In this illustration of a low-density lipoprotein particle, apolipoprotein B (blue) is surrounded by various forms of cholesterol (orange and yellow) and other lipids.
Is It Time To Retire Cholesterol Tests?
Should apoB take the place of LDL in your next checkup? This Science Magazine Archives story looks at how genetic studies and clinical data have caused scientists to take another look at cholesterol tests.
By Mitch Leslie; December 6, 2017
The next time you go in for a medical checkup, your doctor will probably make a mistake that could endanger your life, contends cardiologist Allan Sniderman of McGill University in Montreal, Canada. Most physicians order what he considers the wrong test to gauge heart disease risk: a standard cholesterol readout, which may indicate levels of low-density lipoprotein (LDL) or non-high density lipoprotein (non-HDL) cholesterol. What they should request instead, Sniderman argues, is an inexpensive assay for a blood protein known as apolipoprotein B (apoB).
ApoB indicates the number of cholesterol-laden particles circulating in the blood—a truer indicator of the threat to our arteries than absolute cholesterol levels, some researchers believe. Sniderman asserts that routine apoB tests, which he says cost as little as $20, would identify millions more patients who could benefit from cholesterol-cutting therapies and would spare many others from unnecessary treatment. "If I can diagnose [heart disease] more accurately using apoB, and if I can treat more effectively using apoB, it's worth 20 bucks," he says.
Sniderman and a cadre of other scientists have been stumping for apoB for years, but recent reanalyses of clinical data, together with genetic studies, have boosted their confidence. At last month's American Heart Association (AHA) meeting in Anaheim, California, for example, Sniderman presented a new take on the National Health and Nutrition Examination Survey (NHANES), a famous census of the U.S. population's health. The reexamination, which compared people with different apoB levels but the same non-HDL cholesterol readings, crystallizes the importance of measuring the protein, he says. Across the United States, patients who have the highest apoB readings will suffer nearly 3 million more heart attacks, strokes, and other cardiovascular events in the next 15 years than will people with the lowest levels, Sniderman reported. As lipidologist Daniel Rader of the University of Pennsylvania Perelman School of Medicine puts it, the question of whether LDL cholesterol is the best measure of cardiovascular risk now has a clear answer: "No."
But plenty of scientists disagree. "Many lines of evidence say there's not a lot more predictive power of apoB over LDL cholesterol," says cholesterol researcher Scott Grundy of the University of Texas Southwestern Medical Center in Dallas, who has helped craft several sets of cardiology care guidelines. And changing clinical practice would be disruptive. Standard heart disease risk guidelines downplay or omit apoB, and the algorithms that help doctors decide which patients to treat don't incorporate it.
ApoB backers have a new opportunity to make their case. A committee of researchers and doctors is reworking the most influential U.S. recommendations for cholesterol treatment, published by the American College of Cardiology (ACC) and AHA, and should issue an update next year. The European equivalents are also being revamped, although a new version won't be ready for 2 to 3 years, says cardiologist and genetic epidemiologist Brian Ference of the University of Cambridge in the United Kingdom, who is taking part in the rewrite.
Nobody expects these latest revisions to jilt cholesterol for apoB, but its advocates say there's increasing science on their side. Cholesterol cruises through our blood in several kinds of protein-containing particles, including HDLs, LDLs, and very low-density lipoproteins (VLDLs). When certain particles, such as LDLs and VLDLs, depart the bloodstream and get stuck in the lining of our arteries, atherosclerosis can result. Total cholesterol level was the first widely used indicator of this risk, but after researchers discovered that one form of cholesterol, HDL, may be protective, LDL cholesterol became the benchmark. Now, some physicians favor non-HDL cholesterol, which encompasses multiple cholesterol types, including LDL and VLDL.
All of these measures, however, reveal the amount of lipid in the blood, rather than the number of cholesterol-hauling particles. ApoB, in contrast, provides a direct measure of their abundance because each LDL or VLDL particle contains a single copy of the protein.
Still, even apoB advocates admit that LDL cholesterol's track record is pretty good. About 85% of the time, it provides an accurate indication of a patient's likelihood of developing cardiovascular disease, Ference says. But that means it's wrong 15% of the time, he adds.
A 2009 study found that nearly half of patients admitted to hospitals because of heart attacks had normal or low LDL levels. So by measuring LDL alone, doctors risk overlooking people who need treatment or, if they are already taking drugs to trim their cholesterol levels, a more intensive regimen.
At the same time, some people taking drugs for what seem to be dangerously high LDL cholesterol levels may not need treatment, Sniderman says. A more discriminating test for cardiovascular risk could spare these people from potential side effects and save money. Although cholesterol-lowering statins are cheap, Sniderman notes that newer drugs given when statins aren't enough, such as the PCSK9 inhibitors, can cost tens of thousands of dollars per year.
