***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND In patients with intermittent claudication , a supervised walking exercise program increases peak exercise performance and community-based functional status .  Patients with peripheral arterial disease also have muscle weakness in the affected extremity that may contribute to the walking impairment . However , the potential benefits of training modalities other than walking exercise , such as strength training , have not been critically evaluated in this patient population . The present study tested the hypothesis that a strength training program would be as effective as treadmill walking exercise and that combinations of strengthening and walking exercise would be more effective than either alone in improving exercise performance . METHODS AND RESULTS Twenty-nine patients with disabling claudication were r and omized to 12 weeks of supervised walking exercise on a treadmill ( 3 h/wk at a work intensity sufficient to produce claudication ) , strength training ( 3 h/wk of resistive training of five muscle groups of each leg ) , or a nonexercising control group . Grade d treadmill testing was performed to maximally tolerated claudication pain to define changes in peak exercise performance . After 12 weeks , patients in the treadmill training program had a 74 + /- 58 % increase in peak walking time as well as improvements in peak oxygen consumption ( VO2 ) and the onset of claudication pain . Patients in the strength-trained group had a 36 + /- 48 % increase in peak walking time but no change in peak VO2 or claudication onset time . Control subjects had no changes in any of these measures over the 12-week period . After the first 12 weeks , patients in the initial walking exercise group continued for 12 more weeks of supervised treadmill training . This result ed in an additional 49 + /- 53 % increase in peak walking time ( total of 128 + /- 99 % increase over the 24 weeks ) . After the initial 12 weeks , patients in the strength-trained group began 12 weeks of supervised treadmill training , and patients in the control group participated in a 12-week combined program of strengthening and treadmill walking exercise . The combined strength and treadmill training program and treadmill training after 12 weeks of strength training result ed in increases in peak exercise performance similar to those observed with 12 weeks of treadmill training alone . CONCLUSIONS A supervised treadmill walking exercise program is an effective means to improve exercise performance in patients with intermittent claudication , with continued improvement over 24 weeks of training . In contrast , 12 weeks of strength training was less effective than 12 weeks of supervised treadmill walking exercise . Finally , strength training , whether sequential or concomitant , did not augment the response to a walking exercise program Percutaneous transluminal angioplasty ( PTA ) is a commonly performed procedure for the treatment of  intermittent claudication  despite the lack of controlled studies . The aim of this study was to compare PTA with supervised exercise therapy for patients with arterial occlusive disease judged suitable for PTA at angiography . Patients were assessed before treatment commenced and at three monthly intervals afterwards . Assessment included measurement of resting ankle brachial pressure indices ( ABPI ) , and claudicating and maximum walking distances on a treadmill up a 10 degrees incline .  Twenty patients were r and omised to receive PTA and 16 exercise .  The groups were similar in age , sex , smoking habits and arteriographic pattern of disease . In the PTA group two patients had angioplasties that were technically unsuccessful and two other patients subsequently required surgery . One patient in the exercise group subsequently had a PTA . After PTA , mean ABPI were significantly improved at 3 , 6 and 9 months ( P less than 0.01 ) without a corresponding significant increase in mean maximum walking distances . However in the exercise group despite no increase in mean ABPI , mean maximum walking distances increased progressively , with significant increases at 6 , 9 and 12 months ( P less than 0.01 ) PURPOSE Surgical revascularization and angioplasty ( PTA ) are effective therapies for patients with peripheral arterial disease , but there are no data on long-term survival , limb salvage , and hemodynamic status from a r and omized study of such patients . A multicenter , prospect i ve trial compared PTA with bypass surgery ( BP ) in 263 men who had iliac , femoral , or popliteal artery obstruction . PATIENTS AND METHODS Lesions in the iliac versus the femoropopliteal artery and rest pain versus claudication were separately r and omized to the two