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Use of acupressure to reduce nausea and vomiting in cancer patients receiving chemotherapy (literature study) by Maher Battat in Journal of Clinical Case Reports Medical Images and Health Sciences

ABSTRACT

Nausea and vomiting are distressing and serious problems for cancer patients receiving chemotherapy despite the fact that they are receiving antiemetics according to the standard guidelines which this problem is a huge challenge to nurses involved in cancer care.

Purpose: To explore and assess the effectiveness of using acupressure as a non-pharmacological intervention in addition to pharmacological interventions in reducing nausea and vomiting in cancer patients receiving chemotherapy.

Method: A literature review was conducted of 8 articles published between 2006 and 2014. These included one study of a randomized, double-blind, placebo controlled trial; one quasi-experimental model with a control group; four articles reporting on randomized control trials (RCTs); one systematic review study; and one review study. Key Findings: Seven of the articles we read supported the effect of an acupressure P6 Wristband in reducing chemotherapy induced nausea and vomiting in cancer patients and other databases also supported that finding. The one article with neutral results showed that there was no difference between a combination of acupuncture and acupressure treatment at P6 and at the sham point for the nausea score, but the level of nausea was very low in both groups.

Conclusion: We conclude that the acupressure P6 wrist band when applied to acupuncture point P6 is effective, safe, convenient, cost effective, and provides an easy, self-administrated, non-pharmacological intervention that can be used to reduce chemotherapy induced nausea and vomiting.

Keywords: Acupressure, Chemotherapy, Nausea and Vomiting, Cancer patients, Chemotherapy-induced nausea and vomiting.

INTRODUCTION

Nausea and vomiting are serious and troublesome side effects of cancer therapy. We chose this research topic in order to become familiar with the topic of the nausea and vomiting facing cancer patients during their chemotherapy treatment, which we have observed during our experience in the Oncology departments.

As nurses, we normally use updated and standard guidelines for managing clinical challenges. We reviewed the literature to explore whether there are alternative approaches to pharmacological management that might reduce or eliminate this problem. We found there are many interventions, such as music, acupuncture, acupressure, and yoga. We decided to assess the effectiveness of using acupressure to reduce the nausea and vomiting in cancer patients receiving chemotherapy. Acupressure is a type of complementary and alternative medicine which the National Cancer Institute (NCI Dictionary of Cancer Terms) defines as follows: “Acupressure is the application of pressure or localized massage to specific sites on the body to control symptoms such as pain or nausea".

THE RESEARCH QUESTION

Can acupressure reduce nausea and vomiting in cancer patients receiving chemotherapy?

We have chosen to use the definitions of the NCI Dictionary of Cancer Terms:

“Nausea is an unpleasant wavelike feeling in the back of the throat and/or stomach that may lead to vomiting", and “Vomiting is throwing up the contents of the stomach through the mouth”.

Nausea and vomiting affect the patient’s whole life. These side effects lead to metabolic imbalance, fatigue, distress, and lowered quality of life. We would like to fine a simple, effective and cost effective way to manage these problems so we can put it to use in our hospital.

METHOD

A literature study is, “A critical presentation of knowledge from various academic written sources, and a discussion of the sources in view of a particular research question" (Synnes 2014). There are many challenges when doing a literature study. There are many databases and much literature and our search process had to find the correct, scientific and relevant databases. It required a lot of time and effort to find the full text of all relevant articles. Fortunately, we received excellent help from the librarian at the Betanien University High school.

We started the search process by making a PICO outline to narrow down the search and to find the correct key words and mesh terms.

P: (Population or participants) Cancer patients experiencing chemotherapy-induced nausea and vomiting.

I: (Intervention or indicator) Acupressure.

C: (Comparator or control) No comparison or placebo.

O: (Outcome) Reduce nausea and vomiting.

We used PUBMED, Google scholar, scholar.najah.edu and other search engines. When we used Acupressure as a search word we found more than 800 studies. When we added chemotherapy, cancer patients, and nausea and vomiting, we brought this down to 14 articles. We read these and decided to use 8 articles only, one of which was a systematic review. We also used an unpublished Master’s thesis from An Najah National University. This thesis was cited in one of the articles that we decided to review. The key words used were: Acupressure, Chemotherapy, Nausea and Vomiting, Cancer patients, Chemotherapy-induced nausea and vomiting, with Acupressure as a mesh term.

We then critically appraised all the articles according to our checklist. We included only those articles that followed the IMRAD style (i.e. those including an introduction, method, results and discussion section). We excluded all articles that were more than ten years old (i.e. published before 2004), except for two articles: one was about the mechanism of acupressure, which seemed to be directly relevant to our research topic, while the second article was used in the discussion section to discuss certain factors related to the topic. We also excluded one of the review articles because its method appeared to be weak. One of the Cochran reviews was also dropped because it had not been updated.

Despite applying these strict criteria, we were still concerned lest we had left out some important articles or included an inappropriate one. However, we were reassured by the fact that the librarian at Betanien had guided us in our search.

THEORETICAL PART

Nursing Need Theory and basic human needs

The Nursing Need Theory was developed by Virginia A. Henderson to define the unique focus of nursing practice. The theory focuses on the importance of increasing the patients’ independence to hasten their progress in the hospital. Henderson’s theory emphasizes the basic human needs and how nurses can assist in meeting those needs.

The 14 components of Need Theory present a holistic approach to nursing that covers the patient’s physiological, psychological, spiritual and social needs.

Physiological components

Breathe normally.

Eat and drink adequately.

Eliminate body wastes.

Move and maintain desirable postures.

Sleep and rest.

Select suitable clothes – dress and undress.

Maintain body temperature within normal range by adjusting clothing and modifying the environment.

Keep the body clean and well groomed and protect the integument.

Avoid dangers in the environment and avoid injuring others.

Psychological aspects of communicating and learning

Communicate with others in expressing emotions, needs, fears, or opinions. Spiritual and moral

Worship according to one’s faith. Sociologically oriented to occupation and recreation

Work in such a way that there is sense of accomplishment.

Play or participate in various forms of recreation.

Learn, discover, or satisfy the curiosity that leads to normal development and health, and use the available health facilities.

There is much similarity between Henderson’s 14 components and Abraham Maslow’s Hierarchy of Needs. Henderson’s Components 1 to 9 are comparable to Maslow’s physiological needs, with the 9th component also being a safety need. Henderson’s 10th and 11th components are similar to Maslow’s love and belonging needs, while her 12th, 13th and 14th components match Maslow’s self-esteem needs (Vera 2014).

The second of Henderson’s physiological needs is the need to “Eat and drink adequately”. Only the need to breathe is given a higher priority than the need for adequate nutrition. For cancer patients receiving chemotherapy and suffering from chemotherapy-induced nausea and vomiting, this need is the most critical.

Cancer prevalence and treatment

Cancer is a group of diseases characterized by uncontrolled growth and the spread of abnormal cells. It may be caused by internal factors, such as an inherited mutation, or a hormonal or immune condition, or it may result from a mutation from metabolism, or from external sources, such as tobacco use, radiation, chemicals and infectious organisms. Cancer is prevalent all over the world, in both developed and developing nations; it affects both sexes at all ages (Said 2009). The American Cancer Society (2010) estimated that 1,529,560 new cases of cancer were diagnosed in 2010 and that 80 % would be treated with chemotherapy; this means more than 1 million patients will be undergoing chemotherapy in any given year (Lee et al. 2010).

Cancer treatment may be based on chemotherapy, radiotherapy and surgical interventions. Chemotherapy is an important treatment in cancer care but it is associated with several side effects, such as bone marrow suppression, increased susceptibility to infection, diarrhea, hair loss, appetite changes, nausea and vomiting, among others (NCI Chemotherapy Side Effects Series, 2014).

Chemotherapy-induced nausea and vomiting (CINV) is the most prevalent and one of the hardest side effects to manage (Suh 2012).

Nausea and vomiting

Nausea and vomiting (N&V) can be acute or delayed. The incidence of acute and delayed N&V was investigated in highly and moderately emetogenic chemotherapy treatment regimens. Patients were recruited from 14 oncology practices in six countries. Overall, more than 35% of patients experienced acute nausea, and 13% experienced acute emesis. In patients receiving highly emetogenic chemotherapy, 60% experienced delayed nausea and 50% experienced delayed emesis. In patients receiving moderately emetogenic chemotherapy, 52% experienced delayed nausea and 28% experienced delayed emesis. CINV was a substantial problem for patients receiving moderately emetogenic chemotherapy in ten community oncology clinics. Thirty-six percent of patients developed acute CINV, and 59% developed delayed CINV (NCI, Nausea and Vomiting, 2015).

Chemotherapy is the most common treatment-related cause of N&V. The incidence and severity of acute emesis in persons receiving chemotherapy varies according to many factors, including the particular drug, dose, schedule of administration, route, and individual patient variables.

Risk factors for acute emesis include:

Poor control with prior chemotherapy

Female gender

Younger age

Emetic classification:

The American Society of Clinical Oncology has developed a rating system for chemotherapeutic agents with their respective risk for acute and delayed emesis.

High risk: Emesis has been documented to occur in more than 90% of patients on the following chemotherapeutic agents:

Cisplatin (Platinol).

Mechlorethamine (Mustargen).

Streptozotocin (Zanosar).

Cyclophosphamide (Cytoxan), 1,500 mg/m2 or more.

Carmustine (BiCNU).

Dacarbazine (DTIC-Dome).

Moderate risk: Emesis has been documented to occur in 30% to 90% of patients on the following chemotherapeutic agents:

Carboplatin (Paraplatin).

Cyclophosphamide (Cytoxan), less than 1,500 mg/m2.

Daunorubicin (DaunoXome).

Doxorubicin (Adriamycin).

Epirubicin (Pharmorubicin).

Idarubicin (Idamycin).

Oxaliplatin (Eloxatin).

Cytarabine (Cytosar), more than 1 g/m2.

Ifosfamide (Ifex).

Irinotecan (Camptosar).

Low risk: Emesis that has been documented to occur in 10% to 30% of patients on the following chemotherapeutic agents:

Mitoxantrone (Novantrone).

Paclitaxel (Taxol).

Docetaxel (Taxotere).

Mitomycin (Mutamycin).

Topotecan (Hycamtin).

Gemcitabine (Gemzar).

Etoposide (Vepesid).

Pemetrexed (Alimta).

Methotrexate (Rheumatrex).

Cytarabine (Cytosar), less than 1,000 mg/m2.

Fluorouracil (Efudex).

Bortezomib (Velcade).

Cetuximab (Erbitux).

Trastuzumab (Herceptin).

Minimal risk: Emesis that has been documented to occur in fewer than 10% of patients on the following chemotherapeutic agents:

Vinorelbine (Navelbine).

Bevacizumab (Avastin).

Rituximab (Rituxan).

Bleomycin (Blenoxane).

Vinblastine (Velban).

Vincristine (Oncovin).

Busulphan (Myleran).

Fludarabine (Fludara).

2-Chlorodeoxyadenosine (Leustatin).

In addition to the emetogenic potential of the agent, the dose and schedule used are also extremely important factors. For example, prescribing a drug with a low emetogenic potential to be given in high doses may cause a dramatic increase in its potential to induce N&V. For example, standard doses of cytarabine rarely produce N&V, but these often occur with high doses of this drug. Another factor to consider is the use of drug combinations. Because most patients receive combination chemotherapy, the emetogenic potential of all of the drugs combined needs to be considered, and not only that of individual drug doses.

Delayed (or late) N&V is that which occurs more than 24 hours after chemotherapy administration. Delayed N&V is associated with cisplatin and cyclophosphamide, and with other drugs (e.g., doxorubicin and ifosfamide) when given at high doses, or if given on 2 or more consecutive days.

Delayed emesis: Patients who experience acute emesis with chemotherapy are significantly more likely to have delayed emesis as well.

Risk factors: All the predicative characteristics for acute emesis are also considered risk factors for delayed emesis (NCI, Nausea and Vomiting, 2015).

The nausea and vomiting that are often associated with chemotherapy are a serious problem for cancer patients. Despite recent improvements in pharmaceutical technology, about 60% of cancer patients who receive antiemetic medications with their chemotherapy still suffer from nausea and vomiting, and as many as 20% of patients refuse to continue chemotherapy due to the severity of the nausea and vomiting (Shin et al. 2004). Early studies reported that patients cited nausea and vomiting as the most distressing symptoms when receiving chemotherapy. The distressing effect of severe nausea and vomiting can lead to nutritional deficiencies, dehydration, electrolyte imbalance, fatigue, depression and anxiety; they can also disrupt the activities of daily living and cause a lot of work time to be lost (Said 2009).

Uncontrolled nausea and vomiting can interfere with adherence to treatment regimens, and may cause the oncologists to reduce chemotherapy doses. Chemotherapy-induced nausea and vomiting is classified as being either “acute” if it happens within 24 hours post chemotherapy, or “delayed” if it occurs on days 2–5 of the chemotherapy cycle. The latter is particularly troublesome because there is no reliable pharmacological treatment for this problem. The American Society of Clinical Oncology’s (ASCO) recommendations include giving 5-HT3 (5-hydroxytryptamine, or serotonin) receptor antagonists plus corticosteroids before chemotherapy to patients who are at high risk for emesis. Nevertheless, many patients still experience nausea and vomiting related to chemotherapy, and approximately one-third of patients have nausea of at least moderate intensity, resulting in a significant reduced quality of life (QOL). Therefore, the experts emphasize the need for an evaluation of additional ways to reduce these symptoms (Said 2009).

Pharmacological interventions for the management of nausea and vomiting

Historically, antiemetic treatment has steadily improved since the introduction, in 1981, of high-dose metoclopramide which reduced the amount of emesis. This was followed by the development of serotonin (5-HT3) antagonist in the early 1990s, and the 5-HT3 antagonists proved to be more effective than the prior medications in preventing CINV. The concomitant use of corticosteroids was found to further improve the control of emesis. Despite these improvements, nausea and vomiting still remain a problem for many patients. Recently, a new drug, the neurokinin NK (1) receptor antagonist has been shown to be more effective at preventing both acute and delayed CINV for patients treated with highly emetogenic chemotherapy (Said 2009).

Non-pharmacological intervention for management of nausea and vomiting

Traditional Chinese medicine offers a possible intervention for the non-pharmacological treatment of nausea and vomiting in cancer patients. Traditional Chinese medicine (TCM) is a system of medical care that was developed in China over thousands of years. It looks at the interaction between mind, body and environment, and aims to both prevent and cure illness and disease.

TCM is based on Chinese views and beliefs about the universe and the natural world. It is a very complex system. In this essay we can only give a brief overview of what TCM involves. It is very different from Western medicine; Chinese medicine practitioners believe there is no separation between the mind and body and that illness of every kind can be treated through the body. They use a combination of various practices that may include:

Herbal remedies (traditional Chinese medicines).

Acupuncture or acupressure.

Moxibustion (burning moxa – a cone or stick of dried herb).

Massage therapy.

Feng shui.

Breathing and movement exercises called qi gong (pronounced chee goong).

Movement exercises called tai chi (pronounced tie chee).

TCM practitioners say that TCM can help to:

Prevent and heal illness.

Enhance the immune system.

Improve creativity.

Improve the ability to enjoy life and work in general.

Beliefs behind TCM

According to traditional Chinese belief, humans are interconnected with nature and affected by its forces. The human body is seen as an organic whole in which the organs, tissues, and other parts have distinct functions but are all interdependent. In this view, health and disease relate to the balance or imbalance between the various functions. TCM treatments aim to cure problems by restoring the balance of energies.

There are important components that underlie the basis of TCM:

Yin-yang theory is the concept of two opposing but complementary forces that shape the world and all life. A balance of yin and yang maintains harmony in the body, the mind and the universe.

Qi (pronounced chee) energy or vital life force flows through the body along pathways known as meridians, and it is affected by the balance of yin and yang. It regulates spiritual, emotional, mental, and physical health. If there is a blockage or an imbalance in the energy flow, the individual becomes ill. TCM aims to restore the balance of qi energy.

The five elements – fire, earth, metal, water, and wood – is a concept that explains how the body works, with the elements corresponding to particular organs and tissues in the body.

