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(adult brother with schizophrenia, what to do?)

My brother John's my burden now that our mother is dead. My younger brother wants nothing to do with him - been that way a long time. So that leaves me, the middle brother, in the middle.

Its turn my back on John - or take care of him. I guess I'm his enabler. I know my mother was, no matter what, she kept him going, and I can't help but think it killed her in the end.

John is 52, been schizophrenic for years and years. It's getting worse. He's getting worse. You know the story, they only take him at the hospital when he's so bad he's grabbed the wheel while I drove him there, and we ended up in the trees off the highway, and then - even then, he's out in a month - tops. Discharged. No warning, no call from the hospital that he's being discharged - he just shows up at my house, banging on the door.

He has a monthly check, disability, good money, same money what I bring home after deductions, ...he blows it. I don't know where it goes. I call the hospital when he starts threatening, when he starts bringing drunks to the house, the hospital tells me to call 911. I've done that, and either nothing happens or the police come. If the police do come, either they back off and leave - do nothing, or tazer him and put him in handcuffs. I can't stand to see that, though once it's been so bad I stood there and watched them do it, and then thanked them for taking him, afterward. It killed my mother and now, I guess, it's gonna kill me.

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Are you an enabler? I don't think so. Being schizophrenic is not the same as being an alcoholic, even though your brother is also a substance abuser it's not like a 12 step program is all he needs. It's not like if you just showed him some tough love and stopped helping him survive he might just shape up and fly right. He is sick with a real illness, and that illness is more than you can handle. Schizophrenia

(altzheimers, death of a parent, could it have been prevented?)

(appendectomy, "spastic" colon, gas)

October 2, 2007

When I was 21 years old, I had major surgery to remove adhesions of the colon.

At the same time, the doctor removed my healthy appendix, as well. That was more than 30 years ago, and in those days they did this procedure arbitrarily.

Ever since, I've had a "spastic" intestinal tract with chronic gas (which inhibits my social life) and bloating.

Is this condition related to my loss of appendix? If not, what? I've used every form of probiotic available and have eliminated sugars and starches, but nothing seems to help...

J.M.C.

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Let's work through your question. From the history you give, we know for sure that you have had a problem with bloating and gas for years, since about age 21, and that it appeared after surgery on your abdomen. That surgery was, as far as you know, done to remove adhesions; and at the same time an "incidental appendectomy" was performed.

• The first question that comes to my mind is a desire to know more about these adhesions. You see, when adhesions form between loops of intestines and other organs, it's because there was some raw surface or inflammatory condition to begin with.
  • Anytime a person has abdominal surgery, for example, even a C-section, there is a risk that adhesions will form and perhaps require an operation to lyse them. That's because obstruction can develop.
• So, I wonder what caused these adhesions when you were twenty-one? Did you have an infection? Did you have a previous operation? It is very rare for adhesions to form without this kind of previous history, that is: surgery or major inflammation before the adhesions formed.
• • If that was the first time you ever had surgery, and you had no illness involving abdominal or pelvic inflammation before then - I question what was actualy meant by "adhesions".
• That said, sometimes what you were told, or how you interpreted what you were told might not actually be what the surgeon found.
  • It's not that the surgeon lied or that you didn't pay attention. It's just that there is always some element interpretation going on, between what they say (doctors, nurses) and what we hear (patients, family members).
    • and... much like the game of telephone- where one person whispers a word to another, and that person repeats it to a third person, and so on, until the final person in the chain says it out loud - what we hear and what they say always has some wiggle room.
    • that wiggle room gets bigger when there is simplification or reassurance, or any other kind of finesse involved in reporting surgical findings to patients. There is often some distortion over the technically correct findings to begin with, even before the interpretation begins.
• • That's why actually getting the records- including the actual operative report is always a good idea.
    • Of course, that's all over 30 years ago, and is, at this point -most likely water under the bridge. Still, I would advise you -and everyone, to get a copy of the operative report for ANY surgery you or a family member has- from now on- and keep it in a home file. Twenty years from now, the people who care about it will have it (that means YOU).
      • Not just written records, that's also true- by the way of x-ray studies, like a GI series or CAT scan, or even a chest x-ray.
      • It generally costs no more than a few dollars to get a copy of the old-fashioned sheets, and less to get a CD computer copy and print out a hard paper copy to save with it, these things , in 20 years, can be impossible to find at the hospital or office where you had them- and having the actual images can save you all kinds of future trouble.

oops, I've wandered from your question, let's get back:

Now, in terms of the appendix, professors of medicine say, "never say 'never' "; but I am willing to say (despite being that kind of professor, myself-) the appendectomy is not a cause for your problem. An apendectomy, like any abdominal surgery, can result in adhesions - and yes, obstruction can be a problem from adhesions - but the kind of chronic problem you describe really is not that kind of thing, AT ALL. The chronicity of your complaints- which, unless I have misunderstood, have been basically steady for at least 30 years is not the like pattern of bowel obstruction from adhesions, which causes acute problems.

