Six Months

Its been a good week for me!  I had an appointment with my hematologist/oncologist on Thursday and it was good news across the board.  There are two types of response that show progress against the disease--hematologic response and organ response.  My hematologic response is still good showing the disease is in remission.  And, when I asked her directly if my transplant response was a complete response or a very good partial response, she reviewed my results and said it was a complete response.  Granted, the studies show there's no significant difference in overall survival between the two but I guess I feel better knowing it was the best response that could be achieved.  Yes, I even compete with myself!

My organ response is also very positive.  My liver function is improving and my tests showed normal liver function in two of the three key liver function values and the one that has improved 67% from its highest level.  Granted, I still can't lie comfortably on my stomach (which used to be my favorite sleeping position) but I can feel the size improving and I'm hopeful that one day I can sleep on my stomach again and do the Superman/Banana exercise from P90X.

My kidneys are also showing good response to treatment.  The major sign that my kidneys were damaged by the amyloids was the amount of protein in my urine.  The kidney doctor explained that the amyloids pry open the filters in the kidneys allowing protein to leak out into the urine that would normally stay in the blood.  When I was diagnosed my urine protein was 36 times the upper level for normal.  The test this week showed it had improved by 50%. Granted it's still 19 times above the normal limit but a study I read said that the average time to a 50% improvement is 11 months and I got there in 8.  Hopefully, I'll continue to have great progress on my organ response.

Today, I was able to go to one of the workout classes I attended regularly before I got sick.  It's the "Total Body Workout Class" taught by Renee Phillips at the Dublin Rec Center.  I had been going to her core class on Tuesdays but wasn't sure I was ready for the aerobic component combined with the core work that she puts us through in the TBW class.  I was able to keep up really well.  Granted, I wasn't as strong as before but I was able to do about 75% of the exercises and reps and felt really good.

It was nice to see some of the women who I attended class with previously.  They were really happy to see me back and noted how good I looked and how well I did in class.  Their encouragement meant a lot to me.  As I talked to one of the women, I told her that I wanted to work hard to get back into shape in case I need to have another stem cell transplant.  She admonished me not to think that way but I'm not doing it out of fear.  Its really something I feel I can do now to put me in a better place to deal with this disease in the future.  One reason my transplant went so well (relatively speaking) is because of my "excellent performance status" to use the term found throughout my medical record.  I need to get back to that level of physical fitness.

That sense of doing things now so I can deal with this disease in the future is what's motivating me to go to the Mayo.  I trust Dr. Efebera completely.  But I feel that having another physician who is experienced in amyloidosis and knowledgeable about my case will be another source of information for me.  I can integrate that information into my decision making algorithm.  It's the basic predictive analytics process and while I may not be building a huge data set or developing complex statistical models, I still need to have a base of information that is organized and synthesized from which I can make decisions.

In the corporate world, we spend a lot of time trying to figure out how to get individuals to work together effectively.  One of the tools Nationwide uses is the Strengthsfinder survey offered by Gallup.  Its an online assessment designed to help people uncover their hidden talents.  When I took the test last in the summer of 2012, these were my top 2 strengths--

Strategic
People who are especially talented in the Strategic theme create alternative ways to proceed. Faced with any given scenario, they can quickly spot the relevant patterns and issues. 

Self-Assurance
People who are especially talented in the Self-Assurance theme feel confident in their ability to manage their own lives. They possess an inner compass that gives them confidence that their decisions are right. 

I think those two strengths really influence how I go about managing my disease.  I need information to spot the relevant patterns and issues.  Once I have that, I'll have the confidence I need to manage the disease and trust my decisions.

Another good part of this week is today is exactly 6 months after my birthday.  Many of you who are my friends on Facebook will recall the picture that my friend Erin posted of me at the birthday celebration she had for me at her house.  I know a lot of people were surprised by the photographic evidence of how hard the disease and transplant had been on me.  I had Claire take a picture of me tonight so I could look at the progress side by side and I'd say its pretty good.

OK, so maybe the makeup I'm wearing now helps but I don't think its responsible for the majority of the improvement.

Whether its my overall health, physical appearance or physical fitness, I know I'm not fully back to where I was before I got sick but I'm so thankful for the progress I've made.  It's been a team effort between my willingness to work hard (and Alan's efforts early on to make sure I did the work), the care from my amazing physicians and staff, and God's faithfulness that has brought me so far.

