Long-term effectiveness and cost-effectiveness of high versus low-to-moderate intensity resistance and endurance exercise interventions among cancer survivors.

PURPOSE: This study aimed to evaluate the long-term effectiveness and cost-effectiveness of high intensity (HI) versus low-to-moderate intensity (LMI) exercise on physical fitness, fatigue, and health-related quality of life (HRQoL) in cancer survivors. METHODS: Two hundred seventy-seven cancer survivors participated in the Resistance and Endurance exercise After ChemoTherapy (REACT) study and were randomized to 12 weeks of HI (n = 139) or LMI exercise (n = 138) that had similar exercise types, durations, and frequencies, but different intensities. Measurements were performed at baseline (4-6 weeks after primary treatment), and 12 (i.e., short term) and 64 (i.e., longer term) weeks later. Outcomes included cardiorespiratory fitness, muscle strength, self-reported fatigue, HRQoL, quality-adjusted life years (QALYs) and societal costs. Linear mixed models were conducted to study (a) differences in effects between HI and LMI exercise at longer term, (b) within-group changes from short term to longer term, and (c) the cost-effectiveness from a societal perspective. RESULTS: At longer term, intervention effects on role (ß = 5.9, 95% CI = 0.5; 11.3) and social functioning (ß = 5.7, 95%CI = 1.7; 9.6) were larger for HI compared to those for LMI exercise. No significant between-group differences were found for physical fitness and fatigue. Intervention-induced improvements in cardiorespiratory fitness and HRQoL were maintained between weeks 12 and 64, but not for fatigue. From a societal perspective, the probability that HI was cost-effective compared to LMI exercise was 0.91 at 20,000€/QALY and 0.95 at 52,000€/QALY gained, mostly due to significant lower healthcare costs in HI exrcise. CONCLUSIONS: At longer term, we found larger intervention effects on role and social functioning for HI than for LMI exercise. Furthermore, HI exercise was cost-effective with regard to QALYs compared to LMI exercise. TRIAL REGISTRATION: This study is registered at the Netherlands Trial Register [NTR2153 [ http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2153 ]] on the 5th of January 2010. IMPLICATIONS FOR CANCER SURVIVORS: Exercise is recommended to be part of standard cancer care, and HI may be preferred over LMI exercise.

Systematic review of exercise training in colorectal cancer patients during treatment.

Colorectal cancer surgery results in considerable postoperative morbidity, mortality and reduced quality of life. As many patients will undergo additional (neo)adjuvant therapy, it is imperative that each individual optimize their physical function. To elucidate the potential of exercise in patient optimization, we investigated the evidence for an exercise program before and after surgical treatment in colorectal cancer patients. A systematic review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions, the guidelines of the Physical Therapy Journal and the PRISMA guidelines. No literature pertaining to exercise training during preoperative neoadjuvant treatment was found. Seven studies, investigating the effects of regular exercise during adjuvant chemotherapy for patients with colorectal cancer or a mixed population, were identified. A small effect (effect size (ES) 0.4) of endurance/interval training and strength training (ES 0.4) was found in two studies conducted in patients with colorectal and gastrointestinal cancer. In five studies that included a mixed population of cancer patients, interval training resulted in a large improvement (ES 1.5; P≤.05). Endurance training alone was found to increase both lower extremity strength and endurance capacity. The effects of strength training in the lower extremity are moderate, whereas, in the upper extremity, the increase is small. There is limited evidence available on exercise training during treatment in colorectal cancer patients. One study concluded exercise therapy may be beneficial for colorectal cancer patients during adjuvant treatment. The possible advantages of training during neoadjuvant treatment may be explored by prehabilitation trials.

A Rare Case of Intermittent Claudication Associated with Impaired Arterial Vasodilation.

Exercise-related intermittent claudication is marked by reduced blood flow to extremities caused by either stenosis or impaired vascular function. Although intermittent claudication is common in the elderly, it rarely occurs in the young and middle-aged individuals. Here, we report a case of exercise-related claudication in a 41-year-old woman, in the absence of overt vascular pathology. Using a series of imaging and functional tests, we established that her complaints were due to impaired arterial vasodilation, possibly due to a defect in nitrous oxide-mediated dilation. The symptoms were reversible upon administration of a calcium antagonist, showing reversibility of the vascular impairment. Identification of reversible vascular "stiffness" merits consideration in young and otherwise healthy subjects with claudication of unknown origin.

