Addressing the needs of the Canadian COPD patient

A PRIMER ON BREATHINGTECHNIQUES: BREATHING CANBE A CHALLENGE. HERE ARE SOMETIPS. ......................................1

SCENT-FREE? SCENT-FREEPROGRAMS CAN CONTRIBUTE TOWELLNESS................................1

COPD PEOPLE: PETER CLARKELIVING LIFE AFTER LUNG TRANS-PLANT SURGERY........................7

Simple BreathingTechniques

For most people, breathing is aseasy as inhaling and exhaling,without consciously giving any

thought to the process. For themajority of people with COPD,breathing can sometimes be achallenge and for some, it can be amajor struggle. For caregivers tounderstand the difficulty of breathingtry this. Take in a deep breath butdon’t exhale. Take in another andanother. You’re now hyper-inflated.Hold your breath. Now run upstairs.You can now appreciate what it feelslike to have COPD or asthma.

There are some simple techniquesto help COPD’ers cope with breathing. Pursed-Lip Breathing—Pursed LipBreathing (PLB) is the first line of defenseused by most people with COPD when tryingto recover from shortness of breath. Itinvolves breathing in through the nose andexhaling with the lips pursed as if you weregoing to whistle. How hard do you blow out?One guide is to use the same force that youwould use to cool hot soup on a spoon. Blowhard enough to cool the soup but not hardenough to blow it off the spoon.

When we pursed-lip breathe properly wecreate a back pressure in the mouth andthroat and this back pressure actually expandsthe airways. Now that we can breathe ineasier we have to concentrate and breathe outfor at least two to four seconds if possible.This helps expel CO2 and trapped air and webegin to breathe easier. After exhaling for twoto four seconds or more, pause momentarilyand then let the body inhale naturally. Thereason for the pause is two-fold. First of all,it lets you know that you are regaining

Chronic Obstructive Pulmonary DiseaseScent-free is best policy

Scent-free policies have been shown to contribute to the wellness of people.Odors or fragrances are commonly called scents which can refer to both pleasantand unpleasant odors. The term fragrance describes a complex mixture of some

3,000 chemicals which are used in perfumes, deodorants and colognes and a myriad ofpersonal care products. Deodorants, after shave lotions and even some washingmachine detergents (the smell of freshly washed clothes) can adversely affect somepeople—particularly people with a respiratory disease. Even products labelled as beingfragrance-free or unscented may in fact contain fragrances along with a masking agentthat prevents the brain from perceiving odor. Increasingly, people are becomingintolerant of these chemicals that are emanating from fragrances.

It was reported byHealth Canada thatexposure to perfumesposes a serious health riskto some 1.8 millionCanadians. The chemicalsin fragrances aredisbursed in the air andremain in theenvironment for longperiods of time and oftenchange as they come intocontact with othersubstances. Everyoneshould have safe andhealthy places in which tolive and work. It makessense that people shouldrefrain from the use ofscented products while in“hermetically” sealedbuildings. With less freshair in circulation, theimpact of scents isincreased. However, in

Ask COPDCanada

Q I suspect that I have COPD. Whatare typical questions that my doctormay ask me and how will the

diagnosis be made?

A To help in the diagnosis of COPD, your doctorwill ask you questions about your health history.Some of the questions may include:

• Do you currently smoke or did you smoke in the past?• How often are you short of breath?• What makes your shortness of breath worse?• Do you cough and if so, how long have you beencoughing?• Do you cough up sputum (phlegm, mucus)?• Does anyone or did anyone in your family have lungdisease? The most common tests to diagnose COPD are:• Spirometry is the most reliable way to diagnose COPD.It is a simple breathing test that measures the speed and

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2 • Living with COPD Spring/Summer 2016

Canada Post Canadian Publications Mail Sales Product Agreement Number 40016917Please forward all correspondence on circulation matters to: Chronicle Information Resources Ltd., 555 Burnhamthorpe Road, Ste 306,Toronto, Ont. M9C 2Y3Living with COPD is published for COPD Canada by Chroni cle Information Resources Ltd.Contents © 2016, Chronicle Companies, except where noted. Printed in Canada.Supported by an educational grant from Novartis Pharmaceuticals Canada Inc.