The TCM approach uses 8 principles to analyse symptoms and puts particular conditions into groups: cold and heat, inside and outside, too much and not enough, and yin and yang (Cancer Research, UK, 2015).

In summary, chemotherapy related nausea is not well controlled by pharmacological agents and identifying methods to prevent and alleviate treatment-related nausea remains a major clinical challenge. Non-pharmacological interventions such as music, progressive muscle relaxation (Said 2009), and ginger herbal therapy (Montazeri A et al. 2013) have all been shown to reduce CINV. Among the non-pharmacological interventions that reduce CINV are acupuncture and acupressure, based on the assumption that the individual’s welfare depends on a balance of energy in the body and their overall energy level (Said 2009). Yarbro et al. (2011, p. 645) also indicate in Cancer nursing: principles and practice book that acupuncture and acupuncture-related interventions (electroacupoint stimulation, acupressure, acustimulation wrist bands, and electroacupuncture) can be used to control nausea and vomiting in cancer patients.

Molassiotis et al. (2007) claim that the need for additional relief has led to the interest in non-pharmacological adjuncts to drugs, such as acupuncture or acupressure, since combining anti-emetics with other non-pharmacological treatments may prove to be more effective, safe and convenient in decreasing nausea than antiemetics alone.

From the National Cancer Institute website we found that acupressure is recognised as one of the non-pharmacologic strategies used to manage nausea and vomiting (Nausea and Vomiting, 3 September 2014). We used this website to get up to date, relevant information.

Acupressure

Acupressure involves putting pressure with the fingers, or with bands, on the body’s acupoints and is easy to perform, painless, inexpensive, and is effective. The P6 (Pericardium 6) point (Nei-Guan) refers to a point located on the anterior surface of the forearm, 3-finger widths up from the first wrist crease and between the tendons of flexor carpiradialis and Palmaris longus (figure1). P6 can be stimulated by various methods. The most well-known technique is manual stimulation by the insertion and manual rotation of a very fine needle (manual acupuncture). An electrical current can be passed through the inserted needle (electroacupuncture). Electrical stimulation can also be applied via electrodes on the skin surface or by a ReliefBand, a wristwatch-like device providing non-invasive electrostimulation. Pressure can be applied either by pressing the acupoint with the fingers or by wearing an elastic wristband with an embedded stud (acupressure).

Figure 1: Done by M.Battat & I.Amro 2015 The Acupressure P6 point determined in the picture And showing the SEA BAND acupressure

Acupressure is based on the ancient Eastern concept that Chi energy travels through pathways known as meridians. Along the meridians are acu-points, which are controlling points for the Chi energy flow. If the energy flow in meridians is slowed, blocked, or hyper-stimulated, it can be rebalanced or re-stimulated either by applying pressure (acupressure) or by inserting a needle (acupuncture) into one or more of these acupoints. Two points are known for relieving nausea and vomiting: the Nei-Guan point (P6) and the Joksamly point (ST36, located at 4-finger breadths below the knee depression lateral to the tibia).

Patients tend to prefer the P6 point over the ST36 point, Because of its ease of access and the freedom from restriction. When these points are correctly located and pressure applied, either through acupressure or acupuncture, the Chi energy flow is rebalanced, resulting in relief from nausea and vomiting.

The practice of acupressure requires some training and experience, but the technique is widely accessible to any healthcare professionals, particularly to clinical nurses. This acupressure technique is an approach that should be tried not only by healthcare professionals but also by family members or the patients themselves (Shin et al. 2004).

According to the teaching of traditional Chinese medicine, illness results from an imbalance in the flow of energy through the body. This energy or Qi (chee) is restored through the use of acupuncture and acupressure at certain points on the body that have been identified through critical observation and testing over 4000 years. In scientific terms, the neurochemicals that are released after needling or pressure at a specific point may be responsible for this effect. The most commonly used point for nausea and vomiting is Pericardium 6 (Neiguan or P6), located above the wrist (Molassiotis et al. 2007).

The literature review on acupressure

Acupressure for chemotherapy-induced nausea and vomiting in breast cancer patients: a multicentre, randomised, double-blind, placebo-controlled clinical trial. (Said 2009)

For a master degree in public health from An-najah National University, Said (2009) described a randomized, double-blind, placebo controlled trial that was done in Palestine with 126 women on chemotherapy for breast cancer. In this study the researcher divided the patients into 3 groups: the first group (n=42) received acupressure with bilateral stimulation of P6, the second group (n=42) received bilateral placebo stimulation, and the third group (n=42), which served as a control group, received no acupressure wrist band, but all groups received pharmacological management of their nausea and vomiting. Acupressure was applied using a Sea-Band (Sea-Band UK Ltd, Leicestershire, England) that patients had to wear for five days following the administration of chemotherapy. Assessment of acute and delayed nausea and emesis, quality of life, patients’ satisfaction, recommendation of treatment and requests for a rescue antiemetic were obtained. Said (2009) concluded that the acupressure showed benefits for delayed nausea and the mean number of delayed emetic episodes. Acupressure may therefore offer an inexpensive, convenient, and self-administered intervention for patients on chemotherapy to reduce nausea and vomiting at home during days 2-5 after chemotherapy. In addition, the percentage of patients who were satisfied with the treatment (≥ 3 on a 0-6 scale) was 81% (35/42) in the P6-acupressure group, and 64% (27/42) in the placebo group (p= 0.0471). The percentage of patients who would recommend acupressure treatment was 79% (34/42) in the P6-acupressure group, and 62% (26/42) in the placebo group (p= 0.0533). We used this study because it had a lot of essential information, it used the IMRAD system and was also mentioned in the literature (Genç and Tan 2014). This study demonstrated that the mean scores for the acupressure group were lower for both acute and delayed nausea.

Review of Acupressure Studies for Chemotherapy-Induced Nausea and Vomiting Control. (Lee et al. 2008)

In the Journal of Pain and Symptom Management Jiyeon Lee et al. (2008) reviewed ten controlled studies on acupressure in order to evaluate the effects of a non-invasive intervention, acupressure, when combined with antiemetics for the control of CINV. The review evaluated one quasi-experimental and nine randomized clinical trials, which included two specific acupressure modalities, namely, an acupressure band and finger acupressure. The effects of the acupressure modalities were compared study by study. Four of the seven acupressure band trials supported the positive effects of acupressure, whereas three acupressure band trials did not support the effects of acupressure. However, all the studies with negative results had methodological issues. In contrast, the one quasi-experimental and two of the randomized finger acupressure trials all supported the positive effects of acupressure on CINV control. The reported effects of the two acupressure modalities produced variable results at each stage of CINV. Acupressure bands were most effective in controlling acute nausea, whereas finger acupressure controlled delayed nausea and vomiting. The overall effect of acupressure was strongly indicative but not conclusive. We used this article because it is relevant, a review study, and is from a known journal.

The effects of P6 acupressure in the prophylaxis of chemotherapy-related nausea and vomiting in breast cancer patients. (Molassiotis et al. 2007)

As reported in the journal Complementary Therapies in Medicine, acupressure was applied using wristbands (Sea-Band™) in a randomized controlled trial conducted in two centres in the UK. Patients in the experimental group had to wear these bands for the five days following their chemotherapy administration. Assessments of nausea, retching and vomiting were obtained from all patients, daily, for five days. Molassiotis et al. (2007) evaluated the effectiveness of using acupressure on the Pericardium 6 (Neiguan) acupoint in managing CINV. Thirty-six patients took part in the study, with 19 patients allocated to the control group and 17 to the experimental group. The results showed that nausea with retching, nausea, and vomiting with retching, and the accompanying distress were all significantly lower in the experimental group as compared to the control group (p < 0.05). The only exception was the vomiting, where the difference was close to significance (p = 0.06). We used this article because it had a strong study design and also used an IMRAD system.

Acupuncture and acupressure for the prevention of chemotherapy-induced nausea- a randomized cross-over pilot study. (Melchart et al. 2006)

In a randomized, cross-over trial, Melchart et al. (2006) studied 28 patients receiving moderately or highly emetogenic chemotherapy and a conventional standard antiemetic for one chemotherapy cycle, followed by a combination of acupuncture and acupressure at point P6 for one cycle, and for another cycle a combination of acupuncture and acupressure at a close sham point. The results showed that there was no difference in the nausea score between the combined acupuncture treatment at P6 and at the sham point, but the level of nausea was very low in both cases. We used this study because the article had neutral results and because we trusted the source of article, coming as it did from a cancer support care journal.

The efficacy of acupoint stimulation for the management of therapy adverse events in patients with breast cancer: a systematic review. (Chao et al. 2009)

This is a systematic review of 26 articles published between 1999 to 2008 examining the efficacy of acupressure, acupuncture or acupoint stimulation (APS) for the management of adverse events due to the treatment of breast cancer. Published online on 17 September 2009 in the Breast Cancer Research and Treatment journal, 23 trials reported revealed that APS on P6 was beneficial in treating CINV. Chao et al. (2009) also presented the findings from three high quality studies comparing APS groups with control groups, which indicated that APS is beneficial in the management of CINV and especially in the acute phase, even with the non-invasive intervention. Health care professionals should consider using APS, and in particular acupressure on the P6 acupoint, as an option for the management of CINV. Furthermore, as a cost effective intervention, it warrants further investigation. We used this article because it used the IMRAD structure.

'Until the trial is complete you can’t really say whether it helped you or not, can you?’: exploring cancer patients’ perceptions of taking part in a trial of acupressure wristbands. (Hughes et al. 2013)

In Complementary and Alternative Medicine, Hughes et al. report on qualitative research undertaken with patients receiving chemotherapy in the UK. A convenience sample of 26 patients volunteered to participate in the clinical trial and to explore their experiences of using acupressure wristbands. Participants were recruited from three geographical sites: nine were recruited from Manchester, nine from Liverpool, and eight from Plymouth and the surrounding regions. Ten of the participating patients received true acupressure during the trial, 9 received sham acupressure, and 7 received no acupressure. Hughes et al. (2013) concluded that the research provided insights into cancer patients’ motivations and experience of taking part in a clinical trial for a complementary alternative medicine intervention, in which the participants perceived acupressure wristbands to reduce the level of nausea and vomiting experienced during their chemotherapy treatment. This article is important because it includes the benefits experienced by the patients taking part in the trial. This is also the first qualitative study to explore patients’ experiences of using acupressure wristbands and their perceptions of the effects. In the study, the patients perceived the wristbands as reducing their level of nausea and vomiting experienced due to their chemotherapy treatment. The study was an RCT.

The effect of acupressure application on chemotherapy-induced nausea, vomiting, and anxiety in patients with breast cancer. (Genç and Tan 2014)

Genç and Tan (2014) reported on a quasi-experimental study in Turkey with 64 patients with stages 1–3 breast cancer who received two or more cycles of advanced chemotherapy. Thirty two patients were in the experimental group, and thirty two in the control group. To determine the effect of acupressure P6 on CINV and anxiety in these patients, the P6 acupressure wristband was applied to the experimental group. Genç and Tan (2014) concluded that the total mean scores for patients in the experimental group, for nausea, vomiting and retching, were lower than those of the patients in the control group over the five days of application. We used this article because it is a recent and quasi-experimental study and used the IMRAD system.

The effects of P6 acupressure and nurse-provided counselling on chemotherapy-induced nausea and vomiting in patients with breast cancer. (Suh 2012)

Suh (2012) reported in the Oncology Nursing Forum on a RCT in South Korea with 120 women who were receiving chemotherapy for breast cancer. These patients had all had more than mild levels of nausea and vomiting during their first cycle of chemotherapy. The participants were assigned randomly to one of four groups: a control group (a placebo on a specific location on the hand); a counselling only group; a P6 acupressure only group; and a P6 acupressure plus nurse-provided counselling group. The purpose of the study was to evaluate the effects of pericardium 6 (P6) acupressure and nurse-provided counselling on CINV in patients with breast cancer. Suh (2012) concluded that nurse-provided counselling and P6 acupressure were together the most effective in reducing CINV in patients with breast cancer. We used this article because it is the first RCT evaluating the isolated and combined effects of P6 acupressure and counselling in reducing CINV among non-Western patients. The findings of the study support the use of P6 acupressure together with counselling that is focused on cognitive awareness, affective readiness, symptom acceptance, and the use of available resources as an adjunct to antiemetic medicine for the control of CINV. The article used the IMRAD system.

DISCUSSION

Can acupressure reduce nausea and vomiting in cancer patients receiving chemotherapy?

In our experience, we have usually used metoclopramide (pramin) plus serotonin (5-HT3) antagonist (as Ondansetron and Granisetron), plus Dexamethasone plus neurokinin NK (1) (as Emend - aprepitant) for moderate to high ematogenic chemotherapy, yet some of the patients have still suffered from nausea and vomiting. After reviewing the literature we would like to use the acupressure P6 wrist band to solve this problem as the findings of our literature review confirm that the acupressure P6 wrist band reduces CINV in cancer patients receiving chemotherapy. This result is corroborated by 7 of the articles reviewed.

The National Cancer Institute website supports the finding that acupressure is one of the non-pharmacologic strategies that may be used to manage nausea and vomiting (NCI Dictionary of Cancer Terms). Said (2009) adds that acupressure may offer an inexpensive, convenient, and self-administered intervention for patients on chemotherapy, helping to reduce nausea and vomiting at home on days 2-5 of chemotherapy. Genç and Tan (2014) conclude that the total mean scores for CINV in patients in the experimental group to whom they applied the P6 acupressure wristband were lower compared to patients in the control group over the five days of application. Lee et al. (2008) found that the two acupressure modalities produced variable results in each phase of CINV: acupressure bands were effective in controlling acute nausea, whereas acupressure controlled delayed nausea and vomiting. Molassiotis et al. (2007) showed that the experience of nausea and vomiting was significantly lower in the experimental group than in the control group. Chao et al. (2009) found that P6 acupoint stimulation was an option for the management of CINV. In the study reported by Hughes et al. (2013) the participants perceived that acupressure wristbands reduced the levels of nausea and vomiting experienced during chemotherapy treatment. Suh (2012) concluded that the synergistic effects of P6 acupressure together with nurse-provided counselling appeared to be effective in reducing CINV in patients with breast cancer.

Five of the seven articles investigating breast cancer patients, namely Said (2009), Chao et al.( 2009), Molassiotis et al. (2007), Suh (2012) and Genç and Tan (2014), involved breast cancer patients receiving highly ematogenic chemotherapy (e.g. Cisplatin and cyclophosphamide), and moderate risk ematogenic chemotherapy (like doxorubicin).

It is necessary to mention other therapeutic regimens that can also be used in cancer treatment that contain other types of chemotherapy that cause nausea and vomiting, for example, doxorubicin-containing regimens like ABVD (Adriamycin, Bleomycin, Vinblastine, Dacarbazine), CHOP (Cyclophosphamide, Adriamycin, Vincristine, Prednisone) and FAC (5-Fluorouracil, Adriamycin, Cyclophosphamide), and ACT (Adriamycin, Cyclophosphamide, Taxol) (Said 2009) and from our experience cisplatin-containing regimens which that classified as highly ematogenic chemotherapy we noticed the patients still experienced nausea and vomiting after they received the antiemitecs. We think it is necessary to use additional intervention like acupressure to be included in the nausea and vomiting management.

Based on the reviewed findings we plan to use acupressure for cancer patients receiving chemotherapy, because the acupressure in the studies conducted in breast cancer patients reported was used with highly ematogenic chemotherapy in addition to the standard antiemetic treatment, so it is reasonable to conclude that it will work equally well with other less ematogenic types of chemotherapy.

We prefer the use of the acupressure wrist band at P6 acupoint because it is an inexpensive, convenient, and self-administered intervention involving pressure instead of needles at the same point as that used in acupuncture. Furthermore it is safer than acupuncture and patients can easily learn to put pressure on their own wrists, whereas the acupuncture involves using needles that are about the diameter of a hair and can cause temporary discomfort during insertion (Said 2009; Molassiotis et al. 2007). Acupressure seems to be a good way to complement antiemetic pharmacotherapy as it is safe and convenient, with minimal (with bands) or no (finger acupressure) costs involved. It is thus an easy to use, cost-effective, non-invasive intervention (Lee et al. 2008; Melchart et al. 2006).