Endurance athletes with intermittent claudication caused by iliac artery stenosis treated by endarterectomy with vein patch--short- and mid-term results.

INTRODUCTION: Endurance athletes may suffer from intermittent claudication. A subgroup of 16% has severe iliac artery stenosis due to endofibrosis. In this study we report the short- and mid-term results of endarterectomy with venous patching. PATIENTS/METHODS: Athletes with claudication-like complaints were analysed using a protocol including cycling test and provocative echo-Doppler. Thirty-six athletes were diagnosed with serious iliac flow limitation (one bilateral), confirmed by additional magnetic resonance (MR) angiography. Endarterectomy with venous patching was performed for 32 iliac artery stenosis and five occlusions. Postoperative (mean 15.6 months) 33 legs were evaluated using the same diagnostic protocol. A complete follow-up after mean 29 months was obtained by questionnaire. RESULTS: Twenty-eight athletes were symptom free or could perform on a desired level with minor remaining complaints. Two athletes were satisfied though minor complaints prohibited high competition performance. Two athletes developed a re-stenosis and became symptom free after an additional operation. Three athletes had objective improvement but limited decrease in symptoms. One was unsatisfied but refused postoperative tests. The only major surgical complication was a postoperative bleeding necessitating re-operation. Postoperative tests showed significant increase in maximal workload and post-exercise ankle-brachial index. No aneurysm formation was detected. CONCLUSIONS: Precise diagnosis and meticulously performed endarterectomy with vein patching have satisfactory results in mid-term follow-up with acceptable risk in endurance athletes complaining of intermittent claudication due to iliac artery stenosis.

Endofibrosis and kinking of the iliac arteries in athletes: a systematic review.

INTRODUCTION: Kinking and endofibrosis of the iliac arteries are uncommon and poorly recognized conditions affecting young endurance athletes. Deformation or progressive stenosis of the iliac artery may reduce blood flow to the lower limb and adversely affect performance. The aim of this review was to examine the existing literature relating to these flow-limiting phenomena and identify a clear, unifying strategy for the assessment and management of affected patients. METHODS: A systematic review of the literature was performed. A comprehensive search was carried out using Medline, Embase and The Cochrane Database to identify relevant articles published between 1950 and 2011 (last search date 05/08/2011). This search (and additional bibliography review) identified 413 articles, of which 367 were excluded. 46 articles were then studied in detail. Methodological quality of studies was assessed according to Scottish Intercollegiate Guideline Network criteria. RESULTS: Focussed history and examination can successfully identify nearly 80% of patients with iliac flow limitation. However, both provocative exercise tests and detailed imaging are also necessary to identify those in need of intervention and establish most appropriate treatment. Provocative exercise tests and duplex imaging can then be used to confirm flow limitation before detailed assessment of abnormal anatomy with MRA and DSA. These multiple imaging modalities are necessary to identify those most likely to benefit from surgery and clarify whether each patient should undergo arterial release, vessel shortening, endofibrosectomy or interposition grafting. CONCLUSION: We present a systematic review of the literature together with a proposed algorithm for diagnosis and management of these iliac flow limitations in endurance athletes.

Oxygen uptake kinetics in chronic heart failure: clinical and physiological aspects.

One of the hallmark symptoms of patients with chronic heart failure (CHF) is exercise intolerance. Therefore, exercise testing has become an important tool for the evaluation and monitoring of heart failure. Whereas the maximal aerobic capacity (peak VO(2)) is a reliable indicator of the severity and prognosis of heart failure, submaximal exercise parameters may be more closely related to the ability to perform daily activities. As such, oxygen (O(2)) uptake kinetics, describing the rate change of O(2) uptake during onset or recovery of submaximal constant-load exercise (O(2) onset and recovery kinetics, respectively), have been shown to be useful parameters for objectively evaluating the functional capacity of CHF patients. However, their evaluation in this population is not a routine part of daily clinical practice. Possible reasons for this include a lack of standardisation of the assessment methodology and a limited number of studies evaluating the clinical use of O(2) uptake kinetics in CHF patients. In addition, the pathophysiological mechanisms underlying the delay in O(2) uptake kinetics in these patients are not completely understood. This review discusses the current literature on the clinical potency and physiological determinants of O(2) uptake kinetics in CHF patients and provides directions for future research. (Neth Heart J 2009;17:238-44.Neth Heart J 2009;17:238-44.).

Impact of anthracycline dose on quality of life and rehabilitation in breast cancer treatment.