We invite your questions. Please mail questions toAsk COPD CANADA c/o COPD Canada,555 Burnhamthorpe Rd., Suite 306, Toronto,Ont. M9C 2Y3. Or you can e-mail questions to:AskCOPDCanada@gmail.com

control of your breathing and it allowsyou to relax easier. Secondly, you mayfind that if you consciously try to inhaleright away, you may gasp.

When inhaling make sure you donot try to “top off ” the air already inyour lungs. “Topping-off ” is when youinhale once and then inhale again beforeexhaling. This will cause you to use yourauxiliary breathing muscles in yourshoulders and neck and will also cause“air-stacking” in your lungs. This will inturn cause you to expend more energyand use up more oxygen. Also, bypausing after exhaling it gives the lungsa little more time to exchange gases(CO & CO2).

Diaphragm Breathing—Yourdiaphragm is a large muscle separatingyour lungs from your abdomen. Yourdiaphragm can work hard and never gettired. Some people breathe using theirchest muscles instead of theirdiaphragm. This takes extra effort andcan cause fatigue and tension.

Test yourself to see whether youbreathe correctly through yourdiaphragm: A) Sit upright and relax your shouldersB) Rest one hand on your chest and the otheron your stomachC) Breathe in deeply through your nose andpay attention to the movement of your hands

If you use your diaphragm to

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the amount of air you are able to blow out of your lungs. • A chest X-ray will help the doctor see if there is damage to your lungs. • Oximetry: This test measures the amount of oxygen saturation in your blood, painlesslywith a finger probe.

If you are diagnosed with COPD, you may have several questions about theprogression of the disease, as well as the treatments that are typically used. Smoking is thetop cause of COPD, with some estimates stating it causes as much as 90 per cent of allCOPD cases. When you stop smoking, within a few hours, the amount of carbonmonoxide in your blood is cut in half. If you’ve ever had surgery, you were probably toldto stop smoking at least eight hours before. This reduces the carbon monoxide in yourblood to a level that is safe for surgery. A few weeks after you stop smoking, your lungswill begin repairing themselves. Within three months, you’ll likely feel a markedimprovement in your ability to breathe. In just one year, the cilia in your lungs will begin tomove mucus more smoothly again, resulting in a reduction of symptoms such as chroniccoughing and shortness of breath. By your tenth smoke-free year, your risk of lung cancerwill be cut in half. For women, this progress is even faster, according to researchconducted by the National Heart Lung and Blood Institute in the United States. Whileformer smokers will always have a risk of COPD, that risk is increased by the number ofyears you smoke. Continuing to smoke will only exacerbate the disease, potentially leadingto such dangerous symptoms as pneumonia and infections.

Your overall health will have an impact on your reaction to COPD symptoms. Whilediet and exercise won’t cure COPD, they can help slow the disease, as well as help youbreathe better and feel less discomfort. Your doctor can also explain to you the benefits ofbeginning an exercise program that will help relieve the symptoms of COPD.

Q Besides smoking, what are some other factors that canaggravate my COPD?

A Some patients are concerned about allergens like pets, dust, and otherenvironmental factors. If you have extreme COPD symptoms, your physician mayrecommend wearing a mask to cut down on the pollutants you inhale. Explain the

specifics of your lifestyle to your doctor to see if they can make any recommendationsabout changes to your environment that will help you breathe better.

Your doctor will likely also recommend that you stay away from people who haveinfections and contagious illnesses. If you have COPD, even a minor illness can weakenyour immune system, putting you at greater risk for problems. In fact, staying healthy ingeneral can help ensure longevity. A healthy diet that includes vitamins that strengthen theimmune system can help you fight off viruses that come your way.

Some COPD patients choose to get a pneumonia vaccine to lessen their risk ofacquirIng the lung infection. As pneumonia can deteriorate lung health and lead to aweakened system., many people with COPD have found security in getting a pneumoniavaccine, which protects against a couple dozen strains. It is also recommended that you getan annual flu shot, which is readily available at many drug stores, health centres and anddoctors’ offices, if you have COPD. In fact, the influenza vaccine is recommended formost people. Like pneumonia, the flu can weaken a COPD patient’s lungs and immunesystem, leading to problems that healthy patients wouldn’t face.

If you’ve been diagnosed with COPD, you will likely have many questions. It may behelpful to prepare for your next appointment, keep a notepad and write down any

Ask COPD CANADAContinued from Page 1

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questions that come to mind so that youcan ask pose those questions to yourdoctor the next time you get a chance.Working with your doctor, and beinginformed, can help you get handle on thisdisease and will assist you in managingthis condition.

