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starrysnowdrop · 3 years

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Memories Like Scars

Part 2

Yume Aino x Cid Garlond

2,423 Words

Please read the first part HERE

Romantic Tension; Bonding; Expanded Cutscene

This is a retelling of the in-game cutscene where the WoL helps Cid regain his memories and gives him his trademark goggles via the Echo. Here, Yume and Cid relive Cid’s memories together and Yume and Cid discover that they have a strange bond they never imagined that they had.

A gentle breeze blew through Yume’s raven hair as she walked onto the Gridanian airship platform. She brushed a loose strand of hair out of her face and tucked it behind her right horn as she approached the white haired man waiting for her.

When Cid Garlond turned to face her, she could not help but smile. Just why he had this particular effect on her, she really couldn’t explain. She could not stop the butterflies in her stomach and her heart would flutter at the mere sight of him. All she knew was that he has the most brilliant smile, a strong jawline covered with a short, white beard, long, white hair, shining silver eyes, muscular arms, broad shoulders, and a sculpted chest that she always catches herself staring at for far too long... Yes, he was a beautiful man, there was no denying that.

Yet, what she admired most was not skin deep: his jovial nature, his humor, his intelligence, his determination, and most of all, his kindness. Cid helped her to pick up the pieces in the aftermath of the attack on the Scions, with his quick wit and endless compassion for others.

She couldn’t understand it herself, but she felt she could trust him... completely. Such a rarity indeed for the Raen ronin who had left everything behind in Hingashi.

“Yume, you have returned! And just in time too.” Cid smiled as he gestured towards the Enterprise behind him. “According to my tests, the device is now functioning in perfect harmony with the crystal─meaning we can leave whenever you're ready.”

Yume smiled back at him before gently nodding. “That is good to hear. I am ready to go if Alphinaud is.” She gestured to her fellow Scion, who was still talking to one of the airship platform attendants.

The Garlean man nodded in return, then sighed deeply.

“But you must understand: tests can only tell one so much.” Cid folded his arms and looked towards the Enterprise.

“Until we approach the Howling Eye─until we attempt to breach the barrier itself... I cannot be sure that this will work...”

Yume’s sapphire eyes grew wide as she realized what Cid was about to tell her. Not that she hadn’t been in life or death situations before; she had been in far too many for her to count. Still, her heart seized up with the thought of Cid and Alphinaud being in harm’s way. If anyone should be ready to die it was her... not either of her newfound companions.

Cid hesitated a moment before he spoke once more.

“I think it only fair to tell you that there is a small but statistically significant chance that the crystal could trigger a massive...”

Cid shook his head before he unfolded his arms and continued, “Hmmm... Mayhap it is better that we remain positive.”

“Yes, we should foremost be positive, and assured that we will make it through the barrier... then we will defeat Garuda. Doubt will cost you everything,” Yume answered with a calming intonation.

Yume giggled as she looked up to the sky in thought. “A great general once said, ‘Victory belongs to the most persevering’...” She then shrugged as she looked back to Cid, “...or so I have been told anyway.”

The Garlean smiled once more as he seemed to hesitate for a moment. Cid then breathed in deeply as he reached out his hand and caressed Yume’s ivory scaled cheek, while he placed his other hand on her shoulder. Yume’s breath caught in her throat as Cid’s silver eyes looked directly into hers.

“Yume, I want to thank you. For reuniting me with my ship, for trusting in me to develop this plan... for everything. You've helped me to rediscover a part of myself I'd forgotten. I am not the man I once was, and I do not know if I ever shall be... but I do know one thing: this feels right.”

Yume placed her hand over his as she leaned into his touch. Her heart was beating rapidly as she forced herself to stop shaking from the emotions that threatened to overflow.

“There is no need to thank me, Cid. I am glad... glad that we met.”

Cid’s silver eyes softened as Yume continued, “This feels right for me too... as if this was meant to be. I just know that if you are by my side, everything will be alright.”

Cid ran his thumb over her scales on her cheek and brushed his hand down the side of her face till he took his hand back.

He chuckled for a moment, “Ahem... My apologies for the sudden outpouring of sentiment. I would have waited until after the mission, but... well, you understand.”

Yume simply nodded in response before the short elezen in blue and white coughed loudly, finally catching everyone’s attention, “Well, if we are done here, then let us be on our way.”

Alphinaud squeezed himself in between Cid and Yume to step onboard the airship, exasperation set on his face. The two simply shrugged at each other in response before following Alphinaud onto the airship themselves.

———

Once the Enterprise took to the air, Cid was at the helm with Yume standing vigil right by his side. Alphinaud was standing a few fulms behind Cid, his arms crossed while staring out at the cloud filled sky.

Cid reached up and took off his signature goggles, revealing his Garlean third eye. He stared down at the goggles in his hand with a look of longing in his eyes. After a few moments, Cid grabbed his forehead hard, as if the third eye itself was hurting.

“Damn it!” Cid cursed to the winds as he turned towards the Raen.

“I... I once flew in this airship. And I was not alone,” Cid spoke slowly as his mind’s fog began to clear, “There were adventurers on board... adventurers like you, Yume.”

“Cid, are starting to remember something?” Yume inquired.

“I... I think...”

He then was interrupted by a sharp pain in his head. Grasping at his head in a fruitless attempt to stop the sudden painful attack, Cid then turns to Yume with a look of shock mixed with confusion.

Yume gasps as she reaches out to him, but it is no use. She knows what is coming.

A bright light envelops the both of them, as they are transported to an entirely different space. It was a vast empty space filled with a soft light. When Yume looked behind her, Cid was standing there exactly as he was moments before, seemingly stunned at what he was seeing.

“Yume? Is that you?”

Nodding back at him, Yume breathlessly spoke, “Yes... but... I do not know why you are here with me.”

“Where are we? What is this place?” Cid spun around in utter disbelief at the endless nothing around the two of them.

“This is the space where I view visions of the past. This is the power of the Echo.”

“The Echo? The Echo causes THIS?”

“Sometimes, yes... usually I am seeing events unfold already, of someone’s memories. Other times, this space appears while visions appear to me after a short time. I have had this power for as long as I remember, but I still do not know how to control it... or how it works entirely.”