Switching to measuring apoB would improve diagnoses because it better reflects the mechanism of cardiovascular disease, according to Sniderman. "The data support that it's the LDL particles themselves that are the bad actors," rather than the cholesterol they contain, Rader says. The more of these particles that course through a patient's blood, the more get stuck in the arterial walls and the higher the probability of cardiovascular disease. Because LDL cholesterol and apoB are intertwined, both measures give the same result for many patients. However, the amount of cholesterol a particle contains can vary. So LDL cholesterol levels can be misleading for patients who have few large particles or many small ones.
No current drugs drive down just apoB, making its impact difficult to untangle from the effect of lowering cholesterol overall. But in a 2015 paper, Sniderman and colleagues reanalyzed data from the famous Framingham Heart Study, which has been probing the causes of cardiovascular disease for nearly 70 years. The patients with the best odds of surviving for at least 20 years had low levels of apoB and non-HDL cholesterol, the team found. But the patients with the worst chances had high levels of apoB, even though their non-HDL cholesterol was low. Similarly, the reassessment of the NHANES data that Sniderman presented at the AHA meeting suggests that apoB is a better predictor of risk.
Also pointing to apoB's importance is a type of analysis in which researchers comb through genetic data from large numbers of patients to identify gene variants that influence a particular trait. Scientists then track the variants' sway on health, a method called Mendelian randomization because it relies on accidents of heredity to create comparison groups. "It's essentially nature's randomized trial," Ference says. In a study in The Journal of the American Medical Association in September, he and his colleagues dissected the impact of variants of two genes involved in cholesterol metabolism: CETP and HMGCR.
Using data from more than 100,000 patients, the researchers found that people with sluggish versions of the enzyme encoded by CETP showed equivalent reductions in apoB and LDL cholesterol levels and were less likely than people with vigorous versions of the enzyme to suffer cardiovascular crises such as heart attacks or strokes. But the scientists saw a telling difference when they analyzed patients who also produced underactive versions of HMGCR's enzyme. Although these people showed further decreases in LDL cholesterol, their apoB levels—and their cardiovascular risk—didn't decline by as much. That discrepancy suggests that reducing apoB has a bigger protective effect than lowering LDL, Ference says.
The picture is clear, says preventive cardiologist Seth Martin of Johns Hopkins University School of Medicine in Baltimore, Maryland. "The totality of evidence is in favor of apoB being an important marker that can identify risk even when LDL is controlled."
But would the gains be worth the disruption? "The poor frontline primary care doctor doesn't want to have to think about apoB and non-HDL cholesterol," says preventive cardiologist and epidemiologist Jennifer Robinson of the University of Iowa in Iowa City, who was vice chair of the committee that drafted the most recent ACC/AHA recommendations in 2013. "It's too much information—and when you give people too much information they ignore it."
Cardiologist Robert Eckel of the University of Colorado School of Medicine in Aurora, who was also on the ACC/AHA committee, agrees. "I don't see apoB changing the playing field very much," he says.
Many apoB advocates reluctantly concur. LDL cholesterol is deeply entrenched in medical routines, and "it's not going to change any time soon," Rader says. "I go from depression to worse depression," Sniderman says.
But if future guidelines start to emphasize apoB's diagnostic value and drug companies begin to target it, Ference thinks physicians will eventually pay heed to the protein. "The argument is that LDL cholesterol is good enough," he says. "But as we move toward more personalized medicine, it's not."
— sciencemag.org; Health
0 notes
Tangled Up In Blue
Chapter 19
Summary: Fear for her unborn child, a bruised and broken Emma Swan is determined to escape an abusive marriage. After she drives a long way from home to a small town in Maine, she doesn't think her life could get more complicated... that is until she ends up falling for her OBGYN, a blue-eyed British man who's shielded his heart from love long ago. But he may be just what she needs to begin her healing process and start a new life for her child. If only nothing gets in the way.
Rated M for violence, language and smut.
Also on: AO3 FF.N
Chapter: 18
33 Weeks into Emma's Pregnancy…
“Hi Mum, how are you and Papa?”
“We’re fine. Just wondering if you and Liam are coming home for Thanksgiving.”
“Ah, well I don't think I'll be able to, but I know Liam and Cordelia are planning to visit for Thanksgiving,” Killian replied over the phone as he walked into his clinic after lunch, waving at the receptionist as he passed. He had met Liam for breakfast that morning and his brother mentioned that he and Cordelia planned on sharing the news of her pregnancy with their parents on Thanksgiving. Unfortunately, it was not the best time for Killian to leave.
“And what about you, Killian?”