Pulse: News about COPDOutcomes improve with focus on patient’s quality of life n Lisbon / U.K. researchers have found that when chronic obstructive pulmonary dis-

ease is managed with a focus on how the symptoms impact the patient’s quali-ty of life, outcomes can be improved. They learned that exercise training,behaviour modification, education and pulmonary rehabilitation can be helpful.Such interventions should be as carefully considered and as tailored to individ-ual patients as drug dosages, Paul W. Jones and colleagues wrote in theInternational Journal of Chronic Obstructive Pulmonary Disease. Jones, of theDivision of Clinical Science, St. George’s, at the University of London, and col-leagues reviewed information presented at the 1st World Lung Disease Summitheld in Lisbon. Although the symptoms of COPD are well-documented, thedegree to which they limit a patient’s quality of life (QoL) “varies depending ona number of factors, for example, their disease severity and comorbidities,”said the researchers. They added that, “an appropriate level of physical activityis very important in patients with COPD, as it plays a key role in maintaininghealth.”8 http://tinyurl.com/zpt5zmo

Ottawa seeks to join provincial bids to cutprescription drug costs

n Ottawa / The federal government will join the provinces in lowering the cost ofprescription drugs by co-ordinating their purchases, a move that could signal anew era of co-operation between Ottawa and provincial leaders. This will be acritical year as Ottawa works to hammer out a new deal on health that will setnational standards and deliver the stable funding promised by the Liberals dur-ing the election. The new federal minister, herself a family doctor, said sheexpects to reach a new health accord and lay the groundwork for transformingCanada’s health system.

Dr. Jane Philpott wants to steer the talk away from dollars. “My hope is thatwe won’t allow ourselves to be inappropriately distracted by conversations aboutdetails of the transfer at this stage of the conversation,” she said. Reducing thecost of prescription drugs is one of her top priorities. “Canadians pay some of thehighest costs for prescription drugs. That is an area that I am quite determined toaddress,” she said. Joining the Pan-Canadian Pharmaceutical Alliance, an initia-tive started in 2010 by the provinces and territories to drive down costs of publiclyfunded drug programs through bulk buying, is the first step. Home care is anotherpriority for the federal Health Minister, following on the Liberal party’s $3-billioncampaign pledge to improve healthcare.8 http://tinyurl.com/hs4xm24

Living with COPD Spring/Summer 2016 • 3

Pulse: News about COPDAntibiotics not necessary for common respiratory

infectionsn Atlanta / The American College of Physicians and the U.S. Centers for Disease

Control and Prevention have issued new guidelines for prescribing antibiotics foracute respiratory tract infections (ARTIs) in adults. Their advice is that antibioticsare not needed for adults with the common cold, bronchitis, sore throat or sinusinfections. These types of infections are the most common reasons for visits tothe doctor and for outpatient antibiotic prescriptions for adults, the researcherssaid. The guidelines are designed to combat an overuse of such treatments.CDC data estimates “50 per cent of antibiotic prescriptions may be unnecessaryor inappropriate in the outpatient setting, which equates to over $3 billion inexcess costs.”

“Inappropriate use of antibiotics for ARTIs is an important factor con-tributing to the spread of antibiotic-resistant infections, which is a public healththreat,” ACP President Dr. Wayne Riley said in the news release. Doctors shouldadvise patients with the common cold that symptoms can last up to two weeksand they should follow up only if the symptoms worsen or exceed the expectedtime of recovery. Antibiotics should also not be prescribed for uncomplicatedbronchitis unless pneumonia is suspected. Minor sinus infections typically clearup without antibiotics.8 http://tinyurl.com/j92wps2

Smoking stigma affects COPD treatment n Toronto / ”Unfortunately, I believe that a tendency to blame the patient has con-

tributed to COPD getting less attention than other common chronic diseases.There was a belief that, because people with COPD smoked, they were deservingof their fate and not deserving of resources put toward their disease. I think this iswrong on many levels. Luckily, things are changing,” said Dr. Andrea Gershon, anassistant professor of medicine at the University of Toronto. She was responding toquestions related to her latest study, which investigates the efficacy of differenttreatments for older adults with COPD. Her point regarding stigma is an interest-ing one, since it offers an example of how popular stigmas may directly affectboth research and care.

