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asksuccubussides · 9 months

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What if you were an asexual succubus, wouldn’t that be fucked up or what Chapter 2

Masterpost of chapters

“La di daaaaa! I am RoooMaaan! Reeally obviousllyyyy masculine and niiiiceee! la di dada!” Roman sang song to himself while strolling down the street.

Just before he’d looked at some ancient ruins in Europe and had made sure to take pictures of them so he could show them to Remy and Emile later and joke that the ruins were just as old as them. Remy always protested that they weren’t a day over 140.

It’d been a good busy morning. He’d started out with a dip in the caribbean seas followed by feeding off of a man he’d meet on the beach before pretending to drink some coffee to enjoy the music at a jazz cafe and then he’d come to look at the ruins. A bag of souvenirs swung from his tail while he continued to sing to himself. If everything continued as planned he would go to a renaissance fair tomorrow (one of his favorite historical times!!) and hopefully add another sword to his collection.

It took a while until he found a door and he made sure to check so no humans were around so they wouldn’t get confused when he uttered the phrase that opened the door to hell.The door turned ajar and he walked through it into the door interway that was located the middle hallway of the succubi’s sleeping chambers.

It was usually as busy as the elevator interway in a big hotel but now it was just Roman and a few others. She waved hi to one of them but the succubi just hurried away without acknowleding her. She huffed and told herself that the other succubi had simply been too stunned by her sheer coolness to dare respond.

“So here I am, walking bravely all on my own down this dark mysterious hallways” Roman started to narrate to herself, she did that quite often “I would have stayed on earth for the night, tis it was not for the monthly meeting with the manager! Hah! But I need not worry for I am thee greatest demon in my squadron...NO! in the entirety of hell!!”

He had a smug self assured smile on his face as he swaggered through the hallways. He could feel that his twin was also in hell, he couldn’t explain it he just always sort of knew in his gut kind of where his headache of a twin was.

From barely any other demons being around her it shifted to more and more swarming all around her. Every one of them were half running in the same direction and when Roman turned the corner she saw a big cluster of succubi all gathering around the entrance to one of the rooms typically used for the manager meetings. Some were standing on their toes to see while others had extended their wings to get a few feet up in the air.

A sinking feeling fell through Roman as he paled. he tried to shake the feeling off and hoped it wasn’t anything to serious. Instead he forced a laugh and said to the closest demon “Haha a bit crowded here today, am I right?”

The demon looked at her with an excited smile “Yeah duh, I heard a succubi from one of the lower squadrons is getting Punished!”

The horns on Roman’s head started to pulse a darker red as she gulped. She closed her eyes and tried to feel where her brother was but all she could feel was that he was in hell somewhere. There was so much stupid shit Remus did all the stupid shitty time all she could do was close her eyes even tighter and hope he hadn’t done something so unrepentable he’d end up getting Punished like this.

After a deep breathe he opened his eyes and hurried over to the group of demons scrambling to try and catch any sight of the punishment. Hushed whispers buzzed through the evergrowing group.

“Who is it?” “Does anyone know what they did?” “I think he was in the squadron under me” “Did he do a patton?” “Ouugh! it would be so exciting if he did a patton” “What if it’s just a mistake? I hope he’s okay” “I’m betting he killed a human”

Roman could hear the faint sound of a manager’s voice coming from inside the room. The hoarse tone making way for booming words.

“See no evil”

Just hearing those words from the manager made the crowd of succubi turn so quiet a pin dropping would have been heard. A guttural scream followed. It was quick and sharp before slowly morphing into whimpers until it went silent again.

Roman felt sick to his stomach. It was like someone had torn half of him away and all he could do was wait with baited breathe to see if it was his brother or not.

Eventually two guards came out with the punished succubi dragging behind them. Blood was still dripping from the hands of the succubi, smelling like the way only human blood could. Their eyes were open wide but unseeing. The irises had turned completely white as soon as the manager had taken away their sight. Lost in their newly given blindness the succubi shook their head around and let out scream after scream as they heard the crowd around them. They started to scream for the crowd to help them get away before they got sent to heaven. Until they were sobbing that please please they didn’t want to go to heaven.

It wasn’t Remus.

Roman let out a shaky sigh and turned around to hurry back to their sleeping hall. He didn’t have to see the punished succubi being sent away to heaven, he’d already seen everything he had to.

One time when he was younger he’d asked Emile why they didn’t just send the demons away to heaven immediately if they’d broken the rules so badly to be killed. Why was the taking of the senses necessary. He’d answered that it was just a scare tactic. All the other demons had to see what could happen to them.

As soon as she’d found her way out of the crowd she started to run towards their squadron’s sleeping quarter. She sprinted so fast her lungs burned by the end of it. but it was worth it when she got into the room and saw her brother standing. next to Remy’s and Emile’s bed.

A wave of relief ran over her giving her the last energy to run up to Remus pull him into such a tight hug that she lifted him off the ground.

Remus squinted at her but let her hug him for a little bit before poking his fingers into her rib and when that didn’t get her to let go he blew his breathe stench right into her face. She let go of him and kicked him in the knee before whispering

“Someone was Punished”

In turn her brother glanced over to the bed where Remy was sitting and answered “Yeah, We know. Remy is-” Roman shushed him before he could talk his mouth off.

“You’re such a rotting piece of shit asshole!” Roman was on the brink of yelling it out “I thought it was gonna be you again! I always think it’s gonna be you! Because youre such a- a- Urgh!”

“I wouldn’t be punished, I could destroy all my senses in much funner ways than the managers ever could imagine”

Roman hit his shoulder in response.

He looked away from Remus and turned to his friends. Remy was covering their ears with their hands while staring nearly unblinkingly down into the floor. Their body was completely frozen aside from their chest slightly rising and lowering.

Emile was sitting beside them with his arm pulled around their waist. His fingers were idly stroking up and down their side. When his lover suddenly drew in a sharp breathe he murmured sweet nothings to calm them down.

“Did you see which manager gone and fucked that succubi up?” Remus asked.

“Don’t think it was our”

“Good. I don’t need Orange to be any more of an asshat than usual”

“Not his name! We should probably go now if we don’t want to be late to the meeting....” Roman grimaced at his own words while glancing to Remy.

“Nah nah. It’ll be fine. What’ll he do if we’re late? Chop our genitals off? We need those. Our fingers? That’d be fun. I’ve alwaysw ondered what happens if we lose limbs. Like do they grow back? Can we reattach those fuckers” He gasped “What if it’s like lizard tails and it will make way to even cooler limbs”

“It’s common courtesy to not be ass-late dukey”

“Courtesy aint gonna do anything for you. It’s not even gonna kill your enemies for you!”

“We can go” Remy interrupted. “Girlies I can’t even read your lips from here and I can still see you’re like bickering”

Remy gave a last little hug to Emile and he in return whispered “I’ll be here when you get back honey”

‘Alright. C’mon sluts. Meeting time’

The rest of their squadron were already lining up in the meeting room when the three of them arrived. It was about 30 demons in total and while obviously they all knew the names of each other most of the others didn’t talk that much to Remy or Remus. It was like a school class, some people were just closer to others. Besides most didn’t know how to communicate with Remy and Remus was....Remus. Roman could fit in quite well with the others if he tried but he prefered spending time on earth.

Remus noticed some of the succubi went from speaking normally to whispering as soon as he entered the room. He thought about whether sprinting up to them or barking would scare them the most but his twin dragged him over to stand in line before he could do anything.

He shifted his weight and bounced on his heels while waiting for the meeting to start. Remy signed a dirty joke that made him laugh and he was in the middle of signing back when the door opened and their managaer stepped in.

At once the room turned dead silent and all of the succubi stood perfectly still. Their manager wore a well ironed orange suit but looked far less human than any of the succubi for the simple reason that he was a Dominion instead of a succubi. It also meant he was automatically higher ranked than them. His horns were so long they wrapped themself around each other and his limbs were stretched out with his waist being long and slender to fit his organs. His hands tore out into long thin fingers that ended in yellowing claws.

The manager stopped in the middle of the room and clicked his heels together before looking over at the group of succubi. “Good evening. As I’m sure you’re all aware there was a Punishing earlier today so I’ll keep this short since I am certain you all want to go back to sulking or raving or whatever you succubi do after a Punishing” he pointed at the succubi standing at one end of the line “Please list the number of humans you’ve seduced this month”

“21 humans″

Remus and Remy kept signing back and forth while Roman signed for them to shut up which just made Remy sign that he was licking boots while Remus mimicked jerking off before puking.

“18 humans″

It went on demon after demon.

“25 humans″ “19 humans and uh a half maybe. It depends how you count it” “24 humans″

It became Roman’s turn.

“27 humans″

Remus’ let up into a grin of nerves when he realized it was his turn. He steeled himself and boasted up his chest because the last thing he was gonna do was not look confident.

“3! 3 entire humans! The most epic 3 fucks ever witnessed!”

He let out an overly loud laugh while the rest of the room stayed silent and stared at him. Someone let out an awkward cough. Roman signed to Remy that it was their turn. As soon as people stopped looking at his brother the better.

“17 humans″

All of the succubi let out a breathe of relief since Remy was the last in line, hopefully the manager would let them go now. Their hope was in vain as the manager took long dragged out steps towards Remy until he was standing so close they could feel his breathe pressing down against their head.

They held their head high with their eyes staring up at the ceiling while their hands and tail stayed behind their back like they were supposed to. They picked at their nails, a bad habit, and stared. But they couldn’t see the manager’s face, it was all blurry skin at the edges of their eyes and blindingly bright white ceiling.

“Could you repeat the number of humans you have seduced this month” The manager ordered.

Remy didn’t respond because obviously they were deaf so they couldn’t hear if he’d said anything.

“I asked you a question” The manager continued.

“Sir if you are trying to speak to me we both know I have to read your lips” Remy said, trying to keep their voice steady. It wasn’t the first time this had happened.

“How dare you! You may not look in my face! You are far below me!”

“Sir if you are trying to-”

The manager pushed Remy to the ground. A crack echoed through the room as their back slammed into the marble floor.

Some of the succubi tensed up. Others, even those who weren’t close to Remy, looked like they were ready to throw hands. Remus was just about ready to pounce on the manager if Roman hadn’t held him back, and if Remy hadn’t quickly signed for him to calm down.

The manager looked down on Remy and for a second their eyes met. None of the others in the room were able to see what was said between them in that moment, in that look. All they saw was that Remy stayed on the ground and the manager said

“Meeting dismissed”

Roman kept his head down to the floor as he helped Remy up on their feet. The rest of the succubi hurried out of the room, some of them whispering if Remy was okay or saying niceties to Roman in hope she would forward it to them.

'Don't tell Emile' Remy Signed.

'Whatever you say sleeping beauty' Roman Signed back.

Remus tried to disappear into the group of succubi and walk out without being noticed, but just when he was about to step into the hallway-

"Twin 2 stay behind. I have some things to say to you" The managers dry voice called out.

Roman gave her brother a look of pity while closing the door behind her. Remus closed his eyes and imagined pretty thoughts of blood veins exploding to calm himself down before turning towards the manager.

“Didn’t I tell you to increase your human per month capita”

“Well yeah but you see I am actually a total sex machine, sir, It’s just that I got terrible luck okay!?” Remus exclaimed “Like for example I was about to go down on this guy but then a tiger came and ate him! Or I would have had a classic plane orgy but then the plane uh crashed! OOPS!”

The manager grimaced at him “You must understand that the better numbers your squadron has the better it will be for all of you, and me”

Remus didn’t really respond he just picked his nose.

“And there are only so much space here in the lust realm. If you can not meet the demands of your job we might just have to send you to heaven”

“That’s fine with me! Send me up there fucker! I’ve always wanted to try killing some angels anyway! bash their heads in and-”

“You and the other twin are a sort of package deal. You understand, don’t you? If you get sent away, he does too”

“....Yeah....Yes I understand sir”

“Good. You may leave”

Remus didn’t say anything more. He just walked out of the room as fast as he could. A tiny group of his squadron coworkers swarmed him almost immediately.

“Hi R. We’ve been talking a bit between us and we know some easy humans to seduce. We can help you y’know?” One of the succubi suggested.

“Yeah. I mean we get it. Some people are just late bloomers and you’re like a super late bloomer but we don’t judge”

“It’s nothing to be ashamed of”

“Exactly! i know some humans got this concept of shame around like sex and seducing but R you don’t have to mimic them! You silly goose!”

“I’m actually allergic to shame” Remus replied. “ Shame makes my whole face explodes with muckus, like with a nut allergy”

“Girlies don’t bother him. He just gotta find his kink goblin dick pig mode” Remy interrupted “Leave him to me”

One of the succubi turned to Remus and said “Tell Remy to have a good day” before all of them walked away.

‘Girls coulda just said it to me’ They signed and rolled their eyes before turning to Remus. They moved their tail to play with his beard while asking ‘Manager say the same like always?’

‘He got some new threats. You okay or should i kill him with a chainsaw?’

‘its like literally fine girl. he aint getting to me. thaankkkss’ They mimicked the sound of dragging the word out by repeating the motion of the sign.

‘well im getting to him. with these SWEET GUNS’ Remus flexed his arms in the most cursed ways until Remy laughed.

“REMUS! HONEYBUN! HI!” They could see Emile running towards them closely followed by Roman.

Emile and Remy met in a kiss before having a conversation in sign language with such quick signs that even the twins couldn’t follow. It looked like one of the lovers signed something to the twins but Remus’ eyes had turned into a dizzy blur. He squinted and tried to make something out but all he could think about was human flesh.

“Hey. Hey. Stinkey” Roman snapped his fingers in front of her twin’s face “Look at me. You need to feed”

“I need to go to the hospital to look at some wounds. Need to look at some brain surgeries and shit”

“Bro you’re coming with me to earth. I got a meet up with this guy in Tianjin and he’s gonna take me out to the local theater. Perfect time for me to work on my mandarin. And you are gonna come with”

‘Girl me and Em can like help’

“Of course! I’m sure we can help find some lonely soul”

“.....Fine sure. But one of the nights this week I will sneak into one of y’alls beds and fill it with the most horrible of smells and I won’t tell where I found them or how I got them there”

“Sounds great in your lovely Remus way!”

Emile moved his arm around Remus to push him along while his tail intertwined with Remy’s. Roman was the one to open the door to earth and held it open while the other’s got through. She left soon afterwards to meet up with the guy.

‘I can at least slaughter- Oop, I obviously mean feed off a human all on my own’ Remus said.

“You sure Rembem?” Emile replied “The buddy system always works!”

‘Like especially during sex. Buddy system tots works’ Remy added.

“Oh shush hun. You know I didn’t mean it like that” He blew a raspberry against his partner’s cheek making them smile softly “But Rem if that helps we can do it!”

“I’m still thinking about wounds”

“So you sure about being alone?”

“Yeah. Like a nearly extinct animal. yeah”

Emile and Remy turned to each other, one of them happy wiggled his arms around while the other stretched their wrists and cracked their neck.

“EARTH TIME!” They yelled in unison.

Though they weren’t as much of fans of earth as Roman (few was) they still had a soft spot for it since they had originally met on earth.

‘Well girl I got to choose what we like did last time-’

‘Oh but honey I really enjoyed that mall concert! You can choose again’

‘Shut it slut, it’s your turn’

“Well I know there should be a collgage-”

‘College’

“Colegaga campus nearby, maybe they have someone speaking on psychology- OH but I also know there’s lots of cute adorable fantastic animated mascots around this part of earth. We can have a little windowlicking”

They played Cliff, fire, scissor to decide. The mascot windowshopping won. Remy stretched a bit more before taking their jacket off to which their lover immediately held it for them.

“Please DON’T” Remus interrupted.

“Oh girl I am soooo gonna do it bitch”

They took a deep breathe before letting their wings out. The sharp jagged lines of the wing structure grew out of the bones on their back and their skin stretched out to fill the space between. They strained their body to force the final part of the wings out until sweat dripped down the back of their neck.

“Gross gross gross” Remus stuck his tongue out at them “And not in the good way. Wings is some angel shit dude!”

“I like angels! They’re cute!”

“TheY DON’T EVEN HAVE TAILS!”

“Whatevssss”

Emile happily held up their arms and let their lover hold onto him tightly. Remy checked to see so they weren’t gonna fall before flapping their wings. “See you later Rembem. Good luck!” Emile waved goodbye.

Remus wrought his tail around nervously in his hands while looking up at the grey brick buildings around him. "I don't get how Ro can love this. Their homes are boring rectangles and murder is like 100% illegal" He had as much of a habit of talking to himself as his brother.

Earth smelled like gas and cigarettes, two smells he would normally like if it didn’t have the slight human smell as well. A car drove past and he barked at it. When a human walked by and accidentally knocked into his shoulder he barked at them as well.

All of a sudden he stopped and sniffed in the air. “ANGEL FUCKER!” He yelled as he saw one flying past him up above. It had big white wings and a shining halo. Remus picked up stones from the ground and tried to throw it at the angel to which the angel gave him a disappointed look while waging it's finger. He stuck out his tongue and gave it the double bird.

It flied away and Remus was left alone with his ribs aching from how hungry he was. He could feel his fangs rotting away slowly from the lack of feeding and his tail dragged behind him on the side walk. But hey who needs teeth anyway.

Eventually he ended up in a bar. A tiny one with mostly people sitting alone or tiny groups scrunched together around a table. When the bartender wasn’t looking he stole a shot and enjoyed the feeling of his throat burning. Succubi could control if substances affected them or not, he'd once seen a succubi snort an entire line of off a guys cock and just continue like nothing, but he prefered to let it affect him.

"HEY. does anyone wanna fuck me?" He yelled loud enough so the entire bar could hear. Very subtle.

When no one seemed to care he threw the shot glass down into the floor and grinned as pieces of glass burst around his feet. He threw more glasses and a bottle and a few toothpicks just to be extra until the bar owner shouted at him and pressed him up against the wall. Remus laughed right into his face and threw the closest thing he could grasp onto the floor.

Oh how he wished he could have been a demon of the rage circle. He would have made an extraordinary one.

The feeling of a human beating him was one of his favorite. Any kind of pain was already something he loved. When it left bruises or blood he could stare at it for hours. But sadly the humans at the bar threw him out after only a few punches.

He let himself lay in a pile of dirt and mud right outside and lapped the mud up like it was a fine glass of wine. Predictably enough one of the humans from the bar came out soon after and stood down on their knees in the mud next to the demon. Something was uttered in a language Remus didn’t know but it was probably a declaration of sudden love at first sight or an invitation to have sex. That type of short term infatuation tended to happen to humans when they saw a succubi.

