***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: The aim of this study was to establish the relative importance of risk factors for mortality after acute upper gastrointestinal haemorrhage , and to formulate a simple numerical scoring system that categorizes patients by risk . A prospect i ve , unselected , multicentre , population based study was undertaken using st and ardised question naires in two phases one year apart . A total of 4185 cases of acute upper gastrointestinal haemorrhage over the age of 16 identified over a four month period in 1993 and 1625 cases identified subsequently over a three month period in 1994 were included in the study . It was found that age , shock , comorbidity , diagnosis , major stigmata of recent haemorrhage , and rebleeding are all independent predictors of mortality when assessed using multiple logistic regression . A numerical score using these parameters has been developed that closely follows the predictions generated by logistical regression equations . Haemoglobin , sex , presentation ( other than shock ) , and drug therapy ( non-steroidal anti-inflammatory drugs and anticoagulants ) are not represented in the final model . When tested for general applicability in a second population , the scoring system was found to reproducibly predict mortality in each risk category . In conclusion , a simple numerical score can be used to categorize patients presenting with acute upper gastrointestinal haemorrhage by risk of death . This score can be used to determine case mix when comparing outcomes in audit and research and to calculate risk st and ardised mortality . In addition , this risk score can identify 15 % of all cases with acute upper gastrointestinal haemorrhage at the time of presentation and 26 % of cases after endoscopy who are at low risk of rebleeding and negligible risk of death and who might therefore be considered for early discharge or outpatient treatment with consequent re source savings OBJECTIVE : Despite advances in diagnostic and therapeutic endoscopy , the mortality of patients with upper gastrointestinal bleeding ( UGIB ) has remained relatively constant . Inadequate early resuscitation is believed to be a major factor in the persistently high mortality rate in patients with UGIB . In order to evaluate the role of intensive resuscitation in the outcome of patients with UGIB , we conducted the following prospect i ve study . METHODS : A consecutive series of patients with UGIB complicated by hemodynamic instability related to bleeding were enrolled in the study . An initial cohort of patients ( Observation Group ) was followed by a team of physicians to collect data . After recording demographic information , the time interval between presentation with UGIB and the correction of hemodynamic instability , hematocrit ( HCT ) , and coagulopathy was prospect ively recorded . Medical treatment , endoscopic intervention , and subsequent outcome were also prospect ively recorded . A subsequent cohort of patients ( Intensive Resuscitation Group ) was then prospect ively followed and similar demographic and outcome data were collected . However , in this cohort , the physicians involved in collecting the data also provided guidance to the health care team managing the patients . The goal for this group of patients was to allow a more rapid correction of hemodynamic instability , HCT , coagulopathy , and medical/endoscopic intervention . RESULTS : Seventy-two patients were included in the study , 36 males , 36 females , mean age 70 yr ( range 21–94 ) . Thirty-six patients were followed in the Observational Group , and 36 in the Intensive Resuscitation Group . There were no significant differences with regard to age , gender , number and type of comorbid diseases , history of prior gastrointestinal bleeding , or etiology of bleeding between the two groups . Patients treated in the Intensive Resuscitation Group had a significant decrease in the time interval from admission to the stabilization of hemodynamics and the correction of HCT . There were no significant differences in the time interval from admission to endoscopic intervention , length-of-stay ( LOS ) , or the number of units of blood given . Fewer patients in the Intensive Resuscitation Group suffered myocardial infa rct ion ( p = 0.04 ) . Mortality was lower in the Intensive Resuscitation Group ( one death ) compared to the Observational Group ( four deaths ) , ( p = 0.04 ) . CONCLUSION : Early intensive resuscitation of patients with upper gastrointestinal bleeding significantly decreases mortality . Physicians involved in the care of patients with UGIB should focus on early and rapid correction of hemodynamics , HCT , and underlying coagulopathy From September 1991 to December 1992 , a prospect i ve study was conducted