He ran his hand through his hair, trying to summon an excuse as he continued to his office, shutting the door behind him and grabbing his lab coat from the door hook. “I'm sorry, mother, but I won't be able to. I have conferences and surgeries coming up,” Killian explained as he put on his lab coat, transferring his phone to his shoulder to put his other arm through the sleeve. Once it was on, he sat down and propped his feet up on the desk, leaning back in his office chair. “And I don't know if I'll be able to visit for Christmas either. One of my patients is expecting on December fourteenth, but if the baby's late I'll have to stick around,” he lied. It was true that Emma was scheduled to have her baby that day, but even though she wouldn't be his patient, he still wanted to be in the room with her. He and Emma have not discussed this yet but he planned on bringing it up to her soon. There were many discussions about the baby and the baby's future that needed to take place, and Killian wanted to tell Emma that he wanted to be included, but how would he possibly go about doing that with everything going on? Besides the fact that he hasn't even told Emma that he loved her yet.
“You won't be here for Christmas? Can’t you just find her another doctor?” He could hear the disappointment in his mother's voice.
“No, I can't. She's expecting me to deliver her baby and you know I don't like to let my patients down.”
His mother sighed understandingly. There were many times she was forced to be in that situation, of having to chose between being at her clinic or spending time with her family. “Fine, but we will be expecting you to come and visit after New Years at least.”
“Of course.”
“How are Liam and Cordelia? Are they there with you?”
“They're not. I'm at the clinic right now. I'll have them call you, though.”
“Okay, I'll leave you to it. Would you like to say ‘hi’ to your father first?”
“Aye, if he's there.”
Killian could hear his mother speaking to her husband in the background before Brennan took the phone. “Killian, my boy. How are you?”
“I'm good, and I'm not a boy anymore,” he said, rolling his eyes.
“Of course, you're a man now but you'll always be my boy. Now, I overheard that you won't be visiting us for Christmas?”
“No, I'm sorry I won't be able to,” Killian replied reluctantly, expecting a lecture from his father.
“It's alright, son. I understand you have other obligations.”
“You do?” he asked, surprised.
“Of course I understand, Killian. I just have one question.”
Killian smiled in relief. “Sure, what's that?”
“What's her name?”
Killian's throat became dry and his smile started to fade. “How did you- Liam told you didn't he? Bloody hell, I'm going to kick that wanker’s arse-”
“No, actually he didn't… I just know you better than that. You've always studied and worked hard but you've never chosen your career over family. You always did have a knack for learning from your mother's and my mistakes. So tell me, who is this woman keeping our son from us for the holidays? She must be something special, aye?”
Killian couldn't help the smile that pulled at his lips at the thought of her, and he sighed in defeat. “Her name is Emma. And she's very special to me, father. She makes me happy.”
“Ha! I knew it!” Brennan exclaimed rather loudly into the phone and Killian had to pull the phone away from his ear as he chuckled. “When do we get to meet her?”
“Soon, I promise. We just started dating a little more than a month ago so it's still too early to introduce her to you and mother. So, could you not mention it to-”
“Sweetheart, did you hear that? Killian has a girlfriend,” Killian heard Brennan call to his wife and they were both cheering in the background. Killian closed his eyes briefly. He hadn't planned on telling them yet. It was too soon.
“Killian, is that true?” his mother joined in on the conversation. “When do we get to meet her?”
“Not yet, mum. She's coming from a delicate situation, but I promise after the holidays I will bring her to visit.”
“What kind of delicate situation?”
“Something similar to what happened with Milah,” he confessed.
“Oh,” his mother said softly.
“Not again, Killian,” his father added. “Please tell me she's not married too.”
Just then, there was a knock on the door. “I will explain later. Right now I have to go. Goodbye, Mum and Dad. I love you both.” He hung up before they could ask anymore questions. He lowered his feet to the floor and set his phone on the desk, sinking his face in his hands with a sigh. “Come in.”
The nurse opened the door letting him know that his next appointment had arrived. “Thank you.”
He lifted his head and straightened up, adjusting his lab coat as he stood. Mary Margaret and David entered the room as the nurse handed him their file and left, shutting the door behind them.
“Please have a seat,” Killian flashed them a smile as he gestured at the seats in front of the desk.
The Nolans greeted him and sat down as Killian took his seat at the desk. They engaged in casual chit chat as Killian studied the paperwork in his hands before lifting his gaze to meet the two pair of eyes that waited in anticipation.
“Well? What did you find out?” David inquired with a hint of desperation in his voice. Killian gave them a small smile as he ran his hand along his stubbled jaw, tapping his thumb on his chin in contemplation. He was surprised when the Nolans had decided to keep their initial appointment with him to not only get Mary Margaret checked out but David as well, and now the follow up. Although, Killian figured since David knew him a bit more now, he eventually found Killian to be trustworthy, despite the circumstances. And he didn't blame David one bit. He was just being a protective husband. Killian felt the same way about finding the right doctor for Emma when he could no longer be that person for her, that's why he recommended Rosabell in the first place.
