By Lauren Schoenemann
Jennifer Dunmoyer lived the first 34 years of her life feeling invincible -- until she was diagnosed with cancer.
"I have always been very healthy," she says. "I never took any medications. I was young, strong and vital and had a deep faith in God."
"Cancer shook everything I ever believed to the very core."
In July 2010, Dunmoyer learned that she had small cell cervical cancer (SCCC), a rare but aggressive form of cervical cancer.
It develops in about 100 women of the more than 11,000 new cases of cervical cancer reported each year. She learned of her condition after an abnormal Pap smear taken in March of that year prompted her to seek further information.
Though she experienced no symptoms, the results of Dunmoyer's test revealed dysplasia. Because the previous year's test had been abnormal, her gynecologist recommended she see a specialist to perform a conization to remove any precancerous cells that may have been in her cervix.
When she had the conization, the doctor told Dummoyer that nothing appeared to be wrong with her cervix. He said it was even difficult to identify an area containing the abnormal cells, which were smaller than the size of a pencil point.
After the procedure, he sent Dunmoyer home and told her he would see her again for a six-month, follow-up exam.
Four days later, she received a phone call from the doctor asking her to come in the following week. She was advised to bring someone with her.
October 2011 Archives
By Lauren Schoenemann
When entertainment reporter and reality TV star Giuliana Rancic made public her breast cancer diagnosis, rumors began to swirl about whether in vitro fertilization (IVF) might have been a contributing factor.
Rancic was in the midst of her third IVF treatment when her doctor ordered her to get the mammogram that revealed early-stage breast cancer.
"Right now there is no convincing evidence that IVF causes breast cancers," Jennifer Litton, M.D., tells ABC News.
Litton, an assistant professor in MD Anderson's Department of Breast Medical Oncology, sets the record straight about IVF and breast cancer.
By Wendy Woodward, M.D., Ph.D., deputy director, Morgan Welch IBC Program
One of the things that I value the most about practicing radiation oncology at MD Anderson is our extensive clinical history.
As a clinician, there are few things worse than not knowing the right thing to do in a difficult situation. At MD Anderson, we are often faced with unusual or rare problems that are almost always difficult situations.
This is because there are no large data sets or randomized trials on which to base treatment decisions for rare diseases.
There is no clear right answer. That is where decades of institutional experience in rare and unusual problems comes in, to guide us in selecting the best therapy possible based on the best data available.
This is certainly the case for post-mastectomy radiation for patients with inflammatory breast cancer.
The 29th time Vincent "Dale" Sittig checked in to MD Anderson's P12
nursing unit for treatment in a Phase I clinical trial, his nurses
hatched a scheme.
"We said, 'Next time will be 30 treatments,'" says Brandi Barosh, clinical nurse on the unit. "We should throw you a party."
"He said, 'Aww, you don't have to do that.'
"But we kept at him, asking what his favorite foods are," Barosh recalls. "Eventually, we got it out of him.
"He's a celebrity on our unit. Everybody knows and loves him," she explains. "We decided to go all out."
Like all the other patients on P12, Sittig, 51, has metastatic cancer.
The unit is "home base" for the Clinical Center for Targeted Therapy, which offers experimental Phase I therapies that may eventually represent advances in cancer research and treatment.
Diagnosed in 2006 with neuroendocrine carcinoma, Sittig travels to MD Anderson from Ville Platte, La., every 28 days for testing and treatment.
By Frank Tortorella, Margaret Meyer and Alma Rodriguez, M.D.
Why do we ask about distress?
We know MD Anderson patients are getting excellent medical care, but that isn't enough. We also want our patients to get psychosocial support to navigate the emotional and psychological challenges that come with a diagnosis of cancer.
A cancer diagnosis can result in a period of increased distress for patients and their families. Patients experience a variety of emotions when dealing with the diagnosis and accompanying treatments.
Many describe the cancer experience like being on a roller coaster with ups and downs. It's a physically and emotionally draining experience.
Living with a chronic illness can be distressing. Many patients report feelings of anxiety in anticipation of appointments and concerns about family, talking to young children about cancer, finances and employment.
Since research has confirmed a connection between psychosocial concerns and clinical outcomes, we want to address both concerns.
This summer, an international group of clinicians and researchers met in Washington, D.C., for a first-of-its-kind symposium devoted to cancer survivorship and sexual health.