I can't wait to see what the next 6 months hold!

What a difference a year makes!

I had a wonderful Thanksgiving this year.  In so many ways, it was like last year's Thanksgiving--renting a cabin in Hocking Hills, spending time with Alan's brother David and his family, beautiful hiking and lots of good food.  But in so many ways it was totally different because of how I felt.  Last year, I was sick but didn't have a diagnosis and spent a lot of time talking to David, who is an Internal Medicine physician, about what might be wrong with me.  I was feeling poorly and worried about what might be wrong with me.

This year, it was a wonderful time. Not only was David and his family there, but the sisters of David's wife Karen and their families were there, too.  These are the ladies that I bake Christmas cookies with each year--Cookiepalooza.  They have become my sisters over the years and were instrumental in supporting me through my transplant and recovery.  They sent wonderful notes, gifts and care packages to me, visited me often, cooked for Alan and Claire and lifted us all up in prayer.

There were 13 of us in a wonderful cabin located near some of the most scenic hiking in Ohio.  The cabin was great, the scenery was beautiful and the company was even better.  It's located about 1-1/2 hours away from Columbus.  Alan, Claire and I got down there Thursday morning because Alan worked Wednesday night.  I picked him up from work Thursday morning and we drove down.

It was so emotional after the prayer before dinner.  To think about where I was a year ago and everything I've been through in that year and how far I've come was overwhelming.  And then the hugs and words of love and thanks from my adopted sisters, my brothers in law and, of course, Alan and Claire, brought out the true spirit of Thanksgiving.

Friday, we went on a 10-mile hike through three of the park's areas--Old Man's Cave to Cedar Falls to Ash Cave.  It was a beautiful day with a high in the 30s and a clear blue sky.  You can see the photos here.

It was a wonderful time with loving family enjoying so much for which we are thankful.

Liam or Morie

For the longest time, my celebrity crush has been Liam Neeson.

Whether its his work as an opportunist  turned Jewish rescuer Oskar Schindler in Schindler's List, the kick-ass dad in Taken or the sensitive widower in Love Actually, his acting combined with his looks has put him at the top of my celebrity crush list.

But now, he's been replaced by this guy....

Yes, perhaps not as attractive and maybe not as famous as Neeson to the uninformed but to folks knowledgable about research and treatment of Amyloidosis, this guy is a rock star.  This is Dr. Morie Gertz, Chair of the Department of Internal Medicine at the Mayo Clinic and one of the top physicians and researchers in Amyloidosis.  When I called to make my appointment with Mayo, they didn't tell me who my appointment was with.  When I got the letter with the details of my appointment and saw that it was with Dr. Gertz, I felt like I won the lotto.

So many of the studies I've been reading over the last few months have been authored by him.  He's the editor of the book that is considered the gold standard on diagnosing and treating Amyloidosis and he's one of the top physicians in the world at treating Amyloidosis.  From everything I've heard from people treated by him and who have met him, I will love him.  

If he's unseated Liam, I already do.

It's Complicated

I decided to go to the Mayo Clinic for a second opinion on my prognosis and treatment plan.  Mayo is one of the top Amyloidosis centers in the world and with such a rare and poorly understood disease, I thought it was a good idea to have them weigh in on my case.  As someone said on the online Amyloidosis Support Group, "I quickly learned that the doctors that wrote the articles and books do know a lot more about Amyloidosis than the local doctors that read their articles and books."

Granted, my doctor is much more informed than the average local doctor but her primary research focus is Myeloma...related but a separate disease.  She's presenting 6 papers at the American Society of Hematology meeting next month--4 on Myeloma, 2 on complications from stem cell transplants, 0 on Amyloidosis.

Given that I have met my out of pocket maximum for the year and Mayo is considered in-network for my insurance, it was important to get the appointment done before the end of the year.  So, I fly from Columbus to Rochester, Minnesota on Sunday, December 29th for my appointments on Monday, December 30 and Tuesday, December 31.

To prepare for the appointment, I needed to get a copy of my entire medical record from Ohio State, copies of all my radiology studies (3 ultrasounds, two CTs, two MRIs and an echocardiography) and the actual glass slides from my biopsies. I was worried how long that would take so I went on Monday and put in my request.  They pulled together the copy of my medical record--all 350 pages of it--while I waited.