Killian cleared his throat, setting their file down before resting his elbows on the desk and clasping his hands together. “Honestly, I found nothing,” Killian finally replied. He received puzzled looks from the pair before him.
“What do you mean, you found nothing?” David demanded sternly. Mary Margaret placed her hand on one of his to calm him.
“There has to be a reason why we've been trying for a year to have a baby but haven't been able to get pregnant,” she said, confusion laced in her features.
“Aye, there is, but it hasn't shown up in any tests,” Killian explained.
“Care to enlighten us then, doctor?” David asked, a bit irritated. “Or are we just wasting our time here and should go somewhere else?”
“And here I thought I was starting to grow on you,” Killian teased with a smirk. “There is no known cause of infertility here, but being able to rule out several possibilities helps us out quite adequately. The test results were normal for both of you,” he affirmed, averting his eyes from David to Mary Margaret. “And after going over your medical history with both of you and receiving your results, I've only found that you're both pictures of health. So that's very good news.”
They both sighed in relief. “That's good to know,” Mary Margaret uttered, smiling at David. He looked over at his wife, returning a small smile as he squeezed her hand gently.
“So if there's nothing wrong, then what do we have to do?” David implored, facing Killian again.
“Normally, I would suggest an IUI combined with hormones. An IUI is a fertility treatment that involves placing the sperm inside the uterus to facilitate fertilization. There's also some other fertility methods, but before we try anything, there's one thing I would like to ask first.”
“What’s that?” Mary Margaret asked him, her eyes full of curiosity.
Killian stood up and walked around the desk, sitting on the edge of it and crossing his arms. “When's the last time you spent a day together, just the two of you...?” They both started to answer, but Killian put up his hand, making them pause for a beat so he could continue, “...without the interruptions of twin brothers or pregnant roommates or friends or work or other obligations? When's the last time you've just been able to breathe and enjoy each other’s company?” He put his hand back down, crossing his arms again.
“We spend plenty of days alone together,” David shot back defensively.
“Okay,” Killian accepted, pursing his chin and lips in curiosity. “That's great. Name one,” he challenged.
Mary Margaret and David both paused and looked at one another. “Well, there was that one day…” she started and then had to think about it for a moment, “...no, I had to go into the diner that day.”
“What about the time when we went to…?” David shook his head. “No, James was there.”
They both continued to fumble for an answer as Killian waited patiently. “That's exactly as I suspected,” Killian finally spoke, standing up and pacing slowly towards the window.
“What does that have to with getting pregnant, anyways? What's your point, doctor?” David asked him.
Killian turned to face them again. “My point is you both have too much stress in your lives. With running the Bed and Breakfast and taking care of everyone, you're missing out on spending quality time with each other. And having too much stress and too much weighing on your minds can inhibit your ability to conceive.”
“So, what do you suggest then? We can't just put our business and lives on hold while we try to have a baby,” David pointed out as he looked to his wife.
Killian shrugged casually, tucking his hands in his pockets as he walked towards the desk again. “Maybe you don't have to. You have employees that can handle the business for a week. Use that time to take a vacation just the two of you,” he suggested, turning to look at them.
“A week? I don't think that's possible,” Mary Margaret chuckled a bit at the idea.
“Why not?” Killian asked, not accepting her answer as he sat against the desk again and crossed his arms. “You both work hard, you spend so much time being there for the business and other people, why not take some time out for yourselves? You both deserve it.”
“That's a great idea and all, but when would we possibly be able to? There's the baby shower for Emma and not to mention the fact that her husband is lurking around. And she's having her baby soon and we want to be here when that happens. We can't just leave.”
“See, just listen to what you just said. All of your excuses revolve around Emma, someone you both care about nevertheless, but what about the two of you? What about Mary Margaret and David?”
They both looked at him, unsure of how to respond.
Killian let out a soft sigh, resting his hands on the edge of the desk. “Look, I understand you both want to help Emma and be there for her, but she still has seven weeks until her due date. And Neal is still nowhere to be found. I'd say after the baby shower is the perfect opportunity. You'll have enough time to find employees to cover for you and book a trip. It doesn't even have to be far away, just outside of your lives here in Storybrooke.”
“But we’d be too worried about Emma. Won't that defeat the purpose?” Mary Margaret asked him.
“Maybe, but you have no reason to be. Emma will be fine, the police are looking for Neal, she’ll still be pregnant and the town of Storybrooke will be here when you get back, I assure you. If you wait for the opportune moment, it's never going to happen.”
They both looked at Killian skeptically, but he could see that David’s expression was slowly yielding to the idea. He looked at his wife and gave her a soft smile. “Maybe he's right. Maybe we should consider taking some time out for us.”