Cid sighs in exasperation. “Alright, well, we must be here for a reason. Let’s figure out what that is then.”

Yume nodded before she answered him, “Cid, you had said that you flew on the airship with adventurers before, right?”

“Yes... though I had only remembered because I was holding my goggles in my hand.”

Cid held his hand out to Yume, the pair of goggles sitting in his palm. Yume stepped forward and looked down at the goggles. She studied them for a second before Cid spoke aloud his thoughts.

“Just how long have I worn these damn goggles?” Cid sighed as he shook his head. “Wait... I think I am beginning to remember something...”

It was mere seconds afterwards that a small boy ran up to them... a boy with white hair and a Garlean third eye. Yume knew instantly that it was Cid as a child.

Yume smiled at the younger Cid as the present Cid seemingly continued to voice his stream of consciousness aloud.

“Ah, yes. I fancied myself a trendsetter in my younger days. The young prodigy, admired by all... exactly like his father.”

The younger Cid sat down at a desk building a tiny version of what appeared to be Magitek armor. Cid continued, “I was born and raised in Garlemald...”

“It was only natural that the precocious young student should become an engineer. Had his father not done the same?”

Child Cid then got up from the desk, with a distressed look in his silver eyes. The boy walked away and faded away into the emptiness. Yume felt tears come to her eyes as Cid continued, “Father... When did we stop seeing eye to eye?”

Suddenly, the space went dark, then appearing from the darkness, the blood red moon Dalamud hung eerily above them.

Cid’s voice began to shake, “When did Meteor become your everything, and your loved ones cease to matter?” Yume turned to Cid and saw the pain in his eyes. “You abandoned us all. But he was there for me, Father─there for me when you were not.”

Yume turned around to see a large man clad in a rust red coat and black Imperial armor. He walked slowly forward and touched the shoulder of who appeared to be Cid a few years younger than he was right now. The armored man looked rather intimidating to be sure, but the younger Cid was not afraid of him. On the contrary, the young Cid seemed to look to the man with admiration in his eyes.

Cid’s voice floated to Yume’s horns as she watched the two figures slowly fade and the soft light return to the space. “Though he proved no better in the end. Gaius was just another man with an all-consuming obsession.”

The Raen’s gaze returned to Cid, who had closed his eyes in contemplation.

“And so I ran─left the Empire behind and came to Eorzea, where I built the Ironworks.”

Opening his eyes, Cid looked down at the goggles in his hand. Suddenly, the space erupted into light, and was replaced by the two standing on the deck of the Enterprise, but accompanying them were a younger Cid sans beard, along with Biggs and Wedge, Cid’s assistants that Yume had saved from the Garleans soon after joining the Immortal Flames.

“Eorzea opened my eyes. It was home to so many manner of people, each with their own hopes and dreams. People worth saving. And so I fought beside them. I wanted to prove that my knowledge could serve a nobler purpose. I wanted to prove that there was another way...”

Cid smiled at his younger self, who was looking out onto a night sky filled with stars, with the wind blowing through his white hair. “And it all began that day, when I found my new home...”

The peaceful atmosphere was broken when a burst of light appeared just over the side of the airship. Yume and Cid squinted their eyes as the younger Cid approached the light.

After Yume’s eyes adjusted to the change in brightness, she soon realized that the light was in the shape of a person. “What...?” Yume inquisitively stepped forward to see the figure more clearly. She gasped when she saw who the figure in the light was.

Cid mimicked his younger self and stared in awe at the light, clearly not quite believing what he was seeing.

“How can that be... I always thought it was just a dream...”

Yume shook her head. “This is no dream, it is one of your memories. But, how is it possible?”

Cid’s silver eyes smiled down at her and he laughed lightly, “Of course, that light─it was you, wasn't it? All along, it was always you...”

A deep blush adorned Yume’s cheeks as the two watched the scene play out in front of them. The light figure of Yume reaches out to the younger Cid and hands him something. She smiles at him before the light fades away. The younger Cid looks down in astonishment at his open palm and sees the goggles sitting there.

After a few moments, the younger Cid places the goggles on his forehead, clipping them to his third eye. He turned around towards Biggs and Wedge, whom both gave a thumbs up in approval.

Yume held her head with her left hand as she concentrated on the scene that had played out in front of her very eyes. “I gave you the goggles...? I must have used the Echo to give them to you... but when?”

“Well, I have had these goggles since I first came to Eorzea, before the Calamity. But I could never remember where I had gotten them from. I always thought that vision of you in light was a mere dream. I can’t believe it really happened.”

Cid looked around at their surroundings as the scene began to fade back to the softly lit empty space. “Then again, it’s hard to believe that we are standing here reliving my memories. But here we are.”

Yume turned to Cid, as she furrowed her brow. “I am just not sure when that could have possibly happened. Before the calamity, I was still in Hingashi... in Kugane specifically.”

Cid brought his hand to his chin in thought for a moment. “Yume, think back to that time... what happened five years ago? Or go back further than that—perhaps it will spark that particular memory.”

Yume closed her eyes and shook her head. She knew what will happen if she concentrated too hard on her memories... those times filled with pain and heartache.

Cid, the man she admired, the one who made her heart skip a beat just from one look, a dear friend who had been there for her when she needed someone the most... what would he think of her if he saw who she truly was? Would he turn away from her in disgust?

Her heart would be shattered if he walked away from her now... but she needed to know. She had to know... did she truly have this connection with Cid before they had even met?

((To be continued))

#my writing #ffxiv #final fantasy xiv #final fantasy 14 #ffxiv fanfiction #ffxiv oc #cid nan garlond #cid garlond #cid garlond x wol #cid x wol #yume aino x cid garlond #yume aino #oc: paint it black #otp: always you [ yume x cid]

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aswallowssong · 4 years

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OWP Day 4 - Candy Wrapper

Read on AO3

-----

Morgan held out his closed fist to Kit, nodding and saying, “I got you this.”