I have access to lots of test results and other information on-line but it doesn't include any of the info from when I was an inpatient.  Reading through the inpatient notes was really interesting.  Some of the info I remembered, some of it brought back memories and some of it I had no recollection of at all.

It was interesting to read through it, especially the doctor's notes.  During one of my appointments in June, Dr. Levin described me as "a thin chronically ill appearing but animated middle aged woman."  Even at my lowest point physically, I still had some life in me.  Can't keep me down!

I found two things in the medical record that caused me some concern.  I always thought, based on my reading and guidance from folks in the support group who've had this disease lots longer than me, I had achieved a Complete hematologic response.  But my doctor's notes only list a Very Good Partial hematologic response.   At first I was a little concerned because of this graph--

But, the article that goes along with the picture says "Patients achieving a CR or VGPR after HDM/SCT, as defined by the new criteria, had indistinguishable OS (overall survival) and EFS (event free survival), with median OS exceeding 9 years."  Ok, so I'll take that.

The other thing I found that was concerning was a diagnosis of Primary Amyloidosis with Smoldering Multiple Myeloma (SMM).  So it's not enough for me to get a rare disease that is only diagnosed 3,000 times per year in North America, I also get an add-on bonus feature of the possibility of developing Multiple Myeloma.  That's what is complicated.

But, one of the people I met through the online support group said that he had the same diagnosis from his local doctors.  He went to Mayo and Dr. Gertz, who is one of the world leaders in Amyloidosis research and treatment, cured him of the SMM in a few minutes.  He said Dr. Gertz looked at all his test results and determined the other doctors were incorrect and the only issue he had was Amyloidosis.  I sure hope that's what happens with me.  I never thought I'd look forward to getting another diagnosis of Amyloidosis but given this complication, I'm hoping for it now.

My flight back from Mayo lands at 11:59 PM on December 31.  Getting the Amyloidosis only diagnosis would be a great way to close out 2013 and move into 2014 with even more hope than before.

One of the songs I've been listening to a lot lately is "Come Thou Fount of Every Blessing" by Sufjan Stevens.   It's a classic hymn with the words written in 1757.   One of my favorite lines is "Here I raise my Ebenezer;  Hither by Thy help I'm come;".  What's so great about raising an Ebenezer?  This information I found online seems to explain my basic understanding of the line--

In 1 Samuel 7, the prophet Samuel and the Israelites found themselves under attack by the Philistines. Fearing for their lives, the Israelites begged Samuel to pray for them in their impending battle against the Philistines. Samuel offered a sacrifice to God and prayed for His protection. God listened to Samuel, causing the Philistines to lose the battle and retreat back to their own territory. After the Israelite victory, the Bible records: “Then Samuel took a stone and set it up between Mizpah and Shen, and called its name Ebenezer, saying, ‘Thus far the Lord has helped us’ ” (1 Samuel 7:12). 

The word Ebenezer comes from the Hebrew words ’Eben hà-ezer (eh’-ben haw-e’-zer), which simply mean “stone of help” (see Enhanced…, 1995). When Robinson wrote his lyrics, he followed the word Ebenezer with the phrase, “Here by Thy great help I’ve come.” An Ebenezer, then, is simply a monumental stone set up to signify the great help that God granted the one raising the stone. In Robinson’s poem, it figuratively meant that the writer—and all who subsequently sing the song—acknowledge God’s bountiful blessings and help in their lives. 

The next time you sing about raising your Ebenezer, you will be able to “sing with the understanding” that you are acknowledging God’s help in your life (1 Corinthians 14:15).

So, regardless of what happens I'll raise my Ebenezer--acknowledging God's bountiful blessings and help in my life.  I guess I need to find a big rock!

t(11;14) Translocation

Over the last few days, I've been loading an Excel spreadsheet with lab values from key tests that show whether my Amyloidosis is under control and whether my liver and kidney function are improving.  The key test is the Serum Free Light Chain Assay that measures how much of the bad protein my body is producing.  One item I wanted to include were some of the values from my bone marrow biopsy.  It's nice to have all this information in one place so, as I read studies in the medical journals that reference lab values at different points in time--at diagnosis, after transplant, etc.--I have them in one location.

As I was reading the report from my bone marrow biopsy, I found this entry--

FISH analyses on this sample were positive for loss of the probes for 13q and positive for a t(11;14).  These abnormalities were not seen in the banded metaphase analysis.

I've learned that when a pathologist takes the time to include additional notes with the word "abnormalities" its probably a good idea to understand (as best as I can) the abnormalities.

FISH stands for fluorescent in situ hybridization and, according to Wikipedia, is used to detect and localize the presence or absence of specific DNA sequences on chromosomes. I couldn't find too much on my missing probes for 13q but what I found for t(11;14) wasn't very encouraging.

t(11;14) translocation means that part of my 11th and 14th chromosomes have swapped parts.  It's considered to be an acquired translocation as opposed to one that has been present since conception.  I did some medical literature searches on the impact of t(11;14) translocation on Amyloidosis and found an article from 2009 entitled "Translocation t(11;14) and survival of patients with light chain (AL) amyloidosis".  It was published in Haematologica, the hematology journal of the European Hematology Association.

Some of the highlights, or rather lowlignts from my perspective, include the following statements--

• The risk of death for patients harboring the t(11;14) translocation was 2.1 (CI 1.04–6.4), which on multivariate analysis was independent of therapy.
• Although preliminary, our data would suggest that cIg-FISH testing is important in patients with light chain amyloidosis and that t(11;14) is an adverse prognostic factor in these patients.
• On Cox multivariate modeling the t(11;14) translocation retained its significance despite the addition of treatment administered.
• On multivariate analysis, the hazard ratio for death for patients with this abnormality was 2.5 times that of the other patients without this abnormality.
• One can speculate that the indolent nature of the t(11;14) clones – and perhaps their relative resistance to chemotherapeutic intervention –may explain our findings.

So, to translate some of the clinical study language for those of you not familiar with reading this genre of literature---

• on multivariate analysis was independent of therapy=regardless of the type or effectiveness of treatment, it's bad to have this
• adverse prognostic factor=it's bad to have this because people with this don't do as well as those without it
• hazard ratio for death for patients with this abnormality was 2.5 times that of the other patients without this abnormality=people with this die at 2.5 times the rate of those without it so it's bad to have this.
• relative resistance to chemotherapeutic intervention=chemo is the last line of treatment in Amyloidosis after relapse following two stem cell transplants (two seems to be the max I see people receiving), so if this makes the amyloidosis resistant to chemo then there are no effective treatment options after relapse when stem cell transplant isn't an option so it's bad to have this.

Now, this study was based on only 56 patients who were diagnosed between 1998 and 2006 who had the FISH test panel performed.  They started with over 500 patients but only 56 had the test done so it's not like it was based on a large population.

I have a lot of questions for my oncologist during our appointment in December.  I'm looking forward to hearing her perspective on this.  She always tries to be so encouraging and reassuring that I'm sure she'll tell me not to worry about it.  I think her perspective is that each person's disease progresses in a unique way and understanding whether the progression is from a chromosomal abnormality or something else will have little effect on how she goes about treating the disease.  I love her strong focus on only using information as a rational basis for action.

It's been a rough week at work with a lot of challenges and I've been working through them with this t(11;14) translocation thing in the back of my mind.  It does help me keep work problems in perspective.  When Alan asks me how my day at work went, regardless of what happened, I can say, "My free light chains are still under control so everything else is good."

I know that God can overcome the "adverse prognostic factor" that this chromosomal translocation introduces.  I just need to pray, trust and believe.  It's worked so far.

Onward!

I had a great week at the Teradata Partners User Group meeting in Dallas.  It was another great conference and my colleagues on the Steering Committee did a great job planning it.  Sure wish I could have been more involved in the planning but I guess I'll have to make up for lost time next year.

As always, I learned a lot professionally from sessions and meetings with other customers.  It was also another instance in which I was overwhelmed by the encouragement and support from so many people.  So many people went out of their way to give me a hug and tell me they were praying for me or cheering me on.  And, sometimes, I'm surprised by some of the folks who take the time to tell me they care and are happy to see me.

I spent some time talking to a colleague who serves as the Director of Advanced Analytics for Teradata International.  She works with clients around the globe to determine how they can use their data to deliver better business results and sustainable competitive advantage.  She's got a doctorate in Statistics and has been in both academia and industry for more than 25 years.  On top of that, she's one of the smartest people I know.