“I don't know, David. You really think we should just leave now to go on vacation?”
David shrugged. “Honestly, I don't know, but I do know what I want. I want to have a family with you, Mary Margaret, and I'm willing to do what it takes. We’ll give it some more time and then if we still can't conceive then we’ll try some other options. What do you say?”
“Okay, I'll think about it. I don't really want to decide right now, with everything going on.”
“Of course, both of you go home and discuss it privately, weigh your options. And if you decide on the IUI then we will start right away. How does that sound?”
They both nodded. “That sounds reasonable,” David agreed. “If we can conceive naturally, I’d rather do that.”
“I completely agree. There's nothing physically inhibiting your ability to conceive, so I'd like you to keep trying for a little while longer before we try anything drastic. You both know what you need to to do, take more time out for just the two of you. With Emma out of the loft, it should be easier right?”
They both looked at one another and nodded. “Right.”
“Okay then. Let me know if you have any questions about anything.”
“I think we’re pretty familiar with the natural techniques of getting pregnant,” David teased as he and Mary Margaret stood up.
“Aye, I just meant about trying to conceive in general. And Mary Margaret, I suggest taking a prenatal vitamin everyday for when you do get pregnant.” Mary Margaret nodded as the three of them headed for the door and Killian opened it for them.
“Thank you and I'm sorry for the way I acted before, I'm just…” David started, apologetically. “It's just been a little deterring, not being able to conceive like a normal couple. I want to be able to give my wife what she wants… what we both want and have wanted for a while.”
“Of course. I understand, Mr. Nolan.” He knew exactly how it felt to not be able to impregnate his wife. For Killian, it wasn't possible with Milah, but for the Nolans, the solution was rather simple, or at least he hoped it would be.
“Please call me David,” he corrected.
“Apologies, David.”
“Oh and you’re coming to the baby shower next week, right?” Mary Margaret asked him. “Everyone who wants to come was invited, so no one will suspect anything if you do.”
Killian flashed her a smile. He got the invitation in the mail shortly after he and Emma started dating and was very much planning on going ever since.
“Aye, of course I'll be there.”
“Great. We’ll see you later, Killian.”
~~~
Killian locked his office up that evening, saying goodbye to the staff before he pulled out his phone. Emma had the day off of work but he was wondering if she would be home. He didn't want to panic every time he didn't know where she was, Emma had a right to do as she pleased but he was still worried every time she wasn't with him. If Neal weren't a threat to her or the baby, it would be a different story. Still, he didn't want to keep tabs on her or make her feel as though he didn't trust her. So, he called her cell phone to see if she would be home for dinner.
As he walked out the clinic door, his phone rang a few times before she answered, and he couldn't help but sigh in relief.
“Hi love, I just wanted to see if you were having dinner with me.”
“Ah, so you weren't calling to check up on me?” She asked playfully, and he could tell by her tone that she was definitely on to him.
He smiled in surrender as he made the small trek to his car. “I was just wondering if you were home, that's all. I don't want you to feel like I'm smothering you. Just wanted to make sure you and the wee lad were alright since I haven't heard from you since this morning,” he admitted.
“It's okay, Killian,” she laughed lightly. His heart actually fluttered, hearing that wonderful sound. “I don't feel smothered at all, believe me. And to answer your question, we’re not home but we’re both fine. I just had to run some errands and now we’re starving.”
A broad smile took over his lips as he approached his car and pulled his keys out of his pocket, using the small remote to unlock his car. “Good, I'll have dinner waiting for you, love.”
“No need. We brought dinner to you.”
A look of confusion washed over his features as he opened his car door.
“Killian, look behind you.”
He lifted his eyes and turned around, seeing a gorgeous, pregnant blonde in a pink blouse and blue jeans staring at him from across the parking lot with a big smile on her face as she held the cell phone to her ear.
He whistled into the phone. “I see a sexy blonde across the parking lot who is quite a sight for sore eyes.”
Emma laughed, her pearly whites showing through from where she stood. “Would you care for a picnic at sunset with this blonde you see?”
Killian couldn't stop the wide smile that took over his lips. “I would absolutely love that.” He ended the call and lowered his phone, sliding it into the pocket of his dress pants. He walked over to her as she lowered her phone as well. When he approached her, he had to resist the urge to grab and kiss her. Instead he flashed her a flirty smile. “So, where are we going for this picnic?” he asked before reverting his eyes to the vehicle she was standing next to, which was not her SUV, but David's pickup truck instead. “And what's with the truck?”
A mischievous grin took over her lips. “Get in, you’ll see.”
Emma opened the door and he helped her into the driver's seat before he went around to the passenger's side and got in.