BACKGROUND: In 2005 the Dutch national guidelines for treatment of breast cancer were updated. From then onwards, patients with operable breast cancer, who formerly received four cycles of adjuvant chemotherapy with doxorubicin/cyclophosphamide (AC), were treated with five cycles of 5-fluorouracil/epirubicin/cyclophosphamide (FEC), based on data suggesting survival benefit. PRIMARY OBJECTIVE: evaluation of the effect on quality-of-life and trainability after four AC versus five FEC cycles of polychemotherapy. SECONDARY OBJECTIVE: evaluation of the effectiveness of an 18-week training programme for breast cancer survivors. METHODS: A prospective cohort study design was used, comparing two chemotherapy regimens historically. The first cohort (group 1) received 4AC (A 60 mg/m2, C 600 mg/m2) (n=25) and the second cohort (group 2) received 5FE C (F 500 mg/m2, E 90 mg/m2, C 500 mg/m2) (n=50) adjuvant polychemotherapy. Both groups completed an 18-week high-intensity strength-training programme. Outcome measures were changes in quality-of-life (EORTC-QLQ-C30, MFI -20), muscular strength (one-repetition maximum; leg press) and cardiopulmonary function (VO2max) between baseline and follow-up. RESULTS: Between March 2002 and February 2006, 75 female subjects with breast cancer participated in this study. Baseline characteristics were similar in both groups. After completing the training programme, both groups showed a significant improvement in all outcome measures. No significant differences in changes of the EORTC-QLQ-C30 and MFI-20, one repetition maximum of the leg press and the VO2max between the two groups were demonstrated. CONCLUSION: After adaptation of the Dutch national breast cancer treatment guidelines, patients received prolonged and increased doses of anthracyclines. This, however, did not result in a difference in the baseline situation before rehabilitation and in training response, nor in quality of life between the two groups.

Resistance training in cancer survivors: a systematic review.

This systematic review summarizes the research of previous studies that used resistance training in the post-treatment phase of cancer patients with a focus on methodological quality, training methods and physical outcome measures. We found twenty-four studies (10 RCTs, 4 controlled clinical trials and 10 uncontrolled trials) that met all inclusion criteria. The studies were of moderate methodological quality. The majority of studies involved breast cancer patients (54%), followed by prostate cancer patients (13%). Most studies used a combination of resistance and aerobic training, which was mostly supervised. Resistance training involved large muscle groups, with 1-3 sets of 8-12 repetitions. The duration of the resistance training programs varied from 3-24 weeks, with a training frequency of 1-5 sessions per week. The training intensity ranged from 25% to 85% of the one-repetition maximum. Overall, positive training effects were observed for cardiopulmonary and muscle function, with significant increases in peak oxygen uptake (range: 6-39%), and in the one-repetition maximum (range: 11-110%). In general, there were no effects of training on body composition, endocrine and immune function, and haematological variables. No adverse effects of the resistance training were reported. Based upon these results, we recommend to incorporate resistance training in cancer rehabilitation programmes.

Long-term follow-up after cancer rehabilitation using high-intensity resistance training: persistent improvement of physical performance and quality of life.

The short-term beneficial effects of physical rehabilitation programmes after cancer treatment have been described. However, little is known regarding the long-term effects. The purpose of this study was to investigate the long-term effects of high-intensity resistance training compared with traditional recovery. A total of 68 cancer survivors who completed an 18-week resistance training programme were followed for 1 year. During the 1-year follow-up, 19 patients dropped out (14 due to recurrence of cancer). The remaining 49 patients of the intervention group were compared with a group of 22 patients treated with chemotherapy in the same period but not participating in any rehabilitation programme. Outcome measures were muscle strength, cardiopulmonary function, fatigue, and health-related quality of life. One year after completion of the rehabilitation programme, the outcome measures in the intervention group were still at the same level as immediately after rehabilitation. Muscle strength at 1 year was significantly higher in patients who completed the resistance training programme than in the comparison group. High-intensity resistance training has persistent effects on muscle strength, cardiopulmonary function, quality of life, and fatigue. Rehabilitation programmes for patients treated with chemotherapy with a curative intention should include high-intensity resistance training in their programme.

Long-standing, insulin-treated type 2 diabetes patients with complications respond well to short-term resistance and interval exercise training.

