjoying the sight with such… enchanting company.” His heart leapt to his throat, the sudden regret at admitting such a thing nearly choking him.

Arcane tensed slightly, her eyes trailing down to the floor and up into his own. That warm, peachy glow now burning ever brighter on her cheeks. She parted her lips to speak, but found herself speechless. Her hand raised to cup the side of her face and turned away from him, fearing she would burst if she continued to meet his gaze. Warm fingers traced her chin as he turned her head back to him, the subtle mixes of pensiveness and gentility pooling in his eyes.

Gale cleared his throat. “Now, I believe we came here for a lesson, yes? Shall we?” He straightened his back, squaring his shoulders. “Now, this is a rather complicated spell, but not to worry, I will be here with you every step of the way.”

Arcane silently mimicked his stance, squaring her shoulders and nodding curtly.

“Follow my movements.” His hands swam through the air, a soft purple light emanating from his fingertips as he gently formed a ball of light between his hands, repeating the motion before opening them as if he were setting a dove free.

Arcane watched him intently, taking in the fluidity of his movements, the way he grinned as he worked, the way the gentle hues illuminated his dark eyes. When he was done, he turned to her expectantly, gesturing for her to do the same. She shook out her arms, stretching and clenching her fingers, trying to steady the slight tremor in her hands and copied his movements, although lacking in his fluency. There was no unmistakable magical glow from her fingers.

“That was good! Your hands were a tad shaky, though. May I?” He gestured to her hands as if to ask if he could correct her maneuvers.

She nodded and he moved behind her, reaching around and taking her hands in his. He slowly, gently, helped to steady the shake as he moved with her, repeating the movement once more. Arcane resisted the urge to lean back against him, instead trying to calm her mind and focus. It took a minute, but in a bright flash of violet light, magic burst from her palms.

“Ha! That was marvelous!” His voice reverberated against her back, raising the hair along her arms. “You’re a natural. You just need to steady your hand.”

Arcane craned her neck back to look up at him. She felt him stiffen against her, his hands suddenly gripping hers tightly. “You’re a wonderful teacher.” She managed, swallowing thickly. A soft, warm feeling surging through her body. She wasn’t quite sure if it was the magic, or it was due to their pair’s close proximity. Either way, it was calming and gentle. A familiar, but long since lost feeling.

He pulled away, Arcane almost whining at the loss of his heat at her back, and moved to stand in front of her again. “Yes, well…” He didn’t continue his thought, his shoulders rising and falling with a sharp breath. “Ah, let’s get back to it shall we? Repeat after me verbatim.”

She nodded, determined to get it right this time, though her mind wondered if she were to fail again, how he might correct her twisted tongue. She shuddered slightly at the idea.

His voice echoed around them, soft but booming, like some far off roll of thunder. “Ah-Thran Mystra-ryl Kantrach-Ao” His words rolled off his tongue, sweet and dark.

Now words were easy for her; she repeated him, her own voice reverberating around them like his did before. The volume of her voice would have startled her, if it weren’t for the tranquility that enveloped her, the scent of rosewater in her nose, the sweetest taste on her tongue. The familiar memories flowed back to her.

‘I am Mystra’ She remembered the voice she heard so long ago, the calmness, the peace, the safety she felt in the void on that cold, dark day. Arcane closed her eyes, her head lulling back as she embraced the feelings. It tingled her scalp and radiated through her limbs. She smiled and couldn’t help but wiggle her fingers, the soft shivers of walking into Mystra’s presence was an unmistakable and nostalgic one.

“Wonderful! Now, keep your eyes closed and try to bring to mind the purest concept of harmony.”

That was an easy task. Her mother’s lullaby, ringing softly in the back of her mind, gently lilted from her lips. The memory of being held in her arms as she was steadily rocked to sleep. The softness of her hands as her fingers ran through her daughter’s hair. The clearest image of her mother as she was in life: Tall, lithe, beautiful. With her full, blue-black curly hair and her silver eyes. It occurred to Arcane that she had inherited her mother’s face, her long straight nose, her full pink lips, the curve of her wide almond eyes. The corners of Arcane’s lips couldn’t stop themselves from turning upward, her brows pulling together as the vision of her mother began to stream tears down her face.

It was indisputable. This was the presence of Mystra. A feeling she long since thought had been lost to time. “I never thought I’d feel her again.” Her voice was hoarse, breaking slightly from the tears. She lifted her hand to her face to wipe them away. She felt Gale shift, the warmth of his person fanning over her body.

“You did so well.” Gale’s voice was soft and laden with admiration.

She opened her eyes to peer up at him. It had been years since she had seen such pride, especially pointed in her direction, but the way he looked at her… it sent her heart racing. She wasn’t sure if it was the magic that surrounded them, or the honeyed tones of his words, but she felt the growing coils of desire pooling in her stomach. Their smiles slowly fell as they stared at one another. Not out of displeasure, but expectation. The anticipation to see what the other would do. She wanted him. He wanted her, too.

It was Gale who moved first, stepping closer, his eyes dark yet soft. He raised his hand to place his knuckle under her chin, tilting her head upward. All breath seemed to be pulled from Arcane’s lungs, her heart drummed against her chest, as she slowly raised herself onto her toes, inching ever closer to his lips. Their combined soft breaths met one another, their mouths parted, their eyes closed.

And they kissed.

It was tentative, light, and apprehensive. He tasted sweet, tangy, savory; he tasted like magic. Arcane’s hands raised from clenched fists at her sides and slid up his chest, gently clutching at his shirt. His hand hesitantly rested on her hip, experimenting with touch as he pulled her closer, their bodies now flush with one another. Blood rushed to Arcane’s head, the world tilting dizzyingly on its axis, stars blinking behind her closed eyes. He was so much sweeter than magic. He was divinity made flesh.