to determine the risk factors and residual risk of rebleeding , and the evolutionary endoscopic changes in peptic ulcers that rebled . Emergency endoscopies were performed on 452 patients with haematemesis or a melaena , or both within 24 hours of admission . If the lesions were actively bleeding , then the patients were treated with injection sclerotherapy . A multivariate analysis of clinical , laboratory , and endoscopic variables of 204 patients with ulcer bleeding showed that hypovolaemic shock , a non-bleeding visible vessel , and an adherent clot on the ulcer base were independently significant in predicting rebleeding ( p < 0.05 ) . Considering these three factors according to the estimates of their regression coefficients showed that a non-bleeding visible vessel was the strongest predictor of rebleeding . The study of the residual risk of rebleeding after admission showed that most rebleeding episodes ( 94.1 % ) , including all associated with hypovolaemic shock , surgical treatment , and death , occurred within 96 hours of admission . After this time , the residual risk of rebleeding was less than 1 % . Study of the changes in endoscopic findings before and after rebleeding illustrated that all ulcers with a visible vessel or adherent clot showed at follow up endoscopy were derived from ulcers with initial major stigmata . It is concluded that hypovolaemic shock , a non-bleeding visible vessel , and an adherent clot on an ulcer base are of independent significance in predicting rebleeding . Observation for 96 hours is sufficient to detect most rebleeding episodes after an initial bleed from peptic ulcer BACKGROUND Upper-gastrointestinal haemorrhage is a frequent reason for hospital admission . Although most risk scoring systems for this disorder incorporate endoscopic findings , the Glasgow-Blatchford bleeding score ( GBS ) is based on simple clinical and laboratory variables ; a score of 0 identifies low-risk patients who might be suitable for outpatient management . We aim ed to evaluate the GBS then assess the effect of a protocol based on this score for non-admission of low-risk individuals . METHODS Our study was undertaken at four hospitals in the UK . We calculated GBS and admission ( pre-endoscopy ) and full ( post-endoscopy ) Rockall scores  for consecutive patients presenting with upper-gastrointestinal haemorrhage . With receiver-operating characteristic ( ROC ) curves , we compared the ability of these scores to predict either need for clinical intervention or death . We then prospect ively assessed at two hospitals the introduction of GBS scoring to avoid admission of low-risk patients . FINDINGS Of 676 people presenting with upper-gastrointestinal haemorrhage , we identified 105 ( 16 % ) who scored 0 on the GBS . For prediction of need for intervention or death , GBS ( area under ROC curve 0.90 [ 95 % CI 0.88 - 0.93 ] ) was superior to full Rockall score ( 0.81 [ 0.77 - 0.84 ] ) , which in turn was better than the admission Rockall score ( 0.70 [ 0.65 - 0.75 ] ) . When introduced into clinical practice , 123 patients ( 22 % ) with upper-gastrointestinal haemorrhage were classified as low risk , of whom 84 ( 68 % ) were managed as out patients without adverse events . The proportion of individuals with this condition admitted to hospital also fell ( 96 % to 71 % , p<0.00001 ) . INTERPRETATION The GBS identifies many patients presenting to general hospitals with upper-gastrointestinal haemorrhage who can be managed safely as out patients . This score reduces admissions for this condition , allowing more appropriate use of in-patient re sources OBJECTIVE To evaluate the cost effectiveness of the cyclooxygenase 2 ( COX-2 ) selective nonsteroidal antiinflammatory drug ( NSAID ) rofecoxib compared with naproxen and the COX-2 NSAID celecoxib compared with ibuprofen and diclofenac . METHODS Cost-effectiveness analysis based on a 5-year Markov model . Probability estimates were derived from detailed data of 2 r and omized trials and a systematic search of the medical literature . Utility estimates were obtained from 60 r and omly selected members of the general public .  Cost estimates were obtained from Canadian provincial data bases . Incremental cost-effectiveness ratios were calculated for patients at average risk of upper gastrointestinal ( UGI ) events and for high-risk patients with a prior history of a UGI event . Subjects were patients with osteoarthritis or rheumatoid arthritis ( RA ) where a decision has been made to treat with NSAIDs but who do not require low-dose aspirin .  