It didn’t matter if Remus knew very well he was something akin to a man nor that he felt nothing close to attraction, his body changed into whatever the human wanted anyway. He had to desperately feed anyhow. This was what he wanted. This was what he had to do to survive. And he couldn’t die in such a lame way as starvation. If he was gonna die it was gonna be at his own extremly epic hands.

In his mind Remus started to recite every organ he knew of, even the ones that weren’t human, as he let the human lead him into the back alley. It wasn’t the nicest but in a way he liked the dirt, grime and piles of trash bags in the alleyway rather than a hotel room or some car.

His hands and chest got pressed against the rough concrete wall and he tried to count how many stains he could see before trying to decipher if there was more of a lingering smell of piss or vomit.

The feeling of feeding hit him like a freight train. The lust forced itself down his mouth into his organs and gave his body life far too suddenly. He repeated the organs in his mind quicker and quicker. Starting over from the beginning if he forgot one.

The sudden lack of hunger made him delirious. It was like all his senses stopped working except for the immense feeling of fullness. It was heavy like a rock while Remus had always been the type to prefer sprinting light and quick. It was like a coat that was too tight when Remus had always been a bit of a nudist. It wasn’t over. The human had more lust to give.

All of a frog’s organs were held in it’s abdominal captivity. Cows have four distinct parts of it’s stomach. Octopuses have 3 hearts and blue blood. Humans have about 34 main veins. Horses have 205 bones.

It was over. The warmth of the human’s skin went away and the touch of their hands stopped grabbing at him. Maybe the human said something before leaving but Remus was still repeating organs to himself.

He stuck his fingernails under his other nails until blood started to pool out from under the sharp edges to try and connect to his body again. He grabbed at his cheeks until the red of his eyes showed and he could touch the veins making blood flow in his face. He bit at his knees and plucked at his teeth and tasted his own snot until his body felt like his own again. Until he could feel the earth under him again.

And then he screamed. He had to fill the silence with something. He screamed because he loved how his lungs started to burn and his mouth tried to close but he wouldn’t let it.

At least he had energy now. So much energy he could fill a church. He just knew he was always meant to have this type of energy. He was just stuck in his own starvation most of the time.

To both celebrate his energy and forget the feeding he decided to do some of his favorite things. First of he found a baseball bat and a random human’s car and smashed it to pieces. Secondly he got into a packed elevator and started jumping up and down until the entire elevator shook and an old lady fell over. Thirdly he waited until the night and walked omniously out onto the roads right when a lone car was about to pass by.

This continued until he had used up all of his energy. It was always like this. Sudden feeding followed by a binge of all the activities he had fantasised about for the past weeks. Until he passed out in a ditch somewhere.

“Bro? Stinky bitch? I could feel you bitching yourself over all the way from my date” Roman’s voice brought him back from sleep.

When he squinted up all he saw was a dark sky lined with trees. he didn’t recognise where he was or how he’d gotten there but his stomach panged with hunger once more.

“I fed” Remus wheezed out “I crashed a car too...or maybe like smashed it...or both”

“Whatever you say bro” Roman slung her brother’s arm around her shoulder and forced him up on his feet. Remus felt heavy like a corpse and his head lolled to the side as she walked him back to hell.

He kept mumbling out half sentences of what he’d done mixed in with pure nonsense before restorting to nibbling on his brother’s hair and pretending to eat it. Roman let out a heavy sigh and just kept walking.

He was too tired to notice but she lightly patted his hand that was slung close to her chest almost the entire way home and far after he had fallen asleep again she tucked him into their shared bed.

#sanders sides #thomas sanders #tss #roman sanders #remus sanders #remile #remy sanders #what if you were an asexual succubus wouldnt that be fucked up or what #creativitwins #hmmm not the proudest of this chapter. something feels off #but its here

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sunswathe · 1 year

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hi hello i am not a stranger things blog BUT i've had this idea kickin' around in my nog for like. months? and today the first part just beamed itself into my brain and i spat out 1000 words for it. i know i'm not the first to write this concept, but here's my take on the "steve sees dead people" au!

i want to write more for this, but i have a terrible track record for finishing fics (i have like. 13 drafts?? for stranger things fics??) so this is tentatively part 1 of an undetermined amount. it is supposed to be steddie, eventually. if i make more, i'll post it to ao3!

anyway, enjoy! <3

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December 1984

“What the hell are we looking for out here, exactly?”

It’s fucking cold out, and Steve’s fingers are starting to ache where they’re wrapped around the handle of his bat.

“I don’t know any better than you do, Steve.”

Steve scowls and roughly swings at a low hanging branch. It’s thin and bare and twiggy, and it catches on the pristine nails he drove through the barrel. He uses that hold to bend the branch forward and out of his way. His bat sticks when he walks past and he growls as he yanks it free.

The winter-brittle wood snaps with a loud and distinct crack, and Steve locks up.

When nothing jumps out of the shadows at him, Steve shakes the fresh tension from his limbs and continues his trek. The thin scattering of snow that managed to blanket the dead foliage despite the tight clusters of trees isn’t offering Steve any sort of direction.

No sign of anything. Not of squirrels or deer or fucking wolves or whatever the hell else lives in the woods surrounding Hawkins. Steve doesn’t know and he doesn’t really care.

All that matters is that there’s nothing to show for the thing he’s trying to find.

“The fuck do you mean ‘don’t know any better’ than me?! You,” Steve bites out, jabbing an irritated finger at his unhelpful shadow, “are the only one who’s actually seen it!”

Barb rolls her eyes as she sidesteps Steve’s accusatory point and wanders past. Half of her body has to phase into the thick trunk of a nearby tree for her to successfully maneuver around him, and that just peeves him further.

Steve’s out here getting whipped by and stuck on branches, and she doesn’t even have to worry about the trunks.

The petty jealousy fizzles and dies just as quickly as it came, though. It’s easy for him to forget how serious death really is. How permanent it’s supposed to be, for everyone except him.

Steve sighs and tromps after her.

It’s mid-December, which means the forest is quiet. To an extremely unnerving degree. There aren’t any insects or frogs or midnight birds to fill the hush, only the clack of branches rustling in the light wind.

“You don’t even have, like,” Steve steps over a fallen tree, slick with ice, “the teeniest, tiniest idea of what the— what the thing looks like? No more details?”

Barb scoffs. It’s odd, because she doesn’t make a sound, even as Steve hears her. Her voice doesn’t penetrate the stillness of the night, but Steve knows what she says, what she sounds like, her cadence and tone clear as if spoken aloud.

He doesn’t like thinking too much about the mechanics of it all. It gives him headaches.

“Nope,” Barb snips. “I’ll make sure next time I’m ripped to shreds I get a better look at the thing doing it, yeah?”

Steve watches her from behind, and sees her form flicker. He catches glimpses of bloody, shredded clothing over deep gouges in her back. His stomach turns. He looks at the ground under her feet. There’s no shadow to be cast under the faint moonlight, and the snow is undisturbed.

“Right,” he sighs.

“Maybe I’ll stop and take some notes. I could ask it a few questions before it kills me. Whatever makes this easier for you, Steve.”

“Yeah, okay, I get it!”

What they know about the whole situation isn’t a lot. But it’s more than the police, or Barb’s parents, or anyone else on this goddamn planet.

“So are we looking for like,” Steve ponders for a moment, “a den? Or something?”

They know that Barb isn’t just missing.

“A den?” Barb drawls, brow raised.

They know that whatever took Barb was big, at least. Grey, probably, but it was dark so maybe not. Toothy, with long, claw-tipped fingers. Barb wasn’t able to get the best look at it, before she was dragged away, so most of what she’s able to describe is how the different parts of it felt tearing her open.

“Don’t— come on, cut me some slack, here! I’m not a fucking… professional hunter or whatever. I don’t know what I’m doing!”

They know that Barbara Holland is dead.

“Clearly.”

Which is arguably, the most important piece of information that Steve has.

“Do you think we’ll find like… blood? Dead things?” Steve hates to even think it, let alone say it, but he’s not known for his tact, so. “...you?”

The most important piece of information and Steve can’t even share it, not without either going to prison or a fucking psych ward, neither of which Steve is particularly keen on doing.

Barb doesn’t dignify his question with any kind of response. Not even a twitch.

Steve’s hands aren’t getting any warmer. He looks up, through the branches and to the sliver of moon visible despite the clouds. Changes tracks and barrels forward. “Do we have a plan past ‘find the thing’? Or is that as far as this whole hunt goes, right now?”

Barb stops and offers him a flat look. “We?”

Steve scans the shadows when he stops, too. “Uh, yeah,” he says, face scrunched in his best duh expression when he finally makes eye contact with her again. “We’re trying to find the thing that killed you, so I’d say it’s a team effort, here.”

He doesn’t appreciate the deeply judgemental look she levels at him. “Steve. I’m dead.”

Barb’s form flickers again, almost as if she’s proving her point, but Steve knows it’s involuntary. Steve cringes when he sees her battered face. One of her eyes is hidden (or missing— probably missing) in a mangled mess of dark red that Steve can’t stare at or think about for too long before feeling ill. Her jaw and throat are ringed with deep bruises and scraped raw.

She’s back to normal in an instant, looking exactly as she had a month ago. Her glasses intact, clothes and skin pristine and undamaged, not a hair out of place from where it’s pinned.

Steve clears his throat. “Yeah, and I’m an idiot.” Steve lightly swings the bat at his side. “There is not a chance I can figure anything out alone. You know that. You told me that.”

“Yeah, because it’s true.”

“So yes, ‘we.’ This has to be a team effort. You make a plan. You tell me the plan. We find the thing. I hit it with this fucking bat.” Steve swings said bat more forcefully, aiming it at Barb. It swings straight through her. She doesn’t flinch. “Boom. Handled. Done.”

Barb looks physically pained. Or like she sucked on a lemon. “I cannot believe my only hope of getting closure is Steve Harrington,” she says to herself, for what feels like the thousandth time.

Steve flexes his fingers, hoping to bring some feeling back. Tonight is obviously going to be the first of many nights he ventures into the woods behind his house, so he’ll need to pick up some gloves. The ones he has are too bulky, and make using his bat unwieldy.

But cold does the same, so he’ll need to figure something out.

Steve sighs.

“Yeah. I’m your only hope, so it’s shit if I die of hypothermia on our first search.”

Barb doesn’t fight him on it, when he turns around and follows his tracks the hour it takes back to his backyard, even though she looks agitated.

They don’t talk the rest of the night.

The image of Barb, mauled and bloody, sitting on the diving board of his empty pool with her spine hunched and head hanging, glues itself behind Steve’s eyelids.

Steve shuts the sliding glass door behind him.

I cannot believe my only hope of getting closure is Steve Harrington.

“Yeah,” he breathes. “Me either.”

-------

YEAH so it's not an exact au. like. i fucked with the timeline and it's not just canon divergent its like. a monster hunter AND no upside down au? its COMPLICATED

just important that i say that because i made it december 1984 On Purpose. it takes place steve's senior year instead of his junior year.

hope you liked it! lemme know your thoughts if you did!! <333

#not super confident in my characterization of barb OR steve but yknow how it is #also not sold on the way i ended it but its whatever. its FINE. im proud of it regardless #stranger things #stranger things fic #stranger things fanfiction #steve harrington #barbara holland #steve sees dead people au #i feel a little bit like a liar but uhhhhhh #steddie #steddie fic #baubles writes things #<- new tag. i have never posted my writing on tumblr #i will not be tagging people for following parts because that sounds intimidating. sorry?

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unogeeks234 · 9 days

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AMAZON SNOWFLAKE

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kaydoespharmacy · 11 days

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Cold

Symptoms – sore throat, sneezing, runny/blocked nose, cough, mild fever, pressure in ears, headache, myalgia (pain in muscles)

Duration – 1-2 weeks, symptoms peak 2-3 days, incubation period 10-12 hrs

Referral criteria – suspected flu, earache not responding to analgesia, sinus pain not responding to decongestants, no improvement after 10-14 days self-medication

Complications - immunocompromised, who smoke, and with comorbidities such as diabetes mellitus, congestive heart failure, asthma, chronic obstructive pulmonary disease, cystic fibrosis, and sickle-cell disease

Sinusitis – prolonged nasal congestion and facial pain

LRTI - acute bronchitis, acute exacerbation of asthma or chronic obstructive pulmonary disease (COPD), and community-acquired pneumonia

Acute otitis media – common in younger patients

Differential diagnosis

Meningitis – high fever, drowsiness, blank expression, vomiting, loss of appetite, high pitched screaming, non-blanching rash, photophobia, severe headache, malaise

Upper airway obstruction – noisy breathing, drooling, inability to swallow.

Nasal foreign body – persistent discharge from 1 nose with no other symptoms

Management – paracetamol or ibuprofen for headache, muscle pain or fever – only continue use if distressed, change to other agent if not alleviated, don’t give both together

Paracetamol contraindicated in – liver/kidney problems, epileptic

Ibuprofen contraindicated in – pregnancy, perforated stomach, increased bleeding, severe HF, kidney or liver problems, high BP, asthma, hay fever

Intranasal decongestants – improve breathing and promote sleep and has fewer S/E than oral decongestants. Ephedrine HCL 0.5% nasal drops for 12 and older p 1-2 drops 4x daily for 1 week – contraindicated – diabetes, hypertension, hyper thyroidism, CVD, high BP, MAOI in last 2 weeks

Oral decongestants – relieve nasal congestion (phenylephrine) – max 1 week

Antitussive (cough) – dextromethorphan

Expectorants (guaifenesin)

Chlorphenamine or Beecham’s (contains phenylephrine and paracetamol) (Sedating antihistamine – dries up secretions)

Counselling points

Go to GP if

fever for more than 3 days

symptoms worsening after 5 days

symptoms not better after 10 days

follow up meeting

risk and complicated patients within the week

young children – 1 week

Headaches

Types of headaches

Primary – not associated with other conditions – migraines, tension types, cluster

Secondary – associated with other conditions – trauma/injury, vascular disorders, hyper-tension, withdrawal such as opioids, analgesics, or alcohol. Bacterial or viral infection.

Features of serious headache – referral

New severe or unexpected headache – sudden onset reaching max intensity 5 mins and new onset in over 50s

Progressive or persistent headaches that changed dramatically

Associated features – fever, impaired consciousness, seizure, stiffness, photophobia, neurological deficit, cognitive dysfunction, atypical aura (greater than 1 hour) or aura 1st time in patients using combined oral contraceptives.

Dizziness, visual disturbance, vomiting. Head trauma up to 3 months prior, triggered by coughing, sneeze, or physical exertion. Worsened by standing or lying down.

Compromised immunity

Diagnosis

Migraine without aura – at least 5 attacks lasting 4-72 hrs with unilateral location (half the face), pulsating, moderate to severe pain and aggravated by or causing avoidance of routine physical activity. Attack comes with nausea and/or vomiting, photophobia and phonophobia

Migraine with aura – 2 attacks with visual aura (zigzag lines or blind spots), pins and needles, speech/language symptoms, motor weakness, vertigo.

One aura spreading gradually for 5 mins and 2 or more occurring after

Each aura lasts for 5-60mins which is unilateral

Management – stop combined oral anticontraception – contraindicated

Ibuprofen 400mg, paracetamol 1g, advise med to be taken at start of attack – follow up 2 weeks

Tension type – recurrent episodes lasting 30 mins – 7 days with NO nausea or vomiting. May have phot/phono phobia

Bilateral (across head landscape), pressing or tight (not pulsating), mild to moderate pain, not aggravated by physical activity

Management – simple analgesia – paracetamol or NSAID

Identify comorbidities such as stress, mood disorders, chronic pain, sleep disorders to manage

Cluster headache – 5 attacks of severe/very severe unilateral orbital (around ONE eye), forehead or temporal pain lasting 15 mins to 3 hrs with nasal congestion, runny nose, eyelid oedema, sweating, facial slushing, fullness in ear or restlessness

Attacks occur between one every other day and 8 per day for more than half the time the disorder is active

Management – REFER

Advise to avoid triggers and risk of medication overuse, identify and manage comorbidities – insomnia, depression, and anxiety

Medication – occurs 15 days per month and have a pre-existing headache disorder. Regular overuse of drugs for 3 months

Management – withdrawal from medication and advice around this

Sinusitis

Sinusitis usually follows a cold and lasts less than 12 weeks

If over 12 weeks becomes chronic – risk groups are allergic rhinitis, asthma, immunosuppression

Symptoms

Adults

Nasal blockage (obstruction/congestion), nasal discharge, facial pain/pressure, frontal headache, loss, or reduction of smell, altered speech indicating nose blocked. Tenderness, swelling. Redness over cheekbone, cough, headache worse when bending or lying down. Toothache.

Children

Nose block, discoloured nasal discharge, facial pain, pressure and or cough at day or night-time

Bacterial sinusitis

More than 10 days, discoloured, pussy discharge (from 1 nose), severe local pain (1 side), fever over 38 degrees, deterioration after milder sickness

Refer to hospital immediately

If they have symptoms of acute sinusitis and;

Severe systemic infection

Intraorbital or periorbital complications, including periorbital oedema or cellulitis, displaced eyeball, double vision, or new reduced vision

Intracranial complications, including swelling over frontal bone, symptoms or signs of meningitis, severe frontal headache, or focal neurological signs

Refer to GP

Severe symptoms, painkillers don’t work, symptoms worsen, symptoms don’t improve after 1-week, recurrent infection, sudden worsening, antibiotic failure, unusual or resistant bacteria, recurrent episodes, immunocompromised, allergic cause

Treatment

Acute with symptoms less than 10 days

DON’T OFFER ANTIBIOTIC, assure that it usually self resolves without bacterial complications. Symptoms managed

Paracetamol or ibuprofen for pain, headache, and fever

Use nasal saline spray or decongestants spray

Clean nose with saltwater solution (boil 1 pint of water and add 1 teaspoon of salt and bicarbonate soda. Wash hands, stand over sink, cup the palm of 1 hand and pour small amount of solution into it. Sniff water into 1 nostril at a time, breath through mouth and allow water to pour into sink, don’t let it go into your throat. Do 3x daily)

Acute for 10 days or more with no improvement

High dose nasal corticosteroid for 2 weeks for over 12s (mometasone 200mcg 2x daily)

Counsel that It may improve symptoms but won’t make the infection any shorter, could have systemic effects, may be difficult to use correctly.

Symptoms should get better 3-5 days of treatment – REFER if not

1st line antibiotic for adult

If not life threatening - phenoxymethylpenicillin 500 mg four times a day for 5 days.

Is systemically unwell, symptoms of more serious illness or high risk of complications - co-amoxiclav 500/125 mg three times a day for 5 days.

Allergic or intolerant to penicillin - clarithromycin 500 mg twice a day for 5 days.