She drove out of the parking lot and through town, passing the autumn trees, colorful leaves covering the ground. The sun started to descend as Emma pulled up near the beach that was secluded this time of year. She did a U-turn, facing the truck away from the ocean before she put it in park and turned the engine off. “Is this okay?” she asked him. “I mean, it will be dark soon and there's no one here.”
He grinned and leaned in to kiss her cheek. “Are you kidding? It's perfect.”
They both got out of the truck and Emma pulled out a large picnic basket from the cab. Killian lowered the gate and helped her spread a wool blanket over the bed of the truck before scooping her up in his arms and propping her up on the opened gate.
“This is a great idea, love. Much better than eating at home,” Killian said as he looked over across the ocean, the waves rolling and crashing into the shore.
“Well, we both feel cooped up in the house when we have the day off,” she said placing her hands on her belly and looking down at her baby bump. “Isn't that right, baby? We needed to get out, didn't we?” she spoke in her mommy voice and it was the most adorable thing he's ever witnessed.
“Of course, love. I never want you to feel cooped up. Believe me, I want to take you places, go on dates with you. Wherever your heart desires.”
She flashed him a grin and leaned in to kiss his lips. “I know you do, Killian. I'm fine with what we have now. As long as I get to be with you, that's all that matters to me.”
Killian offered her a soft smile as she started emptying the picnic basket.
“I brought some water and grape juice and made some chicken sandwiches and sliced up some fruit and carrots,” she said as she handed him a wrapped sandwich and set down a couple of small containers on the blanket. “And…” Emma reached into the basket again, pulling two more items out, “your favorite of course.”
Killian chuckled at the two slices of apple pie that she wrapped up. “Thank you, but I actually have a new favorite.” Emma arched a brow at him before retrieving some plates and silverware.
He leaned in, whispering in her ear. “It's you, darling. Sorry, but you taste better than that scrumptious apple pie of yours.” He could hear Emma's breath hitch before he pulled away, her cheeks filling with blush, and the shy smile on her lips was well worth the playful smack to his shoulder.
“So how did it go with Mary Margaret and David?” she asked as they started eating their sandwiches.
“They're perfectly healthy, I told them that they need to spend more alone time together before we tried anything drastic.”
“Well, that's good to know at least. And I actually was thinking of planning a trip for them, as a gift for everything they've done for me.”
“That's very thoughtful of you, love. What were you thinking?”
“I'm not sure yet.”
“Well, if you need any help let me know.”
She nodded and looked away, a thoughtful expression in her features. “So, how was the rest of your day?”
They ate their food, watching the sunset as he told her about his appointments and a couple of surgeries he performed. He was afraid that he would bore her to death with his medical speak, but her eyes always lit up with interest when he spoke of work and she always asked him questions if she didn't understand what he was talking about. It was one of the many things he loved about her. He also spoke of his conversation with his parents, but he didn't mention that he told them about her. He didn't want to pressure her into meeting them, especially now.
“So you're not visiting them for the holidays?” Emma asked, surprised.
“Emma, I wouldn't be able to forgive myself if I left and something happened to you, but I promised them I would visit after New Years.”
“I just don't want you to stay because of me.”
“Love, it's only one Christmas. And I would like to be with you when you have the baby… that is if you want me to, of course.” He swallowed thickly, bracing himself for how she might react.
To his surprise, a slow smile graced her lips. “I would love for you to be there. But you don't think Rosabell would mind?”
Killian shook his head. “I don't think so. She knows that I care about you and I told her that you and I are still friends.” He just hoped he could hide his feelings for Emma around her.
“Okay. As long as you think it's safe to do so, then I would love for you to be with me when I deliver my baby.”
A wide smile crossed his lips. “Then it's settled,” he smiled excitedly, taking a bite of carrot. “So tell me, what did you do today, love?”
A guilty look fell upon her features as she started to respond. “I went to the bookstore to talk to Belle,” she replied cautiously.
“Ah, she's a nice lass. How is she and the baby doing?”
“They're both fine. Belle’s definitely ready to have her.”
“I'm surprised she's still working.”
“Yeah, she said she's working until a few days before her due date. I'm going to do the same. I would hate being cooped up in the house just waiting to have this baby,” Emma said lightly.
“Can't say that I blame you, love. I figured you would. You are the stubborn type,” he said with a playful smile. Although, the doctor and caring lover in him wished she would take some time to rest before she had the baby, but he wouldn't fight her about it. He wanted her to feel free to make decisions about her own body, and he would never take that away from her.
“I also went to see Gold at his pawn shop,” Emma admitted, guilt flashing in her eyes again. “I had to know if Neal's related to him.”
Killian's features fell, a lump growing in his throat as he swallowed. “And what did you find out, love?” he asked, attempting to hide the worry in his tone.
