LitCovid-sentences  

PMC:7212965 / 30450-53397 JSONTXT 11 Projects

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Id Subject Object Predicate Lexical cue
T196 0-38 Sentence denotes Rationale for Best Practice Statements
T197 39-41 Sentence denotes 1.
T198 43-423 Sentence denotes In outpatients with new-onset diarrhea, ascertain information about high-risk contact exposure; obtain a detailed history of symptoms associated with COVID-19, including fever, cough, shortness of breath, chills, muscle pain, headache, sore throat, or new loss of taste or smell; and obtain a thorough history for other Gl symptoms, including nausea, vomiting, and abdominal pain.
T199 424-426 Sentence denotes 2.
T200 428-635 Sentence denotes In outpatients with new-onset Gl symptoms (eg, nausea, vomiting, abdominal pain, and diarrhea), monitor for symptoms associated with COVID-19, as GI symptoms may precede COVID-related symptoms by a few days.
T201 636-713 Sentence denotes In a high COVID-19 prevalence setting, COVID-19 testing should be considered.
T202 714-716 Sentence denotes 3.
T203 718-929 Sentence denotes In hospitalized patients with suspected or known COVID-19, obtain a thorough history of GI symptoms (ie, nausea, vomiting, abdominal pain, and diarrhea), including onset, characteristics, duration, and severity.
T204 930-1295 Sentence denotes The overall prevalence of GI symptoms in context of COVID-19, including nausea, vomiting, abdominal pain, and diarrhea, is lower than estimated previously.10 It is important to note that the majority of studies were focused on hospitalized patients with COVID-19, and the prevalence of diarrhea in patients with mild symptoms who were not hospitalized is not known.
T205 1296-1391 Sentence denotes Therefore, the reported prevalence rates may represent either an overestimate or underestimate.
T206 1392-1511 Sentence denotes Information about the frequency and severity of diarrhea symptoms was inadequately reported in the majority of studies.
T207 1512-1682 Sentence denotes Based on our analysis, among hospitalized patients, the prevalence of diarrhea as the only presenting symptom in the absence of other COVID-related symptoms was very low.
T208 1683-1820 Sentence denotes The majority of patients with diarrhea, nausea, or vomiting also presented with accompanying symptoms typically associated with COVID-19.
T209 1821-1926 Sentence denotes In a handful of studies, diarrhea and nausea preceded the development of other COVID-19–related symptoms.
T210 1927-2121 Sentence denotes In a US case–control study of 278 COVID-19 patients, patients with GI symptoms were more likely to have illness duration of 1 week or longer (33%) compared to patients without GI symptoms (22%).
T211 2122-2436 Sentence denotes This may have been attributable to a delay in testing.47 Therefore, in high prevalence settings, among patients presenting with new-onset diarrhea, monitoring for the development of COVID-19 symptoms and considering referring patients for COVID-testing is reasonable, especially if testing capacity is not limited.
T212 2437-2864 Sentence denotes The Centers for Disease Control and Prevention has recently expanded the criteria for COVID-19 testing to include presence of olfactory and gustatory symptoms as triggers for testing, as these symptoms have been demonstrated to occur in up to 80% of patients.79 As of April 19, 2020, diarrhea as an initial preceding symptom of COVID-19 has not been included on the Centers for Disease Control and Prevention symptom checklist.
T213 2865-3228 Sentence denotes To more accurately inform our understanding of the true prevalence of diarrhea, nausea, and vomiting as a manifestation of COVID-19, it is critical to systematically collect information about onset of diarrhea; duration of symptoms; and documentation of whether and how long symptoms of diarrhea, nausea, and vomiting precede upper respiratory infection symptoms.
T214 3229-3433 Sentence denotes Therefore, we advise health care professionals and researchers to obtain a thorough review of systems, systematically inquire about respiratory and GI symptoms, and ascertain information about exposure.4.
T215 3435-3576 Sentence denotes There is presently inadequate evidence to support stool testing for diagnosis or monitoring of COVID-19 as part of routine clinical practice.
T216 3577-3839 Sentence denotes While stool shedding has been reported in a prior meta-analysis in 48.1% of specimens, 2 small case series showed conflicting findings about the presence of living virus in stool.10 , 32 , 78 Therefore, stool infectivity and transmission have not been confirmed.
T217 3840-4015 Sentence denotes Further studies are needed to determine whether isolated virus from stool specimens confers infectivity and determine the role of stool testing is in patients with COVID-19.5.