Judy told me how she'd been thinking about me and keeping track of my progress.  She's gone through a battle with breast cancer so we talked about how being an analyst has impacted the way we manage our disease.  She found my data collection of test results to be totally normal and could empathize with my desire to build some process control charts for my key test results so I can identify when my values start to go "out of control."  We talked about our commitment to understanding the science of our diseases and staying up to date on treatment options.  Judy said, "Cancer is my hobby."  I can relate to that.

We talked about the challenge in diagnosing my disease and I described how impressed I was with Dr. Levin's thorough approach in my first appointment with him.  Judy said, "That's because he has the mind of an analyst.  He thinks comprehensively and can find the story in the data."

We talk a lot in my group about structured problem solving....the ability to take a problem and break it down into possible causes that are mutually exclusive and collectively exhaustive.  We use issue trees to help in this process.  As I watched my primary care doc use very unstructured, superficial thinking during my diagnostic process, I thought about the value of an issue tree that listed my symptoms at the top level, each body system at the next level, possible diseases at the third level and tests needed to confirm or refute the diagnosis at the fourth level.  She could then see the tests that were most common across the possible diagnoses and move through those possibly ruling out multiple diseases at a time as the tests were completed.

Judy and I talked about how primary care physicians are sorely lacking in this skill.  I take college courses that will help in my career or that I find interesting on coursera.org.  While perusing the catalog one day, I found a course entitled "Clinical Problem Solving."  The descriptions says, "Participants will learn how to move efficiently from patient signs and symptoms to a rational and prioritized set of diagnostic possibilities and will learn how to study and read to facilitate this process."  Obviously, the medical community recognizes the limited diagnostic prowess within its ranks.

We had our closing gala in Cowboy Stadium with a concert by One Republic.  The stadium was really extraordinary and the huge TV screen over the field was the most impressive feature.  I could not believe the quality of the picture.

Before the One Republic show, the Dallas Cowboy cheerleaders appeared on stage.  The rush of people, primarily men, moving rapidly toward the stage was quite remarkable.  I could see this word bubble floating in the air representing the primary thought of the men in the crowd--"BOOBIES!"  One of my colleagues on the Steering Committee stayed at the table with me at this point and enjoyed the sights of the cheerleaders on the ginormous tv screen.  15-foot wide booties covered in white polyester short shorts was impressive and disturbing at the same time.

The speaker at the closing session was Jamie Clark, professional adventurer who has summited Mt. Everest twice and climbed the highest summit on each of the seven continents.  His message was one of perseverance, overcoming obstacles, and “climbing your Everest”.  He shared a quote from Sir Edmund Hilary about Everest--"Everest is never conquered, it only tolerates momentary success."  There are times I feel that way about my disease.  How long will my Amyloidosis tolerate my current success?

Jamie also talked about fear.  He said that fear can paralyze us and asked how we conquer it.  Jamie said we don't conquer it, we have to find balance and focus.  But he did say that on the other side of fear we find freedom.

He talked about one of the climbers, John, on one of his Everest expeditions being a few hundred yards from the summit and having to make the choice to reach the summit but knowing it was likely he wouldn't make it back to camp.  Or to decide to stop and turn around, missing what might be his only chance to summit Everest.  He tells the story here.

His talk really made me think of my Everest--getting my Amyloidosis into remission.  I had the opportunity to share that with Jamie when I met him after his talk.  He said, "But I had a choice to go up that mountain, you didn't."  But really, I faced a similar decision as his climbing partner, John.  I could have chosen a less aggressive treatment than the stem cell transplant.  I see stories of some people who choose (or their doctors choose for them) to try chemotherapy first before undergoing a procedure as risky and taxing as a stem cell transplant.  I chose to push on to the summit knowing there was a chance I might not make it back.  Granted, that chance was small and much less than the almost certain risk of death that John faced, but it was there.

What made the decision a no-brainer for me is what Jamie says is found on the other side of our fear--freedom.  I feel that I now have freedom to live a relatively normal life for whatever period of time my disease is in remission, however long it tolerates this current success.

As Jamie signed his book, Above All Else, for me he said, "I think you'll appreciate the word I've inscribed in the book."  I looked down at the book he was signing on the table and he'd written "Onward!"

Yes, onward, enjoying the freedom I've found on the other side of my fear.