Higher-than-anticipated attendance among physicians, mental health providers and other professionals attests to growing recognition of the sexual health needs of cancer survivors.
If I could summarize one theme from this conference, it was a focus on ways to make sexual health services more readily available to our patients.
As cancer survivors become a larger segment of the population, the need for comprehensive survivorship care will only grow.
Specialized care team
Some of the presentations at the meeting described how hospitals and cancer centers created specialized care teams for sexual health problems.
Typically, these teams are partnerships between medical and mental health providers with interests and training in sexuality.
For example, a group of researchers in Sweden found that prostate cancer patients had much better sexual outcomes after a sex therapist was added to their team of medical and surgical staff. Other presentations from researchers in North America, Africa, Australia, Europe and the Middle East echoed the need for a team effort.
By Mindy Loya, MD Anderson Staff Writer
Imagine that after a long day in meetings, training others and getting your work done, you find a blank canvas sitting in your chair. Scrawled on the plastic wrapping are the words "Just Do It."
This is the challenge Lauren Langford, M.D., issued to a fellow colleague in 2010.
An associate professor in Pathology at MD Anderson, Langford grew up in an artistic household, never far from a camera. And, in her eyes, her fondness for photography and art fits hand-in-hand with being a pathologist.
"When I say I look at the human nervous system, I mean it," Langford explains. "Pathologists look at shapes and colors on slides through a microscope and compare what we see to other images. And then we photograph the slides for use in teaching, publications or tumor boards."
Langford says art never was encouraged in medical school or in her pathology training. She was lucky to land a job in a research lab with a darkroom where workers developed their own negatives.
"The person who trained me didn't discourage personal work, because the more you developed, the better you got. So, we'd print our black-and-white pictures from the weekend."
In the 1990s, Langford used what was then a new media, the CD-ROM, to share photographs of diseased cells with pathologists, neurologists and neuro-oncologists. "It was an exercise in art. I wanted to adjust the colors and present the images in a way that was easier than looking at glass slides."
By Patrick B. Mulvey, vice president, Development
At Thursday's annual meeting of the MD Anderson Cancer Center Board of Visitors, we announced big news: the completion of MD Anderson's largest fundraising campaign ever.
Thanks to the generosity of supporters around the world, Making Cancer History®: The Campaign to Transform Cancer Care has raised $1.215 billion. That's a remarkable
accomplishment in these challenging economic times, and extremely important during an era of declining federal and state funding.
Even more remarkable, the campaign closed ahead of schedule, well exceeding its original goal of $1 billion.
Every dollar of private philanthropy generates an invaluable return on investment, and that Return on Investment translates to hope for a future free of cancer.
The more than 630,000 gifts contributed to this campaign since we began just more than five years ago add up to enormous benefits for thousands of patients, their families and friends. Every gift, regardless of size, plays a significant role, enabling researchers to pursue novel ideas, gather data and successfully compete for federal funding.
Making a difference
The Board of Visitors has spearheaded five major campaign initiatives since 1993, and the Making Cancer History® campaign, led by Harry Longwell of Dallas, was by far the most ambitious.
Along with my colleagues in the Development Office, I'm grateful for the efforts and expertise of the 19-member campaign executive committee and for the support of each BOV member whose personal financial commitment was an inspiration others.
By Stephen Collazo, Department of Social Work
October is national Domestic Violence Awareness Month. And while it may be difficult to imagine someone with cancer in an abusive relationship, it's more common than you might think.
Anytime someone hurts or threatens to hurt his or her partner in any way (physically, emotionally or sexually), it's called intimate partner violence (IPV) -- more commonly known as domestic violence.
While statistics show that 85% of people affected by intimate partner violence are female, it doesn't mean that men can't be abused by their partners. Intimate partner violence occurs in all races, ages, economic classes and sexual orientations.
Cancer diagnosis and abuse
When the person being abused has been diagnosed with cancer, there are even more complicated issues that can occur.
For example, the patient might have to rely on the abuser for financial reasons, or to provide transportation to appointments, manage medication or help with basic daily tasks.
All of this can make an abuser feel like he or she has more control and more power, and therefore easier to inflict abuse without meeting any resistance.
In some instances, the abuser might not be related to the person diagnosed with cancer.