There was no study result that showed any negative effect from the acupressure wrist band at P6 point, except the review by Lee et al. (2008), which mentioned that three of the ten reported acupressure band trials did not support the possible positive effects of acupressure, but these studies all had methodological issues, such as a small sample size, no true control group, and a concern about the sham acupressure band having a possible antiemetic effect. Melchart et al. (2006) said that no difference was detected in the nausea score between the acupuncture treatment at P6 acupoint, and that at the sham point. Said (2009) mentioned that the acupressure showed no benefit in relation to the incidence of delayed vomiting, early vomiting, or acute nausea, but Melchart and Said’s studies were done with breast cancer patients and it could be that the acupressure benefits were not evident due to the breast cancer patients having had axillary lymph node resection that may have affected the meridian pathway or caused damage to the median nerve as mentioned by Roscoe et al. (2003). Consequently, we think that the evidence suggesting that there is no benefit from the acupressure method for reducing CINV is weak.

Regarding the placebo effect in the articles reviewed here, Melchart et al. (2006) indicated that there was no difference in the nausea score for the combined acupuncture treatment at p6 or that at the sham point, although the level of nausea was very low in both cases. Molassiotis et al. (2007), Said (2009) and Roscoe et al. (2003) all suggested that the placebo effect may be the result of psychological factors.

Application of acupressure in clinical practice

It is important to put this theory into practice, and health care professionals could consider using APS, in particular acupressure on the P6 acupoint, as an option in the management of CINV (Chao et al. 2009). Melchart et al. (2006) said acupressure bands can easily be used in busy oncological wards, while Suh (2012) supported the use of P6 acupressure with counselling focused on cognitive awareness, affective readiness, symptom acceptance, and the use of available resources as an adjunct to antiemetic medications for the control of CINV. Hughes et al. (2013) concluded that the research provides an insight into cancer patients’ motivations for and experiences of taking part in a clinical trial for a complementary alternative medical intervention in which the participants perceived the acupressure wristbands as reducing their level of CINV. Said (2009) suggests that oncology nurses should include acupressure in their list of options for the management of CINV, and especially delayed nausea and vomiting. Special recommendations by oncology nurses are not only useful but are also much appreciated by patients as shown in a study in which the patients were satisfied with the antiemetic treatment given by both P6-acupressure, and placebo-acupressure. The percentage of patients who were satisfied (≥ 3 on 0-6 scale) with their treatment was 81% (35/42) in the P6-acupressure group, which was in agreement with Roscoe et al. (2003), and 64% (27/42) in the placebo group (p= 0.0471). The percentage of the patients who would recommend acupressure treatment was 79% (34/42) in the P6-acupressure group, which again was in agreement with the results of Roscoe et al. (2003) and Hughes et al. (2013), compared to 62% (26/42) in the placebo group (p= 0.0533). This study presented the patients’ compliance with the use of acupressure. Acupressure is easily learnt and taught and patients should be informed about its potential role and taught how to apply it. Leaflets about acupressure for the management of nausea and vomiting could be available in chemotherapy units so that patients who are interested to use such a technique would be encouraged to come forward and learn more from nurses or other health professionals. This could add to the patients’ options for antiemetic approaches and empower them to be involved in the management of these distressing side effects. Acupressure offers a no-cost, convenient, self-administered intervention for chemotherapy patients to reduce acute nausea. Acupressure devices (i.e. Wrist Bands, travel bands, and acupressure bands) have been developed to provide passive acupressure on P6. Acupressure can be administered by healthcare providers, family members, or patients themselves, and does not involve puncture of the skin.

We therefore found that the acupressure wristband is a good way to reduce nausea and vomiting for cancer patients receiving chemotherapy by applying it in the correct position with the stud over the pericardium 6 acupoint located on the anterior surface of the forearm, 3-finger widths up from the first wrist crease, and between the tendons of flexor carpiradialis and Palmaris longus.

Lee et al. (2008) encourage the application of acupressure bilaterally, rather than unilaterally, in CINV control. They recommend three minutes of finger acupressure once daily, with additional acupressure as needed, as the optimal intervention, because both three and five minute trials have succeeded in achieving positive effects. On the other hand, Molassiotis et al. (2007) claimed that there is no correlation between the frequency of pressing the studs and the level of nausea and vomiting. Lee et al. (2008) and Molassiotis et al. (2007) therefore claim opposite results in the relationship between CINV and the frequency of pressing the stud of an acupressure P6 wrist band. But when applying the acupressure P6 wrist band bilaterally, Lee et al. (2008), Said (2009), Molassiotis et al. (2007), Suh (2012), and Genç and Tan (2014) all reported a positive effect with P6 stimulation in reducing CINV.

We would like to discuss some factors related to CINV in relation to nausea and vomiting: expectancy and gender: Roscoe et al. (2003) argued that patients who received the acustimulation bands and expected them to be effective did report having a higher quality of life and less nausea, and in relation to gender, that women are more likely to experience nausea when receiving chemotherapy. Lee et al. (2008) say this may be caused by classical conditioning and also that breast cancer patients may have had a damaged median nerve due to axillary lymph node removal, but Lee et al. (2008) also mention that P6 acupressure in younger women had a significantly greater positive effect on delayed nausea than those on a placebo or those in the no-intervention control group. On the other hand, Molassiotis et al. (2007) mentioned that younger age is associated with greater nausea. We think that men may have tolerated greater stimulation of the acupressure points, and therefore experienced greater symptom relief, so it may be that the acupressure is more effective for men than for women, but these questions of gender, age and the frequency of pressing the studs would need further investigation.

Based on the reported studies, we support the belief that acupressure on P6 is applicable in clinical practice for CINV for cancer patients provided the required education, training and counselling is given to maintain the acupressure benefits.

Acupressure side effects

The study by Molassiotis et al. (2007) found that there were no side effects from the use of the wristbands, but one patient reported that she had to take the bands off because they were too tight and left her with marks for a few days. Chao et al. (2009) also mentioned that very few minor adverse events were observed.

Melchart et al. (2006) did report adverse effects from the treatment in five cases. One suffered a hematoma when wearing the acupressure band at P6. In the sham group, one hematoma was reported after acupuncture, and another three adverse effects from the acupressure band were reported (one hematoma, one skin irritation, one eczema). Hughes et al. (2013) also reported that participants had not experienced any restrictions from wearing the wristbands in terms of everyday activities, other than when washing and bathing. As one female participant commented, for most participants the wristbands were found to be comfortable to wear. However, a few participants reported that they had experienced minor irritation, such as the wristbands feeling tight or painful, or their wrists becoming itchy. Reported adverse side effects were generally deemed minor and acceptable. In the study by Said (2009), no side effect or discomfort was noticed from wearing the acupressure wristband. Said told the patients that if the bands caused discomfort, they could be removed for 30 minutes every two hours. In this way, by taking it off for regular periods, we can prevent the side effects of acupressure, even its minor and rare effects.

Acupressure reduces CINV in cancer patients, in addition it reduces anxiety (Genç and Tan 2014) and that affects overall quality of life (Said 2009). Quality of life is defined by the NCI Dictionary of Cancer Terms as “The overall enjoyment of life and the individual’s sense of well-being and ability to carry out various activities”. Based on the physiological components of the Virginia Henderson’s theory of basic human needs and Abraham Maslow’s Hierarchy of Needs, the patient needs to eat and drink adequately, and sleep and rest (Vera, 2014). This means that when we are providing the required management for distressing symptoms, such as nausea and vomiting, by including the acupressure wrist band in addition to standard antiemetics, the patient’s appetite will improve, leading the patient to eat and drink adequately and improve their sleeping pattern. These may then also improve other aspects of the cancer patient’s life. According to the Henderson Nursing Need Theory, when we meet a patient’s needs, it results in an improved quality of life for the cancer patient receiving chemotherapy. Another way of expressing this is that it restores the balance of Yin and Yang energy that leads to reduced nausea and vomiting and improves the patient’s ability to enjoy life and work in general through a maintaining of the harmony of body and mind, as described in traditional Chinese medicine (Cancer Research UK, 2015).

We believe that it is essential for cancer patients undergoing chemotherapy treatment to have adequate nutrition to maintain their strength to fight the cancer. Different nursing actions are necessary to maintain adequate nutrition including the relieving of CINV. From this we extrapolate that using the acupressure P6 wrist band to reduce CINV improves the patient’s quality of life.

CONCLUSION

Chemotherapy-induced nausea and vomiting may be life threatening and is therefore a huge challenge to nurses involved in cancer care. Even with the best pharmacological management of CINV, patients continue to experience nausea and vomiting.

From a review of eight articles with strong methodology, seven supported the positive effect of an acupressure P6 wristband in reducing CINV for cancer patients. This was also supported by other databases. The one article with neutral results showed that there was no difference between a combined acupuncture and acupressure treatment at P6 and at a sham point in relation to the nausea score, but the level of nausea was very low in both groups. We conclude that the acupressure wrist band applied to acupuncture point P6 is effective, safe, convenient, cost effective, an easy and self-administrated non-pharmacological intervention from traditional Chinese medicine that reduces CINV. Solving the problem of CINV is a fundamental nursing task that can lead to improved quality of life and nutritional status, reduced anxiety and increases patient compliance. In the light of these results, and due to the effectiveness and inexpensiveness of acupressure, together with its ease of use, we suggest that it should be used in conjunction with pharmacological agents for CINV prophylaxis. To maintain the effectiveness of the acupressure, special education and training is needed to reassure the patient that the acupressure is at the correct point (P6) and counselling by the nurse is required.

We recommend the use of acupressure P6 in oncology departments and that future research should be conducted to include cancer patients receiving radiotherapy, and to investigate more about the relationship between the frequency of pressing the stud on the wrist band for acupressure P6 and CINV, and the relationship between gender and CINV, and whether it is better to apply it unilaterally or bilaterally.

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#Acupressure #Chemotherapy #Nausea and Vomiting #Cancer patients #Chemotherapy-induced nausea and vomiting #NCI #PICO #CINV #Mustargen #Zanosar #Platinol #Cytoxan #BiCNU #DTIC-Dome #Maher Battat #jcrmhs

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nyheadache · 1 year

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Effects of observational learning on placebo responses, or why sham remedies seem to work so well

Many companies selling ineffective treatments for painful conditions manage to attract a large customer base by showcasing testimonials from satisfied customers. Recent research suggests that these individuals might genuinely benefit from hearing others express positive experiences. A study published in the journal Pain, titled “Learning pain from others: a systematic review and meta-analysis of…

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emstefani · 1 year

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I’ve been looking into places that could suction cup my upper back for me (most of my pain is at the top of it), and I might call a place tomorrow not too far from me. I just hope the reviews aren’t a sham.

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cesreliefblog · 1 year

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CES Alpha Stim Therapy Device

The CES Alpha Stim Therapy Device is a non-invasive device that helps relieve symptoms of depression and anxiety. It works through mild electrical stimulation to calm overactive areas of the brain, such as the limbic system. In a recent study, CES applied to earlobes decreased Hamilton Anxiety Rating Scale (HAMRS) scores by 40.4%.

This therapy is approved by the Food and Drug Administration (FDA) to treat insomnia, pain, and depression. The device is available on prescription and can be administered in the comfort of your own home. Unlike traditional electroshock treatments, which are administered under general anesthesia, Alpha-Stim is relatively free of side effects.

The device is used by a mental health professional to trigger certain neurological activities. While the exact mechanism behind the device is unclear, experts believe that the current may travel to the brain in a diffuse manner. One theory suggests that alternating microcurrents may stimulate afferent branches of cranial nerves, such as the glossopharyngeal and facial nerves. Another theory says that the current may interfere with high- and low-frequency noise.

CES is different from electroconvulsive therapy in that it is intended to interrupt ongoing cortical activity. Instead of using a large electrical current, it transmits tiny microcurrents through handheld electrodes. These devices have been used by mental health professionals for years.

Various studies have shown that Alpha-Stim is effective at treating depression. Some studies have found that nine out of ten patients experience significant relief after one treatment. Other reports show that Alpha-Stim has been found to reduce the intensity of pain and headaches. There is also a report of CES calming down the amygdala, an area of the brain involved in emotional processing.

CES has been studied in monkeys and humans, and is believed to produce a calming effect on the central nervous system. Alpha EEG waves slowed after CES in the monkeys. Itil et al., published a study in the Journal of Pain and Symptom Management. They found that CES reduced the frequency of the alpha EEG wave by more than 0.5Hz.

Similarly, a Cochrane review of randomized trials of CES for chronic pain uncovered positive outcomes for CES. However, the results are insufficient to establish whether the improvements in net health outcome are clinically significant.

The primary symptom in a pilot study was a reduction in generalized anxiety disorder. In this study, participants were randomly assigned to receive a sham CES or an active CES. During the scan, participants were instructed to keep their eyes closed and not think about anything. After each scan, they completed a validated questionnaire that assessed their symptoms. Compared to the sham group, the active group did not have any changes in their symptoms.

Disclaimer: This is not professional advice and is simply an answer to a question and that if professional advice is sought, contact a licensed practitioner, or doctor in the appropriate administration.

Seek Professional Help

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Cranial Electrotherapy Stimulation (CES) Device is a safe, painless microcurrent treatment scientifically proven to treat anxiety and insomnia in children, teenagers, and adults alike.

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human-nature-medicine · 1 year

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The Immediate Analgesic Effect of Acupuncture for Pain:

Acupuncture has been shown to be an effective treatment for pain in a number of clinical trials. The aim of this review was to assess the evidence for the immediate analgesic effect of acupuncture for pain. A systematic search was conducted in five electronic databases. Twenty-two trials involving 3,993 participants were included. The results showed that acupuncture was effective for reducing pain in a variety of conditions, including headaches, dental pain, postsurgical pain, and musculoskeletal pain. The effect was immediate, with a significant reduction in pain reported within one hour of treatment. Acupuncture is a safe and effective treatment for pain, with a rapid onset of action. It should be considered as a first-line treatment for pain, particularly when drug therapy is not effective or not tolerated.

Acupuncture is a traditional Chinese medicine technique that has been used for centuries to treat a variety of health conditions. In recent years, acupuncture has been shown to be an effective treatment for pain in a number of clinical trials. The aim of this review was to assess the evidence for the immediate analgesic effect of acupuncture for pain.

A systematic search was conducted in five electronic databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov. Studies were eligible for inclusion if they were randomized controlled trials that assessed the immediate analgesic effect of acupuncture for pain.

Twenty-two trials involving 3,993 participants were included in the final analysis. The results showed that acupuncture was effective for reducing pain in a variety of conditions, including headaches, dental pain, postsurgical pain, and musculoskeletal pain. The effect was immediate, with a significant reduction in pain reported within one hour of treatment.

Acupuncture is a safe and effective treatment for pain, with a rapid onset of action. It should be considered as a first-line treatment for pain, particularly when drug therapy is not effective or not tolerated.

Acupuncture, a key component of traditional Chinese medicine practices, is commonly used to relieve pain. There is significant evidence that acupuncture can effectively treat both acute and chronic pain. Until recently, however, most of the research on acupuncture has been conducted in Asia. A recent systematic review and meta-analysis of clinical trials published in the journal Pain Medicine provides an up-to-date evaluation of the evidence for the efficacy of acupuncture in treating pain.

The systematic review included 22 randomized controlled trials that enrolled a total of 3,993 participants. The trials were conducted in a variety of settings, including outpatient clinics, hospitals, and dental offices. All of the trials compared acupuncture to either sham acupuncture or no treatment.

The results showed that acupuncture was effective for reducing pain in all of the conditions studied, including headaches, dental pain, postsurgical pain, and musculoskeletal pain. The effect was immediate, with a significant reduction in pain reported within one hour of treatment.

The authors of the review conclude that acupuncture is a safe and effective treatment for pain, with a rapid onset of action. They recommend that acupuncture be considered as a first-line treatment for pain, particularly when drug therapy is not effective or not tolerated.

The evidence reviewed in this systematic review and meta-analysis provides strong support for the use of acupuncture as a treatment for pain. Acupuncture should be considered as a first-line treatment option for pain, particularly when drug therapy is not effective or not tolerated.

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brisbanehipnkneeau · 2 years

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Knee Replacement - What Are the Risks?

Performing a custom knee replacement is a surgical procedure that helps patients relieve pain and improve mobility in their knee joints. It is also known as knee arthroplasty.

Arthroplasty

Having knee replacement surgery can relieve pain and increase mobility. However, there are risks associated with this procedure.

Before surgery, patients may need to undergo pre-operative tests. These may include a chest X-ray, electrocardiogram, and blood work. Some procedures also require an MRI or CT scan.

Arthroplasty procedures may vary by hospital and provider. Patients can resume most activities within three to six weeks of surgery. However, some patients may need to stay in a rehabilitation facility.

Patients undergoing arthroplasty may also need to stop taking certain medications. They may also need to stop taking blood thinners. In addition, some patients may need to wear compression stockings. This is to prevent blood clots in the leg veins.

After surgery, patients are typically monitored for several hours in the recovery area. Patients may then return home. They will receive pain medication and an exercise regimen.

Patients may experience loss of appetite for several weeks. They may also experience numbness in the skin around the incisions. They should also expect to wear a brace or an assistive device.

Arthroscopic washout and debridement

Surgical treatment for osteoarthritis of the knee involves arthroscopic washout and debridement. This method involves removing loose bodies and damaged bone from the knee joint. In some cases, arthroscopic debridement may be combined with meniscectomy.

Arthroscopic debridement for knee replacement may reduce pain and improve motor function. However, it is not recommended by the American Academy of Orthopaedic Surgeons.

Arthroscopic debridement is used to remove damaged cartilage and meniscal fragments, but it is not a cure for OA. According to the American Academy of Orthopaedic Surgery (AAOS), arthroscopic debridement is not a good treatment for patients who have a primary diagnosis of meniscal tear or who have a loose body.

The AAOS's policy is based on an assessment of the evidence. A Cochrane review examined the effectiveness of arthroscopic surgery for knee OA. The review included three randomized controlled trials (RCTs). These trials compared arthroscopic surgery with arthroscopic lavage, medical and physical therapy, and sham surgery. The Cochrane review concluded that arthroscopic surgery for knee OA was not more effective than sham surgery.

Partial (unicompartmental) knee replacement

During the procedure, your surgeon will remove the damaged cartilage and replace it with a metal and plastic implant. A plastic spacer is inserted between the metal components to allow the newly resurfaced compartment to glide smoothly with movement.

The partial knee replacement may be an attractive option for patients with a single worn compartment in their knee. It is also less invasive than a total knee replacement. Patients often return home the same day as the procedure. However, it is important to remember that partial knee replacements are not for everyone.

In addition to removing damaged cartilage, your surgeon may also remove bone spurs and release any tight ligaments. This is an important step in ensuring that your new knee is as stable as possible.

Depending on your individual needs, a partial knee replacement may require hospitalization and a brief stay. A recovery period of one to three days is common. You may be able to return to your normal activities within a few weeks, although you will need someone to help you during the first several days.

Reverse knee replacement

Having a knee replacement surgery is one of the most effective procedures in medicine. The aim of the surgery is to help the patient relieve pain and improve mobility. However, this procedure can be a complex process. It is not recommended for younger people, as their bodies are more susceptible to wear and tear.

Reverse knee replacement is the most common type of knee replacement. In this type of surgery, the knee that has been damaged is used to replace the knee that is no longer functional.

The procedure is done under general anesthesia, with an incision made over the knee. Before the surgery, the surgeon will evaluate the knee and the components of the joint. The doctor will also perform imaging modalities such as x-rays and bone scans. This will help the doctor determine the location and extent of the damage.

In some cases, the original components of a Total Knee Replacement may wear out and need to be replaced. The doctor may also perform a revision surgery.

#knee replacement

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spencerheartcare · 2 years

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Is PrTMS Treatment safe for the brain?

The primary goal of PrTMS is to slowly nudge neural alpha wave responses toward a common fundamental frequency, which changes over time and is thought to be related to behavioral symptomologies. When neural activity is coherent across the brain, it is said to be closer to a more efficient and natural state. Neuronal coherence is thought to alleviate the symptoms of brain-related diseases and enhance cognitive function.

Side effects of rTMS therapy

If you are considering rTMS therapy for brain treatment, you should be aware of the side effects associated with this procedure. Some people may experience seizures while receiving treatment. If you are at risk of seizures, your doctor may recommend another treatment option, such as antidepressants. However, this therapy is not for everyone. People with epilepsy or brain damage should not receive rTMS. Other side effects of rTMS include frequent headaches, nausea, and loss of appetite.

The most common side effect associated with rTMS is a headache. Patients may experience headaches within a few days of receiving the therapy, while others may have mild or no side effects at all. Some patients experience nausea and vomiting, as well as a buzzing or throbbing sensation on the side that has been stimulated. Fortunately, these effects are relatively rare, and most patients do not have severe problems after undergoing rTMS.

Safety

Murphy's claims about the safety of brain PrTMS treatment are untrue or based on his personal opinion. The company has since removed the article from its website. According to his website, his VA project never got far enough to get started, but in the same month that his VA project didn't get off the ground, his proposal was reviewed by the UCSD Institutional Review Board (IRB), which oversees clinical trials and protects the rights of human research subjects.

This study aims to determine whether the treatments are safe. Participants will be randomly assigned to one of two groups, either an active or a sham intervention. In addition to the study, the participants will wear a sleep tracking ring provided by the lab. They will also be required to fill out daily and weekly surveys. The research team will also collect data on the participants' moods and general health. The researchers will not disclose which treatment condition they received.

Effectiveness

Researchers are currently studying the effectiveness of personalized repetitive transcranial magnetic stimulation (PrTMS) as a brain treatment. The technology is noninvasive and can improve sleep quality and cognitive performance. In addition, it can help improve mood and reduce stress. The study is currently ongoing and aims to find out whether PrTMS treatment is safe for most people. However, some people may experience side effects such as nausea or tingling.

Researchers have demonstrated that PrTMS brain treatment is effective for treating PTSD in patients. The treatment works by targeting neural alpha wave dynamics. The technique uses PeakLogic software to determine where and how often to apply the therapy. This data should allow researchers to monitor specific changes as the treatment progresses. For example, improvements in alpha wave coherence are associated with improved sleep behavior and cognition. These changes in neural activity can help alleviate symptoms of brain-related disease and improve cognitive function.

Cost

If you're looking for a non-invasive, pain-free way to treat your brain and improve your overall health, you may want to look into getting PrTMS brain treatment. There are many benefits to this type of treatment. Not only will it improve your overall health and wellbeing, but it can also help you sleep better. But how much will PrTMS cost? That's the question that we'll answer in this article.

The goal of PrTMS is to gradually nudge the neural alpha wave responses toward a common fundamental frequency. This frequency varies over time, but larger variations are often associated with specific behavioral symptomologies. This process is known as coherence and results in heightened cognitive functions. This is believed to relieve symptoms associated with brain-related disorders and can improve mood and anxiety levels as well. Cost of prtms brain treatment.

#prtms therapy #prtms san diego #prtms near me #prtms treatment #mental health agencies in san diego #behavioral health services los angeles ca

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suttonucrdugan · 2 years

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Bodily Remedy For Steadiness Issues

But, according to an article in Handbook of Clinical Neurology, older adults usually have a tendency to develop this situation than are youthful people. They send info out of your muscle tissue to your central nervous system. Damage to sensory nerves could cause numbness, tingling, extreme sensitivity to the touch or temperature, and even pain. There are great teams for older adults the place physical activity is supervised and age-appropriate. Surgical remedy may be really helpful for individuals with nerve damage from injury or nerve compression. Mobility aids, such as a cane, walker, or wheelchair, may be useful. The condition ends in weakness, numbness, and burning pain, which usually starts in the arms and toes and sometimes progresses throughout the physique, affecting different areas as nicely. Both elderly women and men with diabetes have a better threat of fractures than adults without diabetes, despite comparable bone mineral densities . Nerve Renew Reviews could additionally be because of extra extreme glycosylation of amino protein teams in bone tissue, in comparison with other tissues, as the effect of diabetes . This scenario increases the risk of fractures by 64% in folks with diabetes compared to wholesome folks . It was shown that amongst individuals who have been greater than 65 years old and had diabetes, 30.6% fell recurrently, whereas only 19.4% of individuals without diabetes had recurrent falls. Recurrent falls were defined as a minimal of 2 falls within a 6 month period . We initiated this examine to determine whether therapies with the ATS would decrease ache and/or improve sensation diminished due to DPN beneath a sham-controlled, double-blind protocol. Balance issues brought on by peripheral neuropathy happen when nerves that carry messages to and from the brain/spinal cord to the rest of your physique are damaged. This nerve connects the brain and spinal wire to muscular tissues, organs, and skin.

#Nerve Pain #Pain Management

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journalofclinical · 2 years

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Lupine Publishers | A Critical Review of Publications related to Al-Hijama Therapy

Short Communication

Evidence-based clinical practice emphasizes the use of information from well designed and conducted research in healthcare decision-making. It largely depends upon the outcomes from prospective randomized clinical trials in which the number of patients are sufficiently high to ensure that the results are robust. Such trials need to be adequately powered and to define from the beginning what magnitude of difference between treatments is being sought. The classical approach when assessing the value of new medications has been the use of blind assessments in which both patients and assessors do not know which drug or placebo they are receiving. The application of such an approach in Al-Hijama is either impractical or even unethical as it would require use of sham wet cupping. A recent review from Iran Bamfarahnak et al. [1] suggested Al-Hijama is currently prescribed for up to 120 diseases that are difficult to treat, including cutaneous (21.7%), musculoskeletal (15%), and central nervous system (13.3%) disorders. However, the number of such treatments subjected to rigorous assessment is relatively limited. In this review those studies which have dealt with pain will be considered first. Subsequently studies dealing with hypertension and cardiovascular risk factors will be assessed. In addition, its potential benefit in management of shingles will be considered. Al-Hijama and wet cupping are used in many other conditions, but research papers published in peer reviewed journals during the last twenty years are mainly restricted to the above fields. Of note few of the reported studies draw attention to the religious distinction between the technique of Al-Hijama and simple wet cupping, the recipients and the practitioners. However, in 2014 the Taibah theory was put forward as the basis for a physiological explanation of how Al-Hijama works and its distinction from simple wet cupping [2].

Read more about articles: https://lupinepublishers.com/clinical-community-medicine/fulltext/a-critical-review-of-publications-related-to-al-hijama-therapy.ID.000107.php

Read more about Lupine Publishers Google Scholar articles: https://scholar.google.com/citations?view_op=view_citation&hl=en&user=vfbCW-wAAAAJ&cstart=20&pagesize=80&citation_for_view=vfbCW-wAAAAJ:k8Z6L05lTy4C

#Lupine publishers #lupine publishers llc #Lupine Publishers Group #communicable diseases

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authorlimit7 · 2 years

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Why Is Chiropractic Therapy Good For Me?

You've probably asked yourself "Why is chiropractic therapy beneficial for me?" This is a valid question because there are numerous benefits to this type of treatment. It reduces inflammation, improves function and offers immediate relief. Continue reading to find out more about the many chiropractic benefits. Chiropractor Greenville TX will be amazing how quickly you will feel better. Although your body may appear to be recovering from a procedure, it's beneficial to visit a chiropractor for a complete examination.

Reduces lung inflammation

There are numerous benefits to chiropractic therapy for chronic inflammation conditions. The adjustments can decrease the production of certain chemicals referred to as cytokines. These chemicals regulate the immune system and can cause an inflammatory response if they are excessively high. Other benefits include a healthy diet rich in fiber, fruits, vegetables, and lean meat, as well as anti-inflammation supplements. Regular exercise is beneficial for healthy bodily functions and helps eliminate inflammatory chemicals. In September 2016, a study published in the Journal of Alternative and Complementary Medicine investigated the effects of spinal manipulation on COPD patients. The review examined six studies where patients received a spinal manipulation treatment. The review covered observational studies, case studies and controlled studies that were randomized. All studies included the control group as well as a group receiving an sham-chiropractic treatment. The results of this study proved that chiropractic treatment significantly improved the function of the lung in the experimental group.

Relieves chronic pain

Chiropractic therapy can be an excellent option for pain relief that is chronic. In addition to using their hands to adjust the joints and spine, chiropractors often use exercise and stretching to ease pain and increase range of motion. This kind of treatment is common among athletes, people recovering from work-related injuries as well as those who have suffered injuries in automobile accidents. The kind of care patients receive will depend on their medical history, range of motion, and other aspects. Chronic pain sufferers who seek chiropractic treatment to treat their chronic pain can are able to avoid the cost and risk of pain medication. Pain medications can be addictive and can cause an increase in tolerance. Patients who use painkillers frequently may have to take more than is healthy. Patients may not always get the relief they need from painkillers. Chiropractors may also use techniques to reduce the amount of therapy that is required over time.

Function improvements

Chiropractic care offers many benefits to your body. It can help ease pain, improve range of motion, and improve mobility after injury. Chiropractic treatments can also enhance your health and overall health. They can be a great alternative to drugs and surgical procedures. These are just a few of the many benefits that chiropractic care could improve your health and functioning. - Increases self-esteem and confidence - Changes your brain functions. A study conducted by the Spinal Research Foundation shows that chiropractic adjustments improve brain function, specifically in the pre-frontal region, which is responsible for higher learning and higher levels of consciousness. While chiropractic adjustments are usually associated with stiff necks or low backs research has demonstrated that chiropractic adjustments can enhance the function of the brain and improve focus. This discovery has profound implications for your health and well-being. This kind of care is beneficial for everyone from athletes to seniors.

Offers immediate relief

Chiropractic care can reduce the severity of various symptoms such as tension headaches, depression back and neck pain and even tension headaches. Because chiropractic care uses an approach to healing that relies on the mind rather than the body, adjustments made by a chiropractor can help alleviate some of the symptoms that are associated with poor mental health. This includes fatigue and fatigue. Chiropractic care is also less expensive than traditional treatments for chronic back pain. Chiropractic treatments can also involve manipulation of the spine. Cryotherapy relieves the joints and muscles through shrinking blood vessels. Patients can expect relief from pain within a matter of minutes, that's why many chiropractors alternate between heat and cold therapy. At-home cold therapy is also an option and should be handled with diligence. The chiropractor will determine the right temperature for each patient.

Does not have any known negative side negative effects

The benefits of chiropractic therapy are greater than its risks. Studies show that the process is safe and can even replace certain types of medication. However, there are a few uncommon side effects associated with chiropractic therapy. Although there aren't any clinical studies to determine the incidence of serious adverse effects, the literature suggests that they are very uncommon. The risks associated with spinal manipulation, for instance can lead to an injury to the brain or rupture of the disc. The American Chiropractic Association (ACA) is a professional organization that provides education to people on chiropractic care, promotes research and assists chiropractors in maintaining ethical practices. They advocate evidence-based care for patients and support the Choosing Wisely campaign. The American Chiropractic Association's goal is to provide high-quality medical care for patients of all different ages. They're committed to making sure that everyone in the country has the best possible health by making the public aware of chiropractic treatment.