• What you describe sounds like the clinical picture that is called irritable bowel syndrome.
  • That sounds good, doesn't it, definite- like here we have a diagnosis! Yet, it doesn't help us much - because so little is really understood about the actual causes of this so-called irritable bowel syndrome. In other words, doctor know very well that it's a chronic problem with abdominal pain that is like gas pain, that is usually relieved with defecation - and can also involve bouts of either diarrhea, constipation - or both. What we don't know is what irritable bowel syndrome really is.
  • That's cause, IBS (Irritable Bowel Syndrome) is pretty much just a name for any condition of large bowel issues that drags on for at least 3 months, without involving any of the red flag symptoms of known serious digestive disease (or tumors) that affect the colon.
• In fact, IBS is a sort of catch-all term for the clinical picture of large bowel/colon dysfunction that may well include a whole variety of specific causes and so be a different thing for many of those that have it - in other words, some people with these same symptoms may have an allergy, some may be lactose intolerant, some may have "hyperactive" intestinal nervous systems, and that just begins the list.It's not like "strep throat" where each person has the same thing, even though there may be somewht different manifestations. Here, we are talking about the chronic manifestations of poor colon function, from unspecified cause.
• On the other hand, there are so many Americans that have this, and that have been carefully followed by doctors over the years that there is some real knowlege about the syndrome.

What we do know is that IBS usually starts between adolescence and the 40s, and that is twice as common among women as men.

(mold in the basement, penicillin allergy)

September 27, 2007

Dear Dr. Nancy,

We had a flood in our basement last April. I wasn't too worried about it , until I noticed that things have stayed so damp down there that there is mold growing on the joists now. On the advice of a neighbor, I got the mold tested - and found out that one of the kinds growing is penicillin!

I am highly allergic to penicillin, I once went into shock because of it. Am I in danger if I go into the basement?

I noticed that the "fine print" on the Tylenol bottle says "may cause liver damage."

What volume (frequency? over time?) of this would you have to take for it to be dangerous?

-n-

---

• Many people are suprised to find out that acetaminophen (brand name tyelenol) can cause liver damage, and shocked to discover that the damage is non-reversible in cases of tyelenol poisoning. (Other names used for this drug include paracetamol and N-acetyl-p-aminophenol.)
• In other words - all of them plain English, too much acetaminophen kills the liver.
• So, how much is too much? Now that you pick up the bottle and read the label - why is it sort of vague? Why not just give an exact maximum that it's ok to take? This many pills, period. That's because the truth is :it depends. It depends on both body weight and liver function. It also depends on the actual weight of the drug - which is different between formulations.
• For most people- the amount to wory about is very high - but small children and anyone who is not eating, is recovering from anorexia, has anorexia, is drinking alcohol, is a recovering alcoholic, or who has some liver impairment already for any reason- is at risk even if their dose is much lower. In some cases, even when the recommended dosage is not exceeded.
• In fact, in the United States, the single most common reason for a liver transplant is acetominophen overdose. (Other names used for this drug include paracetamol and N-acetyl-p-aminophenol.)
• How much is too much? The answer for most people is a whole, whole lot- more than they would ever take, even if they took more than the label of the medicine bottle advises. But the problem is that everybody is not "most people": and, even temporary conditions, like fasting, can lower the threshold for damage and put a you or me at if we should take a bigger dose than recommended.
• In fact - if you have reason to believe that a history of alcohol abuse, anorexia or illness that you had in which you were told your liver was affected - do NOT take acetaminophen without specifically asking your doctor if your liver function is ok.

So let's run the numbers, answer the question and then get into a discussion about why this remains a safe drug for the great majority of people and how you can be sure that you are in that group:

What makes this a toxic drug is the particular pathway that breaks it down.