If you're a caregiver and someone is abusing you, it's important to remember that there's no excuse for violent or abusive behavior in a relationship.
By Katrina Burton, MD Anderson Staff Writer
Are you unhappy with your weight? Do you strongly dislike some other aspect of your appearance? Are recent changes to your body negatively affecting that way you feel and think about yourself?
Whether you've had body image issues most of your life or these problems are more recent, almost everyone at some point and time has concerns about their body. How we cope with these issues is what matters most. Negative body image can lead to low self-esteem, depression and a host of other psychological and social issues.
In recognition of Love Your Body Day, Wednesday, Oct. 19, MD Anderson is participating in the National Organization for Women (NOW) Foundation's Love Your Body Campaign. This campaign is part of a national program that encourages people to recognize the dangers of societial perceptions that promote unrealistic and unhealthy body images. The goal is to help people learn how to attain a more healthy and positive perspective about their bodies.
Today, Oct. 19, MD Anderson will offer interactive fitness demonstrations and free educational tips and materials about body image, from 9 a.m. to 1 p.m, in the Main Building, Floor 1, near The Aquarium.
"Society has placed a great deal of pressure on how a person should look and feel, "says Michelle Cororve-Fingeret, Ph.D., assistant professor in the department of Behavioral Science and director of the Body Image Research and Therapy Service at MD Anderson. "These expectations not only affect healthy individuals in the general public, but people suffering from medical conditions that can significantly change the way they look and how their bodies function."
By John Chattaway, MD Anderson Staff Writer
Imagine showing up on your first day of a new job knowing just what your office looks like.
You know the location of your desk, your files on the computer and how to work every program and application before ever logging on.
Would be nice, right?
Thanks to a generous gift from the Kinder Foundation, Radiation Therapy students from MD Anderson's School of Health Professions know exactly how that feels.
The gift was used to buy the Virtual Environment Radiotherapy Training system, or VERT, from Vertual Ltd.
"VERT is a virtual representation of a radiotherapy treatment room," explains Shaun Caldwell, assistant professor, School of Health Professions. "It's an amazing tool that's revolutionizing the way we teach radiation therapy."
Jerry Wilson claimed a front row seat. Wilson, diagnosed with stage IV colorectal cancer in 2009, has beaten the disease so far. What he can't shake is the fatigue he's experienced during his cancer journey.
"If you ever had a severe case of flu that totally drains you both physically and mentally, this is what I felt like all the time after starting a multiple chemo treatment," Wilson says.
Wilson has regained some of his energy now that he's taking a lower dose of chemotherapy and has learned to pace himself. He attended the recent Anderson Network Cancer Survivorship Conference to hear about other options.
He is among more than 100 cancer survivors and caregivers who heard Ellen Manzullo, M.D., professor in the Department of General Internal Medicine at MD Anderson, offer management strategies for cancer-related fatigue.
Manzullo, deputy division head in Internal Medicine, is one of two specialists who regularly evaluate patients in the MD Anderson Cancer-Related Fatigue Clinic.
According to Manzullo, fatigue is a common symptom. In fact, 30% of cancer survivors experience fatigue years after receiving treatment.
By Laura Nathan-Garner, MD Anderson Staff Writer
Want to add a side of cancer prevention to your next meal? Whip up these recipes to get a tasty dose of breast cancer-fighting nutrients.
Kale Chips Recipe
Who said it's not easy eating greens? Kale chips are sure to please even those who normally turn their noses up at veggies. That's because kale chips offer the crunch and flavor of potato chips with almost none of the fat and sodium.
Added bonus: leafy greens like kale are a great source of fiber, folate and cancer-fighting carotenoids, which probably protect against cancers of the mouth, pharynx and larynx. And, according to some laboratory studies, kale's antioxidant effects also may help fight off certain breast, skin, lung and stomach cancers.
Get our recipe for kale chips.
Shortcake Biscuits with Berries Recipe
When it comes to foods that fight breast cancer, it's hard to beat strawberries. They're filled with ellagic acid, which has been shown to help prevent breast, skin, lung, esophagus and bladder cancers. And, like other berries, they're loaded with cancer-fighting nutrients such as vitamin C and fiber.
When patients are being prepared for surgery, the last thing on their mind is the risk of a fire in the operating room.