He parted his lips against hers, moving to deepen the kiss when abruptly, the magic around them dissipated. The sudden cold of the nighttime air on her skin forced a sharp gasp from Arcane’s lungs. She pulled away, eyes wide, face flushed. Gale was breathless, his chest heaving as he struggled to steady himself. His eyes were dark, intimately soft.

“I-I… I didn’t know it could feel like that.” Stars still spotted her eyesight, shaking her head to clear them. “I mean, um… th-the magic. I didn’t…” Her words were lost and her eyes fell to the floor, trying to find them.

Her mind whirled at what just happened. Of course, he wasn’t the first man she’d kissed without knowing too well, but he was certainly the first to ever kiss her so tenderly. Her fingers raised to press against her lips, an unconscious attempt to replicate the feeling of his kiss. To say she was flustered would be an understatement. Gale started to speak, but Arcane covered his mouth with her hand.

She pulled away from him, praying she had the strength to dismiss her arousal. She wanted nothing more than to pounce on him, to feel his tongue in her mouth, on her skin. But the memories of moving too quickly haunted her. No, she’d take her time with this one. She’d savor every soft moment, every gentle touch. Her hands lingered on his chest for another moment before dropping to her sides completely.

“Thank you, Gale.” She managed a smile. “This was a wonderful experience.”

[hoagmaster]

Truly New Horizons

We made it, folks. The end of 2023 is upon us. We have a new year upon us, a year that ideally will be full of new opportunities and new possibilities. A year where we can learn new things about ourselves and become better versions of ourselves.

Well, it's also an election year, so any hesitation or mounting dread is definitely understandable.

But as I think what may come next year, I realized a while back that a couple of constants from the past several years will no longer be there. The slate will be much cleaner than it has been in years past without these known quantities coming at some point.

In terms of shows I've followed, both Hilda and The Owl House ended this year to varying results (for me). I went on a while ago about how the former spurred me to watch more animation to see what I've been missing, which has mostly worked out. The latter is one of several shows I've warmed up with and have come to really appreciate from the past couple years.

We might possibly be coming down to the end of The Ghost and Molly McGee, which is another one I've come to really enjoy. Fans will surely keep these alive through fan art and writings, but their absence will be noted.

There was just one movie I was really following since we got the first snippets from years back, being my favorite of the year (shocking no one who knows me) The Super Mario Bros. Movie. You'd think they would have immediately told us about making another one but there is reportedly nothing yet.

Then there was also Nimona, a movie whose previous cancellation made everyone sad but then everyone happy when it turned out to be probably the comeback story of the year alongside Elemental (for me, anyway). I've really fallen off movie watching the past few years, so maybe I can get that back on track next year.

The biggest one: video games! The Mario Kart 8 Deluxe Booster Course Pass is over. The Legend of Zelda: Tears of the Kingdom dropped nearly four years after it was first announced. Pikmin 4 dropped after years of wondering whether it actually exists. We got the first 2D Mario in over a decade.

The only MIA from the past six or so years is Metroid Prime 4, which we're all assuming now is being saved for the next system. Aside from a couple of remasters and smaller scale games, it really feels like we're coming up on the end of the Switch's life. That's sure to be another bittersweet day where I'll probably spew a few paragraphs.

There are still several constants. My main show Big City Greens is still chugging along with most of its fourth season yet to air. I've gotten into recent fare like Kiff, Hamster & Gretel, Hailey's On It!, and have shows like the other half of Invincible and the much anticipated season two of Arcane on tap.

I'm sure to play all those Switch games like the remaster of Paper Mario: The Thousand-Year Door and Princess Peach: Showtime!. And sure, some of the other new things could provide some good times. I guess having become a fan of the series or something this year means I'll check out Persona 3 Reload. Maybe keeping some kind of blind eye to news feeds and being surprised by some new stuff is not a bad way to do things.

But maybe the biggest constant of all will be the company I keep. Sharing my experience with Persona 5 Royal with someone was perhaps the most exciting thing I did all year. I've begun to participate a bit more in some areas because maybe it could pay off with new connections. Then while nothing is set yet, I'd like to think it's a strong possibility that going to visit someone may be in the cards...

I've shared a bit of myself every day since July with my daily reports, and I'm happy to say those will not be going anywhere. It's interesting to look back at them months later and see what I was doing and wonder how I've changed since then. Another year of doing those is sure to provide more enriching opportunities and guide me with anything I want to do.

Thank you all for reading this year. Here's to 2024!

[moomyclam]

Different loves

My first love was lustful, all-encompassing. It filled my head with dreams and my heart with giddiness; I was blinded by a brilliant soul, and I’d never felt anything like the fireworks and butterflies that coursed through my guts when his light shined on me. The kisses made my head swim and I fell into a whirlwind of promises that obscured all flaws, from red flags to air raid sirens. I ignored them all; I was constantly in a cloudy state of esoteric adoration, breathing in the sickly sweet haze of obsession. I gave my all, tried my hardest to make my commitment and loyalty known, and showed my appreciation at every opportunity. And in return I received half-hearted proclamations of feeble dedication, excuses, and manipulation. When the storm clouds began to clear, my friends and family immediately jumped in and helped me sweep up the debris, unearthing the underlying toxicity of the relationship dynamic. Evil little creatures started spilling from the cracks in his facade; Arrogance, Entitlement, Self-Assuredness, Immaturity. The warmth turned to dread and the haze gave way to a crystal clear realization that half the time I just wasn’t happy. I lost myself in the flood, and put that love before everything else. I felt like I was constantly walking on eggshells and burying my feelings to make room for his ego. The night I left I didn’t sleep; I cried for hours and got so high that I could barely see. I felt sick, like the flu, and I had a migraine behind my eyes that turned my world black and white. I called him the next morning to wake him up for work just like I always had; his voice ripped a hole straight through me and I hung up quickly and clawed at my gut while I sobbed. But that didn’t last forever; the next day I was on Tinder trying to fill that fissure in my being. He’d taken up a bigger part of my heart than I did, but my therapist helped me find the pieces that I’d broken off and locked away to make room for him. I told her my biggest fear was that did never find that feeling again; that genuine connection, that spark - the star that blinded me for 8 long months and made me glad to relinquish my freedom and live in his captivity. She told me I was right; that I probably wouldn’t. Her was my first, no one else will ever have that title. I’ll never be able to experience it again - but that’s okay. Every love is different, every love language is arcane, and everyone’s is equally valuable. No love is better or worse than another, they’re simply different. When I accepted this, that’s when I found you. My first love was like cliff diving- exhilarating, terrifying, and an ending that was less than graceful and actually quite painful, yet I don’t regret it. It was an experience, something off my bucket list- something the Universe threw at me to not only test my mettle, but to show me what I can and cannot put up with; or, rather, what I should and should not put up with. Because of him, I refuse to settle for anyone that makes me feel anything less than divine - and with you, I am a goddess.