Pregnant or intolerant to penicillin - erythromycin 250 mg to 500 mg four times a day or

Children 1st line

Phenoxymethylpenicillin

1 to 11 months, 62.5 mg four times a day for 5 days.

1 to 5 years, 125 mg four times a day for 5 days.

6 to 11 years, 250 mg four times a day for 5 days.

12 to 17 years, 500 mg four times a day for 5 days.

If very unwell - co-amoxiclav

1 to 11 months, 0.25 mL/kg of 125/31 suspension three times a day for 5 days.

1 to 5 years, 5 mL of 125/31 suspension three times a day or 0.25 mL/ kg of 125/31 suspension three times a day for 5 days

6 to 11 years, 5 mL of 250/62 suspension three times a day or 0.15 mL/kg of 250/62 suspension three times a day for 5 days.

12 to 17 years, 250/125 mg three times a day or 500/125 mg three times a day for 5 days.

If allergic or intolerant to penicillin – clarithromycin

Under 8 kg, 7.5 mg/kg twice a day for 5 days.

8 to 11 kg, 62.5 mg twice a day for 5 days.

12 to 19 kg, 125 mg twice a day for 5 days.

20 to 29 kg, 187.5 mg twice a day for 5 days.

30 to 40 kg, 250 mg twice a day for 5 days.

12 to 17 years, 250 mg twice a day or 500 mg twice a day for 5 days.

2nd line – if symptoms are still worsening after 1st line treatment for 2-3 days

Adults – co-amoxiclav 500/125mg TD x 5 days

Children – specialist advice

ANTIHISTAMINES can be prescribed for allergic triggered sinusitis

Diabetes type 1

Body stops making insulin and the blood sugar (glucose) level goes extremely high - persistent hyperglycaemia (random plasma glucose of 11mmol/l or more). We must control glucose level with insulin injections, healthy diet and reduce the risk of other health complications. Typically occurs in children and young adults.

Symptoms of T1D- Frequently thirsty, pass a lot of urine, tiredness, weight loss and feeling generally unwell. Develops quite quickly, over days or weeks, as the pancreas stops making insulin.

Pathophysiology of T1D- Autoimmune disease (environmental & genetic factors). Antibodies attach to the beta cells in the pancreas destroying the cells that make insulin (pancreatic islet cells).

Diagnosing T1D- Simple dipstick test to detect glucose in a sample of urine BUT only way to confirm the diagnosis is to have a blood test to look at the level of glucose in your blood (level of 11.1 mmol/L or more in the blood sample indicates that you have diabetes) PLUS a fasting blood glucose level is taken (level of 7.0 mmol/L or more indicates that you have diabetes).

Management- Should be offered multiple daily injection basal-bolus insulin regimens as the first-line choice. Twice-daily insulin detemir should be offered as the long-acting basal insulin therapy. Once-daily insulin glargine may be prescribed if insulin detemir is not tolerated, or if a twice-daily regimen is not acceptable to the patient. Insulin detemir may also be offered as an alternative once-daily regimen. There are multiple types of insulin…

Rapid Acting- Insulin Aspart (Novorapid®), Lispro (Humalog®) and Glulisine (Apidra®)

Short Acting- Soluble insulin (Actrapid®)

Intermediate Acting- Isophane (Insulatard® or Humulin I®) & NPH - neutral protamine Hagedorn

Long Acting- Insulin glargine (Lantus®), detemir (Levemir®)

Combination insulins (biphasic)- e.g., Novomix 30®, Humalog Mix 25®, Humalog Mix 50®, Humulin M3® and Insuman Comb 50®

Diet & Lifestyle- Diet low in fat, salt, and sugar and high in fibre and with plenty of fruit and vegetables. If you are overweight try to lose weight, increase your physical activity even if it’s only going for a walk (community groups)

Other Health Complications- Get regular checks with your GP, podiatrist, and optometrist. Also get the flu jab every year.

Complications – microvascular, macrovascular (MI, stroke), metabolic (diabetic ketoacidosis) and hypoglycaemia (blood glucose less than 3.5mmol/l)

Psychological complications – anxiety, depression, and eating disorders and those at increased risk of developing autoimmune diseases

Suspect DKA in diabetics – greater than 11mmol/L

Increased thirst and urine frequency, inability to tolerate fluids, persistent vomiting, diarrhoea, visual disturbance, lethargy, fruity smell on breath, deep sighing when breathing and dehydrated

Management

HbA1c levels target of 48mmol/mol or lower - Measure 3-6 months but more often if not controlled

Self-monitoring – need glucose monitor, lancet, finger pricking device and testing strips

Taught at diagnosis and review technique 1 yearly.

Before breakfast, 2 hours after meals, during illness, before driving, if they feel hypo – at least 4 times a day including before and after meals and before bed.

More frequency required (up to 10x daily) if

Target HbA1c not achieved, frequency of hypo increases, during illness, before, during and after sports, planning, during and while breastfeeding.

Target glucose readings

Fasting plasma glucose level of 5–7 mmol/L on waking.

Plasma glucose level of 4–7 mmol/L before meals at other times of the day.

For adults who choose to test after meals, plasma glucose level of 5–9 mmol/L at least 90 minutes after eating.

Agree bedtime target plasma glucose levels with the person. This should:

Consider the timing of the last meal and its related insulin dose.

Be consistent with the recommended fasting level on waking.

Provide information of effects of food and drinks – carbohydrate training (match carb quantities to insulin doses)

Educate to be careful of body weight and diets, feasting and fasting, fibre and protein intake, diabetic foods and sweeteners, alcohol intake, matching carbs with insulin and physical activity

Advice on alcohol – avoid drinking on empty stomach, eat carb snack before and after drinking (extra insulin not required). Measure glucose more regularly and maintain it with carb intake. Alcohol can exacerbate or prolong hypoglycaemic effect.

Exercise – lower glucose levels and reduces CVD risk and can help weight

Sick day rules – never stop or skip insulin – dose may need altering seek advice. Check blood more frequently – 1-2 hours including in the night. Check blood or urine ketone levels – 3-4 hours including night and if 2+ or 3mmol/l or higher then contact GP immediately.

Maintain normal meal pattern where possible if not then replace meals with carb rich drinks, milk, fruit juices and sugary drinks. Aim to drink at least 3L of fluid to prevent dehydration.

Offer multiple daily injection basal-bolus insulin regimens as the first-line choice to all adults with type 1 diabetes.

Offer twice-daily insulin detemir as the long-acting basal insulin therapy

Offer a rapid-acting insulin analogue injected before meals for mealtime insulin replacement

If a multiple daily injection basal–bolus insulin regimen is not possible and a twice-daily mixed insulin regimen is preferred

Insulin pump therapy is recommended as a treatment option for adults with type 1 diabetes mellitus if condition isn’t controlled by treatment

Diabetes type 2

The body still makes insulin however, you do not make enough insulin for your body's needs OR the cells in your body do not use insulin properly (insulin resistance means you need more insulin than normal make to keep glucose levels down. Occurs mainly in people aged > 40 but inc diagnosed in younger people, commonly associated with obesity, physical inactivity, raised blood pressure, dyslipidaemia, and a tendency to develop thrombosis (CV risk).

Symptoms of T2D- Gradual (weeks-months) and can be quite vague at first. Frequent thirst, passing large amounts of urine, tiredness, which may be worse after meals. Some people also develop blurred vision and frequent infections, such as recurring thrush.

Management- Metformin HCl 1st choice for treatment of all patients (à weight loss, red risk of hypoglycaemic events and long-term CV benefits). Has an anti-hyperglycaemic effect, lowering both basal and postprandial blood-glucose conc. It does not stimulate insulin secretion and therefore, when given alone, does not cause hypoglycaemia. If metformin contra-indicated/not tolerated trial MR formulation or initial treatment should be a sulfonylurea e.g. gliclazide OR a dipeptidyl peptidase-4 inhibitor e.g. linagliptin OR Pioglitazone.

Insulin- can be added if intensification of treatment needed. If needed, bedtime basal insulin should be initiated, and the dose titrated against morning (fasting) glucose.

Diet & Lifestyle- Avoid foods heavy in saturated/trans fats, beef and processed meats, sugary drinks, high-fat dairy products and salty/fried foods & have fibrous fruits and vegetables, high omega-3 fatty acid food and poly/monosaturated fats. Lose weight and inc physical activity (min 5 x 30 min brisk walk / week) and smoking cessation. Also see optician regularly in case of damage to retina, GP and podiatrist.

EXTRA INFO FOR BOTH

Holiday- Pack about x3 the amount of insulin needed, test strips, lancets, needles or glucose tablets you would use, in case you need it (take cool bag to avoid insulin getting too hot). Carry your medicine in your hand luggage just in case checked-in bags go missing or get damaged (insulin can freeze and render it unusable). If injecting (i.e. will have needles/sharps) get a letter from your GP that says you need it to treat diabetes. If you use a pump or CGM, check with your airline before you travel about taking it on board as may require paperwork for medical equipment. If you use a pump, pack insulin pens in case it stops working. Take plenty of snacks in case there are any delays. Do not put your pump through the hand luggage scanner – let airport security know so they can check it another way.

<18 & Diabetic- Paediatric diabetes care team until 18 will help w injecting insulin, testing blood glucose levels, and diet. They can give advice on school or nursery and talk to your child's teachers and carers. Initially, every 1 - 2 weeks but will eventually be every 3 months.

Check Ups Needed- Annually get feet checked by podiatrist to check for loss of feeling in your feet, and for ulcers and infections. Get your eyes checked to check for any damage to blood vessels in the eyes, and checks for high blood pressure, heart, and kidney disease by your GP, also ensure to book in annually for a flu jab. Every 3 months have a blood sugar test (HbA1C test) checks your average blood sugar levels and how close they are to normal when newly diagnosed, then every 6 months once you're stable (~48-53 mmol/mol recommended).

Education- free education courses to help you learn more about and manage your diabetes, your GP will need to refer you. Diabetes UK run local charities for extra support, their website plus the NHS website offers a lot of diabetes information and advice. Maybe invest in a medical ID to carry w you.

Extra Lifestyle Advice- Eat a meal w carbs (e.g. pasta) before you drink alcohol and make sure people around you can recognise a hypo, choose diet soft drink mixers where possible, check your blood glucose regularly/before bed/the next day, drink plenty of water the next day. Avoid hypos by eating the right amount of carbs before, during and after exercise, adjust your insulin and check your blood glucose regularly, drink plenty of water. Recommended to have HbA1c <48mmol/mol when pregnant as high blood glucose levels can harm your baby, especially in the first 8 weeks of pregnancy, also a risk of having a large baby, which can cause complications during labour. Speak to your diabetes team If you're planning to get pregnant or if you get pregnant unexpectedly.

Item for disposal

Method of disposal

Needles

Sharps bin

Lancets

Sharps bin

Used blood test strips

Sharps bin

Leftover/expired insulin

Sharps bin/return to pharmacy

DVLA- tell the DVLA you’re diabetic or you could get fined due to hypoglycaemia/low sugar levels crisis. Check your blood glucose no longer than 2 hours before driving, check your blood glucose every 2 hours if you're on a long journey, travel with sugary snacks and snacks with long-lasting carbs, like a cereal bar or banana. If you feel your levels are low: stop the car when it's safe, remove the keys from the ignition, get out of the driver's seat, check your blood glucose, and treat your hypo, don't drive for 45 minutes from when you feel normal again.

Sharps Removal- Patients issued a sharps bin from the diabetes clinic/hospital on first diagnosis. Some pharmacies offer this sharps disposal service, or the diabetes clinic do too. Can arrange w GP/LHB for sharps collection (Cardiff Council does NOT offer kerbside sharps disposal)

Other Technologies- Insulin Pump (attached to skin via tiny tube which is replaced every 2-3 days & pump moved to diff part of body) will deliver a set background amount of insulin into blood day and night, can add your extra mealtime insulin using the pump. Continuous glucose monitoring (CGMs) means you can check your sugar levels at any time (see patterns in your levels, sends an alert if glucose too high/low) but as interstitial fluid sugar readings are a few mins behind your blood sugar levels you'll still need to do finger-prick checks every now and then. It’s a sensor you attach to your abdomen which needs replacing every 7 days, but some models can be worn for months. Free Style Libre is a flash glucose monitoring system measures your glucose levels continuously throughout the day via interstitial fluid (few mins behind). Attach sensor to your arm and a reader will scan to see your sugar levels (can also use a smartphone app to scan the sensor), sensors usually last for 14 days.

Testing blood glucose

Glucose monitor, specific in-date test strips, primed lancing device and cotton wool pad.

PRIMING LANCET

Twist cap off lancing device

Place fresh lancet into device so grooves line up and twist off the cover, so the needle is visible – change lancet every time so you don't get skin infections

Replace device cap - it should click and then adjust the depth metre – how far the needle will puncture – this is personal preference

Pull sliding barrel at bottom of device back to prime the lancet

CALIBRATING MONITOR

Turn on monitor – put new in-date test strip inside it and test it with in-date control solution – to make sure readings are correct

Do this every time you open a new pack of test strips, if you damage your monitor and if you think the readings are wrong.

TESTING process

Wash hands with warm water and soap and dry. Then rub hands for 10 seconds – warms hands to improve blood flow to fingers

Turn on monitor and place strip inside and wait for it say it’s ready for blood

Place device firmly on side of the finger (less nerves so less painful) and press release button then remove device from site. - change fingers regularly to stop hardening of skin.

Wipe first drop of blood away with cotton pad, use second one to test make sure by touching the blood onto the test strip

If successful wipe blood with cotton pad and apply plaster

Note readings

Remove cap of device exposing lancet. Place lancet cover on table and press lancet hard into this blue plastic cover – this will cover the needle and make it easy to remove

Place lancet and cotton pad in bin

Injecting insulin

Inject in stomach, thighs, or buttocks. Inject an inch away from previous site. Prevents lumps – this reduces absorption of insulin.

check that its correct insulin and is in date. Always check manufacturer’s instructions.

Wash hands with soap and warm water

Attach needle to pen – peel back cover, screw cap onto pen, remove white outer cover and the green cover to expose needle – change needle every time

Dial to 2 units and push plunger so you can see insulin coming out – to make sure no air stuck in there – can take multiple goes in new pens

Set correct dose

Press directly into skin and inject slowly – count to 10

Remove needle straight without bending it

Use the white outer cap to remove the needle and dispose in yellow sharps bin

Asthma

Symptoms – episodic, worse at night/early morning, triggered by exercise, infection and exposure to cold air or allergens. Triggered by emotion and laughter in children. In adults by NSAIDS and BB use.

Common with atopic eczema, dermatitis and allergic rhinitis and family history

ACUTE EXACERBATION OF ASTHMA IN ADULTS

First-line treatment for acute asthma is a high-dose inhaled short-acting beta2 agonist (such as salbutamol) given as soon as possible. For patients with mild to moderate acute asthma, a pressurised metered-dose inhaler and spacer can be used. For patients with acute severe or life-threatening symptoms, administration via an oxygen-driven nebuliser is recommended, if available. If the response to an initial dose of nebulised short-acting beta2 agonist is poor, consider continuous nebulisation with an appropriate nebuliser. Intravenous beta2 agonists are reserved for those patients in whom inhaled therapy cannot be used reliably.

In all cases of acute asthma, patients should be prescribed an adequate dose of oral prednisolone. Continue usual inhaled corticosteroid use during oral corticosteroid treatment. Parenteral hydrocortisone or intramuscular methylprednisolone are alternatives in patients who are unable to take oral prednisolone.

IN CHILDREN OVER 2

First-line treatment for acute asthma is an inhaled short-acting beta2 agonist (such as salbutamol) given as soon as possible. For children with mild to moderate acute asthma, a pressurised metered-dose inhaler and spacer device is the preferred option. The dose given should be individualised according to severity and adjusted based on response. For children with acute severe or life-threatening symptoms, administration via an oxygen-driven nebuliser is recommended, if available. Parents/carers of children with acute asthma at home, should seek urgent medical attention if initial symptoms are not controlled with up to 10 puffs of salbutamol via a spacer; if symptoms are severe, additional bronchodilator doses should be given as needed whilst awaiting medical attention. Urgent medical attention should also be sought if a child's symptoms return within 3-4 hours; if symptoms return within this time, a further or larger dose (maximum of 10 puffs of salbutamol via a spacer) should be given whilst awaiting medical attention.

COPD

Symptoms - persistent respiratory symptoms and airflow obstruction, which is usually progressive and not fully reversible, exertional breathlessness, chronic/recurrent cough, or regular sputum production, wheeze

Treatment – education on condition and risk factors, smoking cessation, pneumococcal and flu vaccination yearly, treatment of associated comorbidities

1st line – SABA or SAMA to relieve breathlessness and improve exercise tolerance – reviewing medication, adherence, and inhaler technique regularly

THEN IF they have NO asthmatic features or no features of steroid responsiveness – offer LABA AND LAMA

If they continue to have day-to-day symptoms, consider 3-month trial of LABA+LAMA+ICS

If NO improvement go back to LAMA+LABA only but if it works continue and review annually

If they have asthmatic or steroid responsiveness features offer LABA+ICS if they have day to day symptoms of 1 severe or 2 moderate exacerbations a year, then offer LABA+LAMA+ICS

WITH ICS DISCUSS RISK OF USING ICS including pneumonia

Acute exacerbation of COPD – triggered by infections, smoking and environmental pollutants

Severe breathlessness, increased cough, increased sputum production and change in colour, increased wheeze, and chest tightness, cold or sore throat, reduced exercise tolerance, ankle swelling, increased fatigue, and acute confusion

FOR SEVERE exacerbation – ADMISSION

FOR non-severe – increase dose or freq of SABA and maybe change to nebuliser for ease of admission

If no contraindications with significant increase in breathlessness – offer 30mg oral prednisolone OD x 5 days or if caused by infection then amoxicillin 500mg TD x 5 days, doxycycline 200mg day 1, 100mg OD x 5 days, or clarithromycin 500mg BD X 5 days

Epilepsy

Cause – abnormal excessive or synchronous brain activity

Symptoms

Short-lived (less than 1 minute), abrupt, generalised muscle stiffening with rapid recovery — suggestive of tonic seizure.

Generalised stiffening and subsequent rhythmic jerking of the limbs, urinary incontinence, tongue biting —suggestive of a generalised tonic-clonic seizure.

Behavioural arrest — indicative of absence seizure.

Sudden onset of loss of muscle tone — suggestive of atonic seizure.

Brief, 'shock-like' involuntary single or multiple jerks —suggestive of myoclonic seizure.