treatment interventions . One hundred twenty-six patients underwent BP , 129 patients underwent PTA , and eight patients were not treated for lower extremity ischemia . RESULTS Three operative deaths occurred in the BP group and none in the PTA group . For the entire study , average annual mortality was higher in the BP group , but survival was not significantly different on life-table analysis ( P = .08 ) . Primary success favored BP , while limb salvage favored PTA , but differences were not statistically significant ( P = .08 and .35 , respectively ) . Patients with iliac disease or claudication fared better , but there was no statistical difference in response to PTA or BP . CONCLUSION Patients in both treatment groups had prompt and sustained increases in hemodynamics and quality of life . This study of patients r and omly assigned to BP or PTA shows no significant difference in outcomes during a median follow-up of 4 years The success of percutaneous transluminal angioplasty ( PTA ) in the treatment of common and external iliac atherosclerotic lesions has been established for the general population . However , several studies have suggested that the presence of diabetes may reduce the effectiveness of iliac angioplasty  , particularly in the setting of limb-threatening ischemia requiring concomitant lower extremity revascularization . This study compared the results of iliac artery PTA performed in conjunction with infrainguinal bypass for limb-threatening ischemia for diabetic ( DM ) and nondiabetic ( non-DM ) patients . Between 1991 and 2000 , 159 PTA were performed in 126 patients ( DM = 99/79 % , non-DM = 27/21 % ) in conjunction with subsequent infrainguinal bypass for limb-threatening ischemia ( gangrene = 42 % , ulcer = 36 % , rest pain = 22 % ) . These patients were followed prospect ively using a computerized vascular registry . Stents were placed in 34 ( 21.4 % ) cases for suboptimal angioplasty results . In this study the combined use of st and ard surgical and endoluminal modalities for the treatment of multilevel arterial occlusive disease result ed in excellent cumulative patency and limb salvage rates . The presence of diabetes did not alter these favorable results . Multimodal vascular therapy may be used effectively in diabetic patients with limb-threatening ischemia due to multiple levels of arterial occlusion PURPOSE To determine if improvements in physical function and peripheral circulation after 6 months of exercise rehabilitation could be sustained over a subsequent 12-month maintenance exercise program in older patients with intermittent claudication . METHODS Seventeen patients r and omized to exercise rehabilitation and 14 patients r and omized to usual care control completed this 18-month study . Patients exercised three times per week during the first 6 months of a progressive exercise program , followed by two times per week during the final 12 months of a maintenance program . Patients were studied at baseline , 6 months , and 18 months during the study . RESULTS Eighteen months of exercise rehabilitation increased the initial claudication distance by 373 meters ( 189 % ) ( P < .001 ) , the absolute claudication distance by 358 meters ( 80 % ) ( P < .001 ) , walking economy by 11 % ( P < .001 ) , 6-minute walk distance by 10 % ( P < .001 ) , daily physical activity by 31 % , and maximal calf blood flow by 18 % ( P < .001 ) . These changes were similar to those found after 6 months of exercise rehabilitation ( P = NS ) , and were significantly greater than the changes in the control group throughout the study ( P < .05 ) . CONCLUSION Improvements in claudication distances , walking economy , 6-minute walk distance , physical activity level , and peripheral circulation after 6 months of exercise rehabilitation are sustained for an additional 12 months in older patients with intermittent claudication using a less frequent exercise maintenance program CONTEXT Concerns about the safety and efficacy of diabetes interventions persist , in part because r and omized clinical trials ( RCTs ) have not measured their effect on patient-important outcomes , ie , death and quality of life ( morbidity , pain , function ) . OBJECTIVE To systematic ally determine the extent to which ongoing and future RCTs in diabetes will ascertain patient-important outcomes . DATA SOURCES On November 10 , 2007 , we search ed primary RCT registries Clinical Trials.gov ( http://www . clinical trials.gov ) , International St and ard R and omized Controlled Trial Number Register ( http://is rct n.org ) , and Australian New Zeal and Clinical Trials Registry ( http://www.anzctr.org.au ) . STUDY SELECTION We identified phase 2 through 4 RCTs  enrolling patients with diabetes . Of 2019 RCTs , 1054 proved