T218 4017-4155 Sentence denotes In patients (outpatients or inpatients) with elevated LFTs in context of suspected or known COVID-19, evaluate for alternative etiologies.
T219 4156-4158 Sentence denotes 6.
T220 4160-4384 Sentence denotes In hospitalized patients with suspected or known COVID-19, obtain baseline LFTs at the time of admission and consider LFT monitoring throughout the hospitalization, particularly in the context of drug treatment for COVID-19.
T221 4385-4387 Sentence denotes 7.
T222 4389-4516 Sentence denotes In hospitalized patients undergoing drug treatment for COVID-19, evaluate for treatment-related Gl and hepatic adverse effects.
T223 4517-4691 Sentence denotes Abnormal LFTs were reported in approximately 15% of patients across the pooled studies, but with variable reporting of mean or median values for the whole sample of patients.
T224 4692-4888 Sentence denotes While the studies used in this analysis helped us to better understand the prevalence of abnormal LFTs among hospitalized patients, LFT abnormalities were not consistently reported across studies.
T225 4889-5111 Sentence denotes Also, many of the studies in this analysis did not report on how many patients had underlying liver disease and whether these patients were at an elevated risk of having increased LFTs in the setting of COVID-19 infection.
T226 5112-5262 Sentence denotes Furthermore, diagnostic evaluation of abnormal LFTs on admission was not performed routinely, such as testing for viral hepatitis or other etiologies.
T227 5263-6162 Sentence denotes The available studies suggest that abnormal LFTs are more commonly attributable to secondary effects (eg, systemic inflammatory response syndrome, cytokine storm, ischemic hepatitis/shock, sepsis, and drug hepatotoxicity) than primary virus-mediated hepatocellular injury.7 , 9 , 80 However, liver histopathology from patients with COVID-19 have revealed mild lobular and portal inflammation and microvesicular steatosis suggestive of either virally mediated or drug-induced liver injury.81 In addition, some studies have revealed that abnormal LFTs at hospital admission may be associated with a higher risk for severe COVID-19 (odds ratio, 2.73; 95% CI, 1.19–6.3).9 Therefore, we advise checking baseline LFTs in all patients on admission and monitoring of LFTs throughout the hospitalization, particularly in patients undergoing drug therapy for COVID-19 associated with potential hepatotoxicity.
T228 6163-6297 Sentence denotes We additionally advise that all patients with abnormal LFTs undergo an evaluation to investigate non–COVID-19 causes of liver disease.
T229 6299-6377 Sentence denotes What Are Common Gastrointestinal/Liver Adverse Effects of COVID-19 Treatments?
T230 6378-6475 Sentence denotes `There are currently no US Food and Drug Administration–approved routine treatments for COVID-19.
T231 6476-6698 Sentence denotes The FDA has issued an emergency use authorization for 3 therapies: choloroquine or hydroxychloroquine, remdesivir, and convalescent plasma.82 In China and Japan, favipiravir has been approved for the treatment of COVID-19.
T232 6699-7032 Sentence denotes Numerous medications are under investigation; the World Health Organization is spearheading a multinational, multicenter trial for the 5 treatments highlighted below.83 We aim to provide a summary of the Gl and liver adverse effects of the most commonly utilized medications for COVID-19 at this time, irrespective of their efficacy.
T233 7033-7173 Sentence denotes Medication GI-related adverse events are summarized in Supplementary Tables 1 and 2 (direct evidence sources and indirect evidence sources).
T234 7175-7199 Sentence denotes Antimalarial Medications
T235 7200-7511 Sentence denotes Although efficacy and subsequent optimal dosing in COVID-19 is still under investigation, both chloroquine and hydroxychloroquine are currently FDA-approved in the United States for other indications (ie, malaria and systemic lupus erythematosus) and now have an emergency use authorization for use in COVID-19.
T236 7513-7547 Sentence denotes Chloroquine and hydroxychloroquine
T237 7548-7925 Sentence denotes Both chloroquines have reported infrequent Gl adverse effects (ie, nausea, vomiting, abdominal pain, and diarrhea).84 , 85 The National Institute of Health LiverTox resource rates both drugs with a likelihood score of D (possible rare cause of clinically apparent liver injury).86 Chloroquine is rarely linked to aminotransferase elevations or clinically apparent liver injury.