Management

During seizure – protect from injury by placing in recovery position. If tonic-clonic seizure is prolonged (more than 5 mins) or recurrent – emergency buccal midazolam or emergency admission

Annually reviewed – assess seizure control, how it’s affecting QOL, adverse effects and compliance with drug

Women of childbearing age – 13 to 60

Epileptic women not treated with drugs or on non-enzyme inducing antiepileptic (except lamotrigine) – contraceptive options are same as general population

Woman on exyzme-inducing drugs – drug can reduce effectiveness of combined hormonal contraception, progestogen-only pills, transdermal patches, the vaginal ring, and progestogen-only implants. OFFER medroxyprogesterone acetate injections or an intrauterine method (copper intrauterine device or the levonorgestrel-releasing intrauterine system)

Woman on lamotrigine – oestrogen containing contraceptive reduces efficacy of lamotrigine

USE progesterone only instead but educate them to report signs of lamotrigine toxicity

Category 1 (ensure the person is maintained on a specific manufacturer's product) — phenytoin, carbamazepine, phenobarbital, primidone.

S/E – common and usually mild, advise to report and can usually be fixed with dose adjustment or change of drug

Sedation and dizziness, suicidal thoughts and behaviour, acute psychotic reactions, weight gain and loss, skin rashes.

Safe in pregnancies – lamotrigine (Lamictal) and levetiracetam (Keppra) are safest options

Anxiety

Uncontrollable widespread worry and range of cognitive and behavioural symptoms

Slow onset and symptoms don’t usually improve but are better controlled with intervention

Diagnosis – worry associated with restlessness, insomnia and muscle tension, fatigue, poor concentration, irritable. ALWAYS ask about alcohol and drug use including OTC

Treatment

Establish diagnosis and severity of anxiety and any other comorbidities (usually insomnia and depression and whichever is the most pressing is treated first) – explaining the disorder and treatment opportunities and starting them with active monitoring of symptoms either self or through regular meetings

Offer CBT – non-facilitated self-help for 6 weeks, individual guided self-help, educational groups

High intensity CBT, applied relaxation or drug therapy

Drug therapy – 1st line is SSRI (sertraline, paroxetine, or escitalopram) 2nd line SNRI (duloxetine or venlafaxine). If both contraindicated or intolerable then Pregabalin.

Review effectiveness and ADR every 2-4 weeks during first 3 months then every 3 months.

Counsel on common effects during treatment initiation (suicidal thoughts and worsening of anxiety) but importance of reporting this instead of withdrawing from drug

SSRI – don’t take NSAIDS or if prescribed take with PPI

For pregnant women step 3

DO NOT give benzo or antipsychotics in primary care

Benzodiazepines (SCH 3 and 4)

Most commonly used anxiolytics and hypnotics

Short rem relief (2-4 weeks only) of anxiety that is severe, disabling, or causing the patient unacceptable distress

use to treat short-term ‘mild’ anxiety is inappropriate

Sch 4 CDs, apart from temazepam

Sch 3 (CD no register) and midazolam

Pharmacological effects of benzodiazepines

Sedation, sleep induction

sleep, but can still cause arousal

decreased anxiety, amnesia at higher doses

muscle relaxation (both midbrain and spinal effects)

anticonvulsant activity

Reduced aggression

Depression

Persistent low mood and/or loss of pleasure in most activities and range of emotional, cognitive, physical, and behavioural symptoms

Diagnosis

Low mood

Loss of interest/pleasure from normally pleasurable activities (anhedonia)

Reduced energy (fatigue)

Low self-esteem; feelings of guilt

Inability to think/concentrate

Altered psychomotor activity

Sleep disturbance; early morning wakening

Altered appetite

Suicidal thoughts

Diagnosis requires 2 core symptoms plus 2 or more others present for most of the day on most days for the last 2 weeks

Differential diagnosis

Ensure symptoms are not caused by physical illness, alcohol, medication, or illicit drug use

The symptoms aren’t caused by normal grief (death of family) – maybe consider very long grief

Never been a manic (severe levels of high mood) or hypomanic (to a reduced level) episode

Treatment

Dependant on accurate assessment and diagnosis of depression

Psychological

CBT, behavioural activation, interpersonal psychotherapy, problem solving therapy

Social

Identify stressors and work on strategies/signposting to other supporting organisations

Biological – moderate to severe

Antidepressant therapy or antidepressant and antipsychotic combination therapy in psychotic depression

Drug classes

Tricyclic antidepressants (TCAs) e.g., amitriptyline

Selective serotonin reuptake inhibitors (SSRIs) e.g., fluoxetine

Serotonin and NA uptake inhibitors (SNRIs) e.g., venlafaxine

Monoamine oxidase inhibitors (MAOIs)

Irreversible e.g., phenelzine (MAO-A and B)

Reversible e.g., Moclobemide

Atypical antidepressants e.g., Mirtazapine

Noradrenaline reuptake inhibitors (NRIs) e.g., Atomoxetine

TCA - S/E – Short lasting (days) sedation, confusion, and Incoordination in both normal and depressed patients, antimuscarinic effects, dry mouth, blurred vision, decreased mucus production. Dangerous CV effects in OD

Severe depressive at risk of suicide shouldn’t be given TCA

Interactions – potentiation of the effects of alcohol – alcohol is a depressant and will only compound the depressive effects

SSRI’s - S/E – nausea, anorexia, insomnia, and loss of sexual function

Less anticholinergic side-effects and less dangerous in OD than TCAs. Prolonged QTc – cardiovascular complications risk with citalopram interactions – NSAIDs, Anticoagulants, triptans

SNRI’s - S/E – significant withdrawal effects – have short half-lives so need to be taken regularly to avoid these effects. Complex nature of TCAs makes them difficult to prescribe to complex patients unlike SNRIs

Interactions – NSAIDs and anticoagulants

MAOIs - S/E – antimuscarinic effects, restlessness as a result of CNS excitation

Interactions – serious food and drug reactions e.g., cheese (tyramine from food such as cheese is broken down by MAO. The lack of breakdown from MAOIs can lead to tyramine actively displacing neurotransmitters such as 5HT, DA, NA – causing hypertensive crisis

VERY IMPORTANT COUNSELLING POINTS

No other drugs or illicit drugs with this

Side effects

Drug and food interactions are unacceptable.

“Cheese reaction”: this occurs when amines that are generated during fermentation, like tyramine, are ingested and absorbed from the gut. (The main danger is ripe cheese, yeast products - Marmite).

Large rise in systemic tyramine indirectly results in a large release

of catecholamines

Hypertensive crisis characterised by throbbing

headache, tachycardia & cardiac arrhythmias.

Same can occur with drugs (Pseudoephedrine)

Atypical antidepressants - S/E- sedation, weight gain, increased appetite – good in patients with anorexia or depression causing loss of appetite or weight

Blood disorders – counselling

Withdrawal issues

Can be used with other antidepressants that cause sleep issues

Interactions – alcohol

FDA black box warning – suicide

Treatment

Mild symptoms – psychological therapy

Persistent mild symptoms or moderate to severe symptoms – combination of psychological and drug therapy

1st line treatment usually SSRIs

2nd line switch to alternate SSRI

3rd line switch to different class (normally an SNRI)

Practical issues

Initiating an antidepressant can cause feelings of anxiety consider co-prescribing short course of benzodiazepines to counteract the anxiety

During the first few weeks of antidepressant treatment can have worsening suicidal thoughts with improved motivation so ensure counselling and regular reviews

Consider prescribing limited supply of meds to reduce chance of OD

Side effects often transient and improve with time

Caution when switching antidepressants – table of different half-lives and how to taper them

Treatment approach

If no response to 3 antidepressants, then check concordance, review diagnosis, and consider if social problems are maintaining depression

Consider augmentation – addition of drug to the current therapy

Mirtazapine – sleep

Quetiapine – mood

Aripiprazole

Lithium – mood stabiliser

Lamotrigine – mood stabiliser

Electroconvulsive therapy

Response

2-4 weeks usually for response to be seen (longer in elderly)

Improvement greatest during weeks 1-2

If no response during 2–4-week period, consider first increase in dosage then if again limited efficacy, then switch to alternative

Extended duration if treatment trial will lead to additional benefit in some

Differences between drugs

Mirtazapine, escitalopram, venlafaxine, and sertraline

more efficacious than

duloxetine, fluoxetine, fluvoxamine, paroxetine and reboxetine

Reboxetine less effective overall

Escitalopram and sertraline

better tolerated than

duloxetine, venlafaxine, fluvoxamine, paroxetine and reboxetine

Preventing relapse

Relapse rate 3-6 months post remission is 50% with no drug treatment

A/D treatment reduces absolute risk of relapse by about 50%

After 1st episode continue for 6-9 months

After 2nd episode continue for 12 months

After 3rd episode continue for 2 years

Insomnia – difficulty in getting to sleep or staying asleep long enough to feel refreshed the next morning

Causes

Recreational drugs

caffeine, nicotine, alcohol, cannabis)

Medicinal drugs

anticonvulsants, antipsychotics, b-blockers, SSRIs, MAOIs, steroids, decongestants, Alpha agonists and antagonists, narcotic analgesics

Drug withdrawal

from CNS depressants (eg alcohol, anxiolytics/hypnotics)

Physiological

Diet, late night exercise, shift work (night and evening work)

Environmental

Noise, bright lights, extremes of temperature

Medical conditions

Psychological - anxiety, depression, grief, stress

Non-psychological eg chronic pain, gastric reflux, asthma, sleep apnoea

Types of insomnia

Primary insomnia - insomnia not attributable to a medical psychiatric or environmental cause

Secondary insomnia- insomnia secondary to another condition

Transient (2-3 days) – caused by changes in routine (for eg. change in time zone, alteration of shift work)

Short term (<3 weeks) – may result from temporary environmental stress

Chronic insomnia (>3 weeks) –usually secondary to other conditions

Treatment

FIRST LINE IS ALWAYS NON-DRUG treatments e.g., lifestyle changes and CBT

Drug therapy – Hypnotics

Benzodiazepines

Benzodiazepine-like drugs (Z-class)

melatonin

BEFORE hypnotic is prescribed the cause of insomnia must be established and where possible, underlying factors should be treated

NICE recommends

if hypnotic medicine is the appropriate way to treat one for only short periods of time and strictly according to the licence for the drug. (Usually, 1-2 weeks and max 4 weeks) and should be prescribed on a weekly basis

Benzodiazepines

Most benzodiazepines

decrease time taken to get to sleep

in individuals who habitually sleep <6hr, the drug increases duration of sleep

Few short-acting BDZs recommended for insomnia (short-term treatment – max 2-4 weeks)

Should only be used when SEVERE, DISABLING or causing EXTREME DISTRESS

Benzodiazepine – like drugs

Z -Hypnotics – Zaleplon, zopiclone, zolpidem (Short acting – t1/2 < 8 hr)

Short term use only (2-4 weeks)

Lack of anxiolytic effects –drowsiness or dizziness - just induce sleep

Melatonin treatment

Prolonged release melatonin available for primary insomnia in over 55yr olds (can be used up to 3 weeks)

Antihistamine gen 1 – can cause drowsiness

Anxiolytics

Kalms, Kalms day, Karma, Karmamood, Potters Newrelax, Relaxherb, Stressless

Hops, valerian, passionflower, passiflora, vervain, St John’s Wort

Sedatives

Kalms night, Kalms sleep, Dormesean, Niteherb, Nytol herbal, Potters Nodoff, sominex herbal

Hops, valerian, vervain, skullcap, wild lettuce, passiflora

Some herbal remedies do contain active ingredients so be careful of interactions

Lifestyle changes – promote sleep hygiene

establishing fixed times for going to bed and waking up

trying to relax before going to bed

maintaining a comfortable sleeping environment avoiding napping during the day

avoiding caffeine, nicotine, and alcohol late at night

avoiding exercise within four hours of bedtime

avoiding eating a heavy meal late at night

avoiding watching or checking the clock throughout the night

using the bedroom mainly for sleep if possible

avoid going on phone, looking at screens immediately before bed or whilst in bed

ADHD

Persistent developmentally with inappropriate levels of over reactivity, inattention and/or impulsivity

Diagnosis – based on observation there are no biomed tests

Symptoms – 9 symptoms across 2 domains

Hyperactivity/impulsivity

Inattention

Can be combined type or dominant in one

ADHD – Predominantly inattentive type

Fails to give close attention to details or makes careless mistakes.

Has difficulty sustaining attention.

Does not appear to listen.

ADHD – predominantly Hyperactive/impulsive type

Fidgets with hands or feet or squirms in chair.

Acts as if driven by a motor.

Blurts out answers before questions have been completed.

Difficulty waiting or taking turns.

Interrupts or intrudes upon others.

ADHD – Combined type

Patient meets both sets of inattention and hyperactive/impulsive criteria

ADHD – Differential diagnosis

Sensory impairment – leading to under or over-sensitivity to triggers

Epilepsy and related states – could present as inattention

Effects of head injury

Acute or chronic medical illness

Poor nutrition – linked to poor behavior – not directly linked to ADHD

Sleep disorders – linked to poor behavior – not directly linked to ADHD

Side effects of medication

School or classroom difficulties – bullying or other factors

Large links to exposure to smoking and drinking during pregnancy, childhood illness such as meningitis or other viral infection, low birthweight/prematurity. HIGH heritability

Treatment

Mild-moderate –1st line - parent-training/education programmes with parent and child, group based or individual sessions. Teachers receive ADHD training and offer intervention in schools.

2nd line – CBT or social skills training

3rd line – DRUG THERAPY ONLY FOR SEVERE and should be offered along with psychological, behavioural, and educational interventions

Drug therapy

Methylphenidate – generally first choice

Atomoxetine - if other tics, Tourette's syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present

D-amphetamine – ONLY if other drugs ineffective at raised doses – CD2 high risk in addiction and dependence and misuse so used as last resort

Decide which drug treatment to use based on:

their different adverse effects

potential problems with compliance (for example, if a mid-day dose is needed at school)

potential for drug diversion (taken by others) and misuse

preferences of the child or young person and their parent or carer

When a decision has been made to treat children or young people with ADHD with drugs, healthcare professionals should consider: –

methylphenidate for ADHD without significant comorbidity

methylphenidate for ADHD with comorbid conduct disorder

methylphenidate or atomoxetine when tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present

atomoxetine if methylphenidate has been tried and has been ineffective at the max dose, or the child intolerant to low or moderate doses of methylphenidate.

Atomoxetine

Closely observe children or young people taking atomoxetine for agitation, irritability, suicidal thinking, and self-harming behavior, particularly during the initial months of treatment, or after a dose change.

Liver damage in rare cases (usually presenting as abdominal pain, unexplained nausea, malaise, darkening of the urine or jaundice).

Treatment of adults

In adults, methylphenidate normally first line treatment

Consider atomoxetine or dexamphetamine if symptoms do not respond to methylphenidate or the person is intolerant to it ~6 weeks.

Selection of appropriate medication

Immediate-release preparations if more flexible dosing is required or during initial titration to using methylphenidate, consider determine correct dosing levels

If there is a choice of more than one drug, use the drug of lowest overall cost

modified-release preparations for convenience…

their pharmacokinetic profile,

improving adherence,

reducing stigma (because the drug does not need to be taken at school)

reducing problems of storing and administering controlled drugs in schools

abuse liability

AUTISM

Symptoms

Socialization

Impaired use of non-verbal behaviors to regulate interactions

Delayed peer interactions, few or no friendships, and little interaction

Absence of seeking to share enjoyment and interests

Delayed initiation of interactions

Little or no social reciprocity and absence of social judgment

Communication

Delay in verbal language without non-verbal compensation (gestures)

Impairment in expressive language and conversation, and disturbance in pragmatic language use

Treatments

NEED early diagnosis and defined biomarkers

Currently intervention is through family and educational support

Only some specific programs have an evidence base

Aim is to ‘improve the functional status…through skill acquisition in core areas’

Eg developing relationships

Achieving social and environmental milestones through play

Positive reinforcement of social communication

Pharmacological treatments for co-morbidities

Developmental

Hyperactivity/impulsivity (see ADHD)

Psychiatric

SSRIs, other antidepressants for depression

atypical antipsychotics for OCD

SSRI or a2 agonists for anxiety

Behavioural

Atypical antipsychotics (irritability, aggression)

Sensory

Neurological

anticonvulsants and fits, a2 agonists for tics

Gastrointestinal

Sleep disruption

melatonin and clonidine

Dementia

Symptoms –

Higher cognitive function affected

Memory, thinking, comprehension, learning capacity, language (speaking and understanding it)

Daily living activities/emotional behaviour (non-cognitive symptoms)

Behavioural and psychological symptoms of dementia (BPSD) – include agitation, apathy, depression, anxiety, delusions, hallucinations, irritability, and wandering

Treatment -

Acetylcholinesterase (AChE) inhibitors (donepezil, galantamine, and rivastigmine) — as monotherapies for managing mild to moderate Alzheimer's disease.

Memantine (a N-methyl-D-aspartic acid receptor antagonist):

As monotherapy for managing Alzheimer's disease for people with moderate Alzheimer's disease who are intolerant of, or have a contraindication to, AChE inhibitors, or for people with severe Alzheimer's disease.

In addition to an AChE for people with established moderate or severe Alzheimer's disease who are already taking an AChE

For people with non-Alzheimer's dementia the use of AChE inhibitors or memantine is unlicensed, but they may be prescribed by a specialist for people with:

Mild to moderate dementia with Lewy bodies:

Donepezil or rivastigmine are recommended first line.

Galantamine is an option if donepezil and rivastigmine are not tolerated.

Severe dementia with Lewy bodies:

Donepezil or rivastigmine are recommended.

Vascular dementia:

AChE inhibitors or memantine are options if the person has suspected comorbid Alzheimer's disease, Parkinson's disease dementia, or dementia with Lewy bodies.

Risperidone and haloperidol are the only antipsychotics licensed for treating non-cognitive symptoms of dementia, although other antipsychotics are often prescribed off-label for this purpose.

