***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 : It is not known if combination therapy of epinephrine injection and multipolar electrocoagulation or hemoclips are a more efficient or effective treatment for patients with acute nonvariceal upper gastrointestinal ( GI ) bleeding . METHODS : Adult patients with active nonvariceal upper GI bleeding , a nonbleeding visible vessel , or after removal of an adherent clot findings of active bleeding or a visible vessel were studied . Patients were r and omized to either therapy and the outcomes were assessed at 30 days . RESULTS : Forty-seven patients were studied : 26 patients r and omized to hemoclips and 21 to combination therapy .  There were 22 patients with active bleeding , 13 with a nonbleeding visible vessel , and 12 with an adherent clot . The median duration of endoscopic therapy  was 17 min in the hemoclip group versus 20 min for the combination therapy , p= 0.29 . Primary hemostasis with successful initial control of bleeding occurred in 26 ( 100 % ) of 26 hemoclip patients and 20 ( 95.2 % ) of 21 combination therapy patients , p= 0.45 . The rebleeding rates were : 4 ( 15.4 % ) of 26 hemoclip patients versus 5 ( 23.8 % ) of 21 combination therapy patients , p= 0.49 . Overall , the length of hospital stay , units of blood transfused , surgery rates , and mortality were not different . CONCLUSIONS : In this prospect i ve , r and omized controlled trial of endoscopic hemoclips versus combination therapy in the nonvariceal upper GI bleeding , the efficiency , efficacy , and complications of the two treatment modalities were not significantly different AIM To define the optimal injection volume of epinephrine with high efficacy for hemostasis and low complication rate in patients with actively bleeding ulcers . METHODS This prospect i ve , r and omized , comparative trial was conducted in a medical center . A total of 228 patients with actively bleeding ulcers ( spurting or oozing ) were r and omly assigned to three groups with 20 , 30 and 40 mL endoscopic injections of an 1:10000 solution of epinephrine . The hemostatic effects and clinical outcomes were compared between the three groups . RESULTS There were no significant differences in all background variables between the three groups . Initial hemostasis was achieved in 97.4 % , 98.7 % and 100 % of patients respectively in the 20 , 30 and 40 mL epinephrine groups . There were no significant differences in the rate of initial hemostasis between the three groups . The rate of peptic ulcer perforation was significantly higher in the 40 mL epinephrine group than in the 20 and 30 mL epinephrine groups ( P < 0.05 ) . The rate of recurrent bleeding was significantly higher in the 20 mL epinephrine group ( 20.3 % ) than in the 30 ( 5.3 % ) and 40 mL ( 2.8 % ) epinephrine groups ( P < 0.01 ) . There were no significant differences in the rates of surgical intervention , the amount of transfusion requirements , the days of hospitalization , the deaths from bleeding and 30 d mortality between the three groups . The number of patients who developed epigastric pain due to endoscopic injection , was significantly higher in the 40 mL epinephrine group ( 51/76 ) than in the 20 ( 2/76 ) and 30 mL ( 5/76 ) epinephrine groups ( P < 0.001 ) . Significant elevation of systolic blood pressure after endoscopic injection was observed in the 40 mL epinephrine group ( P < 0.01 ) . Significant decreasing and normalization of pulse rates after endoscopic injections were observed in the 20 mL and 30 mL epinephrine groups ( P < 0.01 ) . CONCLUSION Injection of 30 mL diluted epinephrine ( 1:10000 ) can effectively prevent recurrent bleeding with a low rate of complications . The optimal injection volume of epinephrine for endoscopic treatment of an actively bleeding ulcer ( spurting or oozing ) is 30 Acute upper gastrointestinal bleeding is the commonest emergency managed by gastroenterologists . It has an incidence ranging from approximately 50 to 150 per 100 000 of the population each year , the incidence being highest in areas of the lowest socioeconomic status . An audit of patients admitted to hospital in the UK published in 1995 reported 11 % mortality in patients admitted to hospital because of bleeding and 33 % mortality in those who developed gastrointestinal bleeding while hospitalised for other reasons .1 Most deaths occur in elderly patients who have significant