T238 7926-8123 Sentence denotes In patients with acute intermittent porphyria or porphyria cutanea tarda, it can trigger a hypersensitivity attack with fever and serum aminotransferase elevations, sometimes resulting in jaundice.
T239 8124-8175 Sentence denotes This is seen less commonly with hydroxychloroquine.
T240 8176-8335 Sentence denotes Such reactions are thought to be hypersensitivity reactions and there is no known cross-reactivity in liver injury between hydroxychloroquine and choloroquine.
T241 8336-8523 Sentence denotes Hydroxychloroquine is known to concentrate in the liver, thus patients with hepatitis or other hepatic diseases, or patients taking other known hepatotoxic drugs, should exercise caution.
T242 8524-8660 Sentence denotes In addition, cardiac conduction defects leading to clinically relevant arrhythmias are an important adverse effect of these medications.
T243 8662-8683 Sentence denotes Antiviral Medications
T244 8685-8695 Sentence denotes Remdesivir
T245 8696-8789 Sentence denotes Limited data regarding GI adverse events are available, as phase 3 trials are still underway.
T246 8790-9113 Sentence denotes Based on studies regarding Ebola, there have been reports of elevated transaminases, although the severity and incidence have not been quantified.87 There is 1 published case series (n = 53) on compassionate use of remdesivir in COVID-19.88 In this study, the most common adverse effects were notably Gl and hepatotoxicity.
T247 9114-9258 Sentence denotes Five of 53 patients (9%) experienced diarrhea and 12 of 53 patients (23%) had reported elevations in hepatic enzymes associated with remdesivir.
T248 9259-9359 Sentence denotes Of 4 patients (8%) who discontinued treatment prematurely, 2 were due to elevated aminotransferases.
T249 9361-9380 Sentence denotes Lopinavir/ritonavir
T250 9381-9489 Sentence denotes The combination lopinavir/ritonavir is FDA-approved for the treatment of human immunodeficiency virus (HIV).
T251 9490-9544 Sentence denotes More recently, it was utilized to treat MERS and SARS.
T252 9545-9726 Sentence denotes There is 1 trial by Cao et al89 that randomized 199 hospitalized patients with severe COVID-19 to receive treatment to lopinavir/ritonavir (n = 99) or placebo (n = 100) for 14 days.
T253 9727-10118 Sentence denotes GI adverse events were most common among those in the treatment group, and were the primary reason for medication discontinuation; of patients receiving lopinavir/ritonavir, there were 9.5% (9 of 99) with nausea, 6.3% (6 of 99) with vomiting, 4.2% (4 of 99) with diarrhea, 4.2% (4 of 99) with abdominal discomfort, 4.2% (4 of 99) with reported stomach ache, and 4.2% (4 of 99) with diarrhea.
T254 10119-10228 Sentence denotes Additionally, there were 2 serious adverse events of acute gastritis, which both led to drug discontinuation.
T255 10229-10400 Sentence denotes When lopinavir/ritonavir is used in patients with HIV, diarrhea is the most common GI adverse events (10%–30%), with greater prevalence among those receiving higher doses.
T256 10401-10534 Sentence denotes Other GI adverse events in HIV are similar to Cao et al’s RCT, with nausea in 5%–15% and vomiting in 5%–10% of patients90 (Table 3 ).
T257 10535-10626 Sentence denotes Table 3 Gastrointestinal Treatment Adverse Effects of Currently Utilized COVID-19 Therapies
T258 10627-10703 Sentence denotes Medication type Medication name Adverse effects Major drug–drug interactions
T259 10704-10728 Sentence denotes Gastrointestinal Hepatic
T260 10729-10868 Sentence denotes Antimalarial ChloroquineHydroxychloroquine Nausea, vomiting, abdominal pain, and diarrhea reported; frequency not defined Likelihood score:
T261 10869-10941 Sentence denotes D (possible rare cause of clinically apparent liver injury).Description:
T262 10942-10979 Sentence denotes Rare elevations in aminotransferases.
T263 10980-11065 Sentence denotes Most reactions are hypersensitivity with no known cross reactivity to hepatic injury.
T264 11066-11133 Sentence denotes If this occurs, reasonable to switch between chloroquine therapies.
T265 11134-11226 Sentence denotes Substrate for CYP2D6 and CYP3A4 substrateSame as above; also substrate for CYP3A5 and CYP2C8
T266 11227-11303 Sentence denotes Antiviral Remdesivir Not reported (limited data available) Likelihood score:
T267 11304-11327 Sentence denotes Not scored.Description:
T268 11328-11377 Sentence denotes Hepatotoxicity reported; frequency not yet known.