Dr. Gershon’s study—published in JAMA—also makes the point that,despite COPD being a leading cause of death, there is comparatively little avail-able evidence on how to treat COPD patients, particularly elderly patients andthose with similar diseases, such as asthma. But how does stigma surroundingCOPD begin? For the COPD patient, she says, the dreaded question is: “Did yousmoke? They believe in the end they will be shamed and blamed for smoking.”8 http://tinyurl.com/jsyv2k8

4 • Living with COPD Spring/Summer 2016

Living with COPD Spring/Summer 2016 • 5

our society, it seems thatpeople are reluctant to tell co-workers or colleagues that theirperfumes are making them sick.

In December 2004 Health Canada published new cosmeticsregulations strengthening the protection of the health and safety ofthe Canadian public with regard to the labelling of cosmeticproducts. The labels are required to contain a list of all ingredientsused in the products, however, the amounts of each ingredient arenot required to be listed as the formulas are considered to be tradesecrets. A report by the Environmental Health Association ofNova Scotia mentioned that 72 per cent of asthmatics developrespiratory symptoms when exposed to fragrances. In 1989 the U.SNational Institute of Occupational Safety and Health identified884 of 2,983 fragrance chemicals as being toxic substances. Theincidence of skin allergy to fragrance has been increasing and it isnow estimated to be as high as 1 to 2 per cent of the population.

Taking a somewhat contrarian view, an article published in theCanadian Medical Association Journal 1 questioned the scent-freepolicies that are popping up across the country. The article positedthat the science supporting these scent-free policies is fuzzy andinconclusive. While scents can trigger both physiological andpsychological symptoms in some individuals, there is no reliablediagnostic test for fragrance allergies. Much of North Americanresearch into scent sensitivities comes from the Monell ChemicalSenses Center, an independent, non-profit scientific institute inPhiladelphia. Researchers there study taste and smell. Recentlypublished research from the Monell Center reveals that simplybelieving that an odor is potentially harmful can increase airwayinflammation in asthmatics for at least 24 hours. The findingshighlight the role that expectations can play in health-relatedoutcomes. People with respiratory issues often are anxious aboutscents and fragrances. “When we expect that an odor is harmful,our bodies can react as if the odor is indeed harmful, said leadauthor of the study, Cristina Haen, PhD, a Monell physiologist.“Both patients and care providers need to understand howexpectations about odors can influence symptoms of the disease”,she said in reference to asthmatics. It is likely that theseobservations are true for many COPD’ers as well.

Yet, it is widely believed that a scent-free program cancontribute to the wellness of people. Providing a healthy workenvironment is one that is free of fragrance chemicals. Being

scent-free will improve air quality and can help reduce discomfortsuffered by some people, particularly those with asthma or COPD.If poor indoor air quality can negatively affect productivity in anoffice environment then a healthy, scent-free environment shouldincrease productivity.

The Halifax Regional Municipality has had a “No-Scent”encouragement program in effect for many years. The policysimply requests people to be considerate of others who may havemedical allergies or sensitivities to scented products. The scent-freeprogram is promoted in municipal offices and on the city’s publictransportation system.

A number of universities have instituted scent-free or scent-reduced environments. The programs are voluntary and provideguidelines for students, staff and faculty members. Many Canadianhospitals have adopted scent-free policies. People are asked torefrain from wearing any scented products and/or bringing high-fragrance flowers into the facilities.

There are various options for cities to consider in the processof establishing a scent-free environment. A public awarenessprogram that strives to explain to the general public that scentedproducts are not appealing to all individuals and that people havethe right to breathe clean air and not be exposed to chemicalfragrances could be instituted. A scent-free program could beextended to all city buildings and transportation vehicles. Cityemployees could be encouraged to go scent-free or at the veryleast be aware of the issues surrounding scents. A morecontroversial approach would involve a ban on scented products incity buildings and designated public spaces similar to many anti-smoking bylaws.

At the very least, Canadian cities should develop an educationprogram to increase the awareness of the health risks some peopleface when exposed to fragrances and post reminders at keylocations throughout the city and on all public transportationvehicles.