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#Chiropractor Greenville TX

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gloveice1 · 2 years

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The 15 Best Joint Supplements Backed By Science

The researchers did note that the differences between "true" and "sham" acupuncture were "relatively modest." But still, acupuncture is a safe treatment that could be worthwhile for you. If you're interested in acupuncture, look for a practitioner with the professional initials DABMA (which means they've been certified by the American Board of Medical Acupuncture). More than 32.5 million U.S. adults have osteoarthritis, and most of them are older adults. Depending on your height and body type, your weight may subject your joints to pressure that’s either too high or too low for sustainable health. Too much weight puts more pressure on the lower body joints, especially the hips, knees, and feet, which can impact joint pain. Too low of a weight doesn’t provide enough muscular support to keep joints strong and stable. Feel Good Knees For Fast Pain Relief Review may be good to talk with your doctor or a nutritionist to check that you’re at a weight that’s right for your joints. Senior dogs with protein allergies will appreciate this vegetarian-friendly liquid joint supplement. Joseph Wakshlag, DVM, works at the Cornell University College of Veterinary Medicine. Surgery to fuse the joint and stop painful motion may be recommended. Every cell, organ, and tissue in your body needs water to function properly, including your joints. Water helps lubricate and cushion the connective tissues that make up your joints. Strong, outspoken and engaged volunteers will help us conquer arthritis. By getting involved, you become a leader in our organization and help make a difference in the lives of millions. Take part to be among those changing lives today and changing the future of arthritis. Share your experience with arthritis to shape research and patient care for yourself and others. Use these tried-and-true tension relievers when arthritis has you all worked up. The Arthritis Foundation is working to grow the number of rheumatoid specialists so that people can receive more in depth care. Mechanical issues – Certain types of mechanical problems can cause pain despite there being no actual injury to the knee. Examples include a dislocated or loose knee cap and Iliotibial band syndrome which is commonly referred to as IT band syndrome. This is where the iliotibial band becomes tight and rubs against the thigh bone. Surgery – In more severe cases of knee pain due to injury or a medical condition, surgery may be recommended. There are a number of different types of knee surgery available depending on the condition of the knee as well as a number of other considerations. Learn how to get relief from arthritis pain and what treatments are available. We have vaccinations to thank for eradicating frightening, sometimes deadly diseases, like polio, diphtheria, influenza and now, COVID-19. Learn about recommended vaccine schedules for babies, children, and adults, and why they’re so critical. When you or a family member is sick or injured, it can be challenging to know if an acute care clinic or the emergency room is the right place to go for help. Take a moment to learn about what acute care can treat and when it’s your best care option. How to Live a Normal and Healthy Lifestyle with High Blood Pressure High blood pressure doesn’t necessarily mean you’re doomed to a lifetime of medication. The lifestyle choices you make every day can either raise or lower your numbers.

#Joint Pain #Joint #Sacroiliac Joint Pain #Joint Pain Relief #Sacroiliac Joint #Joint Pain Exercise #Joint Pain Treatment #Joint Pain After Workout #Joint Dysfunction #Joint Pain Causes #Joint Pain Protein #Joint Pain Food To Eat #Joint Pain In Fingers #Joint Injections #Joint Fusion #Joint Surgery #Joint Pain Yoga #Joint Sprain #Sacroiliac Joint Dysfunction

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allsadnshit · 3 years

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in honor of endometriosis awareness month i want to acknowledge the absolutely evil and divisive ads i get every single day on this app promising me their company's endo friendly super supplement will regulate my body and fix all my incurable problems with only $60! i see your well curated pages and your make shift products! i see your fake promises and pretend 5 star reviews! and i see your woman-owned-we-are-here-for-you-sister business models made to make me feel understood while you sell me snake oil in my time of desperation and need. thanks for wasting my money while i'm facing chronic illness and medical bills. your companies are a sham and your practices are insincere.

i hope everyone battling chronic pain and illness every day find people who truly care for them and find natural medicines that are there to help you heal and manage your body.

and for all the brands capitalizing off our failing health, consider this a public fuck you for your pretend empathy for the sick.

>:,-(

#chronic pain #chronic illness #endometriosis #endo

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dwellordream · 3 years

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A Six of Crows Review: Kaz IV through Jesper II

Previously

Kaz IV is pretty gore heavy, which I’m not complaining about, though as far as interrogation tactics go, it feels like Bardugo just really had a hankering to write some eye trauma. I also feel like the pain of that would probably put someone in such a state of shock they’d be unable to speak at all, but whatever, this is a YA dark fantasy novel where teenage boys rip apart wolf jaws and tear out oculars, I guess we’re rolling with it.

You’d think the shock of nearly losing Inej would inspire maybe a modicum of self reflection in Kaz, and honestly his treating Jesper like his valet actually pissed me off on a visceral level, which, to be fair, is the most emotion I’ve ever felt while reading one of his POV chapters.

Thus far I would sum up my problems with Kaz’s character are this: my problem is not that Kaz is not likable or relatable. He doesn’t need to be either, he’s an amoral gangster. My problem is that he’s not terribly believable and he’s not terribly compelling.

I don’t think the wanton violence gives his character more dimension; if anything it reduces him further to a cardboard cut out of say, Tommy Shelby from Peaky Blinders. Bardugo apes a lot of gangster tropes with him but there’s no nuance or meat to it. He doesn’t fascinate me and I don’t care about his backstory or his future.

None of the characters in this book so far are hitting it out of the park, but I am much more invested in Nina, Matthias, and Inej than I am in Kaz, and that’s a problem, since the entire novel arguably revolves around him.

He is the antihero protagonist. He’s directing much of the action as the leader of the Crows. He should be reeling the reader in more. Instead it’s like a brick wall with more intestines slathered on it for edgy effect.

We do get some nice backstory and development for Nina in her second POV. I don’t have much context for the Little Palace or Zoya since I never finished Shadow and Bone, but Bardugo continues to do a decent job at developing Nina and making her feel both strong and vulnerable, as well as a sweet romantic at heart.

We also get some of her backstory with Matthias. I honestly find the trope of ‘we know he’s not quite as bad as the other war criminals because he doesn’t hold with rape!’ to be pretty absurd and despicable, but Matthias and Nina’s dynamic is arguably the only compelling relationship in this story so far, even if he’s a shit person* and she’s a sweetheart.

*Matthias is very particular about not being called a slaver. This, of course, is an important correction, as he and his fellow soldiers weren’t capturing grisha to enslave them, but to put them on sham trials and then exterminate them as part of the Fjerdan nation’s vile agenda.

Between this and the constant references to his blonde hair, blue eyes, and ‘impressive’ build… it’s hard not to think Bardugo was making some deliberate Nazi allusions. I don’t exactly applaud her for it.

I don’t have anything to say about Inej V other than that Inej’s account of her enslavement is heartbreaking and her and Nina singing together as she recovers from her wound is the only scene so far in this book to make me emotional. I wish more time was spent developing Inej’s friendship with Nina as opposed to her feelings for Kaz.

Finally, Jesper II evaporates the little goodwill I had accumulated from the Nina and Inej chapters tonight, because Jesper is literally a walking camera once more.

No development. No reflection or interiority. None. I would not have known he was even narrating this chapter if not for the header. It’s almost all dialogue. This is ridiculous.

#JusticeforJesper

#in review #six of crows #kaz brekker #nina zenik #jesper fahey #inej ghafa #matthias helvar

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pinkbubbles-and-bigtroubles · 4 years

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Wicked Game

Another round of the 5sos fic writing collab brought to you by @maluminspace and @h0tsos. There are so many amazing writers involved and I highly recommend checking out the event master list linked below. Thank you to the Sagittarius sorceress @sexgodashton for being very caring, patient, and kind while helping me tame this monster. Massive shout out to @ghostofmashton for the photo edits, especially Ashton’s eye. that’s my favorite. You’re a rock star. Texas girls forever, love you to bits!

Event Master List

Prompt: Chef AU with Cashton

Dialogue Prompt: “Kissing you is all I’ve thought about since the moment we met” First person to spot it in the fic and send me a screenshot gets a personalized blurb request.

Word Count: 20K+ Team Long Winded Bitch strikes again, this will be posted in multiple parts over the next couple of days. This first part is about 5K

Rating: 18+ Slash fic Strong language, alcohol and drug use, and a misogynistic and racist comment. Sexual scenes including masturbation, toys, voyeurism, oral, and anal sex.

Summary: Ashton is ready to move on with his life after his painful divorce from Luke and the demise of the restaurant they’d built together. With the help of his protegee and sous chef Hima Singh, Ashton is ready to take on opening weekend of his new restaurant Anne-Marie’s. Calum is a reporter filling in on an assignment and is surprised when his past comes back to haunt him. Hima arranges an interview that takes an unexpected turn between the two men.

Part 1

"Great job, guys, we couldn't have had a better opening weekend. Thank you so much for making it happen," Ashton told the two staff members in the kitchen who'd closed as he unlocked the back door.

"No problem boss, glad to be here. We made money this weekend. See ya tomorrow," DeSean told him as he left.

Ashton locked the door behind them and walked out into the empty dining room, his steel-toed boots echoing heavily on the distressed blonde faux hardwood floors. He stopped to adjust a few tables, double-checking sightlines and looking over the layout of the tables. The upside-down chair legs cast long shadows in the soft pink neon glow.

He looked up at the sign above the bar that read "Anne-Marie's." He smiled, not caring if anyone thought it was cheesy to name his restaurant after his mother. His mom had always been his lucky star, and he couldn't have gotten through the last couple of years without her.

"You look so serious,' a voice behind him startled him out of his thoughts.

"What the fuck Hima," Ashton yelped, clutching his chest dramatically. "I thought you were still in the kitchen."

"The guys didn't leave me anything to do so I decided to change and have a drink with you before my brother gets here," she tossed her bag and chef's coat onto a stool grinning at Ashton. She hopped up to sit on the bar before swinging her legs around as she pushed off. Landing without a wobble she reached under the bar and grabbed a bottle of black label Bushmill's Irish Whiskey and two short glasses.

"Straight for the good stuff, I like the way you think," Ashton smirked, taking a seat at the bar.

"To simply mark the occasion, of course" she poured them each a shot before adding a splash of water. She raised her glass, "Cheers to you, Boss, and to Anne-Marie's."

They clinked glasses. "Couldn't have done it without you," he replied before taking a sip.

"Awwwwww thanks Ashtton, " she grinned at him. "Damn that's good, the whiskey makes me forgive the Irish for how dreadful Guinness is. Did you see Kevin Mackie snuck in last night? I expect a write up in the Metro on Tuesday and I know you saw Patricia Bennett," she rolled her eyes at the name.

"She makes herself hard to miss," he snorted. "I missed Mackie though. Why didn't you tell me?"

"Because we were busy and I didn't have time for you to get all giggly and nervous. He got the crab puffs and the Mac and Brie and inhaled them. You were right about the nutmeg; I thought he was going to lick the plate." She opened two bottles of beer before hopping back over the bar and taking a seat next to Ashton.

"How did this weekend compare to the opening of ‘Lune Rouge’? Was it as good as the first time?" Hima finished her whiskey before shaking a pack of Camel Crush cigarettes out of her bag.

"If you get ashes on the bar Paloma will flip her shit," Ashton warned.

"I'm not afraid of her," Hima snipped, but she made sure to be careful. No sense in antagonizing their temperamental main bartender.

"This opening was definitely smoother than the first one. We didn't know what the hell we were doing. The first night we ran out of duck fat and gorgonzola before the dinner rush was over. My sous chef's sister had to run to Whole Foods for emergency supplies. We got lucky the press ignored us for a couple weeks until we got a little buzz going. This time I knew what to expect but there was also more pressure," he paused, taking a pull on the bottle of beer. "This time I expected to succeed right out of the gate."

"You succeeded there," Hima stubbed her cigarette out in her empty glass. "I really need to quit."

"You could get a puff bar and start vaping," he teased.

"I'm not a fucking junior varsity cheerleader. I can take my cancer like a big girl." She checked her phone. "Ugh it's almost nine, and it's gonna take me at least thirty minutes to get home. You're closing tomorrow with me right?"

"Yeah, I'll be in around 11 all this week. Rafi is handling brunch with Gloria but I want to be here," Ashton double-checked his phone. "Tuesday I have that interview with Men's Life and they just emailed me."

Hima saw his nose scrunch up as he read. "What's wrong?"

"I thought they were sending Taj, but instead of rescheduling the interview, they're sending Calum Hood," Ashton sneered.

"Chill dude, it's not that bad," Hima was confused by the venom in his voice. "Yeah he's a bit of a goof, but he's hot and not a pretentious dickhead. They could've sent Felipe."

"True, true," he grumbled as he saw a black Honda pull up outside. "Kabir is here."

"Shit, ok see you tomorrow, Boss," she grabbed her stuff, gave him a quick kiss on the cheek, and ran out the door, locking it behind her.

Ashton walked through once again. He made sure the lights were off in the employee lounge. Since many of his staff members used public transport or worked two jobs, Rafi had convinced Ashton to provide his staff with a decent place to take a break and get ready before or after work. He built a small shower stall, lockers, and provided clean towels, and as his new kitchen manager, Rafi took responsibility for maintaining the space. Ashton took a last look at the bar, double-checking for any stray ashes Hima might have missed before setting the alarm, locking up, and heading home.

Calum opened the email from his editor and swore loud enough to wake the scruffy brown terrier mix snoozing at his feet.

Hey Cal,

Sorry it's such short notice but Taj's mom had an emergency and I need you to cover for him. He's interviewing Ashton Irwin, remember him? He had the Lune Rouge a few years ago. Well, he's got a new place, diverse staff and we're doing a feature. Maybe even the cover if he's really pretty. Tuesday at 2 pm I'll send you the address and details after I talk to Taj. Oh, and my friend Nick is coming into town and I told him you'd show him around. It's been a while since you had a date but you'll like him. He's kinda short, but he's got big muscles, huge dick, perfect credit. You could do a lot worse.

Call me tomorrow

Sham

This isn't good, this isn't good. Calum's mind was racing. He rubbed his temples trying to think. Taj was notoriously reliable and responsible, so if he was taking off on short notice, it must be serious. It was just his bad luck it was Ashton Irwin.

He usually covered travel and sports for Men's Life while Taj handled food and fashion. Calum didn't mind taking back food and dining for the time being. He'd started in that industry, working as a line cook while he went to school for journalism. He'd quit both when a flirty, older professor recommended him for an internship at California Culture and he managed to land a real job. Professor Davis had been highly disappointed to lose him as a student and catch him making out with her son who went to the same college. He'd found a tiny shitty apartment, spent his life on the road for work, and sent every penny he didn't need to live on to his family. He didn't even date for the longest time until he met a handsome blonde with sharp features and a sharper tongue.

He couldn't remember if it was four years ago or five, but he clearly recalled his review of Lune Rouge had not been nice. Calum was in a toxic relationship with the restaurant's sous chef at the time. He'd let his personal life spill over into his work for the first and only time. It wasn't something Calum was proud of and while he felt he owed Ashton an apology, the right time and place hadn't presented itself yet. He'd run into Ashton twice since then. The first time he was with his husband, and Calum wasn't about to humble himself in front of Luke. The second encounter came not long after their marriage broke up. Calum was dating a photographer at the time, when Ashton came to the photographer’s art show. They were briefly introduced but Ashton's chilly demeanor discouraged any further conversation, so Calum avoided him the rest of the evening. He remembered being unable to stop staring at the handsome chef with the sad eyes. He'd always hoped they'd bump into each other under better circumstances. I guess an interview will have to do.

********

Ashton sat out on his condo balcony overlooking Echo Park, taking in the night air and enjoying a second bottle of IPA. Hima was right, the opening had been a smash. Anne-Marie's had the best staff he'd ever had the pleasure of working with, and aside from a small mix up between gruyere and Havarti cheese, the opening had been smooth. The alcohol hummed in his veins as he allowed his mind to wander back five years.

Lune Rouge's opening had been a chaotic mess of brilliance, balls, and blind luck. He was a year out of culinary school, newly married, and ecstatically in love with his husband. Luke was a trust fund baby; his dad ran a major studio. He put up the funding for their restaurant which procured a prime spot in trendy West Hollywood. Ashton had the idea of taking traditional French cuisine and turning it into "pub grub." Luke created a kitschy tacky cool interior with the ambiance of fairy light curtains, vintage 90's movie posters, an eye-popping pink and aqua come scheme. Featuring a bartender who doubled as a DJ, the restaurant became an immediate hot spot.

The culinary press treated them like rock stars and it went to their head. Ashton was portrayed as the mysterious boy genius, boisterous and foul-mouthed, he ran the back of the house, oversaw the business and created the menu. Luke, who's blonde-haired blue-eyed good looks were regularly described as "angelic", was the frontman, often schmoozing in the dining room, taking song requests, or slinging drinks behind the bar. They worked so well together until they didn't.

Ashton shook his head, not allowing himself to linger on negative thoughts, not when he'd fought to regain balance. He'd spent the last year freeing himself from the wreckage of his partnership with Luke. Still, tonight after the opening, alone and overlooking the city lights, his mind kept going back to the exhilaration of that first opening night. After they stayed late with the crew for a drink to celebrate, Luke's hand wandered up Ashton's thigh causing him to almost choke on his tequila. Soon Luke started whining about all the paperwork he had to do before they could go home. The crew quickly bagged it out of there, not wanting to get roped into more work.