T269 11378-11428 Sentence denotes Not a significant inducer/inhibitor of CYP enzymes
T270 11429-11469 Sentence denotes Lopinavir/ritonavir Nausea and vomiting:
T271 11470-11497 Sentence denotes 5%–10% (higher in children:
T272 11498-11517 Sentence denotes 20%)Abdominal pain:
T273 11518-11533 Sentence denotes 1%–10%Diarrhea:
T274 11534-11599 Sentence denotes 10%–30% + dose-dependentOther: dysguesia in adults <2%, children:
T275 11600-11637 Sentence denotes 25%, increased serum amylase, lipase:
T276 11638-11644 Sentence denotes 3%–8%.
T277 11645-11662 Sentence denotes Likelihood score:
T278 11663-11736 Sentence denotes D (possible, rare cause of clinically apparent liver injury).Description:
T279 11737-11918 Sentence denotes Hepatotoxicity ranges from mild elevations in aminotransferases to acute liver failure.Recovery takes 1–2 mo.Re-challenging may lead to recurrence and should be avoided if possible.
T280 11919-12033 Sentence denotes Substrate for: CYP3A4, CYP2D6P-gpInducer for: CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, UGT1A1Inhibitor for: CYP3A4
T281 12034-12062 Sentence denotes Favipiravir Nausea/vomiting:
T282 12063-12078 Sentence denotes 5%–15%Diarrhea:
T283 12079-12121 Sentence denotes 5%Limited data available Likelihood score:
T284 12122-12144 Sentence denotes Not scoredDescription:
T285 12145-12183 Sentence denotes 3% prevalence, but few data available.
T286 12184-12278 Sentence denotes Inhibitor for: CYP2C8 and aldehyde oxidaseMetabolized by xanthine oxidase and aldehyde oxidase
T287 12279-12400 Sentence denotes The Cao et al89 RCT did not show a significant increase in hepatotoxicity in the treatment compared to the control group.
T288 12401-12784 Sentence denotes However, in patients with HIV, there is a well-documented known risk of hepatotoxicity, with liver injury severity ranging from mild enzyme elevations to acute liver failure.91 Moderate-to-severe elevations in serum aminotransferases, defined as more than 5 times the ULN, are found in 3%–10%.91 Rates may be higher in patients with concurrent HIV and hepatitis C virus co-infection.
T289 12785-13009 Sentence denotes In some cases, mild asymptomatic elevations are self-limited and can resolve with continuation of the medication, but re-challenging the medication can also lead to recurrence and, therefore, should be avoided when possible.
T290 13010-13058 Sentence denotes Acute liver failure, although reported, is rare.
T291 13059-13206 Sentence denotes Ritonavir has potent effects on cytochrome P450 and therefore affects drug levels of a large number of medications typically given in GI practices.
T292 13208-13219 Sentence denotes Favipiravir
T293 13220-13277 Sentence denotes There are 2 published studies on favipiravir in COVID-19.
T294 13278-13518 Sentence denotes The first is an open-label RCT for favipiravir vs arbidol conducted in Wuhan, China by Chen et al.92 This study reported digestive tract reactions, including nausea, “anti-acid,” or flatulence in 13.79% (16 of 116) of the favipiravir group.
T295 13519-13612 Sentence denotes Hepatotoxicity characterized by any elevation in AST or ALT was reported in 7.76% (9 of 116).
T296 13613-13878 Sentence denotes The second is an open-label control study of favipiravir or lopinavir/ritonavir, both used in conjunction with interferon alfa, for COVID-19 by Cai et al,93 which reported diarrhea in 5.7% (2 of 35) and liver injury in 2.9% (1 of 35) (Supplementary Tables 2 and 3).
T297 13880-13988 Sentence denotes Limitations of the Evidence on Gastrointestinal and Liver Manifestations in Patients With COVID-19 Infection
T298 13989-14054 Sentence denotes The individual studies in our analysis were at high risk of bias.
T299 14055-14196 Sentence denotes The majority of studies reported on cohorts of patients based on inclusion dates and did not specify whether these were consecutive patients.
T300 14197-14398 Sentence denotes There was an inconsistent assessment of symptoms and/or laboratory tests with missing data, and none of the studies reported whether patients were systematically evaluated for GI symptoms on admission.
