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Hello, and welcome to Inpatient Update. I'm your host, Mason Turner, and this is the podcast for practice changing evidence for the working hospitalist. Today on our show, I will discuss early beta blocker use in cirrhosis, uh, doing half-dose eloquence for folks with cancer-associated clots, and prophylactic antibiotics in patients with biliary obstruction. So I'll start off with introductions as this is the pilot first episode of my podcast. As I said, my name is Mason Turner. I'm an early to mid-career hospitalist. Uh, I'm born certified in internal medicine. I practice at a major academic medical center in the Southeast, a tertiary referral center. I practice both direct patient care as well as um working with teaching services and learners. I started this podcast because I really this was something that I wanted. This was a podcast that I had hoped and wished was already out there, and so I decided to make it be so. Um, this came about because I, as I presume of a lot of the listeners will, really valued being up to date with my medicine. Um, I've always never wanted to become that hospitalist that you read a discharge summary from an outside hospital and you think, man, this provider's practicing 10, 15-year-old medicine, not uh following up-to-date guidelines, not uh following up-to-date data. And um, but it's it's harder said than done. And the further I've gone through my career, the more and more difficult it's been to stay up to date. And that's particularly between being busy clinically along with busy with other things in my life. I'm uh a husband, a father. I have other responsibilities, other obligations, other interests. Um, and all of that makes it really hard to stay up to date on the literature. I've gotten the the mailers in the um in my mailbox every two weeks or whatever that give me all the up-to-date articles and a review of articles in my field. Um, but honestly, have not been able to consistently sit down and read them. Um, and if you miss a couple, if I miss a couple, then I feel like I'm I'm out of date and missing a major part of what is pertinent in the literature out there that could affect my practice and could help my patients. So, because that's been so hard, I thought about it. And one thing that I feel like I can keep up with is my podcast feed. Um, and so I hunted for a podcast that would fill that same void. And the only podcasts I found were either long format internal medicine podcasts on a specific topic, not necessarily um keeping up to date on the literature, or were someone reading general highlights from a particular um journal in a monotone way, just reading through, that I found frankly unlistenable. So, what I decided to do was make a podcast. So, inpatient update. The idea, the guiding principles are kind of threefold. And one is that it's efficient, short, listenable. Goal about 20 minutes, the time it will take you to do your commute, walk your dog, wash your dishes. Um number two, it's uh pertinent. And so I'm a working hospitalist. The articles that I choose to highlight are things that I think I can use with my patients on a daily, weekly, or monthly basis regularly. Um, and then three, trying to make it listenable. I um the scripted format where someone just reads, I find really difficult to really engage in. And so in the future, I um will have co-hosts with me, guests or regular co-hosts, uh, that we can have a discussion um to really make it listenable. Um give kind of that parasocial to help really uh make it an engaging, an engaging podcast to listen to. Um so with all that being said, I'll get into it again. Want to be efficient um and go through a few articles that I found uh interesting in the literature. Um the first one I'll we'll go with is um antibiotics for prophylaxis before ERCP and biliary obstruction. Um if your institution is anything like mine, you perform ERCPs. Um and because of that, patients come from far and wide to get those ERCPs. There seems to be a dearth in my state of providers uh that perform these RCPs and the ones that do having the skill, the skill and the instruments to do them successfully consistently. And so we very often um transfer people from outside hospitals to get ERCPs. Uh the uh holidays were here recently, and our uh GI suite was down for anything other than emergencies for days on end around Christmas time. And then I was on call working that Sunday before that work week after the Christmas holiday came back, and we brought in I don't know how many different patients from outside hospitals to get an ERCP. And you know, the patient, Billirubin, anywhere from two-ish to 20. Um normal vital signs, maybe a tad of a bump in a white count, but no fever, negative blood cultures. Um, and then imaging shows biliary obstruction, a stone, malignancy, what have you. Um, but they're not clearly infected. And I'm constantly having the question of do I throw antibiotics at these people or do I not throw antibiotics at these people? So there was a recent um in November in the Journal of Clinical Gastro Neurology, and I'll put a link in the show notes, but an article entitled Antibiotic Prophylaxis before ERCP for biliary obstruction. It was a meta-analysis that entailed and totaled 2,100 patients from 11 different randomized controlled trials, and it looked at um prophylactic antibiotics versus no. And these are in patients that, again, didn't have any clear indication of infection coming in, but did have biliary obstruction. Um, and it showed that there was significantly improved outcomes in the folks that got antibiotics. So less infection, uh, two for percent versus 11%, with a number needed to treat of 12. Um bacteremia rates were lower, um, statistically significant. And um the most common antibiotic used in all of these cases was acephalosporin. So, highlight I took from this is that all of these patients coming in after a weekend, after the holidays, um, who are backlog of ERCPs from other institutions that aren't able to provide them, I'm giving them at least one dose of acephalosporin sporin before they go to um go to ERCP, hopefully the next day. And then from there, basing things on um on what my gastroenterology colleagues think about how um significant the concern was for infection based on the procedure. And now this uh recommendation for this dose of antibiotics is whether or not uh the my colleagues think they've got good drainage, even if they've got good drainage with an ERCP and a stin and a sphincterotomy, um, it was still shown that antibiotics were overall helpful. All right, the next study um I looked at was regarding extended reduced dose of pixaban for cancer-sodiated venous thromboembolism. And now this um is a case that, or a study that in my practice honestly has influenced me more in making me realize why other providers are doing what they're doing. They were probably more up to date than I am, um, rather than anything that has actively changed my practice yet. But this was an article from March, New England Journal of Medicine, looked at 1,766 patients, was a non-inferiority trial in patients with a cancer diagnosis along with a proximal DVT or a PE. And so they all got an initial six months of treatment of um aliquist, presumably with the 10 milligram load, and then going to five milligrams forward from there. But then after those six months, patients um in the treatment group and the intervention group were dropped down to 2.5 milligrams BID. And the primary outcome they looked at was recurrent DVT. Um, and uh the sub-hazard ratio was 0.65, 95% confidence in vol crossed one, and so it was indicative of non-inferiority. Um and then the bleed rate was less, and that was statistically significant with the confidence interval 0.58 to 0.97. Um, and so for me, I'd been seeing more and more this 2.5 milligrams BID eloquist being used in patients. And um, as we know, all the initial guidelines and studies for this was that half dose. Um, eloquence was specifically for folks AFib um with uh stroke uh risk reduction and meeting two of the three criteria of age, weight, and renal function. Um, but I was seeing this constantly in these other patients, and I frankly admitted someone who had multiple myeloma and came in um and did have a significant PE and was on this 2.5 milligram uh dose. And I'm talking to my residents about how that's not the correct dose and that we don't dose reduce in patients who have cancer. Um but probably my uh presumably board certified hematologists in the hemok department who was treating this gentleman with multiple melanoma knew about this data that it's shown in an aggregate to be non-inferior. Um, and so I've been agreeable to using this 2.5 milligram dose in more because the data, at least in these cancer patients, backs it up that it's non-inferior when it's related to clots and has less risk of bleeding. Um, next and last, should we start beta blocker prophylaxis earlier in patients with cirrhosis? Um, this was from a July article from the American Journal of Gastroenterology. Um, it was a study from India with 104 patients with cirrhosis with new uncomplicated ascites. It was a randomized but open label, excuse me, study. Um, and it one year there was shown less ascites associated complications. Um, I got really excited about this article when I saw it in my um little up-to-date article roundups uh literature that I mentioned earlier, uh, because it's I clearly saw how it could change my practice that instead of waiting until folks have varices um on EGD, instead we are going ahead and uh starting them on a beta blocker, reduce the risk of esophageal variceal bleed at the first onset of ascites. Now, uh, when I first read this article, I had a patient that I was dealing with on wards and I was rounding with the teaching team, and I um it was a patient who came in with SBP, spontaneous uh bacterial peritonitis, and um new cirrhotic first instance of ascites. And I said, all right, as we're going through the things we need to do for this patient with new cirrhosis, what do we need to do to risk reduce reduce them? How can we take this hospitalization for this patient and improve her outcomes going into the future? And so I mentioned this article that showed value in starting beta blockers earlier. But I will point out, as I said, this is new, uncomplicated ascetes. And my pharmacist working with me uh pointed that out, and we talked a little bit about the concept of a window of opportunity when it comes to treating uh prevented prophylactically um cirrhotic patients with a beta blocker, that once they have complicated ascites, uh the guidelines are no longer to treat them. So it does not change that portion. My patient has uh SBP because of the infected ascites. Um, she basically would she would not have met the criteria to look at for this this study. She would have been in the exclusion criteria. What it does essentially is just opens that window earlier than it did before, making that window larger. That um, and looking back at it was really a pretty narrow window where you've got esophageal varices, um moderate esophageal to severe esophageal varices on an EGD, but you don't have any um complications from ascites, uh, which is really a pretty small window. And so opening that window sooner than anyone, whether they've got small varices, whether they've got no varices, whether we've never looked for varices, and starting them on carvatololol at a prophylactic dose being beneficial, uh is is significant. It's gonna change, it's changing my practice already. Um, there's been other patients that I have been able to start that beta blocker on. Um, and uh the the outcomes were pretty significant. There was uh significantly fewer large volume paracenteses needed between the growth groups, 27% on the beta blocker group versus 58% in the non-beta blocker group. So a number needed to treat of three. Um ascites was resolved more likely. There were fewer deaths with a number needed to treat of six. Um, so really impressive data that is having genuine improvement in patient outcomes, very specific use case. So be cautious like I did and make sure that this patient actually is in the window. But when you get these patients with new ascites, think let's start them on a beta blocker unless uh they have some complication to their ascetes. Those are my three articles for today. Again, wanted to keep it short, so I'll end there. Uh, I hope you enjoyed the podcast. Thank you for joining me today. If you have any comments, please put comments uh on wherever you're listening to this podcast. If you have ideas of articles that I should uh review on the podcast, let me know if you'd like to be on the podcast and join me as a co-host or a guest. Please let me know. Reach out. You can find me um on the website, you can leave a comment, send me an email, find uh inpatient update on Instagram. So this has been InpatientUpdate. Thank you for joining me. Goodbye.