***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: In an 11 month period , 95 patients with acute upper gastrointestinal hemorrhage underwent early fiberoptic endoscopy .  Patients were r and omized into two groups before endoscopy depending on whether the results of the procedure were revealed immediately or after 4 days . No attempt was made to influence the treatment or diagnostic plan . The groups were comparable with respect to historical features surrounding the bleeding episode and the anatomic site of hemorrhage . There were no significant differences in any aspect of patient management or outcome between groups . Important changes in diagnostic or treatment plan were made after learning the results of endoscopy in only 12 % of the patients , half of whom were bleeding briskly at the time of endoscopy . It is concluded that the natural history of acute upper gastrointestinal hemorrhage ( for example , the spontaneous cessation of bleeding ) precludes endoscopy from having a significant effect on patient management BACKGROUND Time to treatment with thrombolytic therapy is a critical determinant of mortality in acute myocardial infa rct ion . Little is known about the relationship between the time to treatment with direct coronary angioplasty and clinical outcome . The objectives of this study were to determine both the time required to perform direct coronary angioplasty in the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes ( GUSTO-IIb ) trial and its relationship to clinical outcome . METHODS AND RESULTS Patients r and omized to direct coronary angioplasty ( n=565 ) were divided into groups based on the time between study enrollment and first balloon inflation . Patients r and omized to angioplasty who did not undergo the procedure were also analyzed . The median time from study enrollment to first balloon inflation was 76 minutes ; 19 % of patients assigned to angioplasty did not undergo an angioplasty procedure . The 30-day mortality rate of patients who underwent balloon inflation < /=60 minutes after study enrollment was 1.0 % ; 61 to 75 minutes after enrollment , 3.7 % ; 76 to 90 minutes after enrollment , 4.0 % ; and > /=91 minutes after enrollment , 6.4 % . The mortality rate of patients assigned to angioplasty who never underwent the procedure was 14.1 % ( P=0.001 ) . Logistic regression analysis revealed that the time from enrollment to first balloon inflation was a significant predictor of mortality within 30 days ; after adjustment for differences in baseline characteristics , the odds of death increased 1.6 times ( P=0.008 ) for a movement from each time interval to the next . CONCLUSIONS The time to treatment with direct PTCA , as with thrombolytic therapy , is a critical determinant of mortality CONTEXT Upper gastrointestinal tract hemorrhage ( UGIH ) is a common and potentially life-threatening disorder . Re source utilization can vary without adverse effect on patient outcome . Clinical practice guidelines are a potential solution to reduce variation in practice while improving patient outcomes . OBJECTIVE To vali date prospect ively the safety , acceptability , and impact of a clinical practice guideline defining the medically appropriate length of stay ( LOS ) for patients hospitalized with UGIH . DESIGN Prospect i ve , controlled time-series study with an alternate-month design . Outcome surveyors and patients were blinded to study group allocation . GUIDELINE : A retrospectively vali date d scoring system using 4 independent variables : hemodynamics , time from bleeding , comorbidity , and esophagogastroduodenoscopy ( EGD ) findings to predict risk of adverse events . The quantitative risk for the low-risk subset was 0.6 % ( 95 % confidence interval [ CI ] , 0.0%-2.0 % ) for subsequent complications and 0 % ( 95 % CI , 0.0%-0.9 % ) for life-threatening complications from this retrospective evaluation . SETTING A 1000-bed , not-for-profit , university-affiliated teaching hospital . PATIENTS Consecutive adult patients hospitalized for acute UGIH . INTERVENTION Concurrent feedback of guideline recommendation ( same-day hospital discharge ) to physicians caring for patients at low risk for complication . No risk information was provided during control months . RESULTS Seventy percent ( 209/299 ) of UGIH patients achieved low-risk status according to the guideline and were therefore potentially suitable for early discharge from the hospital . Providing real-time quantitative risk information ( intervention group only ) was associated with an increase in guideline compliance from 30 % to 70 % ( P<.001 ) and a decrease in mean ( SD ) LOS from 4.6 ( 3.5 ) days to 2.9 ( 1.3 ) days ( mean reduction of 1.7 days per patient ; P<.001 ) . No differences in complications , patient health status , or patient satisfaction were found when measured 1 month after discharge . An independent variable predicting decreased hospital LOS for low-risk UGIH patients was early EGD . CONCLUSIONS Implementation of the clinical practice guideline safely reduced hospital LOS for selected low-risk patients with acute UGIH . Further prospect i ve validation in other setting s is warranted A prospect i ve study was conducted to see whether emergent esophagogastroduodenoscopy ( EGD ) in patients with active upper gastrointestinal ( GI ) bleeding is associated with more oxygen desaturation than nonemergent EGD . Emergent EGD was performed in the study patients with active upper GI bleeding .  Nonemergent EGD was performed in the control patients .  Determination of oxygen saturation ( Sao2 ) was measured by pulse oximeter . A decrease in Sao2 of > 4 % was more frequent in the study patients ( 26 % , 13 of 50 ) than in controls ( 6 % , 3 of 50 ) ( P < .01 ) . During EGD , mean oxygen saturation decreased significantly in both groups of patients . After EGD , mean oxygen saturation did not recover toward the pre-endoscopy insertion level in the study group ( P < .01 ) . A linear association was found that oxygen desaturation = 5.46 + 0.15 ( status ) -0.06 ( baseline oxygen saturation ) . Emergent EGD for active upper GI bleeding in the emergency department tends to be associated with more frequent significant oxygen desaturation than nonemergent EGD . Continuous oxygen supplementation and oxygen saturation monitoring may be used during emergent nonse date d EGD in the emergency department BACKGROUND From January 1993 to December 1994 , we conducted a prospect i ve study to investigate the evolutionary change of rebleeding risk in bleeding peptic ulcers . To obviate possible confounding factors that would influence decision making for discharge of patients , subjects with coexistent acute illnesses , systemic bleeding disorders , alcoholism , and use of nonsteroidal anti-inflammatory drugs were excluded . METHODS Emergency endoscopies were performed in patients with hematemesis or a melena within 24 hours of admission . Ulcer lesions were divided into six categories according to endoscopic findings . The residual risks of rebleeding of each type of ulcers were calculated for 10 days , and the critical point of acceptable rebleeding risk after discharge was set at 3 % . RESULTS Three hundred ninety-two patients with bleeding peptic ulcers completed the study . The ulcers , characterized by clean bases , red or black spots , adherent clots , nonbleeding visible vessels without local therapy , nonbleeding visible vessels with local therapy , and bleeding visible vessels with local therapy took 0 , 3 , 3 , 4 , 4 , and 3 days , respectively , to decrease rebleeding risk to below the critical point . All episodes of fatal rebleeding ( n = 4 ) occurred within 24 hours after admission . CONCLUSIONS Patients with clean-based ulcers can be discharged in the first day of admission . The optimal duration required for hospitalization of patients with ulcers characterized by nonbleeding visible vessels at initial endoscopy is 4 days . The remaining patients with ulcers marked by other bleeding stigmata may be discharged after a 3-day observation BACKGROUND The impact of upper endoscopy in patients with upper gastrointestinal hemorrhage treated in community practice is unknown . Thus we examined the effectiveness of endoscopy performed within 24 hours of admission ( early endoscopy ) . METHODS Medical records of 909 consecutive hospitalized patients with upper gastrointestinal hemorrhage who underwent endoscopy at 13 hospitals in a large metropolitan area were review ed . We evaluated unadjusted and severity-adjusted associations of early endoscopy with recurrent bleeding or surgery to control hemorrhage , length of hospital stay , and associations of endoscopic therapy  in patients with bleeding ulcers or varices . RESULTS Early endoscopy was performed in 64 % of patients and compared with delayed endoscopy and was associated with clinical ly significant reductions in adjusted risk of recurrent bleeding or surgery ( odds ratio [ OR ] 0.70 : 95 % CI [ 0.44 , 1.13 ] ) and a 31 % decrease in adjusted length of stay ( 95 % CI : [ 24 % , 37 % ] ) . In patients at high risk for recurrent bleeding , the use of early endoscopic therapy to control hemorrhage was associated with reductions in recurrent bleeding or surgery ( OR 0.21 : 95 % CI [ 0.10 , 