T301 14399-14489 Sentence denotes Most studies did not report on the duration of the GI symptoms preceding the presentation.
T302 14490-14694 Sentence denotes When GI symptoms were reported, it was difficult to discern whether these were isolated symptoms or whether patients also had concurrent typical COVID-19 symptoms (eg, fever cough or shortness of breath).
T303 14695-14813 Sentence denotes LFTs were mostly reported as the mean/median value of the entire cohort and without cutoff values for the institution.
T304 14814-14892 Sentence denotes Many of the studies did not report on underlying chronic GI or liver diseases.
T305 14893-15032 Sentence denotes There was a lot of heterogeneity in our pooled estimates that could not be explained by our subgroup analysis based on geographic location.
T306 15033-15228 Sentence denotes Lastly, the data on prognosis were especially difficult to analyze due to insufficient follow-up of the patients (the majority of the patients were still hospitalized at the time of publication).
T307 15229-15394 Sentence denotes Finally, there was no stratification of GI-related symptoms and severity of COVID-19 or patient important outcomes, such as need for intensive care unit or survival.
T308 15395-15469 Sentence denotes There may be additional limitations of our findings based on our analysis.
T309 15470-15674 Sentence denotes Due to concerns about overlapping cohorts, we used a hierarchical framework to identify unique cohorts based on the number of patients and the hospitals to analyze the prevalence of GI and liver symptoms.
T310 15675-15844 Sentence denotes It is possible that we excluded relevant studies that provided more granularity regarding the GI and liver manifestations, or had more systematic assessment of outcomes.
T311 15845-15938 Sentence denotes As a result, this may have led to an over- or underestimation of the pooled effect estimates.
T312 15939-16147 Sentence denotes However, we have high confidence that we were able to eliminate the counting of some patients in more than 1 report by using our selection framework, unless they were transferred from one hospital to another.
T313 16148-16249 Sentence denotes An important strength of this study is the appropriate statistical analysis used to pool proportions.
T314 16250-16491 Sentence denotes We also reviewed gray literature from prepublication repositories, which allowed us to include a large number of studies that have not been published yet, with data from a total of 10,890 unique COVID-19 patients being included in this work.
T315 16492-16718 Sentence denotes Lastly, we tried to narratively describe studies that informed us on the type of diarrhea symptoms; whether diarrhea was reported as the only presenting symptom; or diarrhea as the initial symptom that preceded other symptoms.
T316 16719-17004 Sentence denotes Based on our study selection process, we may have missed studies, including smaller case series that reported on this information, and studies that were published after our inclusion period, in light of the exponential number of studies in press, under review, and on preprint servers.
T317 17006-17074 Sentence denotes Limitations of Current Evidence on Treatment-Related Adverse Effects
T318 17075-17266 Sentence denotes Most of the information regarding Gl adverse events come from indirect evidence from medications that are FDA-approved for other indications, such as the chloroquines and lopinavir/ritonavir.
T319 17267-17462 Sentence denotes In particular, Gl adverse events are poorly understood for both favipiravir and remdesivir, including the frequency and severity of aminotransferase elevations and incidence of Gl manifestations.
T320 17463-17591 Sentence denotes As ongoing clinical trials are completed regarding efficacy of therapy, additional data regarding Gl adverse events will emerge.
T321 17593-17632 Sentence denotes Evidence Gaps and Guidance for Research
T322 17633-17849 Sentence denotes There is insufficient evidence on the impact of COVID-19 on subgroups of patients, such as patients with inflammatory bowel disease, chronic liver disease, or liver transplant recipients on chronic immunosuppression.
T323 17850-18189 Sentence denotes Early data do not indicate excess risk among patients with inflammatory bowel disease.94, 95, 96, 97, 98 A number of international registries have been established that will provide extremely valuable information about COVID-19 in these potentially vulnerable populations (www.covidibd.org; covidcirrhosis.web.unc.edu; www.gi-covid19.org).
T324 18190-18311 Sentence denotes Other clinical decisions, including optimal medication management and treatment decisions, are still under investigation.
T325 18312-18427 Sentence denotes We encourage clinicians to contribute to these registries to further enhance understanding in these subpopulations.
T326 18428-18547 Sentence denotes Table 4 provides guidance for future studies of GI manifestations in patients with COVID-19 or other similar pathogens.