She wasn’t really paying attention. They were supposed to have another health meeting on Friday - “Another health meeting! We just had one!” - and she was in over her head. She’d been pulled on more cases than usual, which she was secretly thrilled about, but it was leaving her less time to prepare for their biweekly meetings. She’d even suggested to Ramos that they change the requirement to once a month, but he wasn’t budging.

He’d cited the director directly as the one who had approved her position requirements, but she sort of felt like he was full of bullshit.

In her distraction, she held her hand out to him, not looking up as she flipped the article she was reading over to the next page. “Okay.”

He pressed his palm to hers, opening it and dropping the item into her hand. It was made of soft, crinkling plastic, and she tore her eyes away to look at what he’d given her.

An empty candy wrapper.

“Oi!” She called at him as he retreated away, laughing and high fiving Elle. “I am not a trash can!”

He smirked at her, pulling his chair out to settle back in with his paperwork. He and Elle were both incredibly amused, but it didn’t seem that anyone else had noticed what happened. At least, Reid certainly didn’t, his face in a book with his tongue poking out between his lips in concentration.

“Course not,” Morgan said, clicking his pen a few times as he picked it up, “but you were in your own world over there.”

“I’m-”

“Reading, we know,” Elle said, settling on top of her desk and raising an eyebrow. “Did you just say oi?”

Kit sighed and sat back in her chair, the wrapper still held in her hand. It was from a mini Milky Way, and she frowned at Morgan’s choice. “I, yeah,” She rubbed at the back of her neck with her free hand, something she’d picked up from Hotch. “I did.”

“That’s fitting,” she said, crossing one of her legs over the other. “What are you reading?”

Kit flipped her article closed and held it up so they could see the title. “It’s an article about diet and nutrition. That’s what the meeting is going to be on Friday.”

“Spoilers,” Reid mumbled under his breath before turning the page of his book. She frowned over at him. “You all voted for it instead of Sexual Harassment training, how is that a spoiler?”

She held up the wrapper between her fingers for Morgan to see, “And, this is exactly why I put it on the chart to be voted on. Where are you all getting this candy? I feel like I’ve seen wrappers everywhere this week.”

“Garcia has a bowl in her office,” Reid mumbled again, eyes glued to the page, but clearly trying to be in on the conversation. “She filled it on Monday.”

He sat up and set his book down, eyes lighting up and voice solidifying as he started into one of his rants. “You know, more than one third of all offices have a communal candy dish, and while there is a statistically significant decrease in consumption based on proximity, there is also a difference in attempted access when-”

“Pretty boy,” Morgan said, cutting Reid off before he could really get going. “It’s candy.”

Kit shook her head, pulling a pen from behind her ear and flipping her article over to the blank backside. “Oi, no, shut up Derek. This is way better than the article I was reading.”

Derek chuckled at her, shaking his head and picking up a file from his stack. “Your funeral, Lep.”

-----

“Hey Kit, can you hold this for me?” JJ asked. They were standing in the breakroom, and Kit had been trying to pull her taped voting chart off of the cabinets without pulling the paint up. It took focus she didn’t have, but she didn’t know where else she could put it that everyone would see. She also didn’t want to have to admit to Hotch that she pulled the paint off the wood, so she called it a lesson in patience. Sort of a win-win.

JJ and Garcia had already been in there when she entered, talking while standing near the sink in hushed voices.

“Sure,” she said, not really hearing what JJ had said, but holding her hand out all the same. Her other hand pulled gently on the tape, and she could feel her teeth cutting into her lip as she struggled to concentrate.

JJ’s hand uncurled and Kit felt the light weight object settle in her palm. Her other hand froze as she realized what had happened, and her head snapped to look.

A candy wrapper.

“Oi! Derek!” She called, forgetting about her sign completely in favor of turning to look around the room.

JJ and Garcia both wore guilty smiles on their faces, but Kit could hear Morgan and Elle’s laughter in the bullpen. “Sorry,” JJ said, “We didn’t think you’d fall for it.”

“Not after Morgan did it this morning,” Garcia said with a laugh. “You were just so focused, JJ even said it twice!”

Kit sighed, rubbing a hand down her face before shaking her head. “I was focused on this damn tape,” she said, finding herself laughing along with them. “And you all eat too much candy! Since when is there a bowl in your cave?”

Garcia’s face split into a grin. “Well, after Halloween there was so much on sale at the grocery store, and I thought it would be nice. Something happy and yummy in the face of all the icky and sad,” she said simply, eyes showing the hope she was pumping into the air.

That was one of the things Kit liked most about Garcia. She was hopeful when everything felt like it was falling down. A star in the dark.

“I have a feeling there would be a rebellion if I asked you to take it away,” she said, and JJ nodded quickly. “Oh, big time. Elle has to be in there six times a day.”

Garcia nodded happily, beaming at the two of them. “The more visitors I get, the happier I am. Speaking of, I should get back in there. I’m running a diagnostic that should be done any minute!”

Before Kit or JJ could say anything else, she scampered off, heels clicking against the tiled floor. Kit looked down at her hand and scowled. “Is this a tiny Twix wrapper? Really?”

“They’re good!” JJ protested, walking out of the breakroom with Kit at her heels, poster completely forgotten and hanging by a single corner.

“They’re literally all sugar!”

“At least I don’t eat the Milky Ways,” she said with a pointed look at Morgan, who held his hands up in protest. “Woah! We’re attacking people’s candy preferences now?”

“I like whoppers,” Reid said happily, a small smile on his face.

The other’s groaned, Elle booing him and tossing a pack of M&Ms at him from off her desk. “Gross!”

“I guess we are,” Kit said, perching on her desk and dropping JJ’s wrapper next to Morgan’s. “Though, I’d be happier if we were comparing vegetable opinions.”

“Okay,” Elle said, smirking at JJ. “Broccoli is the best vegetable.”

“Broccoli is gross, Elle, I’m not getting into this with you again,” JJ warned, hands going to her hips, and the rest of them broke into peals of laughter.

------

“We’re going to watch this investigation, and as soon as local law requests us, we’ll be in the air. Make sure your go bag is in reach,” Hotch warned, effectively ending their round table meeting. They started to get up, Kit with her eyes glued to the file in front of her. They hadn’t been invited in yet, but JJ and Hotch were both convinced they would be within a few hours, so they’d already started to prepare. The case was strange, and Kit was unsure as to what she was looking for in the medical files before she heard Hotch’s voice over her shoulder.

“Colghain,” he said, “here.”

She raised an eyebrow, turning and looking up at him from her seat. He was holding his hand out to her, and she reached for it quickly. He dropped a single mini Three Musketeers wrapper in her hand, and her jaw dropped open.

“Derek!” she yelled over her shoulder, and she was only met with howls of laughter from outside the door. Her eyes darted back over to Hotch, and he gave her a smirk so small, it was nearly undetectable. She groaned. “Not you, too.”

“I appreciate how much you trust this team,” he said, patting her on the shoulder before grabbing his file and walking out of the conference room.

She groaned again, looking down at the wrapper before taking a deep breath.

She was so talking about the candy bowl at their meeting.

#Brenna writes things #or at least she tries #October Writing Prompts #SCRC #Criminal Minds #day 4 #candy wrapper

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adverworld53 · 4 years

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ambiguous-fixer · 7 years

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The Origin Story

My origin story.

Birth.

I was born in on a cold wintry night in December, it was supposedly 10ºC, the wind was howling. My grandmothers huddled together, wrapped in similar shawls awaiting the main event. My birth. Finally, close to midnight a piercing wail was heard. I had come into the world.

Childhood.

Who can forget those days? The red frock and matching bag and shoes which I wore on my first day in kindergarten, those tears running down and tiny fingers latched on to my mother’s hand so she would not be able to leave me and go. Then the teacher, a Mrs. K, a benevolent lady with a mellifluous voice gently loosening my grip on my mother’s hand and taking me inside with the promise of lots of new friends, fun, and chocolates. I watched sadly as my mom waved to me, calling out to enjoy myself and not to worry about anything. It is true that I do not vividly remember the happenings of that day but I remember till date that it had been a very fun filled day and that was when I met my first friend. I went back home happily with lots of stories to tell my folks at home about my new friends and how I was looking forward to going back the next day. My parents were obviously relieved at my having gotten adjusted quite nicely to my new environment. Kindergarten for the rest of the time passed quite eventfully, learning as well as having fun. My only tension was what I would get to carry for lunch the next day. Life was so carefree. Then came the next step, the school interview which is etched in my memory because it was such a special day and I met one of the kindest yet firm and dynamic visionary teachers I have ever met. My headmistress Mrs. J, the typical stern looking face that looked down at kids through scary (I thought so then!) glasses. But when she smiled, she was a different lady altogether. Soon, we came to know she was a woman who coddled us as much as she expected discipline from us. In fact, she was the one who discovered my penchant for creative writing and inspired me to win several competitions. Soon, I became her pet student because (I am not boasting here!!!) I was pretty good at academics, music, creative writing and karate even. Although school was also fun, life changed quite a bit. All of a sudden we were saddled with something called “homework” failing which, every single day the consequences were bound to be quite ugly. Nails had to be snipped perfectly, every hair in place and we were never to forget our badges. (Psst…there has been many an occasion when I forgot my badge). Even that passed rapidly owing to some really memorable teachers who made learning a fun thing.

Adolescence.

I was now in middle school. Environmental Studies (EVS) was now divided into three chunks- Physics, Chemistry and Biology. Social Studies was divided into History & Civics and Geography.

Middle school and high school too passed fairly uneventfully what with homework and record- writing being my primary concern, leaving me with almost nil time for play and enjoyment. As a result, with a heavy heart, I dropped music classes but continued to sing for the school music team anyway. Here I must thank Mr. S for not only giving me unofficial musical training but also teaching me lessons in humility and simplicity. His simple way of dressing and living despite his numerous achievements was something I strived to emulate and still hold close to my heart.

All I remember about ninth and tenth is the immense pressure from teachers, parents, relatives to compete with my peers and “beat” them at every exam. The only thing that comes to my mind is studying, studying and more studying. Pulling off all-nighters before the geography and physics exams. Plodding my way through a labyrinth of multiple theorems, formulae, incomprehensible archaic Kannada poetry, geographical statistics and practicing diagrams for biology, night after night. High School passed in a blur and soon, I came to college.

College! That wonderful place I had been wanting to attend ever since I was in school and had seen my cousin doing so. The freedom from the ole’ white-and-blue, no more ties and black ribbons, neither badges nor restrictions. I was simply thrilled at the prospect of attending the same college which my old school gang had joined. We would not be separated. My happiness knew no bounds.

College was one place where I learnt much more than just accountancy, mathematics, statistics and business studies. My equation with some of my old friends changed as I found new ones who despite not fitting into the old mould became very close to me. Despite being allowed to wear the dress of our choice, I realized that there were restrictions, even if they were practically invisible. Freedom brought with it responsibilities too.

As with everyone, it happened to me as well. One day we were friends, and suddenly without my knowledge he had become infinitely dear to me. The equation changed. After a good five months, as all good things should come to an end, so did this. Though at that point, I wonder how much of a good thing it really was. This, and a few more disillusionments led me to appreciate my true friendships and also the value of those things which I had but had never quite understood the significance of, until I almost lost them. These trying times strengthened me as a person and changed me a lot. Earlier I might have offered perfunctory prayers but since then, my faith and belief have gotten stronger.

These are not the only transformations that adulthood has brought with it. The rosy glasses shattered, now I can view the world more objectively. I scoff now at the awe and admiration that I held for a teacher in my high school who with her fiery speeches was very provocative. I recognize it now for what it was, misdirecting zeal and aggression, twisting of facts to make things appear more romantic to our adolescent minds; something which my adolescent mind could not figure out then. The lessons learned and the memories, I will carry with me as I step into adulthood.

Adulthood.

Work in progress. I will tell you when I figure it out.

#origin story #my life #story time #figuring it out

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lauramalchowblog · 5 years

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Last Couple of Months in Oncology with Dr. Bishal Gyawali: March 2019

By BISHAL GYAWALI MD, PhD

Hey, I’m back!

Well, you might not have noticed that my blogs were missing for the last three months but anyways, its good to be back. I was having a little time off blogs and social media as I was transitioning in my career but now I am back. Sometimes, it is very difficult to manage time for things that you must do versus things you enjoy doing, especially when these two don’t intersect. For me, these last few months the things I had to do were all bureaucratic while I couldn’t find the time for things I enjoy doing like writing these blogs. But now that we are back, let’s recap what has happened in the oncology world in the year 2019 so far. I can’t cover all of them, but will try to summarise the major events in oncology.

Hundred Foxes’ Howl versus One LION’s Roar

In my country, there is a saying that goes somewhat like the roar of one lion will scare hundreds of howling foxes away. In medicine, I guess, it translates as one good RCT trumps the results from hundreds of observational studies. For patients with advanced ovarian cancer, primary surgery to achieve complete resection is the most important treatment and prognostic factor. However, what to do with the lymph nodes is a question that has troubled the oncology community for a long time. Logically, it makes sense to remove the lymph nodes too because they are the sanctuary sites for cancer cells. However, lymph node dissection carries high morbidity. Although multiple observational studies suggested a survival benefit with lymph node dissection, the LION trial, now published in the NEJM, shows that for women with macroscopic complete resection of primary tumour, lymph node dissection increases morbidity (postoperative complications) and post-operative mortality rates but doesn’t improve survival. I am glad that this trial was carried out and these results will now save many women with ovarian cancer worldwide from unnecessary harmful procedures, but I am also sad that we didn’t answer this question until now and thus, many patients suffered unnecessarily. I hope this LION’s roar scares us from jumping to conclusions based on logic or observational data alone and without RCT evidence in future. Another lesson here is the importance of public funds in supporting RCTs like these.

Practical exercises on trial methodologies and reporting

Going through oncology articles published in top journals in the last couple of months seemed more like a practical course on spotting methodological issues in publications. I don’t have the time to discuss them all here but for any student of research or trial methodologies, these papers will be good learning exercises. I have tried to focus more on statistical than clinical aspects of these trials because they are in general not practice changing yet.

First, in this phase 1/2 trial, a drug in competition for the most difficult drug to pronounce/spell in oncology, sacituzumabgovitecan-hziy, was tested in patients with refractory metastatic triple negative breast cancer. Although the responses look impressive, there is no mention of the criteria for success. Shouldn’t there be an a-priori definition of when success can be claimed for a phase 2? How do we decide when to take them to phase 3?

Second, these two RCTs of direct oral anticoagulants to prevent VTE in ambulatory cancer patients are an exercise on understanding intention-to-treat versus per-protocol treatment. Another lesson here is to look at the absolute difference in event rates besides the hazard ratio. In any case, the burden of therapy here seems to outweigh the benefits.

Third, in this RCT of TDM1 as adjuvant therapy for patients with HER2 positive breast cancer who had received a trastuzumab-containing neoadjuvant regimen but had residual invasive breast cancer, the conclusion reads “the risk of recurrence of invasive breast cancer or death was 50 percent lower with adjuvant T-DM1 than with trastuzumab alone”. The hazard ratio is 0.5 but hazard ratio is not the same as risk ratio. This is a common misconception as we have previously shown in this experiment. The difference in absolute percentage of patients who remained free of invasive disease at 3 years was 11 percent (88 percent v 77 percent) which is impressive, but it’s not 50 percent. Finally, with a median of more than 40 months of follow-up, the OS hasn’t seen significant improvement. Also a tricky question now is whether TDM1 retains the survival benefits when the disease has relapsed now that patients have already used it in the adjuvant setting.

Fourth, this RCT of ramucirumab after sorafenib in hepatocellular cancer provides multiple lessons: Clinically meaningful versus statistically significant difference in outcomes (OS benefit of only 1.2 months but p = 0.0199), highly selected patient population for enrollment (the control arm OS of over 7 months in second-line hepatocellular cancer) and the use of this sentence in the conclusion despite 3 fatal adverse events and an increased percentage of serious adverse events within the ramucirumab arm: “Ramucirumab was well tolerated, with a manageable safety profile.” If you don’t know why I am not happy with this statement, please read this article we published in the BMJ that addresses this exact point.

Another drug that improves an endpoint that you didn’t even know existed until few years ago

Darolutamide has shown to improve metastasis-free survival in patients with non-metastatic castration-resistant prostate cancer in the ARAMIS trial. Metastasis-free survival is a new surrogate endpoint, about which I have discussed in detail in an earlier blog. To be fair, unlike enzalutamide, darolutamide has also shown improvements in overall survival but only 15 percent of the patients in placebo arm received enzalutamide subsequently. When this trial was presented at ASCO GU 19, the discussant Prof. Ian Davis’s summary slide which nicely highlighted all the caveats floated around Twitter, so I will just put his slide here: https://twitter.com/birensaraiya/status/1096175780579561472.

Also, while we are talking about prostate cancer, I’d like to highlight this study which showed that the combination of radium plus abiraterone was harmful than abiraterone alone. Another example to keep in mind to remind ourselves to exercise caution in recommending A B when both A and B are approved agents for a given cancer.

We need more publicly funded trials

An important trial in glioblastoma was published in the Lancet in February. Until now, the Stupp regimen has remained the standard of care but this new RCT of Stupp regimen plus lomustine showed a significant improvement in OS of 17 months compared to Stupp regimen alone without lomustine. The sample size was small and the authors conclude the abstract as “Our results suggest that lomustine-temozolomide chemotherapy might improve survival compared with temozolomide standard therapy in patients with newly diagnosed glioblastoma with methylated MGMT promoter. The findings should be interpreted with caution, owing to the small size of the trial.” I totally appreciate the honest interpretation from the authors here but also can’t help wonder how this paragraph might have read if this was the trial of immunotherapy instead of lomustine and funded by industry rather than the German Federal Ministry of Education and Research.

Let me take a selfie

After a long time, Vinay Prasad and I have written a paper together. This time we talk about risk-benefit trade-offs in the adjuvant treatment setting, especially in the absence of robust data, because the threshold for treatments are different from the metastatic setting. We also list various examples of drugs that are effective in metastatic setting but failed as adjuvant therapy.

Dr. Gyawali is a research fellow at Program On Regulation, Therapeutics And Law (PORTAL) at Brigham and Women’s Hospital/Harvard Medical School. The opinions expressed herein are his own. This post originally appeared on ecancer here.

Last Couple of Months in Oncology with Dr. Bishal Gyawali: March 2019 published first on https://venabeahan.tumblr.com

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kristinsimmons · 5 years

Text

Last Couple of Months in Oncology with Dr. Bishal Gyawali: March 2019

By BISHAL GYAWALI MD, PhD

Hey, I’m back!

Hundred Foxes’ Howl versus One LION’s Roar

Practical exercises on trial methodologies and reporting

Another drug that improves an endpoint that you didn’t even know existed until few years ago

We need more publicly funded trials

Let me take a selfie

Last Couple of Months in Oncology with Dr. Bishal Gyawali: March 2019 published first on https://wittooth.tumblr.com/

0 notes

isaacscrawford · 5 years

Text

Last Couple of Months in Oncology with Dr. Bishal Gyawali: March 2019

By BISHAL GYAWALI MD, PhD

Hey, I’m back!

Hundred Foxes’ Howl versus One LION’s Roar

Practical exercises on trial methodologies and reporting

Another drug that improves an endpoint that you didn’t even know existed until few years ago

We need more publicly funded trials

Let me take a selfie

Article source:The Health Care Blog

0 notes

webanalytics · 6 years

Text

Five Strategies for Slaying the Data Puking Dragon.

If you bring sharp focus, you increase chances of attention being diverted to the right places. That in turn will drive smarter questions, which will elicit thoughtful answers from available data. The result will be data-influenced actions that result in a long-term strategic advantage.

It all starts with sharp focus.

Consider these three scenarios…

Your boss is waiting for you to present results on quarterly marketing performance, and you have 75 dense slides. In your heart you know this is crazy; she won’t understand a fraction of it. What do you do?

Your recent audit of the output of your analytics organization found that 160 analytics reports are delivered every month. You know this is way too many, way too often. How do you cull?

Your digital performance dashboard has 16 metrics along 9 dimensions, and you know that the font-size 6 text and sparkline sized charts make them incomprehensible. What's the way forward?

If you find yourself in any of these scenarios, and your inner analysis ninja feels more like a reporting squirrel, it is ok. The first step is realizing that data is being used only to resolve the fear that not enough data is available. It’s not being selected strategically for the most meaningful and actionable insights.

As you accumulate more experience in your career, you’ll discover there are a cluster of simple strategies you can follow to pretty ruthlessly eliminate the riffraff and focus on the critical view. Here are are five that I tend to use a lot, they are easy to internalize, take sustained passion to execute, but always yield delightful results…

1. Focus only on KPIs, eliminate metrics.

Here are the definitions you'll find in my books:

Metric: A metric is a number.

KPI: A key performance indicator (KPI) is a metric most closely tied to overall business success.

Time on Page is a metric. As is Impressions. So are Followers and Footsteps, Reach and Awareness, and Clicks and Gross Ratings Points.

Each hits the bar of being “interesting,” in a tactical oh that’s what’s happening in that silo soft of way. None, passes the simple closely tied to overall business success standard. In fact, hold on to your hats, a movement up or down 25% in any of those metrics may or may not have any impact on your core business outcomes.

Profit is obviously a KPI, as is Likelihood to Recommend. So too are Installs and Monthly Active Users, Orders and Loyalty, Assisted Conversions and Call Center Revenue.

Each KPI is of value in a strategic oh so that is why we are not making money or oh so that is why we had a fabulous quarter sort of way. A 25% movement in any of those KPIs could be the difference between everyone up and down getting a bonus or a part of the company facing layoffs. Often, even a 5% movement might be immensely material. What metric can say that?

When you find yourself experiencing data overload, don an assassin's garb, identify the metrics and kill them. They are not tied to business success, and no senior leader will miss them. On the ground, people will use metrics as micro diagnostic instruments, but they already do that.

A sharp focus on KPIs requires concentrating on what matters most. Every business will have approximately six KPIs for a CEO. Those six will tie to another six supplied to the CMO.

After you go through the assassin’s garb process above, if it turns out that you have 28 KPIs… You need help. Hire a super-smart consultant immediately!

2. Focus only on KPIs that have pre-assigned targets.

This is a clever strategy, I think you are going to love it.

Targets are numerical values you have pre-determined as indicators success or failure.

Turns out, creating targets is insanely hard.

You have to be great at forecasting, competitive intelligence, investment planning, understanding past performance, organization changes and magic pixie dust (trust me on that one).

Hence, most companies will establish targets only for the KPIs deemed worthy of that hard work.

Guess what you should do with your time? Focus on analysis that is worth your hard work!

Start by looking at your slides/report/dashboard and identify the KPIs with established targets. Kill the rest.

Sure, there will be howls of protest. It'll be John. Tell him that without targets you can’t identify if the performance is good or bad, a view every CEO deserves.

John will go away and do one of two things:

1. He will agree with you and focus on the KPIs that matter.

2. He will figure out how to get targets for all 32 metrics along all 18 dimensions.

You win either way. :)

An added benefit will be that with this sharp focus on targets, your company will get better at forecasting, competitive intelligence, investment planning, org changes, magic pixie dust and all the other things that over time become key assets. Oh, your Finance team will love you!

Special caution: Don't ever forget your common sense, and strive for the Global Maxima. It is not uncommon for people to sandbag targets to ensure they earn a higher bonus. If your common sense suggests that the targets are far too low, show industry benchmarks. For example, the quarterly target may be 400,000 units sold. Common sense (and company love) tell you this seems low, so you check actuals to find that in the second month, units sold are already 380,000. Suspicion confirmed. You then check industry benchmarks: It is 1,800,000. WTH! In your CMO dashboard, report Actuals, Target and Benchmark. Let him or her reach an independent, more informed, conclusion about the company’s performance.

3. Focus on the outliers.

Turns out, you are the analyst for a multi-billion dollar corporation, with 98 truly justifiable KPIs (you are right: I'm struggling to breathe on hearing that justification, but let's keep going). How do you focus on what matters most?

Focus your dashboards only on the KPIs where performance for that time period is three standard deviations away from the mean.

A small statistics detour.

If a data distribution is approximately normal then about 68 percent of the data values are within one standard deviation of the mean, about 95 percent are within two standard deviations, and about 99.7 percent lie within three standard deviations. [Wikipedia]

By saying focus on only reporting on KPIs whose performance is three standard deviations from the mean, I’m saying ignore the normal and the expected. Instead, focus on the non-normal and the unexpected.

If your performance does not vary much, consider two standard deviations away from the mean. If the variation is quite significant, use six (only partly kidding!).

The point is, if performance is in the territory you expect, how important is it to tell our leaders: The performance is as it always is.

Look for the outliers, deeply analyze the causal factors that lead to them, and take that to the executives. They will give you a giant hug (and more importantly, a raise).

There are many ways to do approach this. Take this image from my January 2007 post: Analytics Tip #9: Leverage Statistical Control Limits…

Having an upper control limit and a lower control limit makes it easy to identify when performance is worth digger deeper into. When you should freak out, and when you should chill.

Look for outliers. If you find them, dig deeper. If not, move on permanently, or at least for the current reporting cycle.

Use whichever statistical strategies you prefer to find your outliers. Focus sharply.

4. Cascade the analysis and responsibility for data.

In some instances you won't be able to convince the senior leader to allow you to narrow your focus. He or she will still want tons of data, perhaps because you are new or you are still earning credibility. Maybe it is just who they are. Or they lack trust in their own organization. No problem.

Take the 32 metrics and KPIs that are going to the CMO. Pick six critical KPIs for the senior leader.

Cluster the remaining 26 metrics.

You'll ask this question:

Which of these remaining 26 metrics have a direct line of sight to the CMO’s six, and might be KPIs for the VPs who report to the CMO?

You might end up with eight for the VPs. Great.

Now ask this question:

Which of these remaining 18 metrics have a direct line of sight to the eight being reported to the VPs, and might be KPIs for the directors who report to the VPs?

You might end up with 14 for the directors.

Awesome.

Repeat it for managers, then marketers.

Typically, you'll have none remaining for the Marketers.

Here's your accomplishment: You've taken the 32 metrics that were being puked on the CMO and distributed them across the organization by level of responsibility. Furthermore, you've ensured everyone's rowing in the same direction by creating a direct line of sight to the CMO’s six KPIs.

Pat yourself on the back. This is hard to do. Mom is proud!

Print the cascading map (CMO: 6 > VPs: 8 > Directors: 14 > Managers: 4), show it to the CMO to earn her or his confidence that you are not throwing away any data. You've simply ensured that each layer reporting to the CMO is focused on its most appropriate best sub-set, thus facilitating optimal accountability (and data snacking).

I’ll admit, this is hard to do.

You have to be deeply analytically savvy. You have to have acquired a rich understanding of the layers of the organization and what makes them tick. You have to be a persuasive communicator. And, be able to execute this in a way that demonstrates to the company that there’s real value in this cascade, that you are freeing up strategic thinking time.

You’ll recognize the overlap between the qualities I mention above and skills that drive fantastic data careers. That’s not a coincidence.

Carpe diem!

5. Get them hooked on text (out-of-sights).

If everything else fails, try this one. It is the hardest one because it'll demand that you are truly an analysis ninja.

No senior executive wants data. It hurts me to write that, but it is true.

Every senior executive wants to be influenced by data and focus on solving problems that advance the business forward. The latter also happens to be their core competence, not the former.

Therefore, in the next iteration of the dashboard, add two more pieces of text for each metric:

1. Why did the metric perform this way?

Explain causal factors that influenced shifts. Basically, the out-of-sights (see TMAI #66 if you are a subscriber to my newsletter). Identifying the four attributes of an out-of-sight will require you to be an analysis ninja.

2. What actions should be taken?

Explain, based on causal factors, the recommended next step (or steps). This will require you to have deep relationships with the organization, and a solid understanding of its business strategy.

When you do this, you'll begin to showcase multiple factors.

For the pointless metrics, neither the Why nor the What will have impact. The CMO will kill these in the first meeting.

For the decent metrics, it might take a meeting or three, but she'll eventually acknowledge their lack of value and ask you to cascade them or kill them.

From those remaining, a handful will come to dominate the discussion, causing loads of arguments, and resulting in productive action. You'll have known these are your KPIs, but it might take the CMO and her team a little while to get there.

After a few months, you'll see that the data pukes have vanished. If you've done a really good job with the out-of-sights and actions, you'll notice notice that the focus has shifted from the numbers to the text.

Massive. Yuge. Victory.

If more examples will be of value, I have two posts with illuminating examples that dive deeper into this strategy…

Strategic Dashboards: Best Practices, Tips, Examples | Smart Dashboard Modules: Insightful Dimensions And Best Metrics

You don't want to be a reporting squirrel, because over time, that job will sap your soul.

If you find yourself in that spot, try one of the strategies above. If you are desperate, try them all. Some will be easier in your situation, while others might be a bit harder. Regardless, if you give them a shot, you'll turn the tide slowly. Even one month in, you’ll feel the warm glow in your heart that analysis ninjas feel all the time.

Oh, and your company will be data-influenced — and a lot more successful. Let's consider that a nice side effect. :)

Knock 'em dead!

As always, it is your turn now.

Have you used any of the above mentioned strategies in your analytics practice? What other strategies have been effective in your company? What is the hardest metric to get rid of, and the hardest KPI to compute for your clients? Why do you think companies keep hanging on to 28 metric dashboards?

Please share your ideas, wild theories, practical tips and examples via comments.

Thank you.