Acetylcholinesterase inhibitors

NMDA receptor antagonist

Cholinesterase inhibitors for mild to moderate AD (eventually stop working)

NMDA receptor antagonist for severe AD and moderate AD in some cases

Treatment must be started only by a specialist clinician

Rheumatoid arthritis

Inflammatory disease causing persistent symmetric joint synovitis

Presents as pain and joint stiffness with heat and swelling progressing at rest and after periods of inactivity with malaise, fatigue, fever, and weight loss

Risk factors – smoking, eating large amounts of red meat, drinks excessive coffee

Symptoms

Joints

Pain

Swelling

Stiffness

Systemic

Fatigue, depression, irritability

Anaemia

Flu-like symptoms, such as feeling generally ill, hot, and sweating

Pain worse in morning

Treatment

Drugs, mild exercise (enhance flexibility of joint and muscle strength), lifestyle changes (rich antioxidant diet, no smoking)

Main types of RA meds

NSAIDs (short term symptomatic relief) – reduce inflammation. OTC (ibuprofen, naproxen). POM (celecoxib, etoricoxib)

S/E – GI irritation, ulcers (use at lowest dose and take with food, use PPI to lessen effects)

Caution – asthmatics and renal impairment and patients with increased CV risk

Disease-modifying anti-rheumatic drugs (DMARDs) – 1ST LINE for active RA (methotrexate, sulfasalazine)

S/E – Nausea, diarrhoea, oral ulceration, alopecia, cough, SOB, bone marrow suppression – CAN BE REDUCED by co-prescribing FOLIC acid 1mg daily

Biological therapies (type of DMARD) – used when DMARDS don’t control RA

Glucocorticoids – short term treatment when starting new DMARD for rapid symprom control - also used in flares

Analgesics (painkillers)

Drug Treatment Schedule

Start two DMARD regime once diagnosed, using titration regimens

Use anti-inflammatories (NSAIDs), paracetamol with or without corticosteroids until effective

Review after 6 months: increase dose or switch as clinical condition determines.

Patient counselling in RA

Place of drugs in therapy

Onset of action

Side effects

Immunosuppression

Regular painkillers

Regular monitoring including blood tests

Dexterity aids, prescription services

Osteoarthritis

Predominantly non-inflammatory and caused by cartilage loss from synovial joints and bone remodelling due to excessive and repeated overloading on weight bearing joints or stress of a joint over tome and specific injuries

Risk factors – genetic, age, gender, obesity, damage, occupational, and stress

Symptoms

Pain – tends to be worse when using the joint and at end of the day (Worsens on use, resolves at rest)

Stiffness – feel stiff after rest, usually wears off as you get moving

Grating or grinding sensation (crepitus) – joints creak or crunch as you move

Swelling – may be caused by osteophytes (bone outgrowth) or caused by synovial thickening and extra fluid

Muscles around joint look thin/wasted

Unable to use joint normally – doesn’t move as freely or far as normal

Joints give way – muscles have weakened, and joint is less stable

Management

Provide information on sources of advice and support

Advice on self-care strategies such as;

Weight loss, local muscle strengthening exercises and aerobic fitness training

Appropriate footwear, local heat, or cold packs

Odder psychosocial support – career and occupational health assessments if needed

Advice on simple analgesia

Arranging regular reviews to assess response to treatment

MANAGEMENT GOAL – pain reduction and symptomatic relief

First line:

Paracetamol regularly – 4g daily

Topical NSAIDs

Additional treatment:

Oral NSAIDs– not first line

-Start with ibuprofen

-Monitor for side effects

-Possible place for topical therapy

Topical capsaicin – adjunct and helpful in knee and hand – works by stimulating then decreasing the pain sensation

Corticosteroid injection: â pain and inflammation of flare-up

Role of pharmacist

Counselling:

dosage regimen

side effects

warnings

Monitoring for side effects

Weight loss advice

Physiotherapy advice

Compliance aids & living aids

Gout

Type of inflammatory arthritis – causes severe pain and damage to joints

Caused by abnormal high levels of uric acid in blood which deposits urate crystals in joints and tissue

3 phases

Asymptomatic hyperuricaemia – can remain in this stage for life

Acute attack of gouty arthritis – can vary from months to years before another attack

Final period of chronic tophaceous gout – nodules effecting joints

Treatment

Acute

Ice

Rest affected joint

NSAIDs – short term, 7-14 days, high dose, for pain relief and anti-inflammatory

Colchicine (Dose: 500mcg 2-4 x daily until symptomatic relief or SE (stomach cramps, diarrhoea, vomiting)), steroids (used when NSAID and colchine is contraindicated or not useful)

Choice of drug dependant on comorbidities and renal function (NSAID cause fluid retention whereas colchicine doesn’t)

Colchicine use limited as it can have sudden toxicity at higher conc

Combination treatment can be used as well if monotherapy isn’t controlling the attack

Long term treatment to reduce urate

Lifestyle modifications (reduce dietary intake)

Drug therapy: Allopurinol (1st line – offer to all, 100mg od, increased in 100mg increments every 2-3 weeks) S/E – rashes

Febuxostat (2nd line only use when allopurinol intolerant or contraindicated – 60mg OD dose)

Monitor urate level – aim for < 360 μmol/L or 6 mg/dl (critical level)

Muscoskeletal

Sprain

Commonly ankle, wrist, thumb, knees – pain, swelling, tenderness, bruising, disabled use and no weight

Strain

Common in legs and lower back – pain, swelling, bruising, red, and reduced function

BOTH

Self-limiting gets better in 4-6 weeks and full recovery in 12 weeks

Non-pharma advice

PRICE (Protect, Rest (48-72hrs), Ice immediately after, Compression bandages and Elevate to reduce swelling

Reduce HARM (Heat, alcohol, running and massaging for 72hrs.

Avoid NSAIDs for 72hrs

Exercises for sprains

Gently move joint in all directions to increase and maintain flexibility (lack of movement can delay recovery BUT severe sprains with complete lack of movement rest for 10 days first)

Treatment – topical and oral analgesics

Refer – severe pain, possible break or fracture, no alleviation with OTC meds

Lower back pain

Symptoms – pain, tension, soreness, stiffness without underlying cause

6 weeks usual recovery can be up to 12 weeks

Advice

Back exercises, improve posture, yoga, avoid lying or sitting for too long, remain active.

Sleep in different positions, pillows between legs, under knees, hot baths, hot water bottles, ice packs.

Treatment

OTC – topical analgesics or co-codamol if still painful

Refer

No improvement in 3 days, continues for more than 6 weeks, pain travels higher, pain after injury, younger than 20, older than 50, pain affects sleep, unsteady on feet, unexplained weight loss

EMERGENCY

Pins and needles in back, genital, bum, both legs, lose urine or bowel control

Conjunctivitis

Symptoms

Bacterial

Viral

Allergic

Eyes affected

1 or 2

Both

Discharge

Pussy

Watery

watery

Sensation

Gritty

Itchy

Co-presenting symptoms

None

Cough/cold

Rhinitis

If pussy, red or gritty it is contagious – allergic ISNT contagious

Advice

Don’t wear contacts, hold cold flannel on eyes for few mins to cool them, use FBC water to gently wipe lashes and clean off crust and clean with cotton wool pad. Use a different one for each eye

Control spread by – reg wash hands with hot soapy water, cover mouth and nose when sneezing, don’t share towels or pillows and don’t rub eyes

Refer

Baby less than 28 days old with red eyes, allergic reaction, or spots on eyelids. For all – symptoms not resolved after 2 weeks

111 - Severe pain, sensitive to light, sudden changes to vision

Treatment

Viral – self-limiting, use hygiene and non-pharma advice

Allergic – Opticrom eye drops (Adults and child – 1-2 drops in each eye up to 4x daily)

Bacterial – over 2, chloramphenicol drops/ointment (Optrex Bacterial Conjunctivitis 1%w/w Eye Ointment) - apply a small amount of ointment in the affected eye 3-4 times daily for 5 days

Blepharitis

Symptoms

NOT contagious, rims of eyelids are inflamed, burning, soreness or stinging in the eyes, crusty lashes that stick together, itchy eyelids

Advice

Clean eyelids at least 1x daily, clean eyes even if symptoms clear, don’t wear contacts, or eye makeup

Cleaning eyes – soak a clean flannel/cotton wool in warm water and place on eye for 10 mins, gently massage eyelids for 30 secs, clean lids using cotton wool. Baby shampoo at 10:1 ratio good.

Refer

No improvement after 2 weeks of cleaning eyes

Treatment OTC

Brolene eye drops – 1-2 drops in each eye up to 4 x daily. If not better in 2 days refer

Dry eyes

Symptoms

Dry feeling, sensation of something in eye, burning, grittiness, itching, light sensitivity, over-blinking, redness, excess tears (randomly tearing)

Causes – over 50, contacts, digital screens, AC, windy/cold/dry/ dusty environment, smoking, alcohol, meds (antidepressants/BP) medical conditions (blepharitis)

Refer

Treatment failure after 2 weeks, change in eyelid shape

111 – severe pain and red, contact wearer with red eyes (could be an infection)

999 A&E – sudden change in sight, bursts of light sensitivity, severe headache/nausea, dark red eyes, injured/pierced eye, something stuck in eye

Advice

Clean eyes daily, take breaks when using screens, use screens below eye level, use humidifier, wear glasses instead of contacts

Treatment

Light lubricant – Optrex Double Action Drops for Dry and Tired Eyes - Apply 1-2 drops in each eye.

Hyaluronic Acid - Artelac Rebalance Drops, long lasting relief - Place 1 drop into the conjunctival sac 3-5 times daily or more frequently if required.

Hypromellose drops – 1-2 drops 3 x daily

Excessive ear wax

Symptoms – hearing loss, earache, noise/ringing, vertigo, dizziness, and nausea

Causes – narrow/damaged canals, hairy canal, skin condition affecting scalp around ear, inflammation of ear canal

Refer – not cleared in 5 days, badly blocked, severe, complete loss of hearing, likely infection

Advice – don’t use fingers or cotton buds to remove wax

Treatment

Olive oil drops – 2-3 drops in affected ear and massage around outside of ear BD x 7 days

Use dropper when lying down with head to one side to allow oil into ear, over 2 weeks then lumps should fall out, but symptoms should be better within 5 days

Otitis externa

Symptoms - pain, discharge, itch, irritation, external ear/canal appears red, swollen, eczema, deafness, skin swells, tender to touch

Refer – ear pain in children, inflamed pinna, unsuccessful treatment (after 4 days), hearing aids, excessive discharge (wax or pus), high fever, vomiting, fatigue, confusion, dizzy, stiff neck, rash, slurred speech, fits, light sensitivity

Advice – avoid under/over dressing feverish child, lower heating, offer regular fluids, avoid dummies when lying flat, give paracetamol/ibuprofen if child is unwell/distressed (not together)

Treatment

Acute localised (furunculosis) – infected hair follicles in outer-ear causing swelling and irritation

Treatment – hot flannel, oral analgesics, antibiotics if severe

Acute diffuse (over 3 months – more widespread inflammation of skin, bacterial/fungal infection or contact dermatitis due to irritant/allergens

Treatment – earwax plus or EarCalm

Otitis media

Symptoms – earache, discharge, hot, irritable, sleeplessness, ear pulling/rubbing, crying, temporary deafness

Refer – recurrent infections, no improvement in 3 days

Treatment

Self-limiting should be better in 3 days, single analgesics for pain

Hyperthyroidism

Too much thyroid hormones produced naturally

Symptoms

Tremor, warm sweaty palms, weigh loss despite increasing appetite, heat intolerance, diffused alopecia, hair thinning, tachycardia, diarrhoea

Advice

Healthy diet with foods rich in antioxidants, green leafy vegetables (broccoli, cabbage etc)

Vitamin D, omega 3 fatty acids and calcium rich foods. Smoking cessation

Treatment

Carbimazole (adjunct B blocker propylthiouracil for adrenergic symptoms) – block and replace regime

Combo of fixed high dose carbimazole and levothyroxine

Radioactive iodine destroys thyroid cells, surgery to remove some thyroid

Hypothyroidism

Thyroid gland doesn’t produce enough hormones caused by immune system attacking thyroid gland and damaging ait or by damage to thyroid that occurs during treatments for a hyperthyroidism or thyroid cancer

Symptoms

Fatigue, muscle pain, weakness, weight gain, sensitive to cold, dry skin, brittle hair, nails, depression, reduced libido

Advice

Eat antioxidant rich food, seeds and nuts, tyrosine (meat, dairy, legumes)

Avoid – soy, iodine rick food, leafy green vegs, caffeine, alcohol – quit smoking, alcohol.

Inform GP if pregnant (needs treatment and monitoring during)

Treatment

Levothyroxine 1st line – dose depends on blood test and progression – take tablet at same time every day (MORNING) If taking too much causes sweating, chest pain, headaches, diarrhoea, vomiting. Supressing thyroid supressing hormone with high doses causes atrial fibrillation, stroke, osteoporosis

Cold sores

Symptoms

Simplex - Pain, burning, itching, tingling before lesions and lasts 6-48 hrs

Crops of vesicles burst and crust over and heal, commonly on lower lip and ends of mouth

Gingivostomatitis – fever, malaise, sore throat, painful nodules in cervix or under jaw, excessive salivation. Painful vesicles on a red swollen base that rupture to form ulcers inside mouth, covered with yellow/grey membranes

Refer – immunocompromised, unable to swallow, risk of dehydration, severe infection, complication, pregnant, recurrent

Treatment

Paracetamol/ ibuprofen for symptoms

Topical acyclovir/penciclovir OTC – use from onset of symptoms before lesions until lesions heal

OTC topical anaesthetic or analgesics, mouthwashes, or lip barriers – topical analgesics aren’t licensed in children

DON’T prescribe oral antiviral for healthy people

Consider prescribing oral antiviral for healthy people with episode of primary oral herpes simplex, recurrent labialis if lesions are severe, frequent, or persistent and recurrent

And for those who are immunocompromised

Should take at onset and until lesions have healed – minimum of 5 days

Choice of aciclovir or valaciclovir based on preference, dose, regimen, and adherence

Advice

Reassure its usually self-limiting and heals without scarring

Adequate fluid intake

Offer leaflets or websites for more info

Avoid kissing, oral until lesions fully healed, don’t share pillows, makeup, or lip balms. Don’t touch lesions other than when applying treatment – dab instead of rubbing. Wash hands after touching.

Athletes foot

Interdigital — most common; affects the lateral toe web spaces first; usually caused by Trichophyton rubrum.

Moccasin or dry — diffuse chronic scaling and hyperkeratosis affecting the sole and lateral foot; usually caused by Trichophyton rubrum.

Vesicobullous — least common; multiple small vesicles and blisters mainly on the arches and soles of the feet; usually caused by Trichophyton interdigital.

Risk – hot, humid, occlusive footwear excessive sweating, contaminated surfaces, immunocompromised

Advice

Wear well fitting, open footwear that keep feet cool and dry, replace old shoes that may be contaminated. Maintain good foot hygiene – wear different pair of shoes every 2-3 days. Wear cotton, absorbent socks, don’t scratch skin, after washing feet dry then well and between toes, don’t share towels and wash towel freq.

Treatment

Topical antifungal cream in mild, non-extensive disease

Terbinafine 1% cream (12 and over – apply thinly to affected area 1 or 2 daily for 7 days) or clotrimazole 1% cream (2-3 times daily and continue for 4 weeks minimum) okay for kids – OTC for some ages

Additional mild topical corticosteroid if there’s inflammation

Hydrocortisone 1% cream (OD for max 7 days)

Adult severe or extensive – oral antifungal with confirmed fungal infection

1st choice – terbinafine (250 mg once daily for 2–6 weeks, depending on the severity of infection)

2nd – itraconazole, Griseofulvin if not tolerated or contraindicated

Refer

Treatment failure, severe pain, got, painful and red (indicative of serious infection), infection spreads, diabetic patient, immunocompromised

Warts and verrucae

Warts – small, rough growths caused by infection of skin with HPV, form anywhere on skin most commonly on hand and feet

Verruca – (plantar wart) wart on sold of feet

Spread by direct contact, occur and clear spontaneously at any time or may take years

Common warts are firm and raised with a rough surface that resembles a cauliflower (common on knuckles, knees, and fingers).

Periungual warts are common warts around the nails that can be painful and disturb nail growth — nail biting is a risk factor.

Plane warts are usually round, flat-topped, and skin coloured or greyish yellow (common on the backs of hands).

Filiform warts have a finger-like appearance and may have a stalk (more common on the face and neck).

Palmar and plantar warts grow on the palms and the soles of the feet (verrucae). They often have central dark dots (thrombosed capillaries) and may be painful.

Mosaic warts occur when palmar or plantar warts coalesce into larger plaques on the hands and feet.

Not harmful and don’t come with symptoms and resolve with treatment

Advice

Reducing transmission and limit spread, keep feet dry, wear slippers or waterproof plaster in shower and communal areas. don’t share towels, socks, shoes. Don’t scratch lesions, bite nails or suck fingers with warts

Refer

Painful, facial, uncertain diagnosis, immunocompromised, extensively infected

Treatment

Only treated if painful, cosmetically unsightly, or patient request and persistent as the treatment is long and can have side effects.

Topical salicylic acid – up to 12 weeks

Duofilm® (salicylic acid 16.7% plus lactic acid 16.7%) — licensed for plantar and mosaic warts.

Bazuka® extra strength gel (salicylic acid 26%) — licensed for warts and verrucae.

Occlusal® (salicylic acid 26%) — licensed for common and plantar warts.

Salactol® (salicylic acid 16.7% plus lactic acid 16.7%) — licensed for warts, plantar warts, and verrucae.

Apply OD at night, file and soften area by soaking in warm water for 5-10 mins, peel of remaining film before administering next dose, don’t apply on healthy skin

Cryotherapy – every 2 weeks for max 6 treatments

Liquid nitrogen – only for older children and adults

Corns and calluses

Hard or thick areas of skin that can be painful

Corns – lumps of hard skin on knuckles and joints of toes

Callouses – larger patches of rough, thick skin

Both can be tender and painful

Refer

Diabetic, heart disease, circulation issues. Bleeding or puss, treatment failure after 3 weeks, severe pain

Advice

Wear thick, cushioned socks, wear wide, comfortable shoes with low heel and soft sole, use insoles or heel pads, soak corns and calluses in warm water to soften them, use pumice stone regularly or foot file to remove hard skin. Moisturise.

Don’t try to cut them, walk, or stand for long period, wear high heels or tight pointy shoes, go barefoot

Treatment

Heel pads and insoles, OTC products, pain relief

Carnation brand caps for both – adhesive dressing

Fungal nail infection

Caused by dermatophyte and non-dermatophyte moulds and yeasts

Symptoms

Discoloured, abnormal, small flaky white patches and pits on top of nail and becomes rough and eroded. Nail lifted, wite or yellow opaque streaks on one side of nail, scaling, thickening

Refer

Diabetic, severe, treatment failure, spread to other nails

Advice

Keep nails trimmed short and filed, don’t share clippers and files. Well-fitting shoes, cotton socks, maintain good foot hygiene, weak shoes in communal places, avoid nail trauma

Treatment

Not needed if patient not troubled by appearance and infection is asymptomatic

Advise antifungal treatment if – walking uncomfortable, distress, cosmetic, co-morbid complication, or complication

If dermatophyte or candida infection conformed – topical antifungal treatment 0f 50% of nail involved, 2 nails infected, contraindication to oral antifungal

Topical – amorolfine 5% mail lacquer – OTC apply 1 or 2 weekly to affected nail after gentle nail filing – 6 months minimum for fingernails, 12 months for toenails

If dermatophyte nail infection is confirmed:

Prescribe oral terbinafine first-line.