Ashton swallowed at the memory before glancing around at the other balconies. It was late enough most of his neighbors should be asleep. Already hard, he reached down and squeezed his bulge through the thin fabric of his pajama pants.

After letting everyone else out of Lune Rouge that first night he'd been puzzled to find Luke no longer at the bar. He heard noises coming from the office. When he opened the door, he found his husband, shirtless, and waiting for him.

Ashton slid his hand into his pants swiping his thumb across the leaking tip. He heard a sliding glass door open and froze in place until he realized it was his neighbor below him chatting on the phone. He stroked himself and let his mind wander back to Luke. It had been too long since Ashton got laid, and Luke was still the best sex he'd ever had. He shuddered and bit his lip thinking about the way Luke grinned at him as he opened the office door. Before Ashton could say a word, Luke was sinking to his knees. A bit awkward given his long legs, but it didn't take long before he was letting Ashton fuck his throat. The thought of those blue eyes looking up at him as Ash's hands tangled in those blonde curls caused a moan to slip out, and his neighbor stopped talking at the sound.

"I think somebody is having sex," he heard her whisper. He almost laughed.

His dick was twitching flat against his stomach as he ducked back inside his bedroom, kicked off his pants, and grabbed a small tube of lube. Ashton shut off the light and stepped back outside.

The breeze cooled his fevered skin as he stood there looking out at the city and stroking his dick. The idea that he could possibly be seen turned him on almost as much as his trip down memory lane. He swallowed another moan thinking about how Luke's lips felt against his, their tongues tangled until he pulled back looking at Ashton with mischief and love before giving him a wink and turning around.

Ashton's breath caught in his throat as he worked his cock thinking about it. The red and white striped pants his husband pranced around in that night had been blissful torment working him up until the moment he slid those pants down and bent over the desk.

"Come take what's yours, my love, I've been wanting you all night," he cooed, wiggling his hips.

Luke was a whiny boy when he was getting pounded, and the memory sent Ashton closer to the edge. He felt his knees tremble as he increased his speed, the city lights becoming starbursts in his vision as he edged himself closer. At the moment of release, he swore he could feel Luke pushing back against him taking him in as deep as he could go.

When Ashton opened his eyes, he found himself sweaty and streaked with his own seed. He was amazed he'd managed to stay quiet, but his neighbor was chatting away obliviously. He went back inside, cracked another beer, and took it with him into the shower, trying to focus on his day tomorrow.

It was after midnight by the time he went to bed. His body was exhausted but the adrenaline from the opening weekend hadn't quite worn off. He found himself still restless and playing on his phone. After scrolling through Instagram, he found himself looking at the page belonging to the Galway Grill-- Ashton cringed at the name-- an Irish pub and microbrewery very recently opened by Luke and his boyfriend Finn.

Ashton simmered with resentment perusing the menu; they'd recycled at least half of the Lune Rouge recipes, his creations. He'd heard they'd rushed their opening to launch the week before Anne-Marie's, and even with Daddy's deep pockets the decor looked slapped together, all flash no class. He came to a picture of the happy couple and couldn't help but notice how thin and tired Luke looked despite his huge smile. He felt a twinge of concern for his ex before pushing his phone away in disgust. Rolling out of bed, he headed to the bathroom and fished an orange prescription bottle out of the cabinet. He broke a valium in half and swallowed the smaller piece with a gulp of water straight from the faucet. He scrolled through different sounds on his phone before settling on crashing waves. He spent the next ten minutes stretching and practicing deep breathing to push out any lingering negativity and troubling thoughts. It was too late to drag up the past and there was nothing to be gained. Ashton crawled back under the duvet and sank into a deep sleep dreaming of blue eyes.

*********

Hima rolled into work a little after one, pleased to see a decent lunch crowd and multiple delivery orders going out. She ordered a chicken mojito wrap for her lunch and headed back to the office to find Ashton. She found him in his chair with his laptop open on his desk, a notebook in his lap while scrolling through his phone.

"So what's the Monday morning report, Boss?" She asked, taking a seat across from him.

Ashton was beaming as he spun the laptop around to show her. "We made 30% over our projected sales. We came in right at payroll, actually a little under if you can believe that."

"I've checked the reservation book," she responded, flashing her phone. "We're booked solid for dinner Friday and Saturday and will call is 3 pm-7 pm. We're probably going to have to do that all week."

"Whatever you need. This weekend is going to be bonkers. If you have any suggestions, I'd like to do something for the staff. That reminds me, I've got to talk to Maisie." He scribbled down a quick note.

"She's already on it," Hima laughed. "The servers who struggled are coming in for extra training with her and Dakota. I have no doubt she'll straighten them up or ship them out."

Ashton nodded as Daniel knocked on the office door to bring their lunch.

"How's it going out there? Let us know if you need anything," Ashton told him.

"We've got this, Boss, enjoy your lunch," Daniel closed the door behind him.

"He's Rafi's brother?" Hima asked before taking a big bite.

"Cousin, Gloria is his sister," Ashton replied tucking into his roasted corn and quinoa salad with queso fresco.

"Are you ready for this interview tomorrow? You look tired," Hima looked concerned.

"I am tired," he shrugged. "I just wanna get this over with. I'm thrilled we're doing so well, but that's not what the press wants to talk about."

"Don't think about it like that. Anne-Marie's will stand on her own. You've just gotta get through this week. I know it's a lot," her words were half-muffled by a napkin.

"Tomorrow is the worst of it. Mackie called and is available Tuesday at one or Thursday for dinner around four. Since he's already been here for dinner, I thought I'd let Rafi wow him this time," he told her.

"Good idea, try to keep it short because if he drinks he gets super chatty. He gave a lecture at school and came to the bar afterward; he would not shut up," she warned.

"Chatty bastard, got it," he replied and they both laughed.

Anne-Marie's was his restaurant, but he couldn't have done it without Hima. She was fresh out of culinary school working as a line cook at the Hilton when he'd discovered her a little over a year ago. Ashton only lasted four months before chafing under the corporate yoke and deciding to strike out on his own. She'd been the first person he'd hired for the restaurant, guaranteeing her first year's salary out of his own pocket. Rafi and DeSean were excellent managers for the kitchen, but Hima was a coach: she understood the business as a whole. He'd let her handle most of the press and promotion, and she'd scored two big interviews.

Gourmet Table had interviewed him last Thursday The piece wouldn't be that in-depth, but they'd spent three hours photographing food. He expected the Men's Life article to focus more on him and his personal life. Calum Hood was known for his sharp pen and take-no-prisoners style. He'd given Lune Rouge two stars and a biting review during a brief stint at California Culture before he'd become known. It was five years ago, but Ashton still had the clipping somewhere. Calum had branded Lune's food as tasty and imaginative but thought the presentation was lacking in creativity. He'd ripped into the decor, calling it "somewhere between art house and frat house," and labeled Luke and Ashton "spoiled pretty boys pretending to be chefs." Luke had brushed it off with a laugh, but it still bothered Ashton.

Unlike the Hemmings’, Ashton’s family didn't have money to throw around. He'd started at sixteen, washing dishes and peeling vegetables for Chef François at Bordeaux on Hollywood. He'd taken culinary classes after high school while working full time. Sadly, Chef François had a heart attack and retired around the time he met Luke.

"You're not listening again," Hima complained, licking her fingers. "Rafi killed it with this wrap. The chicken is amazing, but the cucumber-mint salad and the tamarind chili mayo are next fucking level."

"You're right, I'm not. Sorry about that," he pushed his plate aside.

"Ok, what's got you so rattled? You've handled the press like a champ up until now. Is it Mackie or Hood? Who needs to catch these hands?" Hima stood and assumed a fighter's stance, bouncing on her toes.

"Easy there killer, I can defend my own honor. Mackie is an irritating little mosquito. He just wants gossip, but he's got enough readers so we all have to kiss his ass. Hood gave me one of the few bad reviews we got at Lune, and it stuck. He called us frat boys and said we were trying too hard," Ashton rubbed the back of his neck, embarrassed by saying it out loud.

Hima raised her eyebrows and smirked, "I love it when you're petty. You're always so perfect and Zen, it's annoying."

"My therapist would disagree. Oh shit, that reminds me," he straightened up in his chair and grabbed his phone. "I've got an appointment at 2:30. I'll be back before 4," he dropped his eyes to the floor.

"Ashton," her voice was soft but commanding, and he looked up. "I don't know what's going on, and if you don't want to tell me that's fine. I want you to take care of yourself, whatever that takes. Ok?" He nodded and she smiled, "You can tell Dr. Claire that I've confirmed her for 8 pm Saturday, and you're going to personally cook her dinner. We've got the 50th anniversary that night so maybe you could flex and make your Pavlova's? I'll get the berries myself."

"It's a deal; we can comp them champagne, too. I'd better get going before I get yelled at. She's a stickler for punctuality, I think it's a British thing."

"I'll hold things down until you get back," Hima gathered up the dishes and headed out with Ashton right behind her.

*********

Ashton drew a deep breath and exhaled through his nose as the reporter settled in the chair across from him. Kevin Mackie's column in L.A. Metro was the definitive opinion for restaurants on the West Coast. His readers loved the snarky tone, celeb sightings, and bitchy gossip that peppered his column. His reviews could make or break new restaurants.

"Let me start off by saying I love the decor of this place. It's rustic, but not in that played out, hipster-in-the-woods nonsense," he leaned in and lowered his voice towards the end of the comment with a coy smirk.

"You'll find no Mason jars here," Ashton replied, taking the bait. Kevin liked people who liked him, and his most recent column was a snarky takedown of "Pinterest style interiors." Ashton found the article tedious and uninspired, but there was no need to be antagonistic right out of the gate.

Ashton watched as the reporter ordered his lunch from their server Zia. He guessed Kevin to be in his forties, and he thought he could see fresh hair plugs, bleached blonde, and a bit of Botox. Rumor had it, he'd recently split with his long-time girlfriend over a fling with a much younger waiter. Ashton tried not to pay attention to industry gossip. However, his personal problems made their way into the column more than once, and he couldn't help but feel the tiniest bit of satisfaction at the other man's problems.

After they'd both ordered, Kevin sat back and took a sip of his Pellegrino water and smacked his lips. "I was here the other night and I have to admit I was prepared to be underwhelmed. A menu based on sandwiches and comfort food sounded like an upscale Applebee's, but I really liked it despite myself. I was surprised to see your main girl was on the mature side, but she's efficient as hell so I get the trade-off."

Ashton's body tensed at the insult to Maisie, and he took a deep breath. Exhaling through his nose he forced a smile that didn't reach his eyes. Kevin was prattling on with some bit of gossip as Ashton sipped on his iced coffee.

"So let's start with something simple and ease our way into the rough stuff," Kevin set his voice recorder on the table between them. "Tell me how you formulated your top-secret house coffee blend."

Ashton broke into a wide grin as he described taking two months to travel and sample different beans, learn more about the roasting and blending process. Kevin sipped his coffee and nodded as if deep in thought, but his eyes kept wandering to Ashton's biceps. He'd been baking this morning so he smelled of cinnamon, his black t-shirt damp and clingy from sweating under his chef coat.

"So we sell the house blend all year, but we have single-source coffee that's seasonal, all of it fair trade," Ashton finished proudly.

"Coffee has always been your thing if I remember correctly," Kevin said.

"True, true, and once I started roasting my own beans it became a true obsession."

Kevin followed it up with a couple more softball questions about menu details and sandwiches. Ashton expounded on his love of food. "Cooking for someone is a simple way to show care, to be enjoyed almost as much as dining should be. Food is caring and comfort; it sustains us. It brings people together in a shared experience."

"Ooh that's a nice pull quote," Mackie chuckled. "I love when y'all have media training. It makes the bullshit flow much smoother.

Ashton seethed but said nothing. He'd watched this man's pettiness wreck a good opening, and Ashton couldn't do that to his crew. Zia brought their lunch. Ashton noticed Kevin had also ordered the chicken mojito wrap.

"This looks delicious. I think it's a nice touch that you've got so much, let's say diversity, in your restaurant. That you're actually letting them make their own food makes your menu more interesting. Not all restaurants get it. Please tell me you've seen how horribly Finn ripped you off for that tacky Irish pub," Kevin glanced up at him a tiny smirk playing on

"I haven't paid any attention to that," Ashton wanted to end the interview right there.

"Oh come on, you've had to see how much he's trying to recreate the magic you and Luke once had. The menu is tired, I don't give a fuck if he is Irish. Finn has no imagination yet fancies himself an impresario. Luke's still got it though. He even asked when I was coming here. I didn't tell him of course, I'm a professional after all."

"Of course," Ashton nodded checking out of the conversation. The reporter talked as he ate which given the wrap he was eating proved especially messy and little flecks of food kept flying his way. Ashton watched the door, nodding at customers, silently willing someone to come and save him. Kevin was still talking about himself when Hima and Zia came out of the kitchen. Ashton tried to catch their eye when he felt a hand on his arm.

"I wanna ask you about that one," Kevin leaned in so he could almost whisper.

"Who? Hima? What about her?" Ashton was pretty sure he wasn't going to like the answer.

"What's the deal? I've only ever seen you with Luke. Did your palette change that much? India must've been a real spiritual awakening for you huh?" Kevin winked at him, thinking he was clever.

Ashton controlled his breathing trying to keep his temper in check. He looked over at the reporter who kept talking oblivious to the situation.

"Who doesn't like trying something exotic. She seems like a smart cookie. She's darker than most Indian girls you see, like a rich brown butter sauce. I bet she tastes like tumeric though."

"Get out of my restaurant" Ashton hissed, his hands gripping the table to restrain himself from physical violence. "You are not going to insult my staff, my friends, in their restaurant."

Kevin started to speak but Ashton cut him off.

"Not another fucking word" he kept his voice at a low growl so as not to cause a scene. He noticed a couple of the closest tables were already watching them. "You've said enough and I'm barely holding back as it is. Get out of my restaurant, don't ever come back, don't ever speak to me again, and if you trash me in this review I promise you I will find you and fuck you up personally." Ashton stood up and Kevin flinched, the sight would have made him laugh if he hadn't been so furious. He stepped back and the reporter scrambled out of his seat leaving his lunch unfinished. Ashton walked back into the kitchen, Hima fast on his heels. He kicked the door open to the break room and headed for the speed bag hanging in the corner. He'd learned the hard way punching walls usually resulted in the wall winning the fight so he'd given himself something easier on his hands.

Hima watched him from the door, his back and biceps rippling as he went two minutes at full speed. When he finally turned around she could see the anger had cooled somewhat. She hated that her boss looked incredibly sexy when he was angry.

"Are you gonna tell me what happened?" She asked when he turned back around.

"Nope, it'll just piss me off all over again, and I gotta get ready for another fucking interview. With a guy who already doesn't like me," Ashton put this coat back on and headed into the line to check on Rafi.

At least the second interview can't be worse, she thought, wishing she believed it.

*********

Calum eased his beat up Range Rover into the parking lot of Anne-Marie's amongst the Mercedes, Audi's, and Teslas. He cursed the traffic when he checked the time. He was late, and they were busy. Not a good look he thought, grabbing his bag.

He smiled at the ladies waiting for a table before introducing himself to the impossibly serene hostess. He was quickly led to a table in an alcove not far from the kitchen. As he pulled out his voice recorder and notebook, he noticed a young woman heading his way. Her black hair was knotted tightly in a bun on top of her head, and her chef's coat had a large streak of what might be hollandaise sauce. He remembered his editor, Jacqueline, telling him Anne-Marie's had a female sous chef. He checked the notes she'd given him quickly as she was stopped by a server. Hima, Culinary Institute of America graduate, 23, Indian maybe?

"Hello I'm Hima Singh, you must be Calum Hood," she greeted him. From up close, he noticed that her eyes were a rich golden brown and that her smile didn't reach her eyes. He chalked it up to her youth; his editor said she was 23 but she looked like a teenager. He mentally stopped himself there. He'd become jaded by one too many husband/wife teams in recent years trying to rebrand a post-divorce startup as a "new adventure." While the divorce was true, Calum knew Ashton's history.

