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Reductions in liver cirrhosis hospitalizations during the COVID-19 pandemic

The coronavirus disease-2019 (COVID-19) pandemic has changed the world and placed a huge strain on health care systems worldwide. Many hospitals have intentionally reduced non-emergency procedures and hospitalizations for some reasons. Some studies [1–4] have confirmed that the number of hospital admissions decreased significantly during this period. For hospitalized patients with liver cirrhosis, there is still no relevant research in China. This study aimed to explore the impact of the COVID-19 pandemic on the hospitalization of patients with liver cirrhosis (Table 1).


Introduction
The coronavirus disease-2019 (COVID-19) pandemic has changed the world and placed a huge strain on health care systems worldwide. Many hospitals have intentionally reduced non-emergency procedures and hospitalizations for some reasons. Some studies [1][2][3][4] have confirmed that the number of hospital admissions decreased significantly during this period. For hospitalized patients with liver cirrhosis, there is still no relevant research in China. This study aimed to explore the impact of the COVID-19 pandemic on the hospitalization of patients with liver cirrhosis (Table 1).

Methods
We searched the hospitalizations records for liver cirrhosis in a tertiary hospital (The Second Xiangya Hospital). We examined the records of patients with liver cirrhosis who were hospitalized from January 21st, 2020 to March 31st, 2020 (from the first reported patient to the time of downgrading to third-level public health emergency in Hunan Province) and collected their clinical characteristics. We also collected the clinical characteristics of the patients with liver cirrhosis who were hospitalized from the same period in 2016-2019 for comparison.

Results
A total of 63 patients met the inclusion criteria in 2020, among whom 50 (79.4%) were male, and the average age was 49.6 years. In 2016-2019, 351 (ranging from 334 to 391) patients met the inclusion criteria, among whom 258 (73.5%) were male, and the average age was 52.7 years. The number of admissions decreased greatly during the COVID-19 pandemic.
Viral hepatitis was the main cause of liver cirrhosis

Discussion
Recent studies [3,5] showed different results. One study showed that the number of hospital admissions decreased significantly while another showed the opposite result. Our study showed that the hospitalizations decreased greatly compared to the previous years, while the severity and LOS did not vary. However, we found that the proportion of patients admitted due to gastrointestinal bleeding and through the emergency department increased significantly, which may be because hematemesis or black stools are fatal and more likely to alarm people, and some patients did not come to the hospital until their conditions worsened.
The number of beds did decrease to about 50% due to lack of staff (they were assigned to help control the COVID-19 crisis). However, once the patient asked for hospitalization, he/she would be admitted as there still had empty beds during the pandemic. Thus we think the dramatically decreased numbers may be mainly due to the decreased number of consultation of these patients, which may be because they were afraid of going to hospital.
In the current situation of the COVID-19 pandemic, further studies will be needed to investigate the decline in hospitalization rates for liver cirrhosis when national and social isolation measures are adopted. From a public health perspective, more studies are needed to determine whether this is related to adverse long-term results.

Compliance with ethical standards
Conflict of interest All authors declare that they have no conflict of interest.
Ethical approval The study was approved by the ethics committee of The Second Xiangya Hospital, and the need for informed consent was waived due to the retrospective study design.
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