My second love is like home. Safe, secure, patient, warm, serene. It’s the scent of coconut and sunscreen mixing with a salty sea breeze; it lets me forget. It takes me to a better time when I had no responsibilities, no bills to pay, nobody to worry about, and someone to take care of me. I’ve placed my heart squarely in your hands - you clean the wounds and change its dressings regularly. And I’ve begun to heal. I’m myself again, but better, enhanced. You don’t complete me, you compliment me. I’m becoming the best version of myself that I can be and I’m doing it with you. Growing by your side is something I look forward to the most! Our roots and limbs have intertwined and they’ll only become more entangled the more we nurture each other - branches and leaves dancing around each other to the song that echos off the mountain side. The song that resonates from my heart when we touch, from my smile when you call me yours, and from my lips when you make me laugh so effortlessly. This is the type of feeling people write novels about; I could draw countless cliched comparisons and paint the page in idioms but none would suffice to make my thoughts clear. You’re perfect for me - our flaws and strengths compliment one another. Our souls are Daedalean puzzle pieces with labyrinthine edges and only Fate could have brought us together. You don’t encompass, overpower, or overthrow my senses, you heighten them. I experience everything more viscerally; music is richer, deeper, stories are more beautiful, and sunsets hold more meaning than they ever have before. You are my King and I am your Queen and together we will do many great and wonderful things. We’ll paint the skies with all the colors of our love, coat the streets in reds and pinks and smother the sand with cloudy blues. I see galaxies in your eyes and I want to join them, waltzing slowly among the star clusters and asteroids and dark matter of your heart. I’m not afraid - I was born for this. You’re my destiny. I’ve had years of training by now; I’m ready for you. Just trust me, darling, and I will dance us through the light and the dark alike. And if I get tired along the way, I know you’ll be right there to pick up the slack. If one of us starts to stray, the other will take the lead and keep us on track. Remember, relationships are always 100%. Some days it can be 50/50; others it may feel more like 80/20, but it’s always 100% love.

[dancer4813]

chaos is calling

the living and the dead (are one in the same)

In the aftermath of their battle at the ziggurat, Percy feels the weight of the world on his shoulders.

Spoilers for Episode 100

[ao3] [Cassandra]

He sees her disappear and his heart feels like it’s ripped from his chest with the intensity of his fury. He fires with the pistol in his hand and the hammer seizes before the bullet fires, sending hot lines of pain up his arm directly to his brain.

Through the haze he whips out Bad News, but the rifle clicks, and tendrils of smoke unfurl from the gun, the black wisps bringing back memories of a silky voice in his head, of a beak-like face and the feeling of vengeance-

Percy pulls out Retort and a bullet flies true, hitting the sphere…

And disappears. Without a sound, without an impact, without fanfare.

As his hands start shaking, his knees give way beneath him.

Percy’s lungs feel as though he hasn’t breathed in hours, the way they are trying to suck in and push out the musky air around the ziggurat. His mind is working faster than it ever has, but is comprehending slower than usual, and even though he tries to make sense of things, tries to fix his guns (he picks up Animus and taps sharply on the bottom, the side, pulls the trigger, the actions routine, but it sticks and he knows he needs tools, needs a workshop, to fix Bad News espe-), tries to sort out the feelings in his head, he finds everything coalescing to a dull roar of sound that builds and builds and builds and-

There’s a hand on his shoulder.

Through the haze of Deliliah and Fix it and Vengeance and You were DEAD echoing through his mind, Vex’s face comes, breaking apart his thoughts with the concern in her eyes. Her other hand comes up to cup his cheek and he knows it’s her because of the fingers, calloused from the string of a bow and so familiar (more than he would ever dare to imagine).

“You need to breathe, Percy darling,” she says, and he wants to say that he is breathing, that he’s perfectly fine, but the hand on his face moves to his chest, pushing gently, and he realizes just how fast everything is moving and he tries to slow down, the air catching in his lungs.

“That’s it, that’s it,” she encourages, and with another couple shuddering breaths the fog starts to clear from his mind and he hears the dull roar of the others discussing what to do next behind him.

“She’s back,” he gasps as soon as he has enough breath to, and Delilah’s broken body, stabbed and held against the wall by his sister, flashes through his mind – blood trickling from the corner of her mouth, her arm missing.

“I know,” Vex says, and it’s then that he remembers her near death at the ziggurat beneath Whitestone and he finds himself grabbing at her wrist, needing to feel her pulse despite her sitting right in front of him.

(Luckily she lets him more-or-less pull her onto his lap, so he can bury his face in her braid.

He remembers her lifeless body carried gingerly by Grog out of the anti-magic field, the desperation when the potions and healing spells didn’t take hold…

But she’s here and alive and dear gods they’ve got a lot of work to do now.)

Percy counts to ten, telling himself to relax as he feels his breathing finally start to slow down, and when he reaches the end of his count he forces his arms to let go, pulling back as he does so.

