***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: Introduction No existing patient-reported outcome instrument focuses solely on assessment of varicose veins symptoms that are bothersome to patients . Methods The VVSymQ ® instrument is a five-item patient-reported outcome that assesses symptoms most important to patients with varicose veins  ( heaviness , achiness , swelling , throbbing and itching ) . This paper describes how the VVSymQ ® instrument was incorporated into an electronic daily diary to monitor key outcomes over time and capture treatment benefit in two r and omized , controlled , phase 3 clinical trials . Results Patients were highly compliant in completing the electronic daily diary , and the VVSymQ ® instrument demonstrated ability to detect overall change and ability to detect change that is meaningful to patients . Conclusion The VVSymQ ® instrument is a reliable , valid instrument responsive to measuring change in the patient experience of varicose vein symptoms pre- and post-intervention , and is uniquely focused on patient-reported symptoms compared with other widely used question naires completed by clinicians OBJECTIVE The natural history in the general population of chronic venous disease in the legs is not well understood . This has limited our ability to predict which patients will deteriorate and to assign clinical priorities . The aims of this study were to describe the progression of trunk varicose veins and chronic venous insufficiency ( CVI ) in the general population , to identify important lifestyle and clinical prognostic factors , and to determine the relationship between venous reflux and progression . METHODS The Edinburgh Vein Study is a population -based cohort study in which r and omly selected adults aged 18 to 64 years had an examination at baseline . This included a question naire on lifestyle  and  clinical factors  ,  st and ardized assessment and classification of venous disease in the legs , and duplex scan to detect venous reflux in eight segments of each leg . A follow-up examination 13 years later included a reclassification of venous disease to ascertain progression in the development or increase in severity of varicose veins and CVI . RESULTS Among 1566 adults seen at baseline , 880 had a follow-up examination , of whom 334 had trunk varicose veins or CVI at baseline and composed the study sample . The mean ( st and ard deviation ) duration of follow-up was 13.4 ( 0.4 ) years . Progression was found in 193 ( 57.8 % ) , equivalent to 4.3 % ( 95 % confidence interval [ CI ] , 3.7 - 4.9 ) annually . In 270 subjects with only varicose veins at baseline , 86 ( 31.9 % ) developed CVI , with the rate increasing consistently with age ( P = .04 ) . Almost all subjects ( 98 % ) with both varicose veins and CVI at baseline deteriorated . Progression of chronic venous disease did not differ by gender or leg , but a family history of varicose veins and history of deep venous thrombosis increased risk ( odds ratio [ OR ] , 1.85 [ 95 % CI , 1.14 - 1.30 ] and 4.10 [ 95 % CI , 1.07 - 15.71 ] , respectively ) . Overweight was associated with increased risk of CVI in those with varicose veins ( OR , 1.85 ; 95 % CI , 1.10 - 3.12 ) . Reflux in the superficial system increased the likelihood of progression , especially in combination with deep reflux ( OR , 2.57 ; 95 % CI , 1.55 - 4.25 ) and when located in the small saphenous vein ( OR , 4.73 ; 95 % CI , 1.37 - 16.39 ) . CONCLUSIONS Nearly half of the general population with chronic venous disease deteriorated during 13 years , and almost one third with varicose veins developed skin changes of CVI , increasing their risk of ulceration . Age , family history of varicose veins , history of deep venous thrombosis , overweight , and superficial reflux , especially in the small saphenous vein and with deep reflux , might influence the risk of progression 
    Output:
    
The overall key theme to emerge was adaptation , with patients demonstrating how they adapted to the various impacts .
This review demonstrates that varicose veins have a wide range of symptoms and may have a significant impact on quality of life ; people made significant adaptations to enable them to live their lives as fully as possible .
The use of PROMs to gather information about quality of life and symptoms is well established globally ; however , PROMs currently used may not capture the full extent of the impact on patient 's quality of life