T327 18548-18624 Sentence denotes Table 4 Guidance and Research Considerations for Future Studies of COVID-19a
T328 18625-18844 Sentence denotes Study design A prospective inception cohort study is a favorable study design.Another study design that is informative especially when there is a need for rapid data evaluation is a retrospective inception cohort study.
T329 18845-19207 Sentence denotes Participants Enrollment of consecutive patients beginning at pandemic onset.Specific set of symptoms that are predictive of COVID-19 infection, all symptoms should be systematically collected on presentation and before COVID-19 diagnosis is established.• Elicit typical upper respiratory infection symptoms (eg, cough, shortness of breath, chest pain, and fever)
T330 19208-19376 Sentence denotes • Inquire about less typical symptoms, such as GI-specific symptoms: diarrhea, nausea, vomiting, and abdominal pain, and also other symptoms, such as anosmia, dysguesia
T331 19377-19559 Sentence denotes • Describe the GI symptoms in detail, including initial vs late, concurrent vs isolated, duration and frequency, history, and medication initiation relating to the onset of symptoms.
T332 19560-19665 Sentence denotes Investigators should avoid:• Undefined sampling (convenience sampling), including undefined time periods.
T333 19666-19823 Sentence denotes • Overlap of the same population with other publications, which can be done by coordinating efforts between the different departments within the institution.
T334 19824-20012 Sentence denotes Investigators should consider stratification for GI comorbidities, such as inflammatory bowel disease and cirrhosisInvestigators should consider stratification by outpatients vs inpatients
T335 20013-20851 Sentence denotes Laboratory Standardized laboratory confirmation should be based on nucleic acid amplification testing for SARS-CoV-2 on respiratory specimen rather than relying on radiologic suspicion on imaging studies, which are less specificLFTs should be obtained on admission and followed throughout the hospitalization.Changes in LFTs should be reported as normal/abnormal and the cutoff for abnormal should be specified, rather than mean and median at the individual patient levelPattern of LFTs abnormalities, hepatocellular vs cholestatic, should be reported as well as the evaluation performed to work up the abnormalitiesBaseline LFTs (prior to developing COVID-19), changes during the duration of the disease, and after resolution should be reported.Report stool RNA testing, when available, and presence of GI symptoms at the time of testing
T336 20852-21040 Sentence denotes Disease severity Use of standardized disease severity definitions, for example, as per World Health Organization–China Joint Mission100:• mild-to-moderate: non-pneumonia and mild pneumonia
T337 21041-21133 Sentence denotes • severe defined as tachypnea, oxygen saturation ≤93% at rest, or PaO2/FiO2 ratio <300 mm Hg
T338 21134-21279 Sentence denotes • critical respiratory failure requiring mechanical ventilation, septic shock, or other organ dysfunction or failure that requires intensive care
T339 21280-21356 Sentence denotes Patients can be stratified by:• Disease severity and presence of GI symptoms
T340 21357-21384 Sentence denotes • Disease severity and LFTs
T341 21385-21483 Sentence denotes Symptoms and their duration before development of a severe stage of the disease should be reported
T342 21484-21770 Sentence denotes Outcomes Outcomes should focus on patient-important outcomes, such as death, clinical improvement or disease worsening/progression, hospital discharge; include clinical definitions (eg, threshold reached for intubation); select sufficient follow-up time to ensure outcome is obtainable.
T343 21771-22012 Sentence denotes Analysis Analysis should attempt to control for confounding variables; analysis of risk factors should include univariate followed by multivariate analyses to identify independent risk factors predicting more severe disease and poor outcomes
T344 22013-22210 Sentence denotes a aIn the table, we specifically refer to COVID-19, but this guidance applies to any future pathogen similar to COVID-19 that presents as a viral illness with potential GI and liver manifestations.
T345 22211-22293 Sentence denotes Finally, peer-review remains critical to the process of disseminating information.
T346 22294-22605 Sentence denotes Journals should add resources to expedite reviews by increasing the number of editors and reviewers to shorten the review process; maintain accuracy, high quality, and details of the data reported; as well as to avoid overlap in patients between studies or multiple studies being published on the same cohort.99
T347 22607-22613 Sentence denotes Update
T348 22614-22683 Sentence denotes Recommendations in this document may not be valid in the near future.
T349 22684-22818 Sentence denotes We will conduct periodic reviews of the literature and monitor the evidence to determine whether recommendations require modification.
T350 22819-22947 Sentence denotes Based on the rapidly evolving nature of this pandemic, this guideline will likely need to be updated within the next few months.