Note: The CMAJ has since come out in favour of scent-freepolicies in hospitals. 2

1. www.cmaj.ca/content/183/6/E315.full.pdf 2. http://news.nationalpost.com/news/canada/all-hospitals-

should-ban-perfumes-and-other-scented-products-says-canadas-leading-medical-journal

Join Today:The COPD Canada web site is your portal toour association, new and varied educational materials,medical resources and community interaction.Membership is free of charge but is restricted to individu-als living with COPD or their caregivers. Joining is fastand easy. Just visit our web site www.copdcanada.infoand click on membership and follow the step by stepinstructions. Once you’ve joined you will begin receivingour “Living with COPD” newsletter and will have compli-mentary access to all COPD Canada seminars, on-line

discussion forums and our member chat section. COPD CANADA, 555 Burnhamthorpe Rd., Suite 306, Toronto, Ont.M9C 2Y3. For more information contact: Henry Roberts, email: henry.copdcanada@gmail.com, telephone 416-465-6995

Scent Free continued from Page 1

COPD Canada’s web resourcewww.copdcanada.info

6 • Living with COPD Spring/Summer 2016

breathe, the hand on yourstomach will move. If you use your chest muscles to breathe, thehand on your chest will move. Try both ways of breathing andfeel the difference. If you are a chest breather, practicediaphragmatic breathing for a few moments several times a day,and soon it will become automatic. If your neck and shouldermuscles are constantly sore after being short of breath, then youare a chest breather and you have to learn to use your diaphragmto breathe.

Most of the pulmonary rehab programs available providevery good instruction in how to breathe. They also have excellentexercise programs. Exercising regularly helps keep muscles as welltoned as possible and well-toned muscles use a lot less O2. Wehighly recommend pulmonary rehab for all those living with theburden of COPD.

Yoga as an alternate breathing aid—Ten years ago, a 63-year-old male patient diagnosed with emphysema learned yoga. Today,he is pleased to say that his lung function has essentiallyremained unchanged from the day he was first diagnosed. Hebelieves that the credit is primarily due to his nine years ofdaily practice of yoga. Yoga has been contributing to thescience of breathing for centuries.

People with COPD should consider a yoga programwith breathing retraining. These exercises can strengthenyour respiratory muscles, which will provide control overbreathlessness. Yoga can also increase your tolerance to allforms of exercise.

COPD is known to increase stress, emotionalvulnerability, inactivity and muscle wasting. Yogatechniques are particularly suited for promotingrelaxation, emotional stability and exercisetolerance. A correct yoga program can have apositive effect on general health and the respiratory system,increasing a person’s ability to perform the activities of dailyliving.

The benefits of taking yoga are especially good for peoplewith COPD. As the COPD patient gains strength and stamina,their improved posture can create an aerobic effect, improvingcardiac efficiency. Lungs and heart work in coordination tosupply oxygenated blood to the body in a more efficient way.This, of course, increases the efficiency of the lungs and

conditioning of the muscles, which will decrease production ofcarbon dioxide and lactic acid. A word of caution—yoga is notfor all COPD patients (depending on the severity of yourCOPD—so please consult your physician before enrolling in ayoga class.

A recent study, published in CHEST magazine, found thatyoga is as effective as traditional pulmonary rehabilitation inpatients with COPD. Researchers from the Department ofPulmonary Medicine and Sleep Disorders and All India Instituteof Medical Sciences, New Delhi, India, studied the effects ofyoga as a form of pulmonary rehabilitation on markers ofinflammation in the body. Results from this study showed yogaexercises provide improvements that are just as effective astraditional pulmonary rehabilitation methods in improvingpulmonary function, exercise capacity, and indices of systemicinflammation 

In the study, 60 patients with COPD were randomly dividedinto two groups, one of which was taught yoga exercises whilethe other underwent a structured pulmonary rehabilitation

program. These groups were tested on shortness of breath,serum inflammation, and lung function tests. Each groupparticipated in one hour of training twice a week for thefirst four weeks, then training every two weeks for eight

weeks, and the remaining weeks were at home. Resultsshowed that yoga and pulmonary rehabilitation exercisesresulted in similar improvements in pulmonary function,six-minute walk distance, Borg scale, severity of dyspnea,quality of life, and levels of C-reactive protein after 12

weeks of training.“This study suggests yoga may be a cost-

effective form of rehabilitation that is moreconvenient for patients,” said Mark J. Rosen, MD,Master FCCP, CHEST Medical Director. “The

authors recommended adoption of yoga programs as an optionas part of long-term management of COPD. These findingsshould be confirmed in new studies and the potentialmechanisms explored,” he added.