250 mg once a day for between 6 weeks and 3 months for fingernails, and for 3–6 months for toenails

Oral itraconazole if an alternative drug is indicated.

Prescribe as pulsed therapy 200 mg twice a day for 1 week, with subsequent courses repeated after a further 21 days.

If Candida or non-dermatophyte nail infection is confirmed:

Prescribe oral itraconazole first-line.

Prescribe as pulsed therapy 200 mg twice a day for 1 week, with subsequent courses repeated after a further 21 days.

Prescribe oral terbinafine if an alternative drug is indicated.

Prescribe 250 mg once a day for between 6 weeks and 3 months for fingernails, and for 3–6 months for toenails.

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bugoutpest · 7 months

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Power Pest Control Redcliffe

Termites

Termites are destructive wood-eating eusocial insects that occupy and damage homes, offices, and other structures. They can chew through a building’s framing and cause costly structural damage.

Termite colonies can contain thousands or millions of individuals. They are governed by a caste system that includes reproductives, workers, soldiers, and nymphs. Several species are known to infest buildings and other structures. These include dampwood and drywood termites. To know more about Power Pest Control Redcliffe, visit the Bug Out Pest Solutions website or call 0426263320.

Crazy ants are attracted to outlets and electrical components and can cause them to malfunction. They release alarm pheromones when electrocuted and summon other ants to help. When enough ants touch the live wires, they will get shocked and could shut off your air conditioner or short out appliances.

Spray an equal mixture of water and vinegar on ant trails to erase their pheromone scents.

Cockroaches carry germs and trigger allergies in some people. They also shed bits of their skin, which can cause asthma symptoms when inhaled. It’s important to limit their hiding places by sealing cracks, crevices and gaps.

Outdoors, cockroaches live in damp locations such as garages and basements, wood piles, drains and water meter boxes. Indoors, they hide in cupboard cracks and under appliances.

Bed bugs, once a worldwide problem, have made a comeback. They infest homes, apartment buildings, hotels, dormitories and shelters, mainly because people unknowingly bring them home on clothing and luggage.

Adults and nymphs are wingless and flat, allowing them to fit in crevices where they hide by day. Their bodies elongate after feeding. Infestations are often identified by dark spots of dried excrement and by a foul, rotting smell.

Although wasps have a bad reputation for their painful stings, they play a crucial role in ecosystems. They help with pest control and nutrient cycling. However, they can become a nuisance when they build nests in people’s backyards.

When a wasp’s nest is disturbed, it will defend itself by stinging intruders. To reduce the risk of getting stung, remove the nest during the night when they are less active.

Mosquitoes are slender, segmented flies that belong to the family Culicidae. They have one pair of wings, halteres and three pairs of long legs. They also have elongated mouthparts.

Mosquitoes lay their eggs in standing water. This includes water features, bird baths and buckets, flower pot saucers, or low patches in your lawn that collect rainwater. Eggs of Anopheles and Culex are laid on the water surface in raft-like clusters.

Fleas thrive in hot and humid climates. They are most active in sheltered animal enclosures, crawl spaces where feral animals may sleep, and vegetated areas adjacent to buildings.

Their laterally compressed bodies allow them to move swiftly through the hairs or feathers of their hosts. They can also attach themselves to clothing, shoes, blankets and pet fur. Their mouthparts are modified for sucking blood.

Ticks are a serious problem for people who live in wooded or brushy areas and like to spend time outdoors. These arachnids transmit a number of serious diseases that cause symptoms such as fever or chills, body aches and headache, and rashes.

Ticks are more difficult to repel than mosquitoes, but rodent-targeted approaches and deer fencing can provide effective protection for residential properties. Also, new plant compounds with acaricidal effects are being explored.

The bee is a winged insect that feeds on flower pollen and nectar. Its branched body hairs help it recognize the smell of flowers.

Bees use the bristles on their hind legs to comb through the anther cells of flower petals to collect pollen grains. Then, when the bee lands on another flower, it transfers the pollen to the fertilized pistils.

Pesticides can disrupt hives and cause long-term damage to wildflowers and other flowering plants. To prevent drift, do not spray near puddles where pollinators may drink.

Wasps have some of the most interesting and complex life cycles. These hard-working insects build nests to house their colonies.

Observe their flight paths and look for the rounded, grayish-brown nests that they construct. These can be found in sheltered spots such as roof spaces, wall cavities, bird boxes under eaves and sheds.

Care should be taken when spraying a wasp nest, particularly if the homeowner has an allergy to the stings. A professional pest control company can assist with safely removing wasp nests from your property. To know more about Power Pest Control Redcliffe, visit the Bug Out Pest Solutions website or call 0426263320.

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bajaj-eye-care-centre · 8 months

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Do I Need To Have My Eyes Checked If I Have Headaches?

Headaches are a common complaint among both adults and children. The severity and frequency of headaches range from occasional to nearly daily. Headaches can be debilitating for some people, resulting in a lower quality of life.

Headaches can be caused by a variety of unexpected factors, such as an uncorrected vision problem.

If you are having frequent headaches, you must schedule an eye exam, even if it is just to rule out an eye issue as the cause. Not all headaches are caused by vision problems, and not all vision problems cause headaches, but there is considerable overlap between the two, and one must learn more about how eye problems are linked to headaches.

Various types of headaches

There are several types of headaches that can occur, including:1. Migraines 2. Cluster headaches 3. Sinus headaches 4. Tension headaches

Overdosing on certain medications, dehydration, and eye problems can all cause headaches.

Eye strain

Eye strain is one of the most common causes of headaches associated with eye problems. Overuse of the muscles involved in vision focus can cause eye strain and, as a result, headaches. Staring at a computer or phone screen for an extended period of time is a common cause of eye strain.

Typical eye strain symptoms include:1. Headaches 2. Watery eyes 3. Blurred vision 4. Sensitivity to light

Ocular migraines

Visual disturbances are caused by ocular migraines, which can occur with or without a headache.

Ocular migraine symptoms include:1. Headaches 2. See flashing lights 3. Severe eye pain 4. Blind spots in the field of vision

Astigmatism

Astigmatism occurs when the cornea is not properly shaped. It can impair vision and may cause squinting to help focus the eye. It can also cause headaches if left untreated.

Astigmatism symptoms may include:1. Distorted vision 2. Eye irritation 3. Problems seeing at night

Glaucoma

Glaucoma headaches are most commonly felt around the eyes or on the forehead. Glaucoma occurs when fluid accumulates in the eye, causing pressure to build up. The increased pressure damages the optic nerve, resulting in vision loss over time.

Most people do not have symptoms of glaucoma in the early stages, but when symptoms appear, they may include:1. Headaches 2. Seeing halos 3. Blurred vision 4. Eye pain

Cataracts

Cataracts develop when the eye's lens becomes clouded. It is most commonly caused by ageing. As cataracts form, the eye may have to work harder to see. As your eyes work harder, you may experience eye strain and headaches.

Cataract symptoms include:1. Headaches 2. Blurred vision 3. Fading of colors 4. Sensitivity to glare

A simple eye exam could save you from a headache!

If you suffer from frequent headaches, an eye exam is recommended, especially if it has been a year or two since your last exam. Even if you believe headaches have a specific cause, eye problems like eye strain can contribute to existing headaches. To reduce the risk of further headaches, it is also critical to treat underlying eye conditions as soon as possible.

Summary

Headaches may indicate that you have a vision problem, and on the other hand, other eye conditions may also cause a headache. As a result, if you have headaches and/or vision changes, you should see your doctor to rule out any serious medical conditions.

Dr. Rajiv Bajaj, the best ophthalmologist at Bajaj Eye Care Centre in Delhi, can help you identify headache triggers and create a treatment plan that addresses the underlying problems. With help, you can finally get effective headache relief.

Contact him to get all your questions answered!

To schedule an appointment with Dr. Rajiv Bajaj, please contact: Name: Bajaj Eye Care Centre Address: 101, Vikas Surya Plaza, Plot No. 7, DDA Community Centre Road No. 44, Pitampura, Delhi-110034 Phone: 011-47024919 / 27012054 Website: www.bajajeyecarecentre.com

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thetoxicgamer · 8 months

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‘I almost died’: IShowSpeed opens up about medical crisis in YouTube return

After spending two weeks in the hospital in Japan with a sinus infection that spread and gave him cluster headaches, a unique and excruciatingly painful headache that occurs behind the eye, IShowSpeed started streaming on YouTube earlier today. It ended up turning his holiday into an emotional rollercoaster that had fans fearing for his life, and it turns out, the feelings were warranted. Speed opened up about the ordeal on YouTube on Aug. 15 and said the pain was so bad, it almost killed him. The streamer described it as feeling like somebody was stabbing his eye with a knife from behind and said it’s something he prays none of his fans ever experience in their lives. It was so bad at its worst point, he was certain it was going to be the death of him. “That’s the one that almost killed me,” he said. “I almost fucking died.” The doctors were able to make the pain as bearable as possible while treating the infection causing it, which IShowSpeed described as the “worst-ever” infection he’s ever had. If it spread behind his eye, the doctors said there was a chance he could have lost his vision permanently. That’s how serious it was. It took him a while to bounce back, but he did, and he was looking sharp in his return. His eye was no longer swollen, but he was still experiencing mild pain and decided to end the stream after an hour, explaining he didn’t want to “overdo” it. Fans were thrilled to see him back in action. It certainly wasn’t one of his pranks, and given the seriousness of his situation, they applauded him for returning so soon when he should have been resting. It seems like he always goes above and beyond to entertain them, and they very much appreciate it. Read the full article

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magdelanesingerin · 9 months

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Session 7: Accountability

(A life Alone, Chapter 3) -3017 words, M

“How did your conversation with Jaskier go? Did you get a chance to say the things you were hoping to say to him?”

Geralt sits back against the now-familiar couch in Nenneke’s office, arms crossed over his chest, and can feel his brow furrowing as he considers his answer. He’s feeling a lot of things after his conversation with Jaskier.

“It was…fine. A relief. I got to apologize for the things I did and said, and he was willing to hear me out.”

“I’m really glad; that was excellent work you did getting to that point, and taking the risk to be vulnerable and honest,” she says, and he fights the urge to flinch. He feels like she’s being condescending, but six weeks of appointments have taught him that she’s being completely serious in her praise. It’s hard to take.

“Hmm. Um. Thanks. We talked for a long time, after. That was…good. He agreed to– we’re going to try to be friends. Just…just friends,” he says haltingly.

“That’s wonderful, I’m glad that he was receptive,” she says, before she leans in a bit with narrowed eyes. “Now, I think I know what you’re trying to say, but I heard the word ‘just’ sneak in there, and I want to be clear– you know that a platonic friendship is not of inherently greater or lesser value than a romantic or sexual relationship, yes?”

“Yeah, I just meant that–I wasn’t good at–” Geralt sighs heavily, shaking his head as he struggles to put the words together. “I didn’t allow us to be friends, really. The first time. Not for long, anyway. I want this to be different.”

“Hm, good,” she nods, leaning back in her chair again. “I think it will be. I’d like to explore that experience, if we can. I’d imagine that conversation was…difficult for you, in a number of ways. It probably brought up a lot of emotions, and it’s a good opportunity for us to continue to work around identifying and anchoring those emotions. Let’s start here: what are you feeling right now, and where is it in your body?” ___________________________________________________________

Geralt paused for a minute in the doorway watching the three of them together clustered around the end of the long dining room table. They looked completely at ease, despite having met only a few hours before. Aiden and Meg welcomed Jaskier into their after-dinner conversation like he’d been there for years. The fireplace crackled behind the trio, Aiden lounging back with his long arms behind his head, and Meg with her legs sprawled across two chairs. Jaskier leaned forward with his elbows resting on the glowing wooden table as he told the other two some animated story, beautiful and backlit by the glow of the flames. He could hear Eskel and Lambert in the living room arguing happily and laughing about something. It was a perfect evening.

This had been so easy to include Jaskier, for him to fit into Geralt’s family. To be treated like one of their own.

Geralt felt suddenly overwhelmed; this was supposed to be a fling. A fun, straightforward dalliance with a hot guy he picked up at a bar. Nothing serious. He wasn’t supposed to be standing there in his family’s house thinking about a future with this man. He retreated back into the kitchen, leaving the lights off, to lean his palms against the cool porcelain of the sink for a minute while his mind whirled and his breaths came fast and shallow.

Eskel appeared with a stack of dirty dessert plates and forks, adding them to the pile of dishes on the counter that they’d have to deal with later. The clatter of ceramic and silverware sounded impossibly loud in Geralt’s ears and seemed to go on forever. He closed his eyes, gritting his teeth against the sound. Eskel paused, leaning over to look at Geralt’s face bent over the sink in the near-dark. “Uh-oh, I know that look. What are you panicking about right now?”

Geralt clenched his jaw and shook his head, not looking at his brother. “Nothing. I’m fine. Just a headache.” It was a bad lie and he knew it. His eyes flickered to Eskel’s face for a second, seeing a slightly cocked eyebrow and a tilt to his head that confirmed he hadn’t bought a word of it. “It’s fine,” he repeated stubbornly, knowing that the growl in his voice made the lie even more obvious.

“Sure, ok.” Eskel backed off with a resigned shake of his head. He knew better than to push his younger brother. He’d talk when he was good and damn ready, and not a moment before.

continue on Ao3

#my fic #A Life Alone #Geralt #The Witcher #modern AU #Poor Jaskier #you really got him at his worst #bless his heart

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buypsychedelics1 · 10 months

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The Benefits of Buying LSD in Canada

LSD, or lysergic acid diethylamide, is a powerful psychedelic drug that has been used for decades for its mind-altering effects. The drug is derived from a chemical in ergot, a fungus that grows on rye and other grains. LSD is typically sold as a white powder or clear liquid. It is used for recreational purposes as well as for its purported therapeutic benefits.

LSD is known for its ability to produce powerful hallucinations and alter a person's perception of time and space. The drug can also cause changes in mood, emotions, and sensory perception. Some people report feeling more connected to the world around them after taking LSD, while others say they feel more detached from reality.

LSD is considered a safe drug when taken in moderation, but it can be dangerous if used excessively or without proper medical supervision. The drug can be addictive and can lead to psychotic episodes in some people.

If you are considering taking LSD, it is important to be aware of the potential risks and benefits of the drug. Here are some of the potential benefits of LSD:

1. LSD can be used to treat anxiety and depression.

2. LSD can help people with addiction problems.

3. LSD can be used to enhance creativity.

4. LSD can be used to treat migraines.

5. LSD can help people with post-traumatic stress disorder (PTSD).

6. LSD can be used to treat cluster headaches.

7. LSD can be used to increase libido.

8. LSD can help treat pain.

9. LSD can be used to improve focus and concentration.

10. LSD can have spiritual benefits.

1) The Risks of Buying LSD in Canada

If you're considering buy LSD in Canada, there are a few things you should know about the risks involved. First and foremost, LSD is a Schedule III drug in Canada, which means it's illegal to buy, sell, or possess without a prescription. This also means that buying LSD from an underground source comes with a certain amount of risk.

The most common risk associated with buying LSD is that of being scammed. There are a lot of people selling fake or diluted LSD, and it can be hard to tell the difference between the real thing and a fake. This is why it's important to only buy from a trusted source.

Another risk is that of bad trips. LSD can cause intense anxiety, paranoia, and even hallucinations. If you have a bad trip, it's important to have someone with you who can help keep you calm and safe.

Lastly, there's the risk of legal trouble. If you're caught buying or selling LSD, you could be facing serious penalties, including jail time.

Despite the risks, many people still choose to buy LSD in Canada. If you do decide to take the plunge, just be sure to do your research and only buy from a trusted source.

2) The Legality of Buying LSD in Canada

In Canada, it is not currently illegal to purchase LSD. However, it is important to note that there are a number of restrictions on the sale and possession of LSD. For instance, it is illegal to sell LSD without a valid prescription. Additionally, it is illegal to possess LSD for the purpose of selling it. It is also illegal to possess LSD for the purpose of consuming it.

While it is not currently illegal to purchase LSD in Canada, it is important to be aware of the risks associated with taking the drug. LSD is a powerful psychedelic drug that can cause a number of adverse effects, including hallucinations, anxiety, and paranoia. Additionally, LSD can be addictive, and users may develop tolerance to the drug over time.

3) How to Buy LSD in Canada

If you're looking to buy LSD in Canada, there are a few things you need to know. First, LSD is a controlled substance in Canada and it is illegal to possess or distribute without a valid prescription. Secondly, LSD is a Schedule III substance in Canada, which means it has a high potential for abuse and can lead to physical or psychological dependence. Finally, LSD is a controlled substance in Canada and it is illegal to sell, import, or export without a valid prescription.

If you're looking to buy LSD in Canada, the best way to do so is through a licensed dealer. There are a few things to keep in mind when dealing with a licensed dealer, however. First, LSD is a Schedule III substance in Canada, which means it has a high potential for abuse and can lead to physical or psychological dependence. Secondly, LSD is a controlled substance in Canada and it is illegal to sell, import, or export without a valid prescription.

When buying LSD from a licensed dealer, make sure to get a receipt that includes the date, time, and amount of LSD purchased. It is also important to keep in mind that LSD is a Schedule III substance in Canada, which means it has a high potential for abuse and can lead to physical or psychological dependence.

4) The Different Types of LSD Available in Canada

LSD, also known as acid, is one of the most popular drugs in the world. It's a powerful hallucinogenic drug that can produce intense, long-lasting effects. There are different types of LSD available, and each one has its own unique effects.

1. White Light LSD

White light LSD is the most common type of LSD available. It's a pure form of the drug that's typically sold in liquid form. White light LSD is very potent and can produce powerful hallucinations.

2. Blue Light LSD

Blue light LSD is another common type of LSD. It's also a pure form of the drug, but it's typically sold in powder form. Blue light LSD is less potent than white light LSD, but it can still produce strong hallucinations.

3. Green Light LSD

Green light LSD is less common than the other two types of LSD. It's a mix of the two previous types of LSD, and it's usually sold in tablet form. Green light LSD is the least potent of the three types of LSD, but it can still produce mild hallucinations.

4. Yellow Light LSD

Yellow light LSD is the rarest type of LSD. It's a mix of white light LSD and blue light LSD, and it's usually sold in liquid form. Yellow light LSD is more potent than green light LSD, but it's not as potent as white light LSD.