“Better?” Vex asks, and he nods (even though it isn’t exactly true), knowing that he can’t just sit around and let the others figure things out. This is his past coming back into play yet again. First the Briarwoods, then Ripley after he’d let her escape, and now Delilah, after he’d watched her body dissolve in a pool of acid.

Percy really hated magic sometimes. And would-be gods.

They spoke with her henchman about the portal, learning of the stones they needed to pass through safely, unless they wanted to run the risk of the harm it could do them.

(Percy wasn’t sure about the rest of Vox Machina, but he found himself much more worried about what they would need to deal with on the other side of that gate than he was about getting through it.)

He also has Vex’s promise to the Raven Queen running through his head non-stop, and if that wasn’t enough, they take a vote and decide they’re tapped out enough that Scanlan should re-cast the mansion, saving their plans for the next morning and leaving Percy with nowhere to spend his excess energy.

So he goes to bed with Vex after an unsatisfactory dinner and lays in bed until she falls asleep, then slips away. There’s no need to worry her more, not when she has her own demons to worry about, and he creeps out of the room, glad that Trinket is in the Raven’s Slumber so he doesn’t need to avoid waking the bear.

He wanders through the mansion, reacquainting himself with the eerily-familiar halls and taking note of the new changes – generally a subtler décor, a more fully equipped music room, and fewer mirrors scattered throughout.

The silence in the mansion isn’t malevolent, but it is unnerving, especially since the arcane nature of the mansion’s walls mean that while the enchanted windows show perfectly normal night skies, none of the house creaks in the wind or at someone’s footsteps. There are no places where the walls are too thin unless Scanlan plans them that way, and while some of the walls seem to be wooden, and others stone, there’s no difference to the sound they make when you tap your knuckles against them.

It’s like the perfect version of anyone’s house. No defects, no shoddy construction, and certainly none of the quirks that come with a home built from scratch.

At least, Percy thinks, finally deciding that he might as well get some work done instead of simply walking the halls, despite its faults, it has some very nice bathrooms.

Percy retrieves his black powder carefully, glad to see that Vex still seems to be sleeping camly, and goes to the workshop that Scanlan has always created for him, but his mind is so busy that he doesn’t realize the door is already partly ajar until he pushes it open to see Tary at the work bench, head in his hands. Doty was at the side of the worktable, but he was leaning against the wall, eyes dark, the plates on his chest caved in from the force of the spells that had struck him down.

Percy felt himself freeze as Tary looked up, eyes wide. Neither of them had expected company, and while they had spent the better part of the last year sharing workshop space…

“Oh- hello, Percival,” Tary says, straightening up and trying to appear as though he hasn’t been worried.

“Hello, Tary,” Percy replies, trying to muster a smile, though it feels like more of a grimace. “Are you working on something?”

Tary pulls back from the table, revealing a pristine work surface. “Not exactly,” he murmurs, running his fingers through long flaxen hair. “I didn’t realize I would be able to tinker on the go – I left nearly all of my supplies in Vex’s mansion, packed in my bags. I would fix Doty, but…”

His voice trails off, and Percy understands the pained look on his face before he drops his gaze to the floor.

“Well, I was just going to make some bullets,” he offers, “if you’re interested in helping?”

He would be a hypocrite if he criticized Tary’s lack of sleep, and as he had learned it was always good to have an extra pair of hands. Those hands used to be Keyleth’s, but since she’d been spending so much time in Zephra with her people, Percy had shown Tary what needed to be done one lazy afternoon in the workshop, and Tary, intelligent as he was, caught on quickly.

“If you need my help.”

“I always appreciate your help,” Percy says in lieu of an answer, and in an unfamiliar workshop after a harrowing battle, approaching what might be the biggest fight of their lives, it’s enough.

In silence they get out the black powder and the molds, and Tary starts the forge going. The heat suffuses the room, and Tary seems to relax as they get into a rhythm of melt, pour, release, melt, pour, release.

They refill the melting pot twice and cast a little over 30 bullets in all. Then they get to trim the excess casing from them, smoothing the edges so the bullets don’t get stuck in the chambers of his guns and fly true to strike their adversaries.

After meticulously examining five of the bullets they’ve made together, his mind starting to calm, his rational self having taken over in the presence of labor, Percy wipes a trickle of sweat out of his eye and looks over at Tary. The blond, who is staring at one of the bullets as if it has the answers to the universe, doesn’t look over when he clears his throat, and doesn’t even react until Percy sets a gentle hand on his shoulder, making him jump.

“Copper for your thoughts?”

Tary bites his lip, his gaze locking with Percy’s, then it falls back down to the bullet in his hands as he shrugs Percy’s hand off and sets the bullet aside.

“Who was she, the dark-haired woman?”

Percy blinks, and his hand, still outstretched toward Tary, sinks. They had given Tary the basic details of Whitestone’s takeover, but never the full story.

“Delilah Briarwood,” Percy replies evenly, torn between wanting to keep watching Tary and wanting to go back to the bullets to keep his hands busy. “She and her husband killed my family.”

“They took over Whitestone?”

“They did.”

“And now they’re back?”

“Delilah seems to be,” Percy says, and nope, fuck it, he needs something to do.

The scritch-scratch of metal against metal fills the room again.

“Not her husband?” Tary asks after a moment, taking another bullet.

“We killed him. Well, both of them,” Percy murmurs, brushing away the metal shavings left on the bullet and examining its curves. “I honestly didn’t expect either to come back, but I suppose I should stop having such low expectations of the universe’s desire to fuck with my life.”

It comes out more biting than he wanted it to, but Tary just nods and drops his first bullet into the pot of newly-finished ones.

“And she’s back to kill you?” Tary asks.

“Kill the world, more likely,” Percy replies, and his stomach turns as he feels a strong urge to throw the bowl of bullets to the ground and send them scattering, like ants underfoot. “You know Vex has been studying Vecna, yes?”

“She mentioned the name once or twice – was he her husband?”

Percy actually laughs at that, though it feels wrenched out of him like an arrow from a wound.

“No,” he gasps, getting his breath back. “Not quite. Her husband, Sylas, was a vampire whom Vecna brought back to life. Vecna, on the other hand….”

“Not a good guy?” Tary volunteers.

“Not a good guy,” Percy affirms, “He’s a lich who tried to ascend to godhood ages ago. Informally the god of secrets, and is also known as The Whispered One to his followers.

When Tary doesn’t ask anything else, Percy takes a deep breath, the smell of black powder filling his nostrils, and goes back to the bullets.

They work in relative silence for a while, until there’s only a bullet apiece left to grind the stub of the mold away from.

“Vex showed me the ziggurat under Whitestone,” Tary murmurs. “She said that I ‘should know there’s a potentially deadly calamity underneath the city’.”

“Vex always has been the clever one.”

“I don’t know, you’re pretty clever,” Tary says, and then he recoils slightly, blushing.

Percy smiles at the unintentional flirting.

“I’m going to say what I said earlier – I’ll take the compliment.”

Tary chuckles half-heartedly, but Percy can see that the man has a complicated look on his face, much like Percy imagines his own mind to be – an amalgam of emotions that, in his current state of mind, he’s not able to sort out.

“Could you tell me what happened?”

It’s certainly more vague a question than Percy had anticipated, but he thinks he knows what Tary’s getting at.

“Do you want it from the beginning? It’s not a happy story,” Percy warns, and while part of him is wary to recount the tale, he distantly wonders if going through the tale again might help him pick up on a detail he’d missed, or understand something that they might have glossed over in the moment.

“Since coming out into the world I’ve learned that not all stories have happy endings,” Tary says, chuckling.

“It’s a sad but real truth,” Percy agrees. “But if you’re sure…”

Tary nods, and Percy takes a deep breath before beginning.

He tells the story, from the Briarwoods fleeing Wildmount and running to Whitestone to their overtaking the city and laying low for many years. He speaks briefly to his own escape, and then jumps to when he had first heard their names after so long – just after Vox Machina had returned from the Underdark. He tells about their return, and how Vox Machina helped him take back his city, and he explains the ritual (or what he had seen of it) that Delilah performed at the top of the ziggurat under Whitestone.

(And Percy’s never had this before – someone who will listen who knows him, knows some of where he’s coming from, but who hasn’t lived those experiences with him – and he feels an ache in his chest knowing that Tary has set his heart on returning to Wildmount as soon as possible.)

Pressing on, he explains in detail, the images imprinted on his mind, Sylas and Delilah’s deaths, though he tries to leave Orthax’s involvement out of that as much as possible. He finishes with Cassandra’s death blow to Delilah and the subsequent throwing of the necromancer in acid.

He looks up at Tary just in time to catch a distinctly green tinge to the man’s cheeks, and his lips turn up in a smirk at the thought, May you never change, Tary.

“And that’s the story?” Tary asks, swallowing, the glimpse of nausea fading.

“That’s it.”

“You know, I always had ‘defeat an evil wizard’ on my list,” he hums with a wry smile. “But it seems like you’ve all done that already. How many things have you done that I’ve been waiting my whole life to do?”

“Probably everything on your list and then some,” Percy admits, “Though I’m still not sure about the ‘rescuing a damsel’. The stories really are wrong about how often there are any damsels.”

“Mmhmmmm…”

“Is there something else on your mind?”

Tary’s mouth twists into a frown, eyes narrowing as he thinks.

“You said the Briarwoods hailed from Wildmount, once upon a time?”

“Yes – do you know where they might have come from?”

“Not where, exactly, but I do remember there being a bit of uproar six or seven years ago, in the north. There were rumors, never anything concrete, but people started to go missing, and my mother always wanted eyes on us if at all possible, despite my being of age at the time. There was some political upheaval, I remember that, and Maryanne was constantly talking about her friends who lived up there – she said-“

He frowns again, tapping the side of his temple as if it will push the memories into his head.

“What she learned from them, was that one city in particular seemed to be drawing people in, only for them to disappear. I never heard specific names – honestly, I wasn’t very interested at the time, too involved in my fantasies as I was.” Tary gives chuckles again, and shrugs. “I know it’s not much to go on…”

“No, no, it’s something,” Percy argues, taking out his notebook from his bag and flipping to a clean page to draft a quick outline of the known lands of Exandria. Wildmount to the Northeast, Tal’dorei taking up the middle, Issylra to the Northwest, and even, further west, though slightly more south, Marquet.

It’s a sad excuse for a map, he knows, and he imagines Tyriok, the mapmaker, looking at it disdainfully before he quickly jots down the locations of the two ziggurats they’ve been to, in Whitestone and about a days’ walk north of Ank’harel.

“You said it was in the far north of Wildmount?” he asks Tary, who nods.

“Yes, though I’m not sure where. At least a couple days north of Deastok, though still in the Dwendalian Empire.”

Percy makes a dotted circle around the northern half of the continent, not knowing its geography well enough to have a decent bead on where a former temple to Ioun might be…

“There’s one in Vasselheim,” he realizes, glancing over the blank areas on his map.

“There’s a what?”

“A ziggurat,” Percy says, and he wonders why he hadn’t seen it before. Osysa had come from behind one in the temple of Ioun, when they had received their brands from the Slayer’s Take.

“In Vasselheim?” Tary asks, and Percy nods frantically, already marking its rough location.

“There’s one on every continent,” Percy notes, but as soon as he’s said it he feels a swooping sense of dread. “But what if there’s more?”

“More?”

“There’s already three that we know of that have siphons,” Percy points out, and he sets his pencil down as he feels his hands start to tremble. “How many more might they have turned? How many-“

He cuts himself off, realizing the sheer scope of the task before them, and suddenly he feels like he might gag on the sheer enormity of the task set out for them. Ziggurats all over the world, travel to another plane as Vex and Pike had seen… This was so much bigger than just Whitestone. He’d heard the answers to Pike’s questions from the dead man’s lips, he’d known since their first encounter with the ziggurat in Whitestone that Vecna was trying to return through the Briarwoods, but to see, tangibly, laid out before him, the scope of the Vecna’s plans?

“Percy? Percy, look at me,” Tary says, and Percy does so, though it hardly feels as though he’s inhabiting his own body in that moment.

“Percy?”

“We were nothing to them,” Percy mutters, instead of the hesitant placation that had been on his lips, an incredulous sort of chuckle pulled from his lungs as he shakes his head. “Nothing.”

“To who? To whom? The Briarwoods? Percy, you’re starting to scare me-“

“You should be scared,” Percy says, and he remembers Tary when they first met him, shying away from anything and everything. “And… all of us, all of them, have just been some stepping stones on their way up, no more than irritating pebbles in their boots.”

“Percy-“

Tary’s voice seems to get stuck in his throat, and Percy understand that, wants to be empathetic, but then Tary’s hand presses down on his shoulder and its grounding, it’s solid, and even if it’s not quite enough to steady him entirely, he takes a breath.

“My whole family, Tary, my whole city. We were pawns to them, plebeians that they didn’t mind crushing under their boots. We were nothing in their eyes, less than nothing. They walked over us like leaves on the ground and even when we try to get rid of them they come back. We are nothing.”

Percy chokes on his last sentence, laughing again, and almost unconsciously grabs at Tary’s arm to keep himself steady. He’s always considered himself nihilistic, but this is something more, something new, in the wake of a lifetime of life and fate sticking up their middle finger in his face. “They just breezed through, and when they had left their mark they breezed away and kept going – they’re like cockroaches. They just never-“

“Stop.”

Tary’s interruption comes with a light slap to the face and Percy blinks hard, the surface pain working its way through his skull to join the headache he seems to have grown in the back of his head without him knowing it.

“I’m not going to hear you self-depreciate like that,” Tary says, and Percy blinks again, his vision clarifying on the man who is older than him, but looks younger, and who, at one point, seemed so naïve to the world around him. “Alright? Can you do that?”

“I- I can-“

He wants to lie, wants to say he’ll be fine, that he’s just had a long day, they all have…

“I can try,” his mouth says instead, and Tary’s eyes sparkle at that, his frown softening.

“I know something about hating yourself, let me tell you,” Tary says. “And I know it sucks, and I know it’s a loud voice in your head, but you especially have helped me move beyond that, right?”

He nods encouragingly, and Percy copies the gesture, head bobbing slightly. His guns, the destruction they caused, the victories they’d won… It all seemed to pale for a moment in comparison to what was looming on the horizon.

“Now, I’m headed home soon.”

Percy hums in agreement, and the dull ache in his chest sharpens slightly.

“And you know my reasons, but you all? You understand saving the world. You’ve got years of experience and practice that I could only dream of. I know you all don’t want to say it, but you are all so talented and so powerful…”

Percy scoffs before he can help himself, and it earns him a glare from Tary.

“Again, I know you don’t want to believe it, but you are,” he says, shaking Percy’s shoulders slightly for emphasis. “Can you understand that? That you’ve all done good and you’re going to do it again?”

“Maybe?” Percy says, because he really doesn’t know, and he feels like the whole world is going to crash down on him for a moment-

“Hey, stop that.”

Percy’s vision refocuses on the man in front of him, expensive armor dented and hair looking slightly windswept despite having been under a helmet all day.

“I’m going to tell you what you should do, okay?” Tary offers, and Percy nods, letting himself take a deep breath.

“Excellent. You are going to go to the kitchen with me and get some calming tea, alright? And then we’re going to get you back to bed with Vex and you’re going to sleep until morning, when we can do something about things, alright?”

Percy opens his mouth to refuse, but he finds himself nodding yet again. He feels wrung out and almost like he’s drowning under the weight of everything that needs to be done, everything that they’re going to do. Perhaps sleep will help.

“Sounds like a plan,” Tary says with a grim smile, and a pat on the back as he stands up. “Now, do you know the way back to the kitchen, or should we call for a servant to show us the way?”

“I’ve got it,” Percy says, because he does know, and it’s something to do.

And as his feet carry him up the stairs and down the hallway, Tary’s footsteps echoing behind his own in the silence of the magical mansion, Percy takes a deep breath, pushing himself forward.

[ellymackay]

‘We Stopped Using CPAP with Complex Insomnia Patients—We Use More Advanced Devices’

‘We Stopped Using CPAP with Complex Insomnia Patients—We Use More Advanced Devices’ was first seen on https://www.ellymackay.com/

A study finds ASV superior in patients with comorbid insomnia and sleep apnea.

Insomnia, one of the most common sleep disorders, is often thought of as a psychiatric problem treated with therapy or medications. But emerging research shows many cases of insomnia have a physical cause—specifically, obstructive sleep apnea (OSA) or upper airway resistance syndrome (UARS).

This phenomenon is referred to as “complex insomnia,” COMISA, or comorbid insomnia. A new study, published in The Lancet’s EClinicalMedicine and funded by ResMed Science Center, looked at both the prevalence and treatment of complex insomnia. The results revealed OSA frequently disrupts sleep brainwaves among people with insomnia—who are completely unaware of this underlying process. Moreover, their physicians and therapists rarely suspect a sleep breathing etiology.1

The prospective randomized control trial also revealed the superiority of adaptive servoventilation (ASV) in these patients. ASV attained insomnia remission rates measured on the well-known Insomnia Severity Index in nearly 70% of cases compared to only one-quarter of fixed CPAP users.