“After I showed him a picture, he said he had never seen Neal before.” Killian nodded, looking down at the slice of strawberry in his hand as he took a bite, and then she continued. “But he was lying. I could tell that he was.”
He looked up at her and could tell that she adamantly believed that. “Emma… what if you're right and he does know Neal? What if Neal had been in that shop?”
“Look, I know that I was taking a risk by going there, but…” her voice trailed off before she continued, “...I can't just sit back and wait for Neal to show up,” her voice became cracked and he could see her eyes glazing over with tears. “I can't just do nothing. He either came here to hurt me and my baby or take us back to Tallahassee. And he's out there somewhere, laughing and waiting for me to give up and crawl back to him.” A tear escaped down her cheek and he could feel his heart clenching. Killian jumped off of the truck and stood between her legs, taking her hands in his own, his thumbs gently caressing her skin.
“It's okay, love,” he breathed softly. She released his hands and instantly burrowed herself in his arms, burying her face in the crook of his neck. He felt the tears stinging his eyes as she sobbed softly into his shirt. He stroked Emma's hair as he held her as close as he could, tilting his head to whisper in her ear. “I won't let him hurt you or your baby.”
“But you can't always be around to protect us.”
“Maybe I can be.” He pulled back slightly, taking her cheeks in his hands, urging her to look him in the eye as he spoke with all of the sincerity he could summon. “If you want to run away from here, all you have to do is say the word,” he paused briefly before continuing, his words cracked and lowered to a whisper, “and I will take you away in a heartbeat.”
Emma closed her eyes and leaned her forehead on his, grasping onto his shoulders for balance. “I can't… this place is my home. I can't just leave everyone. I finally have a family.”
He nodded. “I understand, love. I just wanted you to know that it's an option. I would give up everything here to go with you.”
She shook her head. “I can't let you give up your life here for me. You can't just leave it all behind.”
He flashed her a weak smile. “But I would. I… I would for you.”
She pulled away, eyeing him in confusion. “But why? Why would you do that?”
“Because, Emma…” A smile pulled at the corner of his mouth and he grabbed her hand, bringing it his lips and pressing a delicate kiss there as he struggled to breathe the three words that he had been reluctant to say for fear of pushing her away. But he knew she felt the same. He could tell by the way she looked at him, the way she smiled at him, the way she spoke to him. “I love you...” His eyes darted to hers and he could see the fear there, but he could also see love.
She gave him a weak smile. “You shouldn't… I’m not good for you.” His features fell in confusion.
“I very much beg to disagree. You're the best thing that has ever happened to me.”
Emma shook her head and pushed him away as she lowered herself from the truck. “How can you say that to me? What about your wife?” She disentangled herself from his embrace and started to walk away. He followed after her.
“Emma, please…” he gently grabbed her hand and she turned around to face him. “Of course I loved my wife, but losing her was the worst thing I've ever faced. And believe me, I've seen many horrible things in my field, love. I never thought I would be able to let go of my love for Milah… I never thought I would fall in love with one of my patients… and then you came along. And I know you're scared. I know that as much as Neal hurt you, a part of you may be afraid to let go of him completely. And when you're ready, I'll still be here waiting. I'm not going anywhere. My heart is in this for the long haul. I'll wait as long as it takes.”
He could see her breaking down, her eyes about to burst with tears, and she stepped closer to him, falling into his embrace. He immediately wrapped his arms around her, his hands sifting through her golden locks and cupping the back of her head as he kissed her temple. She rested her head on his shoulder as she curled her arms around him and he could feel the wetness from her tears soak through his shirt. “I'm just scared,” she whispered.
“I know you are, sweetness. But I won't let him hurt you or your son. I promise.”
She tightened her hold, seeming to accept his words and he just held her like that, offering her the love and comfort she deserved, asking for nothing in return.
It felt like an eternity, Emma in his arms, but it was nowhere close to being enough.
Eventually, they pulled apart and finished eating before they put everything away. Killian offered her his jacket and they sat back in the bed of the truck. Emma was in between his legs as she rested her head back on his chest and they gazed at the stars, just taking in the view.
“Can I ask you something?” Emma murmured, breaking the silence.
“You can ask me anything,” Killian kissed her head as his fingers crept under her shirt, caressing her belly.
“You never told me why Milah couldn't bear children. Did it have to do with... what she went through?”
“Aye.” Killian drew in a deep breath before he continued. “Milah got married at a young age, when she was eighteen. They eloped after she graduated high school. Her husband at the time started beating her not even a year after they were married. I was staying with a friend in Boston during summer break and she lived in the apartment across the hall. That's how we met, and I could hear them fighting in their apartment from time to time. Then one night, I heard her screaming from my mate’s unit. I went out into the hall and saw her husband running down the stairs like a coward,” Killian said, gritting his teeth. “I had to bust down her door to get in and I found her on the kitchen floor in a pool of her own blood.”