• "In adults, hepatotoxicity may occur after ingestion of a single dose of 10 to 15 g (150 to 250 mg/kg) of acetaminophen; doses of 20 to 25 g or more are potentially fatal. Conditions of CYP induction (e.g., heavy alcohol consumption) or GSH depletion (e.g., fasting or malnutrition) increase the susceptibility to hepatic injury, which has been documented, albeit uncommonly, with doses in the therapeutic range." (Goodman & Gilman's The Pharmacological Basis of Therapeutics, 11th ed. Copyright © 2006, Digital Edition Set ISBN: 0-07-146804-8 )
• 325 mg is one pill of acetaminophen. That means 2 is 650. To take over 10 grams, you'd have to take about 200 pills. But note, that if you are anorexic, say, and keep getting starvation headaches, you could take much less and -none-the-less, have a fatal reaction. Also, if you were regularly drinking large amounts of alcohol.

It's important to realize that - like the word "xerox" or "kinko" used for any kind of photo copy, the word "tyelenol" has made its way into American English as a synonym for acetaminophin, even though its not. You might dismiss that as just another case of "brand name versus generic name" of a drug, but you would be wrong to - and here's why:

Acetaminophen is in hundreds of over-the-counter formulations, and there's a reason for that. It's a good pain reliever, and it lowers fever, and in small doses, really is a very helpful ingredient for symptom relief of colds and various general ills. However, even if a person knows that the dose of acetaminophen cannot be infinite- that there must be a strict upper limit, it's easy to somehow assume that acetaminophen in these formulations does not count, because somehow- it's not either" tyelenol" or a generic form of the over-the-counter drug tyelenol. In other words, that person is not on the look-out for acetaminophen as an ingredient in cough syrups, cold pills, or -for that matter, Percocet ands other prescription drugs. It is in all these things.

There's another trap that catches people: drug and alcohol abuse. Once again, many people do not admit even to themselves that taking their friend's prescription pain medicine is drug abuse, or that drinking every day, let alone steadily on from lunch or dinner till they fall "asleep" (also called "passing out") is alcoholism - or at least, alcohol abuse. The trouble with that kind of denial is that the liver is affected even if the psyche is not.

Drink alcohol and your digestive system absorbs it, rather rapidly it gets into the blood stream and builds up a certain level. But realize please, that the liver gets a whole load straight from the stomach and upper intestine, before it even gets into the blood, and so most people who drink several drinks every day have given their liver extra peak levels with every drink. Although liver cells can be steeped in alcohol and survive, at some point they do get damaged. Many people who regularly drink have somewhat abnormal liver function, and some have severe disease, even; few know it. In terms of the prescription pain drugs (prescribed for somebody else or taken in excess by the legitimate patient), some of those can effect the liver, true - but more importantly, many contain acetaminophen along with codeine or oxycodeine or other narcotics.

So there are many "hidden sources" of so-called tyelenol [and let's not blame the tyelenol manufacturers for their success in making the names the same in our mind- it's acetaminophen].

(Cholesterol, Lipitor & Wine - in progress)

Dear Dr. Nancy,

My doctor recently put me on a low dose of Lipitor (10 mg). My total cholesterol was in the 280 range (with a good cholesterol of about 65). I am a 32 year old male, approximately 5'10" and 160 lbs. I exercise fairly regularly and eat well. My question is whether alcohol will impact the effectiveness of the Lipitor or have adverse side effects on the liver. The insert for the medicine indicated that any person who consumes more than two alcoholic drinks per day should consult their doctor. My doctor is aware that I typically consume two glass of wine every day or every other day. May I continue to have several glasses of wine per day while I am taking Lipitor? If so, is it problematic to exceed two glasses per day on occassion?

Thank you in advance for your thoughts.

P.

I'm trying to convince my mom to get checked out to see if she'd be a good candidate for a cochlear implant. If you have any recent info on it, pls let me know. She's very healthy and in good shape, so i think she should do it now while she'd be in better shape for surgery.

She remembers that you recommended the MD whom she went to when the original hearing loss was realized -- 8 years ago in FLA.

HT

(How long is it ok to take birth control pills?)

August 2, 2007

When I was younger, we were told to only use the birth control pill for two years at a time due to the increased risk of stroke.

Now my daughter has been taking it for 6 years and seems to think that it she can continue as long as she wants. Is this a good idea?

DM

(da Vinci Robot Assisted Laparoscopic Hysterectomy)

My gynecologist has offered to do a laparoscopically assisted vaginal hysterectomy—which he says I need because he cannot find a cause for my post-menopausal vaginal bleeding—using the Da Vinci robot.

He says that it will be less traumatic on my body than standard laparoscopy and will allow me to heal in one-to-two weeks, rather than two-to-six weeks. He says I will have five small incisions in my abdomen which will be less traumatizing than the 4 incisions he would have used for regular laparoscopy.

My question to you is that, as using this robot is relatively new, what questions should I ask him

about the procedure, the risks, and the recovery?

MW

---

• First - the short answer:

mmmm...."hysterectomy by standard laparoscopy v. hysterectomy by robot-assisted laparoscopy" doesn't seem to be the issue here.

The small incisions made for both sorts of laparoscopy are in the same ballpark - and would not account for a big difference in recovery time. But: It may be that your surgeon feels that the da Vinci Robot will give him better ability to do the entire procedure laproscopically, in other words, the real issue is: a "hysterectomy using conventional open surgery techniques v. a laparoscopic hysterectomy.

The latter avoids a large abdominal incision (large relative to the small incisions made for laparoscopic procedures) and/or the more invasive cuts done by other routes also used to perform a traditional hysterectomy. This seems to be the key to the faster recovery that comes with laparoscopic surgery. It's a question of not disrupting the muscular body wall, do that - disrupt the muscles with a sizeable incisions and then, after the surgery is over, getting up and moving around is painful and difficult for the patient until the body wall repairs itself; and that takes weeks.

There is no question that the recovery from an uncomplicated laparoscopic hysterectomy is faster and easier than from the conventional kind. However, there is also no question that an "uncomplicated hysterectomy" is much more likely to happen with standard surgery than with laparoscopic surgery in most surgeons' hands.

Although, at this time in the USA, hysteroscopy (looking into the abdominal cavity at the uterus) is extremely common, actually performing the entire excision laparoscopically is not. Only about 10% of hysterectomies are performed that way. Generally, it is only the most experienced and adept laparoscopic surgeons who will do laparoscopic hysterectomy - and even in their hands, major complications like bladder or ureter trauma is significantly more common than with conventional surgery.That's because the laparoscopic surgery is so much more difficult.

A laparoscopic excision of the uterus (hysterectomy) would not take 2-6 weeks for healing, but would be expected to take the lesser recovery period he mentioned, and that would be with or without the robot. In terms of your body, the effects of the incisions and instruments are more or less the same for laparoscopic surgery whether or not the robotic system is used. However, the suturing and other surgical manipulations that need to be done for a hysterectomy take something of a laproscopic technical ace to accomplish. The Da Vinci Robot allows the adequate surgeon to do the surgery laparoscopically - to do it as well as the rare technical star who is adept at laparoscopic hysterectomy "free-hand". In other words, it sounds like the choice is between a laparoscopic hysterectomy with the robot, and a conventional hysterectomy without it.

So, what questions:

1) Confirm that this is the choice.

2) I think that generally it is wise to ask any surgeon who is using new and complicated equipment what his or her experience has been with it. Are they familiar and comfortable with it? I think too that it is reasonable to ask if there is any back-up plan. Is there a chance that he may elect to do the conventional procedure, anyway? Under what circumstances?

3) Knowing from our private discussion that your surgeon is a world expert in the sorts of problems that you are most concerned with, I think that his up-front discussion with you, telling you his plan, asking your permission is really commendable.

4) The cost of the surgery is probably higher with the Robot. That's certainly reported in the literature. I don't say that's not worth it- especially if it allows you to have a very significantly shorter recovery period. In that case, the cost to your body, in a sense, is cheaper with the robot-assisted laparoscopic surgery than conventional hysterectomy. However, double checking your insurance situation and your personal financial liability is probably a good idea. That's the kind of generally prudent planning that I, myself, never do- but the wisdom and advantages of doing so are pretty straightforward.

• Next, more about the robot and procedure:

So, what's the Da Vinci robot?

This is a very expensive system (more than a million US dollars) that is being sold by a company on a commercial basis. It is the latest and most advanced robotic surgical system available, and it allows the surgeon to see in 3 dimensions, to operate without a tremor, and to control mechanical manipulators that move the surgical instruments rather than use her own hands to move the instruments. For those of you who have never done surgery, please realize that the tip of the instrument does the work- the surgeon holds the handle. In laparoscopic surgery-those handles are so long that the surgeons sometimes refer to the instruments as "sticks:, and just like using a poker to move ashes around in a fireplace, that long handle can make moves at certain angles impossible. The robotic manipulators, in a sense, put the surgeons hand control inside the abdomen, and markedly improves the ability to manipulate tissue. (Scroll below to a link to a video of actual surgery)

According to the recent medical literature, comparisons of surgery that does not require the removal of large masses or entire organs (like pyeloraplasty) is not clearly advantageous with the da Vinci robot. The experienced laproscopic surgeon who is adept at suturing with freely held instruments can probably do as well with or without the robot, and do it faster and cheaper without- at least that is the conclusion of one surgeon who compared a series of operations both ways. [Link RE. Bhayani SB. Kavoussi LR. A prospective comparison of robotic and laparoscopic pyeloplasty. [Comparative Study. Journal Article] Annals of Surgery. 243(4):486-91, 2006 Apr. UI: 16552199]. To quote the Urologist, Dr. Link, who performed the surgeries and wrote the paper: "The development and dissemination of robotic surgical tools, such as the da Vinci system (Intuitive Surgical, Inc., Sunnyvale, CA), have the potential to alter the way urologists approach complex laparoscopic reconstructive procedures. Proponents of da Vinci cite the device's 3-dimensional visualization, damping of tremor, and more sophisticated surgical tools with greater degrees of freedom than traditional laparoscopic instruments. Certainly, the device eases the technical challenge of intracorporeal suturing and may make reconstructive laparoscopic procedures more accessible to surgeons without extensive laparoscopic experience. There is mounting evidence that the da Vinci provides significant benefits during laparoscopic radical prostatectomy, particularly in shortening operating time and decreasing surgeon fatigue. The robot is not, however, without significant disadvantages as compared with traditional laparoscopy. These include greater expense and consumption of operating room resources. The purpose of this study is not to discourage the use of the da Vinci system for LP. Certainly, for surgeons unfamiliar with intracorporeal suturing, the robot may lower the learning curve for LP. Rather, this report should serve as a cautionary tale arguing against the indiscriminate application of the da Vinci based only on a perception that it should accelerate suturing. Our results suggest that, for surgeons facile with intracorporeal suturing, dependence on the da Vinci robot adds little speed or quality advantage to the LP procedure and results in substantially greater costs".

However, with hysterectomy - an altogether different procedure, the literature supports the notion that laparoscopic hysterectomy (without the robotic system) has the advantage of a short recovery time after the surgery, but the disadvantage of greater major complications. That's in the hands of the few surgeons who are comfortable doing laparoscopic hysterectomy.

SEE VIDEO of laparoscopic hysterectomy using the da Vinci Robot

The above linked video is surgery performed by the first author, Dr. Advincula, of the first of the papers referenced below:

• Advincula AP, Song A.The role of robotic surgery in gynecology.Curr Opin Obstet Gynecol. 2007 Aug;19(4):331-6. PMID: 17625414 (Two surgeons from the faculty of the Department of Obstetrics and Gynecology at the University of Michigan Medical Center have just published a discussion of the current use of robotic surgery in OB-GYN.)

• Jones BA. Krueger S. Howell D. Meinecke B. Dunn S. Robotic mitral valve repair: a community hospital experience. [Journal Article] Texas Heart Institute Journal. 32(2):143-6, 2005. UI: 16107102

• D'Annibale A. Fiscon V. Trevisan P. Pozzobon M. Gianfreda V. Sovernigo G. Morpurgo E. Orsini C. Del Monte D. The da Vinci robot in right adrenalectomy: considerations on technique. [Case Reports. Journal Article] Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 14(1):38-41, 2004 Feb. UI: 15259586

• Schiff J. Li PS. Goldstein M. Robotic microsurgical vasovasostomy and vasoepididymostomy: a prospective randomized study in a rat model. [Journal Article] Journal of Urology. 171(4):1720-5, 2004 Apr. UI: 15017273

• Hoznek A. Zaki SK. Samadi DB. Salomon L. Lobontiu A. Lang P. Abbou CC. Robotic assisted kidney transplantation: an initial experience. [Case Reports. Journal Article] Journal of Urology. 167(4):1604-6, 2002 Apr. UI: 11912372

July 31, 2007

Dear Dr. Nancy,

I've just finished fifteen months of chemotherapy following a lumpectomy and axillary node disection (21 nodes removed) for breast cancer (her2new, stage 3).

I came through pretty well, but am feeling quite tired. How long before my energy comes back, and what's the best way to get back into exercise? Should I see a physical therapist first for advice on whether and when I can begin weight training? I don't want to aggrivate the slight lymphedema I have under my arm.

Thanks. MM

---

Dear MM,

Such an important and reasonable question! - but one I can't answer directly, as much as I wish that I could. I just don't know.

What I can do is review the published medical literature and see what I can find in terms of the record of other people's experience in similar situations. Here goes:

First off, fatigue has long been recognized by oncologists (physicians specializing in cancer treatment) as being a notable feature in their patients, and has been documented in in breast cancer survivors for fifty years.

"Patients with cancer frequently report that fatigue begins with cancer treatment—or even during the stressful diagnostic process—continues during the course of active cancer treatment, and declines when treatment is over. The fatigue may persist after treatment at a higher-than-baseline level, and a significant percentage of disease-free survivors report disruptive levels of fatigue for years after treatment. For example, in a survey of 1957 survivors of breast cancer, a third reported severe and persistent fatigue 3 years after diagnosis." That quote is from the textbook: Abeloff: Clinical Oncology, 3rd ed. Copyright © 2004 Churchill Livingstone, An Imprint of Elsevier

As a rough guide, I think it is fair to think of cytotoxic chemotherapy (which literally translates as "cell killing" chemotherapy) as the kind that makes hair fall out. Now, today, much of the chemotherapy for breast cancer is not "cytotoxic", but hormonal - aimed at reducing growth factors for tumor cells that thrive on estrogen. Additionally, many people get both kinds of chemotherapy for breast cancer - in multiple courses, usually, the cytotoxic kind comes first. The article Fatigue in "Cancer Patients" discusses some details of what is known about patterns of fatigue during chemotherapy, and in people who have had radiation therapy. Let's get back to you - therapy is over, and - as far as anyone can tell, so is the tumor.

The fatigue you report is recognized to be a frequent occurrence in cancer survivors, what is not recognized are the reasons for it. One of the more pursuasive theories is that the regulation of the physiologic response to acute stress is blunted in those cancer survivors who experience chronic fatigue. However, the chemical system that regulates inflammation in the body, the cytokine system is extra-sensitive and hyperactive. Bower JE. Ganz PA. Aziz N. Altered cortisol response to psychologic stress in breast cancer survivors with persistent fatigue. [Comparative Study. Journal Article. Research Support, N.I.H., Extramural. Research Support, Non-U.S. Gov't. Research Support, U.S. Gov't, P.H.S.] Psychosomatic Medicine. 67(2):277-80, 2005 Mar-Apr. UI: 15784794

Finally, what about the edema under the arm? Which therapies have been helpful in decreasing lymphedema of the arm, at least according to the published English-language peer-reviewed literature in Medicine and the Health Sciences?

Well, in France, a treatment called "decongestion" is used routinely, at least in so far as I can tell from this article:

• Vignes, Stephane; Porcher, Raphael; Arrault, Maria; Dupuy, Alain Long-term management of breast cancer-related lymphedema after intensive decongestive physiotherapy. Breast Cancer Research & Treatment. 101(3):285-290, March 2007.

Interestingly, its first author is a Parisian physician who is part of the "Department of Lymphology" [Department of Lymphology, Hopital Cognacq-Jay, Site Broussais, 102 rue Didot, 75014 Paris, France e-mail: stephane.vignes@hopital-cognacq-jay.fr (Vignes, Arrault)] There is no sort of corresponding department in the United States - to my knowlege. This paper describes the course of over 500 patients treated for one year in just one of the "lymphology units" in that hospital. Again, I know of no center of this magnitude in the USA that concentrates on lymphedema, and suspect that this may be a tremendously valuable resource for patients who are able to visit Paris. The paper describes both physical therapy- usually given in the firt year post-op - and some compression bandages used to prevent lymphedema from worsening, over the long term. I realize that your major concern at the moment is "energy level" and that the arm swelling appears minor, but it strikes me that a center like this one might well have additional resources for its patients that might be helpful in restoration of full activity levels. Of course, the personnel at that center might know of similar centers in other French cities outside of Paris, but I do not know of any similar resources in our country.

Meneses KD. McNees MP. Upper extremity lymphedema after treatment for breast cancer: a review of the literature. [Review] [86 refs] [Journal Article. Research Support, N.I.H., Extramural. Review] Ostomy Wound Management. 53(5):16-29, 2007 May.

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