According to lead author, sleep medicine specialist Barry Krakow, MD, ASV may offer a far more efficient treatment for complex insomnia than sleeping pills; indeed, drugs may actually worsen the sleep breathing problems and thus aggravate the insomnia in the process. In past research, the group has shown that nearly 90% of chronic insomnia patients failing sleep aids were suffering from undiagnosed OSA or UARS.2

In the current project, the researchers selected archetypal insomnia patients like those presenting to primary care or mental health clinics. They experienced chronic insomnia on average for a decade and failed numerous therapies, including drugs and behavioral interventions. To remove any OSA bias at the outset, patients with obvious abnormal sleep breathing risks or symptoms (such as obesity, daytime sleepiness, or witnessed apneas) were excluded. Remarkably, even though 660 patients were initially considered due to a primary complaint of a chronic insomnia disorder, 455 were immediately excluded due to these sleep breathing markers, yet their providers had not taken the steps to diagnose a potential sleep-breathing disorder. Because these patients are so similar to what’s seen in the general population, the prevalence of complex insomnia appears to be astonishingly higher than typically described in the scientific literature.

In a phone interview with Sleep Review, Krakow explained the treatment phase of the study where two sets of insomnia patients were compared for a 14-week trial. One group used ASV, the other CPAP. (The transcript has been lightly edited for clarity.)

Sleep Review (SR): What are the most important findings of this study?

Barry Krakow, MD: Both CPAP and ASV improve sleep quality, but it’s clear ASV improves sleep quality significantly more efficaciously than CPAP. Once you target sleep quality, a lot of other things fall into place: sleep fragmentation decreases so insomnia decreases, then more benefits accrue such as decreased trips to the bathroom and fewer awakenings along with daytime benefits of less fatigue and enhanced quality of life.

The remarkable thing is that in just the first two weeks of the study, ASV patients were already reporting more substantial gains in sleep quality than CPAP patients.

SR: Why is ASV more effective than CPAP?

BK: No surprise; it’s all about the breathing. ASV is more effective in eliminating all breathing events including the flow limitation events, aka RERAs. So, by the end of the study ASV patients average normalized airflow nearly 90% of the time whereas CPAP could only attain a level of normalized airflow 70% of the time.

SR: So if the key is effectively treating RERAs, and other sleep centers keep using CPAP without these optimal results, why do they keep using CPAP?

BK: Great question, but you’re assuming most sleep centers pay attention to RERAs; I suspect that assumption is flawed, because for the past decade we’ve treated thousands of patients on CPAP who sought second opinions at our center, and none of these patients had ever heard of the terms RERA or flow limitation. They knew about hypopneas and apneas but not these breathing events linked to upper airway resistance. I should add most sleep centers still won’t diagnosis UARS.

SR: What would make sleep doctors change their practice models, not just to consider other types of PAP devices, but also to actually schedule sleep studies on these people with insomnia to test for OSA or UARS?

BK: I think a major barrier is that sleep doctors were blindsided years ago when insurance companies rejected the idea that a sleep study was needed for insomnia patients. The great irony here for those of us in sleep medicine in the 1980s and 1990s, insomnia was actually a major criteria to raise suspicions for an OSA diagnosis. Since then, probably more than 50% of sleep doctors have never been trained to suspect a link between the two conditions, even though the late, great Dr Christian Guilleminault discovered the connection almost 50 years ago. So, putting it bluntly, the field of sleep medicine needs a wakeup call to the enormous prevalence of complex insomnia and that the vast majority of insomniacs showing up in various clinics and at sleep centers need a sleep study, and the sleep study needs to measure more than just apneas and hypopneas. Then PAP therapy needs to be offered.

SR: Do you have any specifics to move sleep professionals in this direction?

BK: Surprisingly, I don’t think a large proportion of sleep doctors attempt regular use of a PAP device. I would encourage them to try CPAP for one night and then ASV for one night and see how they stack up. Of course, a patient-centric model is a must. If you work with chronic insomnia patients who are failing therapies, prescription sedatives, OTC sleep aids or behavioral interventions, both patients and providers should zoom in on sleep quality (unrefreshing sleep reports are a dead giveaway). If sleep quality is compromised, then it should be clear something must underlie this condition, and there is no greater threat to the quality of one’s slumber than sleep-disordered breathing.

Once you cross this diagnostic barrier, the patient is still not home free, because these patients are going to receive initial exposure to CPAP, which often causes traumatizing experiences due to the difficulties people report in breathing out against the fixed pressurized air.

Because my initial work in sleep medicine involved nightmare patients with PTSD, I became acutely aware of the suffering these individuals experienced when they first attempted CPAP. In fact, these trauma survivors were invaluable resources as they taught us that we had to find another way. Sadly, many sleep professionals, not to mention arcane insurance guidelines, are wedded to the belief that CPAP works for everybody. If that were true, then why is CPAP compliance the single most problematic aspect in the treatment of OSA? The answer is that CPAP does not work or work well except on prototypical sleep apnea patients, but that hasn’t stopped many sleep centers from attempting to force CPAP on patients who will never be able to adapt to it.

SR: Could you provide more details again on why ASV is superior to CPAP? Also, I understand you’ve raised the question on whether the use of CPAP could be medical malpractice in certain patient cohorts. Could you expand on that?

BK: First let’s dispel one myth. Unfortunately, many individuals working in sleep medicine have persuaded themselves that advanced PAP therapy such as ASV or autobilevel [ABPAP] are all about marketing and therefore about making greater profits with more expensive machines. As we have repeatedly demonstrated reversal of CPAP failure cases by using advanced PAP, we would like to think consideration would be given to how much money is saved by turning a failure into a regular user. That information alone should whet the appetite of sleep professionals searching for better ways to solve CPAP failure, as well as insurance companies eager to see better outcomes in their patients, not to mention the bonus of health cost-savings.