comorbidity and the majority are inevitable , despite improvements in medical and surgical expertise . Mortality is reported to be lower in specialist units2,3 and this is probably not related to technical developments but because of adherence to protocol s and guidelines . Thus guidelines do have the potential to improve prognosis and in addition may be of value in making the best use of re sources by fast tracking low risk patients , thereby optimising duration of hospital stay . “ Medline ” and “ EMBASE ” were search ed to identify the evidence used in formulating these guidelines . The term “ gastrointestinal hemorrhage ” was used to identify general review s , leading articles , meta-analyses , and r and omised clinical trials . Not all of the recommendations have been subjected to clinical trial but represent what , in the view of the British Society of Gastroenterology ( BSG ) endoscopy committee , defines best clinical practice . Guidelines can not replace clinical judgment in the management of any specific patient . Best management depends on close cooperation between medical and surgical gastroenterologists and “ combined care ” is essential in managing the critically ill bleeding patient . The specific management of acute variceal haemorrhage is a special subject and is not considered in detail . # # # 1.1 Grading of recommendations # # # # Grade A # # # # Grade B # # # # Grade Clip application is increasingly used in gastrointestinal endoscopy . Its safety and efficacy in the treatment of gastrointestinal bleeding has been demonstrated in r and omized controlled studies of peptic ulcer , Dieulafoy ’s lesion , and Mallory Weiss tear bleeding as well as case series of postpolypectomy and diverticular bleeding . In addition , the use of endoscopic clipping has been reported in the closure of mucosal defects such as perforations , anastomotic leaks , and fistulas ; the attachment of enteral tube and stent devices to the luminal wall ; and radiographic marking in order to direct fluoroscopic stent placement and target surgical , interventional radiologic or radiation therapy . In this article , we will focus on our technique of using endoscopic clipping for primary hemostasis in severe upper gastrointestinal bleeding BACKGROUND Treating patients of bleeding peptic ulcers with heater probe thermocoagulation and haemoclip is considered to be safe and very effective . Yet , there is no report comparing the haemostatic effects of endoscopic haemoclip versus heater probe thermocoagulation plus hypertonic saline-epinephrine injection in these patients . AIM To compare the clinical outcomes of both therapeutic modalities in patients with peptic ulcer bleeding . METHODS A total of 93 patients with active bleeding or non-bleeding visible vessels were r and omised to receive either endoscopic haemoclip ( n = 46 ) or heater probe thermocoagulation plus hypertonic saline-epinephrine injection ( n = 47 ) . Five patients from the haemoclip group were excluded because of the inability to place the haemoclip . RESULTS Initial haemostasis was achieved in 39 patients ( 95.1 % ) of the haemoclip group and 47 patients ( 100 % ) of the heater probe group ( P > 0.1 ) . Rebleeding occurred in four patients ( 10.3 % ) of the haemoclip group and three patients ( 6.4 % ) of the heater probe group ( P > 0.1 ) . The volume of blood transfused after entry into the study , duration of hospital stay , number of patients requiring urgent surgery and the mortality rates were not statistically different between the two groups . CONCLUSIONS If the haemoclip can be applied properly , the clinical outcomes of the haemoclip group would be similar to those of the heater probe group in patients with peptic ulcer bleeding . However , if the bleeders are located at the difficult-to-approach sites , heater probe plus hypertonic saline injection is the first choice therapy BACKGROUND Effective hemostatic treatment is m and atory for patients with actively bleeding Mallory-Weiss syndrome . This study evaluated the respective efficacy and the safety of endoscopic b and ligation and endoscopic epinephrine injection in Mallory-Weiss syndrome . METHODS Thirty-four consecutive patients with actively bleeding Mallory-Weiss syndrome were prospect ively enrolled and were r and omly assigned to undergo endoscopic b and ligation or endoscopic injections of a 1:10,000 solution of epinephrine . Demographic characteristics , endoscopic variables , and outcome parameters , including rates of hemostasis and recurrent bleeding , were analyzed . RESULTS The number of elastic b and s applied was one or two ; the mean volume of epinephrine injected was 18.0 mL : 95 % CI[16.8 , 19.2 ] . There was no significant difference between the groups with respect to age , gender , alcohol ingestion , presenting symptoms , Hb level , shock , comorbid diseases , coagulopathy , tear location , blood transfusion , or duration of hospitalization . Primary hemostasis was achieved in all 17 patients in the b and ligation group and in 16 of 17 patients ( 94.1 % ) in the epinephrine injection group . There was no recurrence of bleeding or major complication in either group . CONCLUSIONS In this small study , no difference was detected in the efficacy or the safety of b and ligation vs. epinephrine injection for the treatment of actively bleeding Mallory-Weiss syndrome BACKGROUND Endoscopic application of hemoclips ( HC ) was prospect ively compared with heat probe ( HP ) treatment in patients with bleeding ulcers . METHODS One hundred thirteen patients with major stigmata of ulcer hemorrhage were r and omly assigned to receive HP ( n = 57 ) or HC ( n = 56 ) . Clinical and endoscopic features were comparable in both groups . Recurrent bleeding was retreated with the modality previously used . Patients in whom treatment or retreatment was unsuccessful underwent emergency surgery . RESULTS Hemostasis , adequate treatment of visible vessel , 30-day mortality , and emergency surgery rates were similar for both groups . Recurrent bleeding was 21 % for HP and 1.8 % for HC ( p < 0.05 ) . Length of hospital stay and transfusion requirements were significantly lower in the HC group . There was no evidence of clip-induced tissue injury or impaired ulcer healing . Clips dislodged spontaneously in most patients within 8 weeks of treatment . No further hemorrhage occurred on a median follow-up of 11 months ( range 1 - 23 ) . CONCLUSIONS The hemoclip is safe and effective in the treatment of severe ulcer bleeding and is superior to HP in preventing early recurrent bleeding BACKGROUND AND STUDY AIMS The endoscopic hemostatic method has been introduced as a safe and effective mechanical approach to hemostasis for upper gastrointestinal bleeding related to Mallory-Weiss syndrome ( MWS ) . However , the indications for when to use endoscopic treatment are debatable because many patients need only medical observation . The study was design ed to evaluate the necessity and efficacy of endoscopic hemostasis in upper gastrointestinal bleeding related to MWS . PATIENTS AND METHODS From July 1994 to May 2000 , we conducted a clinical trial in 76 patients who were found by endoscopy to have active bleeding ( I , spurting ; II , oozing ) , protruding visible vessels ( III ) , and /or adherent clots ( IV ) . Two study periods can be differentiated : in the first 3 years endoscopic treatment ( n = 30 ) was prospect ively analyzed and in the final 3 years medical treatment ( n = 46 ) was analyzed in both cases to compare the outcome in MWS bleeding II-IV . In the first study period , in addition , endoscopic treatment was r and omised to an injection method , using a mixture of hypertonic saline and epinephrine ( HSE ) ( n = 14 ) and a hemoclipping or b and ligation method ( n = 16 ) . RESULTS Rebleeding was observed in four of 14 patients who had received endoscopic hemostasis with HSE injection and one of 46 patients who had been managed with medical treatment . No rebleeding was found following hemoclipping or b and ligation . While all rebleeding was in bleeding stigmata of the I ( 1 ) and II ( 4 ) grade s , there was no rebleeding in protruding visible vessels ( III ) or in adherent clots ( IV ) , regardless of treatment methods . CONCLUSIONS Our results suggested that endoscopic hemostasis is not necessary in patients without active bleeding stigmata , and the mechanical hemostatic method is more effective than HSE injection in patients with active bleeding stigmata BACKGROUND / AIMS The use of hemostatic clips is conceptually attractive for achieving definitive hemostasis in peptic ul 
    Output:
    
Current evidence suggests that the hemoclip is not superior to other endoscopic modalities in terms of initial hemostasis , rebleeding rate , emergency surgery , and the mortality rate for treatment of PUB