5. Red Light LSD

Red light LSD is the strongest type of LSD. It's a mix of white light LSD and green light LSD, and it's usually sold in powder form. Red light LSD is very potent and can produce intense hallucinations.

5) The Different Strains of LSD Available in Canada

Lysergic acid diethylamide, more commonly known as LSD, is a potent psychedelic drug that has been used for centuries for its ability to induce powerful hallucinations. In recent years, LSD has experienced something of a renaissance, with a new generation of users discovering its potential for spiritual exploration and personal growth.

There are many different strains of LSD available on the market today, each with its own unique effects. Here, we take a look at six of the most popular LSD strains available in Canada.

1. White Lightning: White Lightning is one of the most popular LSD strains available. It is known for its strong visual hallucinations and for its ability to produce powerful spiritual experiences.

2. Blue Heaven: Blue Heaven is another popular LSD strain. It is known for its mellow effects and for producing feelings of euphoria and happiness.

3. Golden Dragon: Golden Dragon is a potent LSD strain that is known for its strong visual hallucinations and for its ability to produce powerful spiritual experiences.

4. Green Dragon: Green Dragon is another popular LSD strain. It is known for its mellow effects and for producing feelings of euphoria and happiness.

5. Red Dragon: Red Dragon is a potent LSD strain that is known for its strong visual hallucinations and for its ability to produce powerful spiritual experiences.

6. Black Magic: Black Magic is the most potent LSD strain available. It is known for its ability to produce powerful hallucinations and for its ability to induce powerful spiritual experiences.

6) The Best Places to Buy LSD in Canada

When it comes to buying LSD, there are a few things that you need to keep in mind. First and foremost, LSD is a Schedule III drug in Canada and is therefore illegal to sell, possess, or use. Secondly, LSD is a very potent drug and should be treated with respect. It is important to start with a very small dose and to increase the dose gradually. Finally, it is important to be in a safe and comfortable environment when taking LSD. With that said, here are the 7 best places to buy LSD in Canada:

1. The Psychedelic Society of Toronto

The Psychedelic Society of Toronto is a non-profit organization that is dedicated to educating the public about psychedelics and their potential benefits. They offer a variety of services, including workshops, support groups, and educational events. They also sell a variety of psychedelics, including LSD.

2. The Vancouver Island Compassion Society

The Vancouver Island Compassion Society is a non-profit organization that provides access to medical cannabis and other natural health products. They also sell a variety of psychedelics, including LSD.

3. The Toronto Psychedelic Society

The Toronto Psychedelic Society is a non-profit organization that is dedicated to education, harm reduction, and community building. They offer a variety of services, including workshops, support groups, and educational events. They also sell a variety of psychedelics, including LSD.

4. The Vancouver Psychedelic Society

The Vancouver Psychedelic Society is a non-profit organization that is dedicated to education, harm reduction, and community building. They offer a variety of services, including workshops, support groups, and educational events. They also sell a variety of psychedelics, including LSD.

5. The Montreal Psychedelic Society

The Montreal Psychedelic Society is a non-profit organization that is dedicated to education, harm reduction, and community building. They offer a variety of services, including workshops, support groups, and educational events. They also sell a variety of psychedelics, including LSD.

6. The Halifax Psychedelic Society

The Halifax Psychedelic Society is a non-profit organization

7) How to Store LSD Once You've Bought It in Canada

If you're looking to buy LSD in Canada, there are a few things you should know about how to store it. LSD is a very potent drug, and it should be stored in a cool, dark place. It should also be kept away from children and pets.

Here are a few tips on how to store LSD:

1. Store LSD in a cool, dark place.

2. Keep LSD away from children and pets.

3. If you are storing LSD for long-term use, consider keeping it in the fridge.

4. Make sure the container you're storing LSD in is airtight.

5. Store LSD in a safe place where it won't be accidentally ingested or mishandled.

With these tips in mind, you should be able to store LSD safely and effectively.

8) The Difference Between LSD and Other Psychedelics

When it comes to mind-altering substances, there is a lot of misinformation out there. So, let's set the record straight: what is the difference between LSD and other psychedelics?

First, it's important to understand that all psychedelics work by altering the brain's neurotransmitters, which affects mood, perception, and cognition. However, each psychedelic has a unique chemical structure that gives it different effects.

For example, psilocybin (the active ingredient in magic mushrooms) is a tryptamine, while LSD is an ergoline. Both of these substances can cause visual and auditory hallucinations, but LSD tends to be more potent and produce more intense effects.

LSD also has a longer duration of action than other psychedelics, meaning that its effects can last for up to 12 hours. This is due to LSD's ability to bind to serotonin receptors in the brain.

Other psychedelics, such as DMT and ayahuasca, work differently than LSD. DMT is a potent psychedelic that is active at very low doses. Its effects are short-lived, however, lasting only 30-60 minutes.

Ayahuasca is a brew that contains the psychedelic substance DMT, as well as an MAOI (monoamine oxidase inhibitor). This combination allows the DMT to be active for a longer period of time, and produces a more intense experience.

So, what is the difference between LSD and other psychedelics? It all comes down to chemistry. Each psychedelic has a unique chemical structure that gives it different effects.

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samreensway · 1 year

Video

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HISTORY-TAKING STATION OF HEADACHE | COMPREHENSIVE HEADACHE ASSESSMENT

HISTORY-TAKING STATION OF HEADACHE | COMPREHENSIVE HEADACHE ASSESSMENT MRCS B OSCE - MOCK EXAM In this informative MRCS mock exam video, learn about the history-taking station of headaches and the comprehensive assessment process for diagnosing and managing headaches. Learn the essential elements of a history of headaches, diagnostic tools, and treatment options to provide adequate relief. Learn the essential steps of a history-taking station of headaches and the comprehensive assessment process in this informative MRCS mock exam video. Gain insights into the golden elements of a headache history, diagnostic tools used, and the various treatment options available for effective headache management. Understanding Headache Assessment: Learn about the importance of a comprehensive headache assessment in identifying the underlying causes and appropriate treatment approaches. Explore the different types of headaches, including tension headaches, migraines, cluster headaches, and white-coat headaches plus more. Essential Elements of Headache History: Learn the crucial elements to consider when taking a headache history, including the duration, frequency, intensity, location, and associated symptoms of headaches. We discuss triggers, relieving factors, and the impact of headaches on everyday life. Diagnostic Tools and Tests: Gain insights into the diagnostic tools and tests used to assess headaches, such as neurological examinations, imaging studies (MRI, CT scans), and blood tests. Understand how these tools help in diagnosing underlying causes and ruling out potentially serious conditions. Treatment Options for Headache Relief: Explore the various treatment options available for headache relief, including lifestyle modifications, stress management techniques, over-the-counter medications, prescription medications, and complementary therapies. We emphasize the importance of personalized treatment plans based on the specific type and severity of headaches. Preventing Headache Recurrence: Learn about preventive measures and strategies to minimize the recurrence of headaches, including identifying and avoiding triggers, maintaining a healthy lifestyle, practicing relaxation techniques, and seeking regular medical follow-ups. Conclusion: In this informative video, we have provided valuable insights into the history-taking station of headaches and the comprehensive assessment process for diagnosing and managing headaches. It is an essential resource for healthcare professionals and individuals seeking a better understanding of effective headache assessment and treatment options for long-term relief. Bli medlem i kanalen för att få åtkomst till flera förmåner: https://www.youtube.com/channel/UCkkvon_blxinTHc7DGuYkpQ/join

#youtube #management help medical healthcare video mrcs mrcsbosce surgery youtube membership royalcollegeexams membershipexams uk nhs workingassurgeon

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faintlysmiling · 1 year

Text

bayonetta 3 rewrite snippet

The first thing she notices is that she’s sore all over. Before any of her other senses kick in, there’s a deep seated ache in her bones that pulls a quiet groan from her lips when she finally starts to rouse. All she can remember while she struggles to regain consciousness is Yaldabaoth batting her away like a fly, a white flash, and then…

“Did I… Fall here…?” Clair murmurs, slowly but steadily finding her bearings while regaining consciousness. She clutches at her head while opening her eyes, her brows scrunched together in an effort to block off a headache before it settles in. She’s no longer in the streets of Giza; no, instead she’s in a forest, lying in the center of a crater presumably made by none other than herself. Her body is covered in branches and leaves, and when she turns her eyes to the canopy she can see a clear beam of sunlight streaming in through a hole in the branches that shows her trajectory. She must have crashed through like a meteor; it’s a wonder she didn’t take more damage than this.

Up, child, Madama Isis mutters. We’re being watched. Further in the trees is something dangerous; you have ten seconds to gather yourself, and then you must run to your right through those trees as fast as you can.

The warning snaps Clair to her senses, and as soon as she focuses she can sense the presence Isis is talking about. Dangerous, indeed; whatever it is is massive, enough that Clair doesn’t know how she missed it. She doesn’t dare turn to look at it, knowing that the moment she acknowledges it’s there, the hunt will begin.

Eight seconds. Clair breathes. The flow of her magic steadies, focusing in her core and filling in the gaps in all her fingers and toes. The leaves above her are still, and if Clair couldn’t feel the oxygen evenly pushing and pulling her lungs, the silence is so heavy and suffocating it would be as though there is no air at all.

Four seconds. Her eyes sharpen. The presence is understood now, a distinct shape on her radar steadily filling in like a fresh Polaroid. Her heartbeat flutters when she understands that Madama Isis had been serious; whatever this thing is, it’s massive, easily outclassing any angel that would sneak up on her like this.

Two seconds. Her thighs tense. She inhales through her nose.

One second.

Clair launches into beast within a moment before her assailant crashes into the tree she’d been lying at the foot of, snapping it at the base and sending the tree toppling over into another. She doesn’t turn to look at what it is, but she’d caught a glimpse of fur and picks up a dog’s frustrated whine while the creature gathers its bearings before chasing after her. Clair’s leopard within is swift and nimble, yet she feels her attacker’s hot breath licking at her heels within seconds. She runs like it’s the only thing she knows how to do, bounding over thick roots and fallen branches with remarkable agility while avoiding any direct line of sight with whatever is after her by dodging in and out of rows of trees. In the thick darkness of the forest, the mad dash stretches on forever, but eventually she’s greeted with bright sunlight again when she breaks through the treeline and bolts right into a large clearing. She leaps through the brush and flips, turning back into her human form in a flash while facing the trees she’d just emerged from with Le Ciel aimed and at the ready.

Her hunter hasn’t followed her into the light yet, and she can see where its dark shape stands just beyond the obscuring shrubbery, watching; waiting. A menacing growl thunders from the woods, and Clair gasps when soon after the gigantic form of a monster comes into view. It’s a gargantuan wolf nearly twice the size of a bus, with a cluster of several murderous eyes in place of a standard left one, and rows of frothy drool-covered jagged fangs that could be confused for steak knives hammered through a piece of wood in the shape of a crude weapon. The beast snarls and snaps as it carefully approaches Clair, dragging its forked tongue across its wet muzzle while sizing her up before attacking.

Oh my… You’re…

“Fenrir,” Clair finishes with a dawning realization, Jeanne’s teachings flooding back into her mind. Fenrir recognizes the name, narrowing its eyes before standing tall and tilting its head back to let loose a harrowing howl that nearly stops her heart from sheer dread. It readies itself in a low stance, and Clair hardly has time to react when in the next second it lunges forward with a bite that could swallow her whole. She jumps straight into the air, and in their shared time granted by heightened senses their eyes meet where Clair is hovering in a crouch and Fenrir is recovering from the miss. Before it can pull back or attack again, she kicks down onto its snout and stomps its head into the ground, spring-boarding off of it into a back handspring before immediately ducking underneath another savage bite. They trade several blows like this, with Clair deftly avoiding each bite with a twist of her body before responding in turn with a punch to the brow, a knee to the chin, or a bullet to the forehead. She leaps and twists before firing off a wicked heel to slam into the monster and knock it back to make some distance, then watches as it darts to and fro to feint to her left before spinning to lash at her with its tail from the right. She swivels on her knees and arches her back to slide underneath the slash, and launches from the recovery into an afterburner kick that strikes the hip and lifts the great beast off the ground with the force. Fenrir, unfazed, whirls around to snap at Clair again, and the two delve into a whirlwind around the vicinity of the clearing.

Clair ducks and tumbles and throws herself into acrobatics to avoid the God-eater unbridled, all the while firing off round after round of bullets that pelt the landscape and bounce off of Fenrir’s thick hide. The occasional lucky shot will nick his ear or glance his muzzle, but the wolf’s fearsome size does not make him an easy target. A twist on her heel to dodge an attack offsets into a wicked weave sucker punch that sends Fenrir rolling away, and when he’s recovered he lets out a roar that blows Clair’s hair and medallions back with sheer force. A smothering darkness blankets the area like a fog, and Clair narrows her eyes to focus on what’s happening while widening her stance to prepare for whatever mysterious technique the creature is unleashing. She hardly sees it when it happens; Fenrir bolts forward into a black shape that manifests from the shadow and swallows him up, and immediately reemerges from another portal directly behind Clair at mach speed. She rolls to avoid the rush, and cartwheels her way in and out of a flurry rush of attacks that bombard her from all angles. Every time Fenrir tears out of a portal, he shoots through the clearing and darts into another one only to do it again from a random direction, and Clair dances through the barrage with serene grace while waiting for the moment to counter.

One step-over puts her directly in front of another portal that Fenrir fires out of, though instead of dodging outright Clair bursts into a swarm of hummingbirds and reforms immediately behind him once he runs through the flock. Witch time pulses out from the watch on her chest in a tidal wave of magic, rippling reality as she pushes her senses to the limits to grab Fenrir by the tail before he can take off. The momentum of his attack is used to propel her into rotation, and she spins on her heel before letting him fly into the hard trunk of a great tree at the edge of the meadow. The counter is all she needs to go on the offensive, and before he’s even hit the ground she’s upon him with a devilish fury. Blow after blow she pounds into him, avoiding any of his feeble attempts to bite back while continuing her assault. Her beatdown tears through the environment, crashing Fenrir’s hulking form through forest overgrowth and changing the landscape around them with their duel. A string of kicks knocks the beast into the air, and Clair leaps into a back twist like a football player to bring her heel arcing over her head in one final sweep to score the winning goal.

The kick conjures and guides a wicked weave to fire into Fenrir’s back and send the wolf flying back toward the ground. It crashes through a lone great tree, rolls through the dirt, then careens to a stop in a cloud of dust. Bloodied and bruised, the beast of legend groans pathetically while trying to push itself up to a standing position, then collapses for good in a battered heap.

Clair brushes her bangs back while her hair re-threads into her suit, lowering her leg and sucking in an excited breath while preparing to finish off her foe. She has full intention to summon a demon, but right as she draws up her arms and straightens her posture to begin the spell, Isis’ amused laughter bubbles up in the back of her head and stops her short.

Now, now, why so hasty? She coos, her tone drenched with smug amusement. This is a sight to behold. Fenrisulfr, the God eater, brought to its knees. Do you not wish to savor the moment?

Clair’s eyes shine with interest. “I take it you have something in mind? I was just about to start some fireworks to celebrate, but if you have a better idea, I’m all ears.” Exhilaration churns in her breast when Isis crows with glee; her power rushes through Clair’s veins and invigorates her spirit, and the air between the witch and her prey crackles with electric anticipation.

None have ever quelled this beast with their own mettle, and none have ever tamed it; yet here it lies before you, collarless and defeated. You know the spell, shining star; you have the strength to conquer, and though mighty, before an Umbra it is no more than another denizen of Inferno. Bind it to your whims, dark witch. A hound has no choice but to obey the leash, and you hold that very rope in your hands.

The way forward is clear; Isis’ urging only serves to stir Clair’s welling elation, enticing her with the intoxicating prospect of domination. Raw magical energy burns off of her figure in wisps of charged amethyst-hued steam, and ahead of her Fenrir tries in vain to drag itself to safety. Ragged breaths heave out of its split muzzle, and bullet hole-torn ears stay flattened against its skull as it slumps against the ground pathetically and accepts what will surely come. Four of the eyes in the cluster are squeezed shut, no doubt having been blown out from offset bullets. The eyes that remain open are unfocused and shaky, occasionally dragging over to her to watch its demise unfold. Clair licks her lips. The dog’s chest heaves. She stands tall with her back straight and raises her arms to the sky. Fenrir’s eyes slip closed. The spell begins.

She steps to the right and waves her arms down, then swirls her hips counter clockwise before sweeping her arms downward and twirling into her right shoulder. The dance is quick and snappy, with sharp punches of her arms and harsh steps that reaffirm her center of gravity again and again while her suit unravels and her magic begins to weave her will of subjugation. Two summoning circles appear around both her and Fenrir, with the latter clearly coming as a surprise to her victim. The shock of what’s happening grants it a momentary rush of adrenaline, and it makes to escape with a frightful whine before being snapped back into the circle by a sudden lash of crimson hair that threads through its mouth like a bridle and reigns.

OL UMDE GI ALLAR GE SIBSI I OHORELA

Clair booms, the incantation thundering throughout the entire forest surrounding them and drowning out the sound of Fenrir struggling in front of her. Hair and chains twist and knit themselves around its emaciated figure, dragging at limbs and constricting its chest and pulling it down into the depths of Inferno. Despite moments ago appearing to be at death’s door, the impending fate of becoming an Infernal servant has ignited a last desperate wish to flee, and it thrashes about in an impressive yet futile display of strength to fight off the inevitable. Clair continues to dance; her movements guide her magic like needle and thread, wrapping chains around Fenrir’s very soul with each flick of her wrist or twist of her ankle. The ritual draws to a climax with dramatic, strong dance patterns that counter the beast's erratic struggling, its massive figure shaking the ground every time it stomps a gargantuan paw to try and resist.

G EMETGIS I IXOMAXIP CA A IAIDADNA

Clair steps to the left, pirouettes to the right, and strikes a pose with the final lyric that seals the contract. Her voice calls forth a demonic hand from Inferno that pierces through Fenrir’s throat and grabs the back of its skull to finally drag the great wolf of legend down into the portal with Clair’s binding weave. The circles around the both of them dissipate once he’s completely submerged and devoured, and Clair’s hair spirals back down into her formal suit to signify the end of the spell. With that, the forest is still for the first time since she’d arrived after being sent flying from the aftermath of her confrontation before.