eligible . We r and omly sample d 50 % of the eligible RCTs ( 527 of 1054 ) and selected 436 registered since registration became m and atory ( 2004 ) . DATA EXTRACTION Pairs of review ers working independently collected study characteristics and determined the outcomes measured and their type ( physiological outcomes , surrogate outcomes thought to reflect an increased risk for patient-important outcomes , and patient-important outcomes ) . RESULTS Of the 436 registered RCTs included in this analysis , 24 ( 6 % ) had not started enrollment , 109 ( 25 % ) were actively enrolling , and 303 ( 69 % ) had completed enrollment . Primary outcomes were patient-important outcomes in only 78 of 436 RCTs ( 18 % ; 95 % confidence interval [ CI ] , 14%-22 % ) , physiological and laboratory outcomes in 69 of 436 ( 16 % ; 95 % CI , 13%-20 % ) , and surrogate outcomes in 268 of 436 ( 61 % ; 95 % CI , 57%-66 % ) . Patient-important outcomes were reported as primary or secondary outcomes in 201 of 436 ( 46 % ; 95 % CI , 41%-51 % ) . In multivariate analysis , large trials ( odds ratio [ OR ] , 1.10 ; 95 % CI , 1.02 - 1.19 for every additional 100 patients ) and trials of longer duration ( OR , 1.03 ; 95 % CI , 1.01 - 1.06 for every additional 30 days ) were more likely while parallel design RCTs ( OR , 0.15 ; 95 % CI , 0.05 - 0.44 ) and type 2 diabetes trials ( OR , 0.23 ; 95 % CI , 0.09 - 0.61 ) were less likely to assess patient-important outcomes as a primary outcome . CONCLUSION In this sample of registered ongoing RCTs in diabetes , only 18 % included patient-important outcomes as primary outcomes PURPOSE Percutaneous transluminal angioplasty ( PTA ) is an increasingly popular invasive treatment for peripheral arterial disease , but there have been very few controlled trials to justify its use . This r and omized controlled clinical trial was performed to determine in patients with mild and moderate intermittent claudication differences in outcome between PTA and conventional medical treatment after 2 years . METHODS Six hundred patients with claudication were screened at the Peripheral Vascular Clinic , Royal Infirmary of Edinburgh . Sixty-two patients with short femoral artery stenoses or occlusions ( 47 patients ) and iliac stenoses ( 15 patients ) were r and omized to either PTA plus medical treatment ( PTA group , 30 patients ) or to medical treatment alone ( control group , 32 patients ) . Medical treatment consisted of daily low-dose aspirin and advice on smoking and exercise . Outcome measures studied were patient-reported maximum walking distance , exercise treadmill distance until onset of claudication , treadmill maximum walking distance , ankle-brachial pressure index ( ABPI ) , quality of life ( Nottingham Health Profile ) , and duplex ultrasound-measured extent of occlusive disease . RESULTS At 2 years of follow-up , the PTA group and control subjects did not differ significantly in patient-reported maximum walking , treadmill onset to claudication , treadmill maximum walking distances , or ABPI ( p > 0.05 ) . However , the PTA group had significantly fewer occluded arteries ( p = 0.003 ) and a lesser degree of stenosis ( expressed in terms of the velocity ratio ; p = 0.004 ) in patent arteries . Quality of life was not demonstrably different between the two groups ( p > 0.05 ) . CONCLUSIONS Two years after PTA , patients had less extensive disease than medically treated patients , but this did not translate into a significant advantage in terms of improved walking or quality of life . There are important implication s for patient management and future clinical research BACKGROUND The optimal first-line treatment for intermittent claudication is currently unclear . OBJECTIVE To compare the cost-effectiveness of endovascular revascularization vs supervised hospital-based exercise in patients with intermittent claud 
    Output:
    
Compared with medical management , each of the three treatments ( surgery , endovascular therapy , and exercise therapy ) was associated with improved walking distance , claudication symptoms , and quality of life ( high- quality evidence ) .
Evidence supporting superiority of one of the three approaches was limited .
However , blood flow parameters improved faster and better with both forms of revascularization compared with exercise or medical management ( low- to moderate- quality evidence ) .
Compared with endovascular therapy , open surgery may be associated with longer length of hospital stay and higher complication rate but result ed in more durable patency ( moderate- quality evidence ) .
In patients with claudication , open surgery , endovascular therapy , and exercise therapy were superior to medical management in terms of walking distance and claudication .