OBJECTIVE: To determine the feasibility and the benefits of combined resistance and interval exercise training on phenotype characteristics and skeletal muscle function in deconditioned, type 2 diabetes (T2D) patients with polyneuropathy. DESIGN: Short-term, single-arm intervention trial. METHODS: Eleven male T2D patients (age: 59.1+/-7.5 years; body mass index: 32.2+/-4.0 kg/m2) performed progressive resistance and interval exercise training thrice a week for 10 weeks. Besides primary diabetes outcome measures, muscle strength (MUST), maximal workload capacity (Wmax), whole-body peak oxygen uptake (VO2peak) and muscle oxidative capacity (MUOX), intramyocellular lipid (IMCL) and glycogen (IMCG) storage, and systemic inflammation markers were determined before and after training. Daily exogenous insulin requirements (EIR) and historic individualized EIR were gathered and analysed. RESULTS: MUST and Wmax increased with 17% (90% confidence intervals 9-24%) and 14% (6-21) respectively. Furthermore, mean arterial blood pressure declined with 5.5 mmHg (-9.7 to -1.4). EIR dropped with 5.0 IU/d (-11.5 to 1.5) compared with baseline. A decline of respectively -0.7 mmol/l (-2.9 to 1.5) and -147 micromol/l (-296 to 2) in fasting plasma glucose and non-esterified fatty acids concentrations were observed following the intervention, but these were not accompanied by changes in VO2peak, MUOX, IMCL or IMCG, and blood glycolysated haemoglobin, adiponectin, tumor necrosis factor-alpha and/or cholesterol concentrations. CONCLUSION: Short-term resistance and interval exercise training is feasible in deconditioned T2D patients with polyneuropathy and accompanied by moderate improvements in muscle function and blood pressure. Such a specific exercise regimen may provide a better framework for future exercise intervention programmes in the treatment of deconditioned T2D patients.

Recognising vascular causes of leg complaints in endurance athletes. Part 2: the value of patient history, physical examination, cycling exercise test and echo-Doppler examination.

UNLABELLED: Leg complaints at maximal exercise in endurance athletes may have many causes, including arterial flow limitations in the iliac arteries. Such flow limitations can evolve into serious health problems due to increasing intravascular obstruction or even complete obstruction as a result of dissection or thrombosis. Early detection is therefore of clinical importance, but conventional diagnostic tools often prove inadequate. In the current study simple sports-specific tests are examined for their diagnostic power. Test variables derived from patient history, physical examination, cycling exercise testing followed by arterial pressure measurements at the ankle, and echo-Doppler examination with provocative manoeuvres were tested in 92 symptomatic legs (80 patients). A validated clinical classification acted as a reference. Several test variables proved useful. However, no single test variable combined a high sensitivity with a high specificity. Multivariate testing resulted in the correct classification of 91 % of patients, reaching a sensitivity of 0.90 and specificity of 0.93 (kappa 0.76). Four patients wrongly classified as non-vascular suffered from kinking in the common iliac artery that could not be visualised using the diagnostic tools currently available in this study. IN CONCLUSION: simple sports-specific tests accurately diagnose iliac artery obstruction in endurance athletes.

Recognising vascular causes of leg complaints in endurance athletes. Part 1: validation of a decision algorithm.

Flow limitations in the iliac arteries of endurance athletes during exercise were previously ascribed solely to intravascular lesions. We postulate that functional kinking of the arteries can also result in flow limitations. However, the diagnostic tools in routine practice are not effective in diagnosing such flow limitations in a substantial proportion of athletes, mainly because these diagnostic tools do not measure in the provocative situations. Ninety-two symptomatic legs in 80 endurance athletes were examined with newly developed, sports-specific vascular tests. Thirty-five asymptomatic cyclists matched for working capacity served as the control subjects. Legs were classified as vascular or non-vascular following a decision algorithm, based upon the results of these diagnostic tests, excluding orthopaedic causes by the effects of specific treatment. Independently of this clinical classification, an alternative method was applied to find stable characteristics in the total patient group using factor analysis. This characterisation was based on scores on 14 test variables deriving from diagnostic tests that were not used in the decision algorithm, thus avoiding dependency between the clinical categorisation and the statistical categorisation. The hypothesis was that these characteristics were sufficiently sensitive to classify patients with vascular and non-vascular complaints. If so, these characteristics should correspond with the one derived from the decision algorithm. Following the decision algorithm, 58 legs (63%) were classified as vascular, 29 (32%) as non-vascular and 5 (5%) as inconclusive. The latter were considered non-vascular. In a substantial proportion of the vascular patients, kinking of the iliac arteries was identified as the major cause of flow limitation. The characteristics derived from factor analysis proved to classify 87% in agreement with the decision algorithm (kappa 0.56). The agreement is sufficient for validation of the clinical classification. The algorithm can therefore be applied in clinical situations to diagnose endurance athletes with flow limitations due to both intravascular lesions and kinking of the arteries.