At MD Anderson − and a small, but increasing number of institutions nationwide − patients should know that there are people like Charles Cowles, M.D., who think about safety issues such as operating room fires every day, and dedicate themselves to making them an even rarer occurrence than they already are.
Cowles is chief safety officer for MD Anderson's Perioperative Enterprise and an anesthesiologist. As a former firefighter and paramedic with the Beaumont, Texas Fire Department for 14 years, Cowles brings a unique perspective to the role.
Cowles reports that there are roughly 550-650 surgical fires nationwide annually, many which result in severe burns, disfigurement or death. Most patients are unaware of the risks and many surgeons and nurses are not formally trained in handling a fire emergency, he says, but the good news is that the issue is gaining attention nationally.
Today, as National Fire Prevention Week winds down, the U.S. Food and Drug Administration is announcing a new initiative to reduce the risk of fire in the operating rooms.
All this week Cowles and his team have been giving training sessions, running drills and calling attention to the risks of fire in an OR. He says the operating rooms host components of the "fire triangle" that can spark surgical fires any time these elements are present. They include:
- Ignition source (laser or cautery device)
- Fuel source (surgical drapes, alcohol-based skin preps)
- Oxidizers (oxygen, nitrous oxide)
Cowles reminds patients that the risk of fire is rare but encourages them to be aware of the risk and ask questions of their doctor, including:
By M. Kay Garcia, Dr.P.H., M.S.N., L.Ac.
Acupuncture is an important accompanying therapy for symptom management among cancer patients. MD Anderson has offered acupuncture to patients since 2003. Common questions physicians and patients ask about acupuncture are: When should I use it? Is it safe?
First, acupuncture doesn't work for everyone, but many do benefit when it's carefully integrated into their overall treatment plan.
The effects of acupuncture often are cumulative, so it's important not to expect too much too soon. We consider 8-10 treatments as one course. For long-term problems, multiple courses may be necessary.
What is acupuncture?
Acupuncture involves the placement of solid, sterile, stainless steel needles into various points on the body that are believed to have reduced bioelectrical resistance and increased conductance.
Various techniques are used to stimulate the needles and improve the therapeutic effects, including manual manipulation or adding a mild electrical current. Stainless steel or gold (semi-permanent) needles, or "studs," are sometimes placed at specific points on the ears and left in place 3-5 days.
When performed correctly, acupuncture has been shown to be a safe, minimally invasive procedure with very few side effects.
Clinical trials suggest that acupuncture is effective for treating nausea/vomiting and some types of pain. There's also a growing body of evidence for treating hot flashes, xerostomia (dry mouth) and fatigue.
On Sunday, California signed into legislation the nation's toughest law on teens and tanning beds. The law prohibits anyone younger than 18 from using a tanning bed beginning Jan. 1. I sat down this week to discuss the new legislation with Dennis Hughes, M.D., Ph.D., who specializes in sarcomas and skin cancers at MD Anderson Children's Cancer Hospital. In 2009, Texas passed a law prohibiting tanning bed use in children younger than 16.
1) What are your thoughts on the new California bill prohibiting tanning bed use in children younger than 18?
First and foremost, no child younger than 18 needs to be in a tanning bed. There's no reason, medical or societal, for kids to be in a tanning bed. I think this is another good step toward protecting our kids. We already have laws in place protecting them from smoking and drinking as teens, and this runs along those same lines.
2) What are the risks of using a tanning bed while a teen?
People get the bulk of their sun exposure and sunburns by the time they're 18. Premature aging, wrinkling and skin cancer risk all result from this exposure. Prohibiting tanning bed use will help cut down their ultraviolet (UV) exposure at an early age, which in turn will help reduce the risk of premature aging and cancer as adults.
3) Are there benefits to using a tanning bed that this law would be eliminating? For instance, some people say that tanning beds are beneficial for people with skin conditions such as eczema and psoriasis.
Ronald DePinho, M.D., has a mission -- to impact the human condition.
"All my science, all my efforts drive toward changing the stories we tell about our lives," he says. "That parents don't have to lose children, that grandmothers get to see their families grow up."
The fall issue of Conquest magazine features a package of stories about MD Anderson's new president. In addition to learning how he intends to bring science in line with the daily practice of medicine in the clinic, you can read about his research, his mentors, his wife, Lynda Chin, M.D., and his appearance on "The Colbert Report."
