Joshua Niforatos, MD, MTS
@reverendofdoubt.bsky.social
Emergency Medicine Physician | #MedSky
I love it lol - also it’s exactly what I wear on shift 😍
April 13, 2025 at 12:13 AM
I love it lol - also it’s exactly what I wear on shift 😍
Reposted by Joshua Niforatos, MD, MTS
CJEM debate: clinical decision rules–thinking beyond the algorithm
link.springer.com/article/10.1...
We need to think deeply about how we use decision rules in medicine
Thank you so much @emlitofnote.bsky.social @lwestafer.bsky.social @reverendofdoubt.bsky.social for joining me in this debate
link.springer.com/article/10.1...
We need to think deeply about how we use decision rules in medicine
Thank you so much @emlitofnote.bsky.social @lwestafer.bsky.social @reverendofdoubt.bsky.social for joining me in this debate
CJEM debate: clinical decision rules–thinking beyond the algorithm - Canadian Journal of Emergency Medicine
Canadian Journal of Emergency Medicine -
link.springer.com
February 12, 2025 at 2:00 PM
CJEM debate: clinical decision rules–thinking beyond the algorithm
link.springer.com/article/10.1...
We need to think deeply about how we use decision rules in medicine
Thank you so much @emlitofnote.bsky.social @lwestafer.bsky.social @reverendofdoubt.bsky.social for joining me in this debate
link.springer.com/article/10.1...
We need to think deeply about how we use decision rules in medicine
Thank you so much @emlitofnote.bsky.social @lwestafer.bsky.social @reverendofdoubt.bsky.social for joining me in this debate
for the oncologists out there:
which types of presumed new cancer diagnoses (non-liquid tumors) found in the ED require expedited inpatient work-ups vs outpatient referrals?
i.e.: time from diagnosis to therapy is critical?
which types of presumed new cancer diagnoses (non-liquid tumors) found in the ED require expedited inpatient work-ups vs outpatient referrals?
i.e.: time from diagnosis to therapy is critical?
March 31, 2025 at 7:54 PM
for the oncologists out there:
which types of presumed new cancer diagnoses (non-liquid tumors) found in the ED require expedited inpatient work-ups vs outpatient referrals?
i.e.: time from diagnosis to therapy is critical?
which types of presumed new cancer diagnoses (non-liquid tumors) found in the ED require expedited inpatient work-ups vs outpatient referrals?
i.e.: time from diagnosis to therapy is critical?
"Overall, we found no high- or moderate-level evidence to suggest that SEP-1 compliance was associated with improved mortality; however, there may be a signal of mortality benefit in certain populations." | Annals of IM
www.acpjournals.org/doi/10.7326/...
www.acpjournals.org/doi/10.7326/...
The Effect of Severe Sepsis and Septic Shock Management Bundle (SEP-1) Compliance and Implementation on Mortality Among Patients With Sepsis: A Systematic Review: Annals of Internal Medicine: Vol 0, N...
Background: The Centers for Medicare & Medicaid Services (CMS) Severe Sepsis and Septic Shock Management Bundle (SEP-1) is now included in the Hospital Value-Based Purchasing (VBP) Program. Purpose: T...
www.acpjournals.org
March 31, 2025 at 2:24 PM
"Overall, we found no high- or moderate-level evidence to suggest that SEP-1 compliance was associated with improved mortality; however, there may be a signal of mortality benefit in certain populations." | Annals of IM
www.acpjournals.org/doi/10.7326/...
www.acpjournals.org/doi/10.7326/...
Twitter / X is … spiraling.
February 12, 2025 at 3:07 AM
Twitter / X is … spiraling.
Reposted by Joshua Niforatos, MD, MTS
Do clinical decision rules actually help with diagnosis in medicine?
The latest #CJEMDebate explores the question with
@first10em.bsky.social @emlitofnote.bsky.social @lwestafer.bsky.social @reverendofdoubt.bsky.social and @paulatkinsonem.bsky.social. #medsky
link.springer.com/article/10.1...
The latest #CJEMDebate explores the question with
@first10em.bsky.social @emlitofnote.bsky.social @lwestafer.bsky.social @reverendofdoubt.bsky.social and @paulatkinsonem.bsky.social. #medsky
link.springer.com/article/10.1...
CJEM debate: clinical decision rules–thinking beyond the algorithm - Canadian Journal of Emergency Medicine
Canadian Journal of Emergency Medicine -
link.springer.com
February 5, 2025 at 8:23 PM
Do clinical decision rules actually help with diagnosis in medicine?
The latest #CJEMDebate explores the question with
@first10em.bsky.social @emlitofnote.bsky.social @lwestafer.bsky.social @reverendofdoubt.bsky.social and @paulatkinsonem.bsky.social. #medsky
link.springer.com/article/10.1...
The latest #CJEMDebate explores the question with
@first10em.bsky.social @emlitofnote.bsky.social @lwestafer.bsky.social @reverendofdoubt.bsky.social and @paulatkinsonem.bsky.social. #medsky
link.springer.com/article/10.1...
Apparently the fad of using propensity matching is switching to the new fad of target trial emulation, regardless of the quality of data.
February 4, 2025 at 3:48 PM
Apparently the fad of using propensity matching is switching to the new fad of target trial emulation, regardless of the quality of data.
The fact that this paper got so much press despite its profound limitations and really not adding anything to the literature is more of a testament of how physicians have no research background or ability to interpret the academic literature
pubmed.ncbi.nlm.nih.gov/39173173/
pubmed.ncbi.nlm.nih.gov/39173173/
Evaluation of Etomidate Use and Association with Mortality Compared with Ketamine among Critically Ill Patients - PubMed
<span><b>Rationale:</b> Uncertainty remains regarding the risks associated with single-dose use of etomidate. <b>Objectives:</b> To assess the use of etomidate in critically ill patients and compare o...
pubmed.ncbi.nlm.nih.gov
February 4, 2025 at 3:45 PM
The fact that this paper got so much press despite its profound limitations and really not adding anything to the literature is more of a testament of how physicians have no research background or ability to interpret the academic literature
pubmed.ncbi.nlm.nih.gov/39173173/
pubmed.ncbi.nlm.nih.gov/39173173/
Reposted by Joshua Niforatos, MD, MTS
When EM has to absorb all of the social failings of society it’s going to lead to long wait times.
January 30, 2025 at 5:34 PM
When EM has to absorb all of the social failings of society it’s going to lead to long wait times.
I’m 100% convinced that until hospital reimbursement is tied to ED boarding times, no meaningful changes will occur.
January 30, 2025 at 5:37 PM
I’m 100% convinced that until hospital reimbursement is tied to ED boarding times, no meaningful changes will occur.
January 30, 2025 at 5:32 PM
Whenever I hear "tox/metabolic etiology,"... you should be able to identify the toxidrome or metabolic derangement causing [insert X] condition...
January 15, 2025 at 4:26 PM
Whenever I hear "tox/metabolic etiology,"... you should be able to identify the toxidrome or metabolic derangement causing [insert X] condition...
A total of 2.5 hours of shoveling my driveway over the last two days and my entire body hurts
January 8, 2025 at 1:07 AM
A total of 2.5 hours of shoveling my driveway over the last two days and my entire body hurts
I wish someone would’ve told me as a medical student and as a resent that working your @$$ off for years with dozens and dozens of first author publications (study design, data analysis, writing, presentations) means nothing at the early career level … I would’