Detection and treatment of claudication due to functional iliac obstruction in top endurance athletes: a prospective study.

BACKGROUND: Endurance athletes often have restrictions in flow in their iliac arteries during exercise. Such restrictions have previously been ascribed solely to intravascular lesions. We postulate that flow could also be restricted by functional kinking in the arteries, and that surgical release of these kinks might be an effective treatment. METHODS: We prospectively studied 80 endurance athletes who had complaints suggestive of flow restriction in the iliac arteries of one (n=74) or both (6) legs (total 92 legs). Using vascular diagnostic tools, we examined athletes while they were doing activities that often provoke flow restrictions. Restrictions were determined by measurement of systolic pressure in the ankle after exercise; peak systolic velocities were measured with echo-doppler. Kinks were detected with echo-doppler and magnetic-resonance angiography. When functional kinking was diagnosed as the cause of the restriction, the athlete was offered surgery to release the iliac arteries, as part of our prospective study. FINDINGS: We recorded flow restrictions in the iliac arteries of 58 of 92 (63%) legs. In 40 of these legs (69%), kinks were the most important cause of the restriction, making these legs suitable for surgical release. We operated on 23 of 58 (40%) legs. All athletes who had an operation subjectively improved. Maximum workload in a cycling test and ankle pressure significantly improved after the operation. 20 (87%) athletes were able to successfully return to their desired high level of competition. INTERPRETATION: Our sports-specific protocol is effective in detecting kinking of the iliac arteries as a cause for flow restriction in athletes who have few intravascular abnormalities when investigated with conventional vascular diagnostic tools. Surgical treatment directed at the kinking was less invasive and therefore a better alternative to vascular reconstruction in these athletes.

Color Doppler used to detect kinking and intravascular lesions in the iliac arteries in endurance athletes with claudication.

OBJECTIVE: In endurance athletes, flow limitations in the iliac arteries are commonly ascribed to mechanically induced intravascular lesions (endofibrosis). We hypothesize that kinking of the vessels, occurring during exercise, can also cause such flow limitations. Conventional diagnostic tests fail to demonstrate such kinking. METHODS: In the current study, the iliac arteries were examined in 50 endurance athletes suffering from flow limitations in the iliac arteries with color Doppler using provocative maneuvers of hip flexion, isometric psoas contraction and exercise. Five had both-sided complaints resulting in 55 symptomatic legs and 45 asymptomatic legs. Sixteen national level competitive cyclists served as control subjects resulting in 32 healthy reference legs. RESULTS: The iliac arteries could be visualized accurately in 127/132 (96%) of the legs. The legs with insufficient image quality were not scored in the further analysis. In the external iliac artery, kinks were detected in 21/54 symptomatic legs (39%) compared to none in 28 reference legs. Intravascular lesions could be detected in 33/54 symptomatic legs (61%) compared to only 1/28 reference legs (4%). In the symptomatic legs Doppler measurements showed significantly higher peak systolic velocities in all test conditions compared to the reference legs (P<0.05). These differences increased significantly with provocative maneuvers (P<0.05).In the common iliac artery, kinks were demonstrated in 3/54 symptomatic legs (6%) and an intravascular lesion in 2/54 symptomatic legs (4%) only. Neither kink nor intravascular lesions were demonstrated in the reference legs. Peak systolic velocity measurements in the common iliac artery were in line with these observations and did not show differences between symptomatic and reference legs. The incidence of intravascular lesions in the external and common iliac artery is as expected, however, the incidence of kinks in the common iliac artery is much lower than reported from magnetic resonance angiography. This discrepancy is most probably caused by the fact that kinks in the common iliac artery are predominantly situated in the coronal plane, which cannot be visualized by color Doppler. CONCLUSION: Both kinks and intravascular lesions are associated with flow limitations in the iliac arteries in endurance athletes. Color Doppler appears to be an effective technique to visualize and scale kinks and intravascular lesions in the external iliac artery and to visualize and scale intravascular lesions in the common iliac artery.

Magnetic resonance angiography used to detect kinking in the iliac arteries in endurance athletes with claudication.