Other feature articles in this issue include:
Journey Into Reality
Texas Community Bus Rounds helps health care professionals learn how to identify complex issues faced by patients near the end of life.
A Quiet Crisis
Cancer is a disease of the aging, and our society is aging. Geriatricians are playing an increasingly critical role in the care of elders.
A Firm Foundation
Education forms the foundation for MD Anderson, where the latest teaching tool is generating excitement for instructors and students.
In April 2011, Shane Leonard was diagnosed with adenoid cystic
carcinoma, a form of cancer so rare for his age that MD Anderson only
had about six recorded cases comparable to his in the last 40 years.Shane had surgery to remove the tumor in his neck and this past summer completed seven weeks of proton therapy, an advanced form of radiation. Shane, now 18 and enjoying his senior year of high school, is an outstanding student who loves physics and a member of the Colorado Springs Youth Symphony.
While in Houston for treatment this past summer, Shane missed the symphony's annual camp and was asked to share his experience with his fellow students in a letter. The following is an excerpt from that letter that shows what a profound impact cancer has and will continue to have on his life.
Proton therapy, huge machine, even bigger impact
My radiation treatment is an interesting experience. Every day, at five o'clock, I get strapped down onto a table and I wear a special mask that was molded specifically for my face. For half an hour, a 200-ton machine rotates around my body into various positions and bombards me with protons.
The machine is so large that there are entire rooms above and below my treatment room that house most of its body while it rotates. It reminds me of a church organ -- though the facade is massive, most of the machinery is hidden from sight. The sheer size of the proton machine encourages me that God is literally moving mountains on my behalf.
A community of caring
My family and I are staying in a hotel next to the medical center, which means that nearly all the guests here are like me, cancer patients undergoing treatment.
Being so close to so many hurting people has radically changed my perspective. It's an indescribable feeling when you look around and realize that everyone around you is in need.
By Michelle Moore, MD Anderson Staff Writer
This year's Anderson Network Cancer Survivorship Conference was a celebration, one like I'd never experienced.
The conference was not just a place of hope, it was overflowing with love.
Love for new life, new opportunities and new friends.
We are all survivors
The truth is, I didn't expect this conference to affect me as much as it did. After all, I'm an MD Anderson employee, not a cancer survivor.
But at the conference I learned that we're all survivors.
Some have survived cancer, some abuse and some a broken heart. Some of our scars are physical and easy to see. Some are emotional, and we are the only ones who know they exist.
Some say we're only responsible for ourselves, but that couldn't be further from the truth.
We are responsible for each other, and that was more than evident at the conference.
Dave Dravecky was one of the keynote speakers. He blew me away.
across the world are mourning the death of Apple co-founder Steve Jobs,
who passed away Wednesday, Oct 5, following a battle with pancreatic
cancer. Jobs' death has turned attention to rare form of cancer, for
which the U.S. Food and Drug Administration this May approved a new drug
- the first new option in nearly 30 years. Learn more about the drug,
everolimus, and how it's helping patients with pancreatic
By Lori Baker, MD Anderson Staff Writer
Not many emails make you cry. But tears of joy rolled down Carmen Jacobs' face when she read that the drug everolimus had been approved by the U.S. Food and Drug Administration (FDA) for patients with pancreatic neuroendocrine tumors (pNET).
She considers this treatment one of her biggest efforts as a research nurse, and this news meant it had just been delivered to patients everywhere. It's a much-anticipated arrival, since this is the first new treatment option for these patients in nearly 30 years.
"I was there when Dr. Yao treated the first patient in the very first clinical trial about six years ago," says Jacobs, research nurse supervisor, Gastrointestinal (GI) Medical Oncology, who also worked on each subsequent trial. "I was so happy when I got his message saying it was approved. Now all of these patients have access to a new treatment that provides more hope for a longer and better life."
It was Father's Day weekend, and photographs of my brother were sprinkled among the tables at the reception. Raymond wasn't physically present at the wedding of his oldest daughter, Amy, but his memory lives on among those of us who loved him.
"Mrs. Barton, your son is dying." The harsh words of reality were delivered to my mother by Raymond's oncologist more than 21 years ago.
Could they have been revealed a little more gently like a slow, boiling pot of water rather than as a quick deep fry? When do you finally cave in to reality, especially when miracles do happen?