The biggest question about PAP modes revolves around how patients breathe out against incoming air. And, the answer may surprise many sleep professionals, because they probably haven’t given it that much attention, otherwise they would have ceased using CPAP as we did back in 2005. What we learned is that patients either self-report the discomfort of trying to breathe out against CPAP…what we call subjective expiratory pressure intolerance or EPI. Or, in the sleep lab we observe irregularities on the expiratory limb of the airflow curve (objective EPI). Once you take note of these poor responders, you switch the patient to bilevel modes, and you will often see improvement straightaway. We have found during the past 10 years that either ABPAP or ASV are the most effective in resolving this issue.

Last, keep in mind we’ve only mentioned expiration. The second part of this equation, once you prevent or eradicate EPI, is to then raise inspiratory pressures to more effective levels to eliminate the flow limitation. Because ABPAP and ASV devices have special proprietary algorithms to solve these problems, we found we could fine-tune the settings by overriding these algorithms in the sleep lab environment.

If you appreciate this approach to care, then you need to develop a great deal of sensitivity when you attempt to start PAP therapy on a PTSD or other anxiety patient. If you force CPAP on such a patient, they will not only reject it, but they will engage in classic avoidance behavior and drop out of care for months or years or longer. In my view, we have unintentionally traumatized the patient with CPAP, causing them both short-term and long-term harm. Regrettably, this model of care approaches a medical malpractice scenario, because the provider offered the patient no other PAP modes at the get-go to rescue the patient from experiencing the phenomenon of “drowning in air.”

SR: Sounds like there’s a conflict in the way you and others are practicing sleep medicine versus some of the standards in the field?

BK: Which brings up something of a sore spot, because we have been very surprised that the American Academy of Sleep Medicine [AASM] has shown so little interest in promoting more research on complex insomnia. The AASM will occasionally cover this topic at the annual SLEEP conference. But it’s never promoted as one of the most important areas of discussion, which is shocking in that comorbid insomnia and sleep apnea is arguably the single most common sleep disorder combination diagnosed and treated at the vast majority of sleep centers.

I believe once the AASM assumes a more assertive position on the nature and prevalence of complex insomnia, then more sleep specialists will reassess their current approach to the condition. At that point, I would expect to see a lot more push back against the poorly written insurance policy statements we all confront in everyday practice.

SR: What are some additional research questions that still need to be investigated?

BK: There are many. For example, one of the most important aspects of insomnia is to recognize that it’s a complex disorder. It has psychological and physiological aspects. Even though we had stellar results for the ASV patients, we still saw the need for additional therapies for many of these individuals, such as cognitive behavioral therapy for insomnia [CBT-I].

An immediate question is: How do you integrate this type of treatment plan into the clinical realm? Do you start with CBT-I and then get a sleep study? Do you start with a sleep test, then treat the OSA/UARS with PAP, and then do CBT-I? You can easily imagine that one’s specific field of healthcare strongly influences how to proceed.

Another big gap in knowledge is that no one’s ever determined what constitutes a perfect or optimal titration on a PAP device. As I alluded to earlier, it seems there is scant interest in the concept of normalized breathing. That strikes us as odd. We’ve seen normal sleepers in our sleep lab, and we were quite excited to see that their breathing looked identical to the sleep breathing of someone obtaining a great and consistent response to PAP. I can recall only one research study examining this concept,3 which we believe is critical because our results show how ASV produced substantially more time with normalized airflow signals compared to CPAP.

SR: Are there any other big challenges?

BK: The findings do pose a challenge to virtually all types of clinics that insist on viewing insomnia as a psychological disorder. Think about the psychiatric clinics and primary care clinics that often jump to prescription sleeping pills faster than a bullet train to nowhere. Because of the constrained environments in these clinical settings, how will these types of providers come to realize the incredible importance of physiological sleep testing?

This challenge affects all the behavioral sleep medicine professionals and the psychologists. They provide CBT-I services that are crucial components of therapy, but I believe it’s a mistake to delay sleep testing. Sleep apnea affects so many different organ systems in the body that adversely influence physical and mental health. Just because these types of patients are initially viewed through a psychological lens should not preclude raising questions early on about sleep apnea. In fact, I would predict mental health cohorts will eventually generate the largest number of referrals to sleep centers because the insomnia, so common in mental disorders, is going to turn out to also be fueled in part by sleep-disordered breathing.

Unfortunately, the wakeup call to providers and insurers to change referral practices may require repeated alarms going off, because fields like psychiatry and psychology have their own unique administrative hassles to manage in dealing with insurers. Indeed, I’ve broached the topic of inserting sleep disorder centers into 10 different psychiatric hospitals. Over the last decade, I’ve reached out to some of the most prestigious facilities in the country, and you may or may not be surprised to know they all respond the same way: “We can’t bill for it.”

References

1. Krakow B, McIver ND, Ulibarri VA, et al. Prospective randomized controlled trial on the efficacy of continuous positive airway pressure and adaptive servo-ventilation in the treatment of chronic complex insomnia. EClinicalMedicine. 2019 Aug 8;13:57-7. 2. Krakow B, Ulibarri VA, McIver ND. Pharmacotherapeutic failure in a large cohort of patients with insomnia presenting to a sleep medicine center and laboratory: subjective pretest predictions and objective diagnoses. Mayo Clin Proc. 2014 Dec;89(12):1608-20. 3. Condos R, Norman RG, Krishnasamy I, et al. Flow limitation as a noninvasive assessment of residual upper-airway resistance during continuous positive airway pressure therapy of obstructive sleep apnea. Am J Respir Crit Care Med. 1994 Aug;150(2):475-80.

from Sleep Review http://www.sleepreviewmag.com/2019/12/complex-insomnia-advanced-devices/

from Elly Mackay - Feed https://www.ellymackay.com/2019/12/18/we-stopped-using-cpap-with-complex-insomnia-patients-we-use-more-advanced-devices/