Just the memory of that fight pisses her off. The adrenaline and ecstasy from her duel with Fenrir is gone in an instant, replaced with an aggravated frown and haughty hands on hips. She blows out a frustrated raspberry, reaching up to stretch and relieve tension while finally getting a good look at her surroundings. The sky above her bleeds an angry red, with several large masses of land floating like chains of islands visible in the distance. Some are filled with remnants of civilization in the form of dilapidated cityscapes and sprawling neighborhoods, but others seem to be floating islands that were once a part of continents. In the dark expanse of trees she’d crashed into, Clair has no clue how large the mass of land she’s on may be, but she recalls catching a glimpse of the surrounding area while hurtling through the sky like an asteroid. There had been several other islands around the one she’s on now, all reminiscent of a wasteland of shattered icebergs floating at sea.

“Just what the hell is all of this, anyway?” She asks aloud, hands falling to her waist once more. “That bearded bastard really did a number on the place. I don’t know of any woods like this around where we were.”

That is because they were much further north than the streets of Giza, my shining star, Isis voices. This is the Forest of Purgation. Were this the world as it were, this forest would be hidden in the seas surrounding the Isle of Mann, safeguarded by the beast that now calls you master.

Clair’s eyes shoot open with surprise, brows pushing up towards her hairline as she ponders the implication. Jeanne had hammered geography into her thick skull when she had first become an apprentice, but she’s never been good with numbers, so trying to calculate the exact mileage makes her head spin. She juts out her tongue with mild distaste. “Great. Fantastic,” she grumbles. “I get into a fight with the asshole who’s causing all of this, and he’s able to knock me halfway across the damn globe. Just incredible. Wait until the others hear about this.”

It is not so simple, Isis hums. This is not the world you know, unrecognizably shattered from the cataclysm we endured. Do not be so hard on yourself; Yaldabaoth is a fearsome entity. That you were able to keep pace shows remarkable growth, and that you survived at all shows even more remarkable luck. You should be proud, Clair.

“Thanks for the encouragement,” Clair says, shifting her weight. “But I’d like a proper answer to my first question, please. What the hell happened here? It feels like…” She trails off, pursing her lips in thought. By all rights, this should just be Purgatorio; it certainly isn’t Paradiso, and isn’t quite miserable enough to be Inferno. Just what the hell happened?

Isis being privy to her thoughts is a blessing as much as it is a curse. This is Armageddon, she explains. The beginning of the end. Half a century ago, the Lumen Sage attempted to cause this very event with the resurrection of Jubileus, the Creator, but your Queen managed to retrieve the Left Eye in time, and the rite failed. That man is impossibly powerful, but he is not at his peak. This seems to be similar.

“Armageddon?!” Clair screeches, clearly shocked. “You’re telling me the fucking world ended?!”

Yaldabaoth is of a far greater magnitude than Balder had been, but he lacks the Eyes necessary to see the event come to pass. This Armageddon is incomplete; I suspect it is also a result of him needing to separate you from the other witches. I cannot sense either of them any longer. When you were engaged with him in battle, so too was your Queen with the young Sage, and I could feel their clash from across an entire continent and a vast ocean. Now, it has gone silent.

The implications of that are certainly frightening when initially considered, but Clair knows better. Momentary panic quickly subsides when she thinks about it for a split second; if she made it here alive, then Bayonetta and Jeanne are definitely still getting up to no good somewhere. There’s no way something that she survived could have taken out either of them.

“It’s definitely not ideal, but… Well, there’s not much I can do about it now. What do you recommend, then? I don’t suppose I can get started on that errand you asked me to run?”

How thoughtful of you. The moment you forged a contract with me, that task was started; continue on your path, my shining star, and you will continue towards destiny.

Clair grimaces, annoyed at the vague answer. “You know, I thought you were supposed to provide counsel–?”

Her retort is cut short by a blinding light from above, and her eyes snap up to the source. A portal to Heaven opens up directly overhead, and like a ray of sun breaking through storm clouds, a massive holy figure blots out the red sky as it emerges from Paradiso. Clair’s jaw drops at the sheer size of it, marveling at the solar splendor of an impossibly large Resplendence.

She does not get long to enjoy the view. It opens its mouth almost immediately, locking on to her position before firing a catastrophic beam into the clearing where her and Fenrir had fought; divine energy with the force of a nuclear bomb surges into the ground, instantly obliterating the area with the blast. Entire trees are scattered if they aren’t completely vaporized, and the beam sears through the very core of the island.

In the midst of the explosion, time slows to a stop with a deep pulse of magic, and a booming roar of enochian sounds out from the epicenter of the devastation:

IADADNA

A portal to Inferno opens underneath a flying boulder that had been brought to a standstill, and the hefty frame of a rose-wreathed Fenrir bursts through with Clair posing between his ears to take command! Witch time ends moments later, and both Clair and her new steed dash across the remaining treetops to make a break for it. From the bowels of Resplendence break free several Worship and Kinship vessels that chase after the pair and fire barrages of missiles in an attempt to subdue her– yet Fenrir is as quick as lightning and as agile as the wind, and he carries his rider over the forests and across the fields that span the entire length of the dilapidated landmass. When they reach a cliff that quickly reveals to be the edge of the island, he does not hesitate for a moment to spring from the precipice, soaring through the air to hop from one smaller island to another while deftly evading the onslaught of sanctified artillery. Clair cackles with delight throughout the chaos, continuing to twist and turn and dance with glee to keep the spell going while her hair and chains cascade behind her, whipping wildly with the wind from the back of her head.

As Fenrir dashes across the rocks and their escape blooms into possibility, another heavenly ring sounds out when the beast leaps again, and this time the impressive mechanical mast of Sapientia tears through time and space to immediately shoot a savage fireball with deadly accuracy. Clair spins in place and kicks out her left heel, and a wicked weave summons Isis’ leg with the attack to knock the projectile straight back into his face. He yells in pain upon impact, and falls through the clouds to disappear from view after taking the hit.

The respite is not long; Fenrir is hardly on another island before Sapientia is breaching up towards them again, but this time he is carried by an unimaginable surge of seawater that he swims upon like a dolphin riding the crest of a wave.

“COWER IN FEAR, YOUNG UMBRA!” He roars, keeping pace with Fenrir’s mach speed while Clair shoots him a cheeky grin. “THE MIGHT OF THE SEAS SHALL DRAG YOU DOWN! YOUR BRILLIANT DARKNESS WAS SHORT LIVED– NONE CAN ESCAPE THE RADIANCE OF THE HOLY SPIRIT, AND YOUR TRESPASS WILL SURELY BE PUNIS–MMPHFG!” His gloating is interrupted when the full weight of the fell wolf slams directly into the hull of his dreadnought figure, and Clair hits a strong pose to weave a spell under her feet for her next move.

“Bayonetta always said you were a mouthy one!” She calls, waving her hands around her in flowing, precise movements that hit the beat to a song only she can hear. “Come on!”

A frigid gust runs through the hair binding Fenrir to reality, and after using Sapientia as a launch pad to jump away, she guides him with her dance across the mighty waves that the Auditio willed into existence, using his frozen claws to instantly freeze the water on impact. With the water providing a new runway to stomp across, they take the chase into a new direction while avoiding another round of missiles fired from a fleet of Kinships that had caught up during the chaos. Clair’s heart pounds in her chest, her eyes shine like stars, and her lips stay permanently twisted upwards with wicked joy as they weave their way through the battlefield. The onslaught of Heaven is nothing more than her own personal Gala; a glorious stage for her to showcase her budding talent and blossoming skill.

A large, dilapidated city becomes visible as they descend further into the clouds, and it takes only a moment’s examination for Clair to extrapolate that they’re approaching the ruins of Cairo. With a seductive swish of her hips, she steers her companion towards them, and Fenrir somersaults through the air with a raucous bark, landing on the rooftop of a large skyscraper further below.

Sapientia swims past them and brings the cascade of water to the base of it, immediately flooding the side of the city and submerging both himself and the streets below. Only his golden wings, reminiscent of a shark’s fin, remain visible, and the water level continues to rise up the height of the building. Up top, Fenrir skids to a stop on his claws across the concrete roof, just in time for a flock of Braves to greet them in a bright flash. The largest one immediately launches itself forward with a hefty swing of its consecrated war pick, and Clair flips off of Fenrir’s head in the same breath that he ducks to avoid it. The wolf lunges with a ferocious snap of moon-white fangs that tears its head clean from its shoulders, bathing the roof of the building in golden light and crimson blood. The moment Clair’s heels hit the ground, she’s moving her body in an alluring dance yet again, now to direct Fenrir to snatch the dead angel’s weapon in his jaws to wield himself against the remaining five that march towards them with no fear for the consequences that befell their leader just moments before. Fenrir flips and aerials around the three that target him with ease, the blissful ringing of the weapon in his mouth providing a dichotomous soundtrack to the carnage he causes with each sweep of his head. Clair commands him expertly while continuing to nimbly avoid the attacks of the two that approach her, mixing in stylish poses with monstrous kicks and punches that knock the Braves around to and fro. One is kicked off the side of the building after missing a shot aimed for Clair’s head when she arches backwards to dodge, and the other is launched skyward when the pointed toe of her shoe slams into its chin, setting it up for a swift execution from Fenrir with one final slash of his stolen weapon.

The skirmish, while short, gave the fleet of Worships that had been left behind enough of a buffer period to catch up, and several sacred beams sear through the skyscraper’s tall midsection, immediately causing it to crumble. Clair performs a series of acrobatics through the falling debris with Fenrir following close behind across the quickly-collapsing rubble before taking her place on top of his head yet again, and he narrowly avoids Sapientia’s jaws when the Auditio breaches out from the sea with the majesty and grace of a great white hunting a seal.

Once again the wolf carries her across the water, his tongue flopping out of the side of his mouth while he sprints across the sides of buildings and darts from surging tides to ruined streets in a mad dash through the center of downtown Cairo with Sapientia swimming close behind. She pirouettes once before launching into a graceful back flip to reposition herself on his back the same way she would ride a horse, taking large fistfuls of his dark fur to steer him properly. A sharp turn takes them down a side street that Sapientia is too large to maneuver into, and both Clair and Infernal bound through the city’s underbelly to try and shake him off.

When Fenrir crosses a street after zipping underneath an overpass, Sapientia appears from between buildings maw-first to bring an abrupt end to the chase. His fiery jaws close around Fenrir’s neck and skull in slow motion at the same time that Clair leaps from her mount, and just as it seems that she may be devoured as well, a massive, dark, rose-tinted shape sweeps in and snatches her up right as Fenrir is messily sheared into chunks and dispelled from the summon. Clair remains unscathed, now riding through the air atop the deathdwelling bat Mictlantecuhtli. Its two pairs of wings allow for unmatched speed, and even while riding atop the water Sapientia is unable to reach them personally. Instead, it switches to cannon fire, with the armor plating on its sides opening up to launch several missiles that each sing the word of God while honing in on Clair’s position. The bat is far too nimble to be shot down however, and it whips around streets before ascending towards a Worship with increasing speed while aptly flying through the torrential rain of miraculous sunlight that wreaks havoc on the city below. The destruction it causes is finally culled when Clair reaches her peak and commands Mictlantecuhtli to attack, willing it to tuck in its wings and spin with violent ferocity in a dive aimed directly for the face of the hulking angel. The Infernal drill, though a fraction of the Worship’s size, pierces through its ivory hull with ease, spearing through internal systems and organs before bursting out of the side. She repeats this process for the remaining four in the fleet as well, carving through each one and sending them crashing down to the crumbling ruins that make up the floating island of Cairo. The drilling stops just long enough for her to catch sight of Sapientia’s location below, and the moment she does the Auditio is repositioning its head to reveal four large tentacles that immediately take aim at their skybound target and charge up four intense beams of light.

“Do it!” Clair calls, prompting Mictlantecuhtli to pull an Immelmann turn in a graceful arc for extra momentum. Clair launches herself off of it as it begins to spin again right as Sapientia’s lasers fire, and the bat meets all four head on in a shrieking collision that splits the shots in twain and sends them into the surrounding ruins. There’s a brief struggle in the center where it’s unclear which monster will break through, until the action reaches its climax and Mictlantecuhtli pierces through the lasers with its grinding assault. Just as it did with the Worships, the Infernal punctures through Sapientia’s hulking frame and brings the colossal confrontation to an end. The Auditio screams in agony while being ripped apart by the attack, and several portals to Inferno open up for its denizens to rise forth and drag its carcass into the abyss as a sacrifice. Clair sings with joy as she falls towards the ground from half a mile in the air, admiring her deadly handiwork in the downtime provided by her lengthy descent.

She dives with the graceful posture of an eagle, falling head-first towards the ground until she draws close enough that a single spin when she tucks herself into a ball positions herself to hit the ground standing. The asphalt cracks upon impact, and she stands tall to face the three portals to Paradiso that open to greet her. Manifesting through God’s radiant light, a Belief charges into the scene followed closely by two Urbane. Clair shifts her weight to the side nonchalantly, giving each one a once over before barking out a cocky ‘heh!’ and reaching into her hair to pull out Le Ciel and prepare for combat.

“You boys want some of the action, too?” She croons, giving each pistol a twirl in her hands then shifting into her Umbran stance. “I don’t know if you’ll be able to keep up with the ones who I just wiped the floor with, but I love teaching newbies how to dance!”

The Belief, incensed by the taunt, whips its tentacle at Clair, who table-hops over it to avoid the attack, and the fight begins.

With the shrill cry of a kite and a shower of golden plumage, Clair opens with an Umbran spear that closes the gap between her and the Belief in a fraction of a second. Her foot smashes into its face with a loud ‘crack!’, and porcelain skin shatters upon impact. Clair twists, a round of bullets firing from her heel to salt the wound before she vaults over the angel and kicks again, this time beckoning forth a wicked heel that sends the giant flying. Both Urbane bring down flaming cages upon her position with a devastating crash, but the moment the attacks are supposed to connect, Clair bursts into a swarm of hummingbirds to negate the blows. Invigorated, she activates witch time and unleashes her magic in a frightful flash, comboing one hulking titan into the other with a flurry of punches and kicks that smack it around more violently than a boxer whaling on a sandbag. When one is sent skyward with an uppercut finisher, she runs across its body in her pocket of time to grab the rim of its halo and flip the entire monster overhead, using it like a hammer to bash the other Urbane into the ground. Witch time ends once she lands again, and a casual turn to the side moves her out of the way of the injured Belief’s sneak attack from behind. Its tentacle instead pierces through the back of one Urbane, killing it on top of its comrade in a fountain of gore, and Clair stomps her heel with a haughty cry to summon another wicked weave that finishes off the remaining one without even turning around to watch it die. Instead, she remains focused on the charging Belief, turning a back handspring, an aerial, and a full twist to dance around catastrophic sweeps of its trunk-like tentacle. The makeshift mouth on the right side of its head opens up to fire a glob of green goo that she rolls towards it to avoid, sweeping her leg in a twist after and snapping its tibia with the blow.

“Filthy!” She cries with malevolent glee, comboing into another kick that shatters the white-gold armor encasing its midsection and brings the second sphere Power to its knees. “But I know someone who will absolutely eat you up!” With an outward flair of her arms, the hair that hangs from her biceps whips about with magic to summon both of Madama Isis’ great arms to grab the Belief on either side so that she can throw it overhead, immediately striking a pose after to bring the action to a final climax with a screaming chant of enochian;

IADADNA

Her hair spirals off of her body to reveal her stunning bare form, and with a harrowing howl, Fenrir tears out of Inferno behind her and flies like a bullet towards the airborne Belief, leaping up to grab the angel in his massive jaws before immediately turning around and bounding back to Clair. With a delighted giggle, she grabs the angel by its hanging tentacle and throws it again in the opposite direction, playing a demonic game of fetch with the infamous God eater the same way she would a normal dog. The third time she tosses the bludgeoned Belief, who’s holy screams have echoed throughout the cracked city plaza the entire time Clair has been throwing him around, Fenrir brings it back, but does not drop it at her feet. With a flash of amusement in her eyes, she summons Madama Isis’ arms once more and grabs the Belief by the legs, and the two monsters tug and pull and snarl while the angel wails in agony before finally, with a gruesome ripping sound, it’s torn to shreds between the two. Clair falls onto her behind with a chime of laughter, and Fenirir hungrily snaps up the remains of the Belief before tossing back his head to howl at the weeping sky, returning from whence he came as Clair’s hair unravels from around his body and retreats back into the portal. It forms her suit once more, and she blows a kiss to send him off.

The wreckage of the chaos churns around the vicinity of the plaza, and Clair examines the damage while trying to get a feel for what to do next, weighing her options. Isis is blatantly silent in her mind palace, shrouded in a smug mystery that tells Clair she’s pointed in the right direction while simultaneously dangling the answer tantalizingly close in front of her face. It’s frustrating not being able to get any more information out of her, but she suspects she’ll figure something out soon enough wherever they end up. What she does know is that now there’s another asshole she has a bone to pick with on the steadily growing list, and standing around waiting sounds like a bore. This area feels like a hot spot after all of her romping around anyway, and if she keeps letting herself get caught up in fights she’ll never get anywhere.

The rush of water streaming from debris and flooding the broken streets helps her focus, and she thinks about what’s happened; An entity known as Yaldabaoth attacked her and caused Armageddon, separating her from Bayonetta and Jeanne and kicking off the end of the world; The earth seems to be mixed up like puzzle pieces while also having merged with Purgatorio, and both the Laguna and Infernals are able to fully manifest regardless of the area; The sinister presence Madama Isis has her chasing after is still able to be sensed, and even feels brighter than it did before this whole mess started. All in all, she could be in worse shape, and even got a new pet for her troubles.

With no clear direction, she decides to pick up where she left off and continue her search. “I might as well make my way towards Luxor,” she voices aloud, and turns to face the direction her destination is in with a newfound determination in her eyes. The thought of walking that far almost makes her shoulders sag, but right as she’s about to accept her bleak future, she spots a shiny toy just at the end of the block ahead of her. It’s a beat up old convertible, with white leather seats that beckon for Clair to try out. Other than a few dents and scratches, it looks otherwise untouched, miraculously surviving the apocalypse to appear in her hour of need. Her face lights up with pleasant surprise before she saunters over to investigate, dragging her finger over the hood of the car before giving the rim of the windshield a sharp pound with her fist. The engine springs to life on impact, spluttering some dust out of the exhaust before settling into a hearty purr at Clair’s insistence. She licks her lips, pleased with the machinery’s compliance with her bewitchment, then opens the door to take a seat and kick back. Her long legs stretch languidly across the dash, and a caress of her finger over the clutch charms the gears to switch as needed for the car to back out of its parking space and maneuver onto the road. Sated, comfortable, and set for travel, she twirls her finger once in the air to cast a spell over the car, then folds her arms behind her head to relax while her new ride obediently revs the engine and speeds her out of town.

#bayonetta #writing #clair tag #if u read this and happen 2 be interested... please feel free to ask teehee

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