Raymond was only 36 years old when he was diagnosed with non-Hodgkin's lymphoma. Always the life of the party, he died a year after diagnosis, leaving his widow, Sandy, to raise their three children on her own: Jason was 12, Amy was 5 and Shelli, the youngest, was 3.
The message revealed
When should the end of life be discussed and who is responsible for initiating the discussion?
Knox Todd, M.D., chair of the Department of Emergency Medicine at MD Anderson, says there's a lack of understanding about palliative care and hospice, both among the general public and the medical staff who treat them.
He says the end-of-life conversation should begin much earlier, right along with discussion about the diagnosis and treatment.
"It's important not only to assist our patients in living well," Todd says. "It's just as important to assist them in dying well."
By Barbara Bowman, J.D, vice president, Patient Services
Customer service a focus all year round
National Customer Service Week is Oct. 3-7, and this year MD Anderson is doing it up big by celebrating our patients and their families, as well as our employees and volunteers who demonstrate exceptional customer service.
Those visiting our main campus in Houston's Texas Medical Center will see posters featuring employees and volunteers who were nominated by peers for their customer service. The posters are accompanied by videos in which the employees and volunteers share their stories.
Throughout the week, you can see some of these videos on the MD Anderson Cancer Center News Facebook page or on our YouTube channel. I'm so honored to work with such dedicated and amazing people.
At MD Anderson, we're always working to improve and enhance the experiences of our patients and visitors. One of the ways we're doing that is through a customer service work group called the "Wait Watchers."
This group, along with employees from our Facilities Management team, are refurbishing the clinic waiting and lobby areas, and making pagers available to patients so they can move around our institution while waiting for their appointments.
The team also is working to add patient communication monitors to most of our care centers, so you'll have a better idea of how long it will be before your appointment.
Do you have thoughts on how we can enhance your experiences?
By Johanna Pule, L.M.S.W., Department of Social Work
If your doctor were to tell you that you need to stay in the hospital for a month or longer for treatment, what concerns would you have?
You might worry about the upcoming treatment or how you will feel physically. You might focus all of your attention on the physical and avoid how it will affect you emotionally.
You might just be worried about having to stay in a room in an enormous hospital for such a long time.
These concerns are normal.
More than a patient
It's a significant physical undertaking that can take an emotional toll. Though the reason for staying in the hospital is for your cancer treatment, it's important to remember you're not just a cancer patient.
You're a whole person and it's important that you attend to all of you, and not just the cancer. This is especially true when, for a month or more, you have to essentially live in a setting that constantly reminds you of your illness.
Terry Arnold was diagnosed with a right inflammatory breast cancer
(IBC) in August 2007 and a left contralateral tumor soon after. She had
weeks of chemotherapy, radiation treatment and eventually a double
mastectomy. She completed treatment in June 2008 and has been an IBC
ambassador and advocate since.
I recently received this brief message and a link to a "pink" organization from an acquaintance: "Thought you'd like to see this in case you are affiliated."
Are you affiliated? A song floated through my tired brain. The question wove around and aligned itself with the Jimi Hendrix song, "Are You Experienced?'
Are you affiliated? I went to visit a woman I know named Cindy, a 49-year-old mother of Ian, 11, and Jamie, 8. Cindy was in her last day of home hospice, after an 18-month, downhill battle against inflammatory breast cancer.
Are you affiliated? The older son came into Cindy's bedroom, unaware he wouldn't see his mom awake again. He absentmindedly leaned into me and I, with the absentminded habit of a mom of five, drew him near. He hugged me, looked up and said aloud, "I don't know you, but I love you."
Are you affiliated? When the family couldn't handle what was happening, I was the one wiping the bile off of Cindy's face; the vomiting was so bad. Finally, the emergency team came.
Are you affiliated? And when the ambulance doors closed in front of her house, I was the only one on the sidewalk to smile and tell her it would soon be OK.
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- Woman Beats Rare Form of Cervical Cancer With Help of Faith and Family
- IVF and Breast Cancer: Setting the Record Straight
- Radiation Therapy for Inflammatory Breast Cancer: One Size Fits All?
- Neuroendocrine Carcinoma Patient Inspires Fellow Patients, Staff
- Cancer Patients and Stress: How to Cope
- Cancer Survivorship and Sexual Health: Now More Than Ever
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