"Yup that's me, it's a pleasure to meet you, Miss Hima," he shook her hand, relieved to see her relax a bit.

"Chef Irwin will be out shortly. He's helping with a problem in the back" she glanced towards the kitchen, and Calum had a feeling she was lying.

"Can I get you something while you wait? Do you like coffee? We have a house blend cold brew Chef Irwin selected himself that we roast and grind on-site," she asked motioning towards the sign listing the daily selection of teas and coffee.

"Thanks, but maybe not coffee. I'm nervous enough without more caffeine," he admitted, "but the lavender and blackberry infused lemonade sounds amazing." He smiled and her face softened.

"Absolutely," she signaled to Zia who brought Calum his drink and a basket of warm, fluffy yeast rolls with Anne Marie's cinnamon honey butter. The smell reminded Calum he'd skipped breakfast as his stomach began to rumble.

"So you're Chef Irwin's sous chef? I heard a rumor you were a partner as well," he asked, almost drooling as he tore into the soft bread, watching the steam escape.

"Yes sir," Hima's smile finally reached her eyes, and she sat down across from him. "When he got his core team together for Anne Marie's, there's three of us total. Desean and Rafi are his kitchen managers, and he gave us the opportunity to buy in as minority investors, no pun intended."

"These rolls are incredible. Please take one before I finish this whole basket and ruin my lunch. How long have the three of you worked for Ashton, excuse me, Chef Irwin?" He asked.

"Desean and Rafi were part of his Lune Rouge crew. They go way back, but he met me fresh out of school and took me under his wing," she told him.

"Did you go to CIA?" Calum was jotting down notes, getting a feel for the story.

"I wish, it's so pretty up there. My twin brother attended Brown, and I went to Johnson and Wales so we could stay close."

"You're a twin? Is he a chef as well?" Calum asked.

"Are you kidding? He's a lawyer, of course, my parents had to have one in the family," Hima laughed.

Zia appeared beside their table. "I'm sorry to interrupt, but Rafi is looking for you, Hima."

A worried frown replaced her warm smile and Calum felt his nerves bubbling back up. He glanced around and caught sight of Ashton, flushed and sweaty from the heat of the kitchen, poking his head around the corner. Their eyes met, and Calum felt like he'd been hit by lightning.

Hima saw his reaction and whipped around to see what Calum was looking at. Spotting her boss she quickly excused herself and hurried to the back.

Zia cleared her throat and Calum realized she was still standing next to his table.

"Would you like to try Rafi's plantain skewers while you wait? It's my favorite thing here, and it'll leave room for whatever these geniuses cook up," she asked with a smile and a wink.

He nodded and she headed to the server station to put the order in. Calum looked around and started taking notes. The most striking thing about the decor was how they'd used diffused skylights for soft lighting to accent the Nakashima-style crafted wooden furniture. Thanks to his Mom’s love of Antiques Roadshow when he was younger Calum discovered his preference for natural grain wood and bespoke pieces. He liked the use of pastel neon signs to complement the muted green and blue tones of the mosaic tile floors and he thought the framed pictures of what he assumed were family photos of the staff provided a really nice personal touch. The largest photo was in the bar of Ashton and his mother, the restaurant's namesake, Anne Marie.

Zia set a plate down in front of him. "The boss will be out in a minute., Let me get you some more tea," she told him.

The skewers consisted of chunks of pineapple, plantain, red onion, and sweet potato grilled and dusted with chili powder and brown sugar served with a yogurt sauce for dipping.

Calum was almost finished with the first one when Ashton came out of the back, making his way towards him. The chef stopped to talk to several customers, the hostess, and Zia before he made it to Calum's table. Cal licked his fingers, wiping his hands clean with a Sani-wipe before standing up and offering a handshake.

Ashton took his hand and Calum wasn't expecting it to feel so soft. Caught off guard Calum stammered out an introduction as he sat, but he noticed Ashton just nodded, barely listening.

"If today isn't a good day we can reschedule," Calum sipped his tea, his throat suddenly dry.

"I'm here aren't I?" Ashton snapped. He folded his arms across his chest, his hazel eyes narrowing at Calum. "I still remember your first review you know."

Calum's pulse was racing. He hated confrontation, and he hadn't expected Ashton to kick off right away. He knew he'd better suck it up and apologize if this wasn't going to go completely off the rails.

"Listen, I wanted to apologize. I shouldn't have been such a dickhead." As he spoke Ashton scoffed at him and Calum felt his cheeks get warm. "I was young and stupid. I let something personal affect that review. I'm sorry."

"Personal? With Luke? What do you mean by that?" Ashton went from annoyed to hostile.

Calum realized he'd said something wrong but wasn't sure what exactly. He was floundering trying to think of what to say next.

"Nothing with Luke, no no no. I was involved with Finn and we weren't getting along. It's so stupid I know, but I think you're a great chef. The new place looks incredible, and Hima is a delight."

The anger drained from Ashton's face, leaving him looking empty and sad. His head dropped to his chest, and Calum held his breath waiting for him to speak.

"I'm really sorry, it's not you, but I can't do this right now. Maybe we can reschedule or something. My apologies, but I have to get back to work," Ashton mumbled, standing up.

Calum spotted Hima watching them from the podium, chewing on her lip, her black eyes wide with concern as Ashton hurried back to the kitchen. Calum started to get up but she was too quick for him.

"Well, aren't you lucky. I'm going on my lunch and I hate to eat alone," she slid back into the seat across from him. "Please forgive my boss. He's had a rough day, but I'm better company anyway." She waved to Zia who headed their way. "You gotta try the toasted gnocchi with gorgonzola cream sauce if you like cheese, but if you want something lighter the apple carrot kale wrap is excellent too," she smiled at him, and to her relief he smiled back, both of them realizing the situation might be salvageable after all.

(A/N: y’all my tag list, much like my life, is a hot mess. I know some of what I write isn’t for everyone. If you want tagged in part 2 of this fic or my upcoming smuts, pink kink series, or dad!calum series please let me know. I apologize for my previous mistake)

@sublimehood @tea4sykes @be-ready-when-i-say-go @scribblesos @kiiiimberlyriiiicker1995 @wildmichaelflower @castaway-cashton @damselindistressanu @notinthesameguey @cashtonasfuck @irwinkitten @mermaidcashton @malumsmermaid

#calum hood #ashton irwin #5sos writing collab #cashton smut #cashton slash #Calum Hood smut #ashton irwin smut #cashton #calum 5sos #ashton fanfic #ashton 5sos #5sos

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lacrow · 4 years

Text

SXF Collaboration Story

@nonokoko13 , @sxfobsessed , @nagy-bari

First off I’d like to apologize. Under my insane direction, this little ficlet has turned into a 12k behemoth. Therefore I will be positing it in two parts (and also linking to ao3 since I threw it in with my one-shot collection). I’ll add the link to Part II when it’s edit/posted. Thank you to everyone who helped come up with this idea, it was a lot of fun to write!

Title: Cabernet Makes Her Clothes Fall Off

Rating: T

Part I: ao3

Part II: tumblr, ao3

Parties Involved: Loid Forger, Yor-Briar Forger, Anya Forger, Bond, Franky, Yuri Briar, Becky Blackbell, Camilla, Dominic, Millie, Sharon Mission Objective(s): host a dinner party for friends and acquaintances, [INCOMPLETE] Reporting Status: [IN-PROGRESS] ADDENDUM 1 [NIGHTFALL]: After careful review of last night's mission report, it has come to my attention that Twilight's conduct has been highly inappropriate for that of a WISE agent. I recommend personnel changes be made for the ensured success of Operation Strix. ADDENDUM 2 [TWILIGHT]: Sorry, I forgot to save you leftovers. ADDENDUM 3 [NIGHTFALL]: That's not what I meant, and you know it. ADDENDUM 4 [HANDLER]: He's married. Also, thank you for the leftovers, they were delicious.

Part I

A cacophony of sounds emanated from the Forger house as Yor frantically tried to get things ready for what was sure to be a total disaster.

In just a few hours, guests would be arriving for an impromptu dinner party that she had no right organizing in the first place. It wasn't her call to make, not without consulting her husband first, but...she went and opened her big mouth anyway. Now she was suffering the consequences for it, and not just her, either. Yor looked up through the window above the kitchen sink as she desperately went about getting things ready for the evening's festivities. Loid and Anya stood by the door as they started to put their coats on. The latter had her school backpack on, though in lieu of books and pencils it was instead filled with a change of clothes and some toys.

"I'll be back soon to help set up," Loid called out to her. He went to gather his hat and gloves. "I already called the Blackbells' nanny and told them I can't stay long."

"Ok," Yor replied meekly. Half of her wanted to tell him not to rush. The other half desperately wished to ask the opposite of him. "Please be careful you two."

"Bye mama!" Anya looked over at Yor as Bond came up to sniff her goodbye. "Have fun with your party tonight!"

The Forger matriarch couldn't help but to frown. "You do the same at your friend Becky's...do everything her parents tell you, okay?"

"I will!" Anya replied back. She smiled brightly in anticipation at her upcoming sleepover, though it waned the longer she stared up at her mama.

Yor had no way of knowing her daughter was reading her mind. If she did, it wouldn't have made her feel as guilty when Anya suddenly ran around the corner and wrapped her arms around her leg in a tight embrace. That wasn't to say she didn't appreciate the gesture; if anything she desperately needed it at the moment. It's just that she assumed Anya's hug was less out of fondness and more out of pity, though in the end she accepted it all the same. Yor knelt down and pulled Anya in close as Loid waited by the door with a well-hidden smirk on his face.

"Love you," Anya smiled encouragingly, eyes closed in content.

"I love you, too," Yor teared up a little. She squeezed her daughter tight. "I'll see you tomorrow."

They held each other for a moment. Though she didn't want it to end, Yor ended up being the first to let go. She smiled at Anya before the little girl waved and skipped off towards the door. Already turning the knob to leave, Loid let their daughter out first before turning to his wife. He said nothing, but gave a small, comforting smile to her before exiting. She nodded as a silent thanks before watching him leave, and it soon became just her and Bond. The Forger hound sat there with his tail wagging, and he looked up at Yor with an expectant look on his face.

Yor glanced down at the dog and sighed. "Well, Bond...time to get back to work."

Bond said nothing back, as was to be expected.

/*\

"You're joking, right? Not even a housewarming party?"

A familiar face; the deadpan look of an unimpressed Camilla, though to Yor she seemed just as pleasant as ever. If only the poor girl knew what every other woman working at city hall knew, which was that Camilla loathed her with a(n admittedly waning) passion. No one had the heart to say anything though, which was mostly why they stayed silent as Yor revealed to them that she and Loid had never had a get-together at their house before. Individual people, of course, but never more than one person at a time.

"Er, well...no?" Yor's lips squiggled. Was that a bad thing?

"Really, Yor, you're hopeless!" Camilla shook her head, exasperated. "Don't you and your husband have any friends?"

Yor blinked. "Well, of course we do. You, for starters."

Camilla's jaw dropped as the other women snickered behind her. Yor continued. "And I suppose that includes Dominic, as well? Also Loid's friend Franky, and his co-worker Fiona, and-"

"-Alright, alright, I get it!" the blonde woman grumbled, waving Yor off. "Fine, you have friends. So why then haven't you hosted before?"

Yor frowned a little. She knew why; it was because Loid was always tired and she was terrible in the kitchen. If there was going to be party then he would have to do the cooking, and Yor didn't have the heart to ask that of him. Not when he had so much on his plate already (pun unintended). Still, Yor could see where Camilla was coming from. She had been nice enough to invite her over to a get-together at her house, while Loid and herself had never shown the same courtesy back. It was rude, and not to mention suspicious.

Couples invited people over for dinner, right? So then, what would people think if she and Loid never did?

The more Yor thought about it, the more she realized her attempts at playing house were falling short again. Yor looked up at Camilla, Millie, and Sharon, and all of a sudden she felt self-conscious. They seemed to be waiting for an answer that Yor couldn't give them, or at the very least one she refused to share; that her marriage was a sham and she didn't know the first thing about entertaining guests. It was the truth, but they weren't meant to know that. All Yor could do was think about what her husband would do in her situation. What would Loid's response be?

He'd make it happen. One way or another, he'd pull through like he always did.

"W-well," Yor stammered. She flinched a little. "Why don't you all come over this Saturday?"

The other women paused, most of all Camilla. The three of them threw glances at one another, suddenly finding the spotlight reversed on them. They seemed to have a wordless conversation amongst themselves, while at the same time Yor kicked herself for opening the door to her home like that without talking to Loid first. He liked his privacy just as much as she did, and the weekend was one of the few times he got to relax (and even then it wasn't guaranteed). Yor's head started to slowly spiral; what if he got called into work, or she suddenly had to take a contract-killing job on short notice? This was a bad idea. She had to rescind her offer, and fast-!

"-Do you want us to bring anything...?" Camilla asked reluctantly. It almost looked like it pained her to say it out loud, mostly because it did.

Yor froze. The worst case scenario had come to pass, even more so because she had brought it upon herself. She stood there as three pairs of eyes stared at her once more, only there was no going back this time. The window of opportunity for backing out had already passed, and the only thing Yor could do was try her best to swallow the quickly growing lump in her throat.

"...N-no," Yor shook her head. She gulped. "...My husband and I will cook something for dinner..."

/*\

"I'm a horrible wife," Yor lamented as she straightened out her white polka dot dress. "I never should have agreed to this. I'm sorry. I'm so sorry!"

"It's fine, Yor," Loid eased. He closed the oven door and threw his mitt onto the stove top. He turned towards her. "There's no reason to beat yourself up."

Yor frowned. Loid sighed. They both looked to the clock on the wall next to them and immediately came to the same conclusion; their guests were fashionably late. A quarter past six and no one had shown up yet, but that ended up being more of blessing than anything else. Loid had gotten held up at the Blackbells' a little longer than expected, and Yor had only just barely finished cleaning by the time he made it home. She at least had it to where all he needed to do was fix up the casserole for later; the rest of their home, from the living room to the bathroom, was immaculately spotless.

"So remind me again who all is coming?" Loid asked uncomfortably as he looked back to the kitchen. He was fairly certain there was enough food, but...

"Well..." Yor thought for a moment. "The girls, so, Camilla, Millie, and Sharon. Dominic as well, and he of course told my brother so Yuri's coming, too. And also Fiona-?"

Loid shook his head. "She won't be coming. Something came up at work and she won't be able to make it."

Some hostage situation at the embassy, last he heard. Nothing Nightfall couldn't handle, though it'd certainly take her the whole night to sort through it all. Tragedy aside, it at least worked in favor of Loid's dinner planning. Along with some easy-to-make finger foods, there would be more than enough to keep everyone satisfied. On top of that, they'd rearranged the furniture in the living room to open it up a bit more. They had also moved the dining room table up against the wall, and Loid even got a hold of a couple breakfast nook chairs (courtesy of WISE) for the counter at the kitchen window.

This little shindig of theirs was turning into quite the gathering. Loid smiled a bit at the thought, even as Yor continued to look up at him in dismay. He had half a mind to reassure her some more, but knew it would only fall on deaf ears. Instead, he took it upon himself to leave her for a moment to go digging in the pantry. He fished out one of the cheap bottles of wine they'd gotten for the evening's festivities. Yor immediately held her hand up to protest, though karma had come full circle to spite her. She didn't listen to Loid. Therefore, neither would he listen to her.

A moment later and he arrived with a glass in his hand, filled halfway with blood-red courage. "Everything will be fine."

"I know..." Yor replied weakly as she took the wine glass from her husband. "...I just feel guilty for dragging you along with all this."

"Hey, we're a team," Loid reassured her. He smiled again, and Yor's face became flushed. "You just focus on enjoying yourself, and I promise it'll all work out."

For what felt like the first time that night, Yor gave a smile back. A small one, of course, since she still had a million things running through her head, but at the very least she gave Loid the response he was looking for. Yor closed her eyes and took a sip and, as if her husband had been right all along, there came a knock at the door immediately after. Yor paused; she quickly tried to swallow her wine in order to answer it properly, though Loid was already opening the door by the time she had composed herself.