Main outcome measures were proportion of patients with clinical or complicated UGI events , quality -adjusted life expectancy , and life expectancy . RESULTS Evaluation of rofecoxib versus naproxen in patients with RA at average risk result ed in costs per quality -adjusted life year ( QALY ) gained of $ Can271,188 . Celecoxib was dominated by diclofenac in average-risk patients . Both rofecoxib and celecoxib are cost-effective in high-risk patients . Analyses by age groups and assuming a threshold of Can$50,000 per QALY gained , suggest that rofecoxib or celecoxib would be cost-effective in patients aged over 76 and 81 , respectively , without additional risk factors . CONCLUSION Both rofecoxib and celecoxib are economically attractive in high risk and elderly patients . They are not economically attractive in patients at average risk . Coprescription of proton-pump inhibitors with COX-2 NSAIDs is not economically attractive for patients at high risk BACKGROUND Concurrent therapy with a proton-pump inhibitor is a st and ard treatment for patients receiving aspirin who are at risk for ulcer . Current U.S. guidelines also recommend clopidrogel for patients who have major gastrointestinal intolerance of aspirin . We compared clopidogrel with aspirin plus esomeprazole for the prevention of recurrent bleeding from ulcers in high-risk patients . METHODS We studied patients who took aspirin to prevent vascular diseases and who presented with ulcer bleeding . After the ulcers had healed , we r and omly assigned patients who were negative for Helicobacter pylori to receive either 75 mg of clopidogrel daily plus esomeprazole placebo twice daily or 80 mg of aspirin daily plus 20 mg of esomeprazole twice daily for 12 months . The end point was recurrent ulcer bleeding . RESULTS We enrolled 320 patients ( 161 patients assigned to receive clopidogrel and 159 to receive aspirin plus esomeprazole ) .  Recurrent ulcer bleeding occurred in 13 patients receiving clopidogrel and 1 receiving aspirin plus esomeprazole . The cumulative incidence of recurrent bleeding during the 12-month period was 8.6 percent ( 95 percent confidence interval , 4.1 to 13.1 percent ) among patients who received clopidogrel and 0.7 percent ( 95 percent confidence interval , 0 to 2.0 percent ) among those who received aspirin plus esomeprazole ( difference , 7.9 percentage points ; 95 percent confidence interval for the difference , 3.4 to 12.4 ; P=0.001 ) . CONCLUSIONS Among patients with a history of aspirin-induced ulcer bleeding whose ulcers had healed before they received the study treatment , aspirin plus esomeprazole was superior to clopidogrel in the prevention of recurrent ulcer bleeding . Our finding does not support the current recommendation that patients with major gastrointestinal intolerance of aspirin be given clopidogrel BACKGROUND & AIMS Treatment of high-risk patients with nonbleeding adherent clots on ulcers is controversial . In a previous r and omized trial , there was no benefit to endoscopic therapies compared with medical therapy for prevention of ulcer rebleeding . Our purpose was to test the hypothesis that patients treated with combination endoscopic therapy  would have significantly lower rebleeding rates than those treated with medical therapy . METHODS In this r and omized , controlled trial , 32 high-risk patients with severe ulcer hemorrhage and nonbleeding adherent clots resistant to target irrigation were r and  omized  to medical therapy or to combination endoscopic therapy ( with epinephrine injection , shaving down the clot with cold guillotining , and bipolar coagulation on the underlying stigmata ) . Physicians blinded to the endoscopic therapy managed all patients . RESULTS Patients were similar at study entry , except for older age in the medical group and lower platelet count in the endoscopic group . By hospital discharge , significantly more medically treated patients ( 6/17 ; 35.3 % ) than endoscopically treated patients ( 0/15 ; 0 % ) rebled ( P = 0.011 ) . There were no complications of endoscopic treatment . CONCLUSIONS Combination endoscopic therapy of nonbleeding adherent clots significantly reduced early ulcer rebleeding rates in high-risk patients compared with medical therapy alone . This endoscopic treatment was safe A prospect i ve and r and omized trial involving 
    Output:
    
Clips or thermocoagulation , alone or with epinephrine injection , are effective methods ; epinephrine injection alone is not recommended .
Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended .
Preendoscopy proton-pump inhibitor ( PPI ) therapy may downstage the lesion ; intravenous high-dose PPI therapy after successful endoscopic hemostasis decreases both rebleeding and mortality in patients with high-risk stigmata .
Patients with UGIB who require secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid ( ASA ) again as soon as cardiovascular risks outweigh gastrointestinal risks ( usually within 7 days ) ; ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding