So, Donnie, my thought about this is that the question is really about antibiotic prophylaxis in the case of variceal bleeding and most of your discussion is about just the general management of variceal bleeding. It's a great discussion, but it does feel like it's long and it doesn't spend a lot of time on discussing what the actual point of the question is and where I would, as a user, like to see more information is what resistance are you talking about with fluoroquinolones? What bugs is it that we commonly see there? What is thought about why antibiotics might reduce the risk of re-bleeding and what that mechanism is about in my answer? And if I were you, I would save a bunch of what you wrote and put it in a question about actually managing the acute variceal bleed, you know, put one in about banding or tips or something of that nature, make a whole separate question and use what you wrote here. But that's what I would want to see in the discussion, I think. Yeah, I agree. And this is exactly where the struggle came in of why it ended up taking, you know, it's just having a tough time because there is not much proven in terms of sort of antibiotics and re-bleeding and then resistance patterns being different. I can certainly build it out a little bit more like it's common gastro, you know, bugs that are in the GI tract and things like that. So, I can build that out. And the point you made about like this is the treatment of variceal bleeding and make a separate question is exactly actually where I started. This is like version four where I landed on antibiotics. And the reason was really that there is not necessarily enough data to say banding is the way to go, you know. So, when you're trying to make those choice, answer choices be very distinct and provide four options and a very clear this is the answer, it got really challenging. And I tried to work around oxytocin and mortality and re-bleeding. I tried to work around the endoscopic management. So, if someone has an idea how to, I would love that and I can break this into two questions. I think you could do that, Subhani, because in a way the question doesn't need the case. All you're really asking which of the following is true about the use of prophylactic antibiotics in the management, you know what I'm saying, you don't even need the case. But I wonder if you could do what Steve said, the discussion is fantastic, is make it a next step and put something wrong like angiography or surgery, you know, like those are wrong answers or nuclear medicine. I mean, that would be pretty easy. Right, right. Those would be very wrong, it would be very wrong answers. Yeah, you'll see like on my question, I asked which of the following is the most appropriate next step, which that doesn't mean you have to be right or wrong, that it has to be definitively that it's banding. But if your next steps are like Stephanie says, angiography, tips, variceal banding, esophageal balloon, now nobody's going to say you should go to tips or angiography or an esophageal balloon before you attempt EGD with banding, right? Oh yeah, especially if you make that the first step, the very first, if it's a re-bleed after, then those other options are coming up, initial. Yeah, if it's the initial one. Oh yeah, but this guy has had multiple episodes, right? Balloon tamponade, if you're in a spot where you can't get to EGD and it's a life-threatening bleed, sometimes balloon tamponade might be the first, the right step. But you could certainly get to a number of very wrong answers. I like that idea. One other thought I had about this question and the answers, and I saw Steve Hollenberg joined us, but I think this is a multiple true-false question, which isn't exclusively prohibited, but it's in general discouraged, or at least we try to think, is there another way to pose the answers? Yeah. What would you recommend? I don't know the solution to it. I'm just trying to think through here. I'd have to sort of do the intellectual exercise, but could you say something perhaps that you haven't given? Maybe the initial case is about sort of the resuscitation, and then you say, which of the following treatments has been associated with a lower mortality and reduced risk of re-bleeding? And you could kind of give ceftriaxone and some other, maintaining a heboglobin above nine, and think of some other things that are wrong that you've already touched on in your answer that people might think about. So if I do that, then we are back to one question, right? Because then that would touch upon the different treatments. So maybe then what I can do is, rather than break this up into two and keep the sort of multi-true-false situation, I just flip it and make it about what is the next best step in management, keep most of the explanation. I'll have to adjust sort of antibiotics would move down because they're not the core and things like that. And maybe the answer choices after this initial re-bleed, you know, patients already on octreotide and all the other treatment and just be what is essentially in the next like definitive management step, which would be tips and geography, EGD with bending. And I hear your point about balloon tamponade that is, you know, so I see when it gets used. So I'd need a fourth option. You could do a nuclear medicine, you could do abdominal CT, you know, some very easy, but I guess that's okay. Yeah, it will become easy. I'm trying to think. Transfusion of platelets and plasma maybe, or like, you know, FFP maybe. And I liked your discussion about how, you know, in these cases that has a pretty limited role, but it might be appealing to someone as a potential. Yeah, that might be a better distractor. I'll do a transfusion of platelets and I'll give the patient platelets of about like 75, say. So they're low, but they're not low enough. There you go. I like that. Yeah, about 50. Yeah. I think that's about 50, but still thrombocytopenic. Yeah. Okay. This is very helpful. Is it 6-1-1? For some reason, I feel like we do more like a one, I think we do something different for a massive transfusion. So they, depends actually how you label the platelets. It's a six pack is a one unit. Yeah. Oh, is that what you meant? I'm sorry. I thought you meant six packs. I'll clarify that. Yeah, just clarify that. Yeah, because we call it 1-1-1. Yeah, that's what I think. Yeah, we do that. Yeah. I was a bit confused by that too. Yeah. Okay. I'll clarify that. I'll change the, I'll put like, yeah, you could say like an advanced one or something. But the discussion is fantastic. It's very, it's very salvageable. Yeah. I also like, you know, it's nice to use pictures, nice pictures when you have them. So that's somehow, sometimes how I end up choosing what to write the question about. And I really wanted to use these pictures. Yeah. I agree with taking out the Blake Morsink stocking tube. We had a question about that, didn't we? We did. About different tubes and this and that. Yeah. It was like Blake, it was placement and. Yeah. Oh yeah. That's tough. I figured, so are you saying Steve, hi, to just in, even in the discussion, take out even mention of it, because I felt like we had. You can mention it, just don't make it a choice. Oh. Oh yeah. Yeah. It's not a good distractor because if you're sitting in a resource poor area and that's all you got, why wouldn't you put it in somebody hypotensive and right. Yeah. Well, and it, or alternatively you're sitting in the hospital where the gastrointestinal service says, why don't you call back the coagulopathy and we'll see him in the morning. Not that that's ever happened to me. Yeah. They have been even this patient. Hence the re-bleeding. Um, this is very helpful. So I will edit. I should have called you all earlier because I wrote so many versions of this. That's why we're doing it.

prophylactic antibiotics

variceal bleeding

resistance patterns

gastrointestinal bugs

TIPS or banding