In endurance athletes, leg complaints upon maximal exercise caused by flow limitations in the iliac arteries are frequently encountered. We theorize that functional kinking of the vessels, which occurs especially during hip flexion, may be a cause for such flow limitations. Conventional diagnostic tests cannot demonstrate such kinkings. Using gadolinium-enhanced magnetic resonance angiography, a 3D dataset of the aorto-iliac arteries could be obtained with the hips flexed. An image processing procedure was developed using a new segmentation algorithm to be able to use standard surface rendering techniques to visualize the arteries with an improved 3D appearance. These techniques were applied in the current study in 42 endurance athletes with documented flow limitations in the iliac arteries. As a control group 16 national level competitive cyclists without flow limitations in the iliac arteries were studied. Forty-six affected legs were examined in 42 patients. In all patients and reference persons image quality was adequate and the segmentation algorithm could be applied. In 22 affected legs (48%) a kinking in the common iliac artery could be demonstrated, compared with one leg (3%) in the control group. In 13 affected legs (28%) a kinking in the external iliac artery could be demonstrated, compared with three legs (9%) in the control group. It can be concluded that flow limitations in the iliac arteries in endurance athletes are associated with kinkings in the common and/or the external iliac arteries. Magnetic resonance angiography with the hips flexed followed by this newly developed segmentation algorithm is effective to visualize and score these kinkings.

[Long-term intensive athletic training; few adverse effects on later physical health]. / Langdurige intensieve fysieke sportbeoefening: weinig nadelige late gevolgen voor de gezondheid.

In general, physical activity benefits health. However, long-term intensive physical training may have detrimental effects on the health of some individuals. In cyclists, changes in the femoral arteries may occur leading to stenoses that are manifested in claudication type symptoms. Some endurance athletes may experience atrial fibrillations that are possibly related to long-term physical training. Older athletes only have an increased risk of osteoarthritis in joints that have suffered injuries. Menstrual disturbances and premature osteoporosis may occur in women as a consequence of intensive physical training. However, the risk for these adverse consequences of long-term physical training is small.

Flow limitations in the iliac arteries in endurance athletes. Current knowledge and directions for the future.

Pain and powerless feeling in the leg during cycling may indicate a serious problem that limits the performance in cyclists. Apart from the well-known muscular and neurological origin, such complaints can also be attributed to flow limitations in the iliac arteries caused by functional lesions (kinking and/or excessive length of vessels) and/or intravascular lesions (endofibrosis). Reliable insight in the prevalence is lacking. Most intravascular lesions (approximately 90%) are located in the external iliac artery. The diagnosis is frequently missed because physiotherapists and medical doctors are often unacquainted with the problem. The only finding in physical examination, discriminating for a vascular problem, is a bruit in the inguinal region with the thigh maximally flexed. Available diagnostic techniques are proven to be inadequate for this specific lesion, which has characteristics other than those of atherosclerotic lesions. Moreover, common techniques in a vascular laboratory do not incorporate the specific sport conditions necessary for provoking the complaints. Provocative testing on a bicycle ergometer with high intensity of exercise, combined with postexercise blood pressure measurements (at the ankle of both legs, or the ankle to arm pressure ratio) is used. Imaging techniques (echo-doppler, arterial digital subtraction angiography, magnetic resonance imaging and angiography) are necessary for proper classification of the problem. The application of specific provoking manoeuvres (hip flexion, psoas contraction, high-intensity exercise) in combination with these imaging techniques prove to be potentially valuable, although the diagnostic accuracy has to be established. Treatment should be tailored to the specific problems of the individual patient. Conservative treatment mainly indicates an advice to change sports activity. Surgical mobilization of the iliac arteries for functional lesions, and vascular reconstructions in case of intravascular lesions are possible, although long-term follow-up is lacking. Percutaneous transluminal angioplasty and intravascular stent are contra-indicated because of high risks for dissection and reactive intimal hyperplasia, respectively.

Methotrexate therapy.

Methotrexate may be very helpful for your illness if proper care is taken in the use of this medication. Follow your physician's instructions faithfully. Take methotrexate weekly as directed. Notify your physician at once if an accidental overdose is suspected or if you develop fever, cough or shortness of breath. If you develop vomiting, there is a change in your pattern of diarrhea or you suspect that you are dehydrated, notify your physician before taking the next dose of methotrexate. Do not start or change any medicine without first checking with your physician. Avoid or severely restrict alcohol, including wine and beer. Obtain the blood tests ordered by your physician. Avoid pregnancy during and for several months after taking methotrexate. Keep methotrexate out of the reach of children. It has been prescribed for your current medical problem and must not be given to other people.