They both figured it must have been Yuri (since he was usually quite punctual), but Loid's face fell flat as someone else came into view. "I hope I'm not late!"

Shaggy hair. Scraggly chin. A stature half that of Loid's; the man glowered. "Franky, what the hell are you doing here?"

"I'm here for the party, of course!" Franky gave a stupid grin as he held up another bottle of wine. "I didn't get the invitation, but I figured you must've forgot!"

"...Right, of course," Loid's eyes narrowed. He continued to glare while Franky grinned. "Must have slipped my mind..."

Stiffly, Loid stepped back to allow his friend entry. He looked to Yor as Franky shuffled in, and he shuddered to think what an unaccounted for guest would mean for her party. Surprisingly, his wife seemed pleased at Franky's presence. She set her glass down and gave him a proper greeting, to which Franky did the same. He placed the bottle of wine on the counter after shedding his coat, and immediately made a b-line for the bathroom. The door shut behind him as he made his pit stop, leaving both Forgers alone again for a moment.

"I'm glad Franky could make it!" Yor smiled.

"Likewise," Loid added flatly. He shook his head in dismay.

"Next time I'll be sure to remind you to invite him," she added while grabbing his arm.

Loid relented with a smile to his wife, though the inside of his head was working overtime trying to sort through possible scenarios for the evening. It's not entirely that he didn't want Franky there (part of him truly didn't), but the less he mixed up Twilight's affairs with Loid Forger's the better. Not even taking into account just what a bad idea inviting an SSS agent into his home was, having Franky and Fiona there would have thrown a whole headache of problems into the equation. Nightfall could have handled herself well enough, but Franky...

He prayed to whatever god above that the little fool could behave himself. Just for one night.

All Loid could do was have a little faith, though that wasn't really his M.O. He'd try not to worry in the meantime, but would continue to keep an eye on Franky for the rest of the night. He eased up on the guy once he emerged out the bathroom and approached him and Yor for pleasant conversation; his initial terseness passed, and the three of them actually got on well enough for a time. For how long, specifically, Loid couldn't say. Before any of them knew it, there came another knock at the door. This time Yor was the one to answer.

"I'm so sorry I'm late, Yor!" an impassioned voice cut through their home, and Loid knew right away it was Yuri. "I got held up at work and missed my train!"

"That's okay, Yuri, so is everyone else!" Yor smiled, and Loid did, too. She was letting the guest situation roll of her shoulders, which was good.

There was a shuffle at the door as both Briars came inside. Yor took her brother's hat and coat, and he smiled pleasantly at her in silent thanks. The moment his head swiveled in Loid's direction, however, that pleasantness quickly took a nosedive. Yor was none the wiser, of course, though Loid was more than aware of his brother-in-law's killer vibe. He smiled.

"It's good to see you again, Yuri!" Loid chimed politely. His smile grew as Yuri's turned even more.

"Loi-Loi," Yuri bowed his head stiffly in acknowledgement. Beside him, Franky cracked up at his friend's stupid nickname.

Yuri's eyes fixed on Loid and Yor's other guest. Likewise, Franky looked to Yuri. This was the first time either had met each other properly, though Franky was more than familiar with Yor's brother and his position as an SSS agent. Admittedly, it was a bit unnerving for Franky to be in his presence, especially with that...weird look he stared at him with. Loid had warned him about it multiple times; the dude was nuts about his sister. Him being friends with Loid probably didn't lend him any favors, so his opinion of him probably was at rock bottom at the moment.

Nowhere to go but up from there, right? "Hiya! The name's Franky, nice to meet you!"

Franky held his hand out to shake. Yuri glanced at it before looking back up. He offered no hand of his own.

"Yuri! Don't be rude!" Yor chastised her brother from behind. He cringed and glanced at her over his shoulder. "Franky's my friend, too!"

The Briar boy turned back around to find two smug smiles waiting for him; an obvious one from Franky, and a thinly-veiled one from Loid. Whether he noticed them or not, Yuri made no comment. He simply shook Franky's hand (reluctantly) and offered a halfhearted hello in reply. The two promptly separated and went their separate ways. Franky followed Loid into the kitchen while Yor stayed behind to talk more with her brother, and both groups kept up conversation for a time until another knock came at the door.

Camilla and Dominic. The pair entered, both carrying offerings for the party; a tray of enticing appetizers and another bottle of wine, respectively. The couple were met with multiple greetings and they offered their own before splitting up almost immediately. Loid showed Camilla into the kitchen while Dominic stayed behind to talk with Yuri. Franky joined everyone else in the living room, seeing as how there wasn't a lot of room in that tiny kitchen for three people. Besides, Loid didn't trust him in there, which was fair.

"Thank you for the food, but you really didn't have to go through all the trouble," Loid told Camilla as he dug into the cabinet for plates.

"Well, Dominic insisted we bring something, and it's a recipe I've been meaning to try out for a while now." She stood off to the side to stay out of his way.

"It smells great, can't wait to try it," Loid smiled pleasantly. A moment later and he procured the dinnerware. Camilla offered to take them into the living room for him.

Loid handed the plates off to her. Camilla turned to walk away, but paused as Loid spun around to gather his own appetizers. She shifted uncomfortably as she scanned him up and down; a nice dress shirt, perfectly sleeked hair, muscles, and an air of confidence that most men spent their whole lives pretending to have. Loid Forger had it all, and Camilla couldn't fathom just how in the hell Yor ever bagged such a hot husband in the first place. Seriously, how? It was downright frustrating just how perfect he seemed; the man could cook, raise a daughter, deal with Yor, and still seem nonchalant about everything. If she didn't know any better, Camilla would have said his and Yor's marriage was some kind of front for the mob or something. There was just no way...

"...Babe, you alright?" Dominic's head suddenly popped into the kitchen. "You're spacing."

Camilla jumped out of her skin and nearly dropped the tin, in no small part because she was caught red-handed thinking about Yor's husband. Luckily for her, Dominic didn't come to that conclusion. He smiled and waved her over and, after she shook herself out of it, Camilla followed him obediently towards the living room. The two of them dropped the food off on the dining room table on the way, which was joined by Loid's tin soon after. He stuck around to open some of the wine bottles, and Yor had half a mind to offer him help but ultimately decided against it. He was good at popping corks, and she would have honestly just gotten in the way.

Yuri, Camilla, and Dominic stood off to the side and chatted. Franky kept Yor company until Loid appeared a minute later, and the three of them sat gathered around the coffee table while they waited for the other guests to eventually arrive. So far, so good, Yor thought to herself as she scanned her apartment. Wine glass in hand, she let out a poorly hidden sigh of relief. At that point, Loid smirked. He must have been thinking the same thing she was, at least that's what Yor assumed. He leaned over the table to pat her shoulder comfortingly, and she flinched at his touch (out of habit) before quickly relaxing. Her husband was right; just enjoy the evening, and everything would work out fine.

She nodded to herself and took a sip of wine, and a small smile tugged at her lips soon after.

/*\

Millie and Sharon arrived stag together soon after. With Franky taking up the baton for Fiona, everyone Yor had invited ended up coming. Bond was promptly kenneled in Anya's room (with plenty of food, water, and a bone) and the party was in full swing.

Loid started to drop off plates in front of people, and he couldn't help but be thankful that Handler had secretly requisitioned him the extra chairs. It was just enough for everyone to have a seat, though he distinctly remembered her shaking her head initially at his request. Not that she wouldn't do it, but more to do with the fact that he was going native, as she had so eloquently put it. A dinner party for his wife's friends? The higher-ups would rip them both a new one if they got wind that Twilight was blowing agency funds again over something stupid.

Regardless, she wrote it off as a business expense for an upcoming mission.

Handler always was a sucker for parties.

Loid just needed to save her some leftovers, which was easy enough. A couple missing appetizers and a suspiciously absent square of casserole were tucked safely away in his fridge for his boss. The spy game could get weird sometimes, and vicarious party attendance was just one of those things that agents did to keep themselves entertained during missions. Usually that involved going out of their way to secretly acquire a bottle from the bar to bring back to a safe house or finding out a way to smuggle out a whole chunk of wedding cake without being seen by the bride and groom. It was a stupid inside joke amongst spies; that being said, Loid was no stranger to it. He fully expected the same from Handler the next time she attended a party for a mission.

"Thank you, Loid!" Yor beamed up at him as he pulled up the chair next to her. All the plates had been delivered, and he held the last one in his hands as he sat down.

"Yes, thanks for cooking. It looks great," Sharon added politely across from them. At her side, Millie echoed the sentiment while trying hard not to eat without everyone else.

Loid nodded and waved off their praise. Meanwhile, Yuri grumbled from his spot against the wall. He of course wasn't about to afford his brother-in-law any good will, though Franky next to him had more than enough for the two of them. He stared down at the food in front of him with big eyes and watering mouth; it was by far the best looking thing he'd seen in a long time. He wasn't necessarily the healthiest eater at home. Mostly his pantry was filled with noodles, cereal, and the occasional box of macaroni. This was a downright feast.

There was only one thing missing, and he almost forgot it before digging in. He hadn't eaten anything all day so he'd abstained up until then, but now was definitely the time for a tall glass of wine. He swung down from his chair and shuffled into the kitchen as the rest of the party cut into their food and carried on in conversation. Nobody paid him any mind, save for one man whose head immediately shot over when he noticed a familiar bob of scruffy hair struggle to uncork another wine bottle. Loid quickly excused himself with no one the wiser.

"No drinking," he stated firmly as he came up behind Franky and lifted the bottle from his hands. The latter spun around incredulously.

"Excuse me?" Franky guffawed. He held his arms out to the side to accentuate just how insulted he was.

"Do you remember what happened the last time you drank at my house?" Loid replied flatly. His voice was hushed. Their conversation needed to be quiet.

Franky considered for a moment. He genuinely gave it some thought before slowly shaking his head. "Er...no?"

Loid pinched the bridge of his nose. "You nearly blew my cover, plus you convinced me to spend thousands of dalc on a castle rental for Anya!"

"Hey, that was your fault for listening to a drunk guy!" Franky shot back, which only caused Loid's eye to twitch in annoyance. "Also, what are you talking about?! Yor's drinking and she's way worse than I am!"

"I can handle my wife. I can't handle both of you," Loid shook his head like a father reprimanding his child.

"She's your fake wife!" Franky whispered back loudly. "I'm your best friend! You're really just going to cut me off like this?"

Loid leaned over his so-called best friend. Their height difference was on full display, and Franky gulped. "This whole party was Yor's idea! It's important to her, and I'm going to make sure it goes off without a hitch. If that means keeping you dry for an evening, then so be it!"

Twilight made a brief reappearance; those cold eyes he was known for were suddenly aimed directly at Franky, and they got his point across loud and clear. With a reluctant nod, Franky agreed to skip the booze. Loid soon eased and nodded back before leaving to return to the other guests. That just left Franky alone by himself with an open wine bottle and a half-full glass on the counter in front of him. He grimaced at the thought of pouring it back into the bottle, a social faux pas if there ever was one. Dumping it certainly wasn't an option, either. Franky was never one to waste a good drink, regardless of the situation.

The newly-sober intelligence agent put his brain to work and came up with a quick solution; if Loid thought so lowly of him at the moment, why not prove him wrong? He was trying to score points with Yor (probably, he really didn't know why Twilight cared in the first place), so maybe if he helped make sure she had a good time then that might make him back off a little. Yeah, that's it! He'd pour the rest of the wine and treat her to a glass, then...well, he'd think of the rest later! His first priority was to make sure Yor was liquored up. Can't have a good party without feeling good, of course!

It all made sense. At least, it did to Franky, anyway.

With a smug grin, he filled the remainder of the glass. The bottle glugged in his hand until there was nothing left, and he promptly disposed of it before carefully curling his fingers around the cabernet meant for Yor. He focused intently on the red liquid as he walked, staring down at it to make sure that none of it came splashing out. Franky narrowed his eyes and suffered full on tunnel vision; for all the years he and Twilight had known each other, also taking into account what a connoisseur the latter was, it was a downright shameful how little Franky knew about handling wine.

Anyone who had ever carried a glass before knew to look forward when they were walking, not down at their hand.

Nobody noticed him at first. He scooted into the open room and crept up while everyone was eating and talking. Yor had her back to the wall, and Loid's was towards him. All the better to surprise the Forgers with a kind gesture, Franky plotted. He let a sneer cut across his face as he arrived and cleared his throat, summoning his hosts' attention.

"Here you go, Yor!" Franky announced obnoxiously. All eyes turned towards him. He lifted his nose haughtily in the air. "I thought you might like a glass of wine-!"

-He suddenly stopped.

Not of his own volition, but because something had caught his foot and sent the rest of him reeling forward. Franky's eyes widened, and he looked down to find he'd tripped over one of Bond's stupid chew toys. He hadn't seen it before. It was too late to do anything about it. Already he was lurching towards Yor and Loid, and even if he caught himself from falling over there was no stopping the overflowing cup in his hands from spilling everywhere. Franky watched, captive, as cabernet rained over the one person Loid had done his damnedest to please that evening.

Yor sat helpless as her white polka dot dress suddenly splattered blood red. Warm liquid stained her and her clothes, and the rest of the party froze for a millisecond as what was happening still registered in their brains. Then, immediately after, Loid jumped up. Yuri and Dominic did so as well, while the women covered their mouths in disbelief. Yor stared down at herself in shock as her brother and husband clamored around her, though it was Dominic that ended up gathering all the available napkins to sop up whatever wine was left puddled around her.

Franky ultimately didn't fall. He caught himself at the last second, though he quickly wished he'd landed flat on his face and passed out from the trauma. At least then he could have been spared from Twilight's wrath; when Westalis' legendary agent quickly ascertained his wife was alright and promptly spun around, Franky could feel his soul being pulled out from his body. And the worst part about all that was, Loid wasn't alone. For the first, terrifying time, both he and Yuri seemed on the same wavelength. The two pierced through him with blood lust in their eyes. An SSS and WISE agent both teaming up to gut him; hell had certainly frozen over, and Franky felt the chill down to his bone.

"...Franky!" Loid menaced. He said nothing more. He didn't have to. The mere mention of his name alone was enough to make the agent quake in fear.

Yuri on the other hand was far more animated, though Dominic was at least on standby to forcibly reel him in. "How dare you spill wine all over my sister you q-tip-headed moron!"

"Hey now, it was an accident!" Dominic reasoned with a pained smile, even as Yuri tried to break free from his grip in order to pummel Franky's face into casserole.

"...H-he's right," Yor piped up reluctantly. Everyone suddenly got quiet and spun around to face her. "It's fine, you two. I'll just...have to rinse off in the shower real quick."

Loid paused. He looked at Yor to find her already standing up. She hid her face with a frown, and immediately Loid's heart sank. With a muted excuse me, she walked past Loid and the other guests on her way to the bathroom. The party watched in silence as she darted into the bathroom. No one made a peep, not until the door closed behind her; at that point, things picked back up exactly where they left off. Yuri went to rip Franky a new one. Dominic did damage control. Camilla and the girls mumbled to each other in hushed tones, and Loid was left standing there in the middle of it all. He stared at the bathroom, disheartened. He wanted to help, but knew there was nothing he could do at the moment besides keep the party going. He had to. For Yor's sake.

With a heavy sigh, he flipped on the switch once more. Back to being Loid Forger, the perfect family man.

With a fake smile and calm demeanor, he went about trying to put everyone at ease. Yuri was by the far the most difficult of the bunch to appease, but after much pandering (and an honest promise to kick Franky's ass later) Yor's brother finally calmed somewhat. He sat far off at the other end of the living room away from everyone else, and once he settled down the rest quickly followed. Conversation slowly picked back up, even more so once the sound of a shower being drawn came from the end of the hall. Yor was getting cleaned up. She'd be back at the party in no time, and the thought was enough to finally get things back in full swing. Franky was still the odd-man out, but Loid didn't care about that. The twerp.

New house rule, Twilight thought to himself as he went back into the kitchen to pour the ladies some more wine. No more WISE agents at social functions.

#spy x family #loid forger #yor forger #anya forger #bond #becky blackbell #franky #yuri briar #camilla #dominic #sharon #millie #fricken everybody

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