Emma let out a gasp. “What happened?”
“He um… he stabbed her in the stomach and she had to have abdominal surgery. It caused permanent damage and the doctor told her she would never be able to have children. After that, we ran away together, and she had these big dreams, wanting to become an OBGYN and start her own fertility clinic one day to help women struggling to get pregnant.”
Emma tilted her head back to look at him. “Have you ever thought about doing that? I mean opening a fertility clinic?”
“Aye, actually I have. I’ve thought about expanding and opening a research and fertility center.
“I think you should. I mean if that's what you want to do. You're an amazing doctor. You care about your patients and respect them. You treat a complete stranger a hundred times better than my husband ever treated me, that's for sure.”
“True, but he's a fucking asshole, love. I will never understand why anyone in this world would want to hurt such an amazing woman. You are a treasure to be cherished. Any decent man would kill to have a lass like you.”
“I don't know about that,” she said. “But as long as you want me, that's good enough for me.” He smiled weakly at her, stroking her cheek. If only she knew exactly what she was worth. Killian decided that he wanted to take her out on an actual date to show her how special she really was, and he couldn't wait any longer to do so. As much as he enjoyed their private moments in his home, she deserved to be courted properly. Killian held Emma in his arms and kissed her forehead, mentally making plans for such an occasion as she laid her head on his chest.
After they got home, they went upstairs to his bedroom. She laid on the bed in her mint green nightgown and he stripped down to his boxers before fetching some massage oil that he bought for her nightly massages. He poured it into his hand, rubbing the oil into her left foot. She purred at his touches. He switched to the other one and worked his way up her beautiful long legs, both of them thoroughly enjoying his ministrations.
He climbed on the bed, continuing to massage her thighs and she moaned softly as his fingers made their way up her nightgown. He lifted the satin material over her belly and leaned in, leaving delicate kisses to her thigh and over her covered nub. He could smell the sweet nectar through her panties as his lips came in contact with the thin material, and it took every ounce of control within him not to pull down her underwear and lick her senseless. He often dreamt of doing so, of swiping her soft blonde curls and delving into her delicious folds; it was by far one of his favorite activities. His swan was so beautiful and perfect and she tasted simply devine. Arousal stirred in his groin as the images invaded his thoughts, but instead he grabbed the bottle of oil and poured it into his hand before rubbing it all over her belly.
Emma seemed to be completely relaxed under his hands. He looked up and saw that her eyes were closed as she breathed contentedly. “You still with me, love?”
“Yeah,” she breathed, a gentle smile spreading across her lips. “Keep going.”
“With pleasure.” He continued rubbing her belly, covering her round form with gentle kisses. He stayed there for a while just admiring and appreciating her, whispering sweet nothings to her growing baby inside.
After he covered her belly back up with her nightgown, he turned off the lamp and laid next to her as she looked up at him with her big, green eyes.
“Killian, I have to tell you something.”
He arched a brow as he wrapped his arm around her shoulder and peered down at her. “You can tell me anything,” he said sincerely with an encouraging smile. He could tell there had been something weighing on her mind the whole night.
“I sold my engagement ring at the pawnshop.”
“You did?” Killian swallowed thickly, not really knowing what to think about that.
“I had been holding on to it, because you were right. I was still hanging on to Neal. As much as I hate him, he’s still my husband.” Killian wasn't sure if he liked where this was heading. She wasn't considering going back to him, was she? Killian's heart tore in his chest at the mere thought. “But, I don't love him anymore.” Killian let out a deep sigh of relief. “I was afraid to say this before, because I was afraid that I'm not good enough for you.”
“You are absolutely perfect for me,” Killian assured her. He looked into her eyes as she struggled for the right words, as though she were unsure if she believed him. “Now what is it you want to say, love? You don't have to be afraid with me. My feelings aren't going to change.”
“I know,” she breathed. “Killian… I love you, too. And I want you to be apart of mine and my baby's life. If that's what you want too.”
Killian's heart fluttered, hearing those amazing words. “I want absolutely nothing more.” He cupped her cheeks in his hands. “I love you, Emma. Both of you,” He murmered before leaning in and smashing his lips into hers, kissing her deeply. She responded with the same fervor and passion as they both pulled each other closer, getting caught up in a heated kiss that made his head spin. The feelings he had for her were so overwhelming, he could no longer control his desire to make love to her.
She removed her nightgown as he took off his boxers and he kissed her body from top to bottom before pulling off her panties, turning Emma on her side. He got behind her, pulling her leg over his, and he entered her, whispering exactly how much he loved her in her ear as he thrusted into her warm depths. He would never want to claim her, but he felt a great deal of pleasure knowing that her heart was his and his alone.
~~~
@followbatb @weplaydumbb
17 notes
·
View notes