0.47 ] ) and length of stay ( -31 % : 95 % CI [ -44 % , -14 % ) . CONCLUSION In this study of community-based practice , the routine use of endoscopy , and in selected cases endoscopic therapy , performed early in the clinical course of patients with upper gastrointestinal hemorrhage was associated with reductions in length of stay and , possibly , the risk of recurrent bleeding and surgery OBJECTIVES Patients with an ulcer and active bleeding or a nonbleeding , visible vessel are high-risk for further bleeding and should receive aggressive therapy . In this study , we tried to identify clinical parameters that predict these high-risk groups . METHODS Over a 7-month period , 16 clinical parameters were analyzed prospect ively in 316 patients with bleeding peptic ulcer . A multivariate analysis was used to find the independent predictors for the high-risk patients . RESULTS A total of 114 patients ( 36 % ) was found to have a spurting hemorrhage ( eight patients ) , oozing hemorrhage ( 27 patients ) , or a nonbleeding visible vessel ( 79 patients ) . Using an univariate analysis , a statistically significant predictor was the appearance of coffee ground fluid or blood from the nasogastric tube . This predictor also emerged as an independent factor ( odds ratio , 0.4333 ; 95 % confidence interval , 0.263 - 0.714 ) . CONCLUSIONS Patients with bleeding peptic ulcer who have coffee ground fluid or blood from the nasogastric tube should receive an emergency endoscopy and aggressive treatment Aims —To assess changes in practice and outcome in acute upper gastrointestinal haemorrhage following the feedback of data , the reemphasis of national guidelines , and specific recommendations following an initial survey . Design —A prospect i ve , multicentre , audit cycle . Forty five hospitals from three health regions participed in two phases of the audit cycle . Patients —Phase I : 2332 patients with acute upper gastrointestinal haemorrhage ; phase II : 1625 patients with upper gastrointestinal haemorrhage . Methods — Patients were evaluated with respect to management ( with reference to the recommendations in the national guidelines ) , mortality , and length of hospital stay . Results —Following the distribution of data from the first phase of the National Audit and the formulation of specific recommendations for improving practice , the proportion of hospitals with local guidelines or protocol s for the management of upper gastrointestinal haemorrhage rose from 71 % ( 32/45 ) to 91 % ( 41/45 ) ; 12 of the 32 hospitals with guidelines during the first phase revised their guidelines following the initial survey . There was a small but significant increase in the proportion of all patients who underwent endoscopy  ( from 81 % to 86 % ) , the proportion who underwent endoscopy within 24 hours of admission ( from 50 % to 56 % ) , and the use of central venous pressure monitoring in patients with organ failure requiring blood transfusion or those with profound shock ( from 30 % to 43 % ) . There was , however , no change in the use of high dependency beds or joint medical/surgical management in high risk cases . There was no significant change in crude or risk st and ardised mortality ( 13.4 % in the first phase and 14.4 % in the second phase ) . Conclusions —Although many of the participating hospitals have made efforts to improve practice by producing or updating guidelines or protocol s , there has been only a small demonstrable change in some areas of practice during the National Audit . The failure to detect any improvement in mortality may reflect this lack of change of practice , but may also reflect the fact that a large proportion of the deaths in this unselected study are not preventable ; only a very large study could hope to demonstrate a significant change out of the context of a clinical trial PURPOSE The outcome of patients with upper gastrointestinal hemorrhage is greatly influenced by recurrence of bleeding , but it may be possible to identify patients who have a low risk for rebleeding , and can be discharged after a short hospitalization . To examine the effect of an early discharge protocol ( length of hospital stay < or =3 days ) , we conducted a 2-year prospect i ve study in patients with upper gastrointestinal bleeding at low risk for 
    Output:
    
Seven of the 8 studies examining the effect of early endoscopy on length of stay as a measure of re source utilization demonstrated a significant reduction compared with that of delayed endoscopy .
The overwhelming majority of existing data suggest that early endoscopy is safe and effective for all risk groups .