For more information on the study:http://www.chestnet.org/News/Press-Releases/2015/10/Yoga-as-effective-as-traditional-pulmonary-rehabilitation-in-patients-with-COPDprocedure.com

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Before makingmedical decisionsYour physician should be consulted on all medical decisions. Newprocedures or drugs should not be started or stopped without suchconsultation. While we believe that our accumulated experience hasvalue, and a unique perspective, you must accept it for what it is...thework of COPD patients. We vigorously encourage individuals withCOPD to take an active part in the management of their disease. Youcan do this through education and by sharing information and thoughtswith your primary care physician and respirologist. Medical decisions arebased on complex medical principles and should be left to the medicalpractitioner who has been trained to diagnose and advise.

Peter Clarke is a NovaScotian who spent hisprofessional life travellingnationally and internationallyfirst as a financial advisor witha money management firm inHalifax and later, as a seniorinvestment executive inToronto. He’s married andhas two daughters, one agraduate of Bishop’s, theother from Queen’s. Equallysuccessful young women, oneholds an MBA and one hasher CA. His wife, a Ryersongrad, worked at the NationalFilm Board and the IWKFoundation in Halifax. Nowretired, she remains avolunteer. Peter has beenactive his entire life andattributes his ability to operateat a high level to hisdedication to exercise andkeeping fit. After taking upgolf at the age of 37, hisdetermination and love forthe game enabled him toestablish a handicap in the9/10 range and score anace. The game (and his golfbuddies) have taken him toIreland, Scotland and acrossthe U.S. A few years ago heand his wife bought propertyon the Northumberland Straitin Nova Scotia where they’vebuilt their retirement home.While his wife worked closelywith the architect and generalcontractor, he jokes that hisonly role was that of banker.They can see three provincesfrom their shoreline: N.S.,N.B. and P.E.I. Peter wasdiagnosed with emphysemain 2002.

COPD peoplePeter Clarke

Living with COPD Spring/Summer 2016 • 7

When did you move to Toronto?

Itransferred to Toronto in 2003 to assumea senior role with the firm I’d worked

with in Nova Scotia. The girls were away atuniversity. We came for three years butended up staying 12 after my career blos-somed. I spent time as head of the Swissbank UBS. In 2008 I joined BeutelGoodwin, as a managing partner.Were you a smoker?I smoked the equivalent of 70 pack years. Iwas a heavy smoker.Yet you exercised?I believe that keeping fit allowed me tofunction well in spite of the condition. In2014 I began to decline; it came on verysuddenly.Were you still smoking?I quit smoking 18 years ago, but the damagewas done. When I quit smoking I joined agym and hired a personal trainer. I used mycigarette money to pay for the trainer. How did you get on the lung transplantlist?It was quite onerous. I was referred to theprogram in October 2014. Four monthslater I was put through preliminary analysisinvolving interviews and some initial healthtests. I was advised I was a candidate andwaited until August for a second round ofcomprehensive tests, primarily because Iwasn’t at immediate risk. Further testing andanalysis, including an angiogram, were donein October 2015 and a month later inNovember 2015 I was placed on the trans-plant list.Have you met the surgeon?Yes, we met one of six thoracic surgeons onthe team.How do they decide who’s up next?

They have three categories based on risk.They also segregate by blood type and lungsize. Because of the time involved you canactually move from one category to another. When did you get the call and how soonafter were you in the hospital?I received the call at 11:40 a.m. on TuesdayMarch 29th. We arrived at the hospital foradmission at 3 p.m. that day, anticipating thesurgery would take place after midnight. Itwas actually 24 hours later at noon on March30th that I went into surgery. It was a longwait, but I am very lucky that it wasn’t a falsealarm. Often there is a problem with thedonor organs and the surgery has to be can-celled.When you woke after surgery, can youdescribe your first breaths, your thoughts?In truth I don’t really remember the firstfew days after surgery. However, in recentdays I have been awestruck by the things Ican do without oxygen and/or withouteffort ... things as simple as bending over toput my shoes on, or walking and talking atthe same time.How are you reacting to the anti-rejec-tion drugs?My recovery has been quite easy and I’mnot aware of any side effects from the med-ication.Do they offer counselling?Toronto General Hospital has a supportgroup that meets weekly. Professionals dis-cuss various topics related to the program.Recently a nurse practitioner discussed thepost-transplant process. Is family support important?That’s part of the package. You have tosupply proof of round-the-clock at-homesupport to qualify. I have my wife, so I’mOK. This is a family effort.