Dallas, Indian Food, Gratitude

Tomorrow, I go to Dallas for 6 days for what I call "spring break for data geeks."  Its actually the Teradata Partners Conference that brings together 3,000 data and analytics professionals from the top companies around the world.  I'm on the conference steering committee that plans the conference.  Normally, I have a good grasp of the conference details but I missed all of the planning sessions for this year except the first one in San Diego in February...and I missed half of that because I was too sick with the Amyloidosis to attend the entire meeting.

I always look forward to this meeting because I can talk data and analytics for 24/7....well, that's some of it but I also get to see a lot of former colleagues I've gained in my 15 years in this field.  It's a rewarding time both personally and professionally.  Because my team does such advanced work in the field, there are always a lot of companies that want to learn about what we do.  I have meetings scheduled with folks from a bank in Australia, a bank in Russia and an insurance company in South Africa.  Its always interesting to "talk shop"with folks from across the globe.

But this time, it will be different because it's in the "after."  My fellow committee members and some former colleagues know about my battle but many do not.  I'm sure I'll spend a fair amount of time talking about the disease, treatment and diagnosis.  But I'm OK with that.

It will also be the longest I've been away from Alan since my hospitalization and recovery.   When I was in the hospital, we were together at least 10 hours a day, 7 days a week.  For the 6 weeks after I was discharged before he went back to work, it was 24/7.  Before I got sick, I would have worried how that much togetherness would effect our relationship.  But during my hospitalization and recovery, he became my rock, my protector, my cheerleader and ass-kicker--most of the ass-kicking happened after I got out of the hospital and he pushed me to regain my strength.

We went out to dinner tonight at an Indian Restaurant and talked about my upcoming trip and reflected on my hospitalization and recovery.  We both agreed that it felt like that time was 2-3 years ago, not 5-6 months ago.  I think its similar to what happens when you have a baby.  It's so painful at the time but the memory of the pain fades away.

We joked around about his gruff bedside manner with his hospital patients and I complimented him on how caring and patient he was with me in the hospital.  I said, "But, you were kind of an asshole when I came home pushing me so hard to regain my strength."  He said, "Honestly, there were times I looked at you and wondered if you'd ever get back to some version of normal."  But we both commented on how quickly a decent version of normal has returned.

I still spend a lot of time reading the medical literature on the disease and I'm watching videos from a semester-long immunology course from UMass so I can better understand the science behind the test results I now watch like a hawk--monoclonal protein immunoglobulins, serum kappa free light chains, serum lambda free light chains, serum kappa/lambda ratio.  I check my test results as soon as they come in and ask questions when I see anything that looks like variation.  I'm sure my doctor's nurse practitioner gets tired of my questions but, as I told her, I have an almost post traumatic stress reaction when I see things change.  The reaction is getting less extreme as time goes on.  Maybe that's part of my "new normal."

I'm now at a point where I can talk about the stem cell transplant without crying.  For the first few months after, any discussion of it would take me back to that scary place.   The transplant itself wasn't scary but the pain from all the fluid was. I cried a lot after my diagnosis and during my treatment and recovery.  Those were tears of fear, pain and emotional despair.  I still cry more than I used to before my diagnosis, but now, those are almost always tears of gratitude--for my transplant response, my prognosis, my husband, my daughters, my sisters, my family, my church family, my prayer warriors, my friends, my coworkers.  I have so many things for which I'm grateful.

I subscribe to an Amyloidosis Support Group on Yahoo.  Tonight, the president of the support group sent out a note about a 57-year-old woman who just died from the disease.  She shared this in the discussion...

Dr. Vescio coined the phrase that “Someday this disease will be a treatable nuisance”…and we know he meant if diagnosed quickly and treated well…and Dr. Skinner at a meeting recently said that this disease, in her mind, was almost at the “chronic stage” and we know she also meant if caught early….and treated well so it does all go back to awareness..

Both of those physicians are among the top Amyloidosis specialists in the world.  It's encouraging to see their perspective.  A chronic disease like diabetes or asthma.  So maybe it is incurable.  For me a 30-year remission is as good as a cure.  I get more and more hopeful that its possible.

So, tomorrow I take another giant step toward the old normal...or adding to my new normal.  I'll miss Al but we both agreed that this is much more like normal.  Look out Dallas.  I'm back and better than ever!