Five Strategies for Slaying the Data Puking Dragon. is a post from: Occam's Razor by Avinash Kaushik

from Occam's Razor by Avinash Kaushik http://ift.tt/2EKCNf9 #Digital #Analytics #Website

#Analytics #Occam's Razor by Avinash Kaushik. Web Analytics #Tracking #Metrics #Performance

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ecopoeticsuchicago · 7 years

Text

Week 6: White Noise

Reading Response:

I liked that Don DeLillo really wove his environmental themes deeply into the psychology of his characters. For instance, I noticed that his early descriptions of Babette evoked Jack’s musings on the city. He writes “It’s always fifteen degrees hotter in the cities… The eventual heat death of the universe that scientists love to talk about is already well underway… Heat and wetness.” Later, he describes Babette as “moist and warm, emitting a creaturely hum,” continuing to ask “Who will die first?” I found that this repeated accent on heat and wetness, qualities fundamentally derived from the environment, really helped to intertwine the themes of Babette’s fear of death with humanity’s fear of the death of the city. Both individuals and the great machinery of civilization at large consume and produce heat, and their inevitable burnout is the “heat death of the universe” that DeLillo’s characters fear.

The interplay of technology and ostensible human advancement in the trajectory of our heat death was very interesting to me as well. Babette appears on the TV one night: “Something leaked through the mesh. She was…coming into being, endlessly being formed and reformed… We were being shot through with Babette. Her image…swam in us and through us. Babette of electrons and photons…” If we read Babette as some expression or extension of the city, of the wet hot workings of human civilization, then this scene seems to suggest that our intimate relationship with technology makes the city not just integral to our individual selves but in fact internal—we are “shot through” with it. Its evils, its fear and ambition, are ours, and its heat death, “well underway,” will be ours as well.

Assignment:

1. Environmental issue: stillbirth/miscarriage induced by contaminated food or drinking water

2. Locate hint of problem in immediate environment:

Dark orange puddle of rain-water

Spotted around sunset

Probably reflecting the sky, also orange

Film of oil on puddle surface, iridescent (pink purple blue green yellow), striated

Sediment suspended in layers above asphalt

Cloudy, moving in further clouds (car just passed)

Sediment settles

Less light now and harder to see the oil slick on top

Now looks very thin and drinkable

3. Poem:

Topic: stillbirth induced by contaminated drinking water

He took my finger in the ancient mode, and I slipped on my way down (how correct that it should have been over nothing at all, I mean grown men have wept at less), I thought that anybody from any of the moth-fretted centuries would have known my face that day, goose girl grown pallid in the field, queen who bears no truce in her belly, he lay his fist on my neck and knocked, sweet temper under arachnean shroud, and coughed glum wretched mists onto my tongue, and if he had pressed harder I would have been so glad as to howl, and nearly to let him.

Talk a bit more. Nothing of consequence. Car floats past, spray of rain and gasoline. Might have seen it coming, all told. Sleep to wake to dreams. Swish between the teeth and spit, or lap at the street dribble. What does it matter? Scent of disinfectant. Fear and fearful certainty of calling another beloved. Etc.

I watch storms out the window. In the morning, the sun comes, basilican in its dim glory, up with the papery softness of immortelles.

4. Research:

Trihalomethanes (THMs) are a class of disinfection by-products in public drinking water

Due to reaction of chlorine with organic material in source water

Dependent on pH, temperature, concentration and properties of organic materials, bromide ion concentration, etc.

Epidemiological studies support a modest association with fetal death

Sub-class: chloroform is predominant THM formed

Other by-products include: haloacetic acids (HAAs)

Sub-classes: dichloroacetic acid (DCAA) and trichloroacetic acid (TCAA) are predominant HAAs formed

Total THMs exposure, total haloacetic acid (HAA) compound exposure, and dichloroacetic acid exposure explored as risk factors

For intrauterine death, stillbirth, and miscarriage

Definitely some statistically significant results, but other risk levels unaffected

Personally dislike scaremongering founded on the terror of unpronounceable chemical names

Citations:

“Haloacetic acids in drinking water and risk for stillbirth”: http://oem.bmj.com/content/62/2/124

“Risk of stillbirth in a community surrounding an arsenical based agriculture chemical production facility”: https://hero.epa.gov/hero/index.cfm/reference/details/reference_id/1357027

“No association between ambient particulate matter exposure during pregnancy and stillbirth risk in the north of England, 1962-1992”: http://dx.doi.org/10.1016/j.envres.2009.10.003

Process Notes:

This week I looked at “unnatural” risk factors for stillbirth and miscarriage. These particular phenomena have a particular sense of tragedy to them, and seem to really encapsulate all the uncomfortable contrasts of the human impact on the environment. Our humanness, separate from our animal qualities, makes us clever and ambitious enough to wreak outsize havoc on the environment around us. However, we are not separate from nature, and as we render infertile her fields and beasts, we find ourselves facing similar reproductive challenges, and facing them with a profundity of horror that can only be felt by man. The horror stems I think from the human preoccupation with innocence and guilt—it feels somehow deeply incorrect that the entirely innocent and barely conceived should have to suffer for our offenses.

While walking outside at night, I saw a puddle on the side of the street and started thinking about contaminated drinking water specifically. When cars passed and muddied it, it looked pretty dirty, but as the sun set and the cars stopped passing the water looked quite clean and drinkable. I wrote my poem from the perspective of a woman whose stillbirth is induced by contaminated drinking water. Medical challenges during birth are obviously as ancient a phenomenon as the human race is old, and the particular heartbreak of stillbirth is very old as well. However, our modern impact of the environment introduces a new and unnatural angle, adding the human sense of personal guilt and confusion to the tragedy.

Jackie Feng

#jackiefeng #week6

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kristinsimmons · 5 years

Text

Last Couple of Months in Oncology with Dr. Bishal Gyawali: March 2019

By BISHAL GYAWALI MD, PhD

Hey, I’m back!

Hundred Foxes’ Howl versus One LION’s Roar

Practical exercises on trial methodologies and reporting

Another drug that improves an endpoint that you didn’t even know existed until few years ago

We need more publicly funded trials

Let me take a selfie

Last Couple of Months in Oncology with Dr. Bishal Gyawali: March 2019 published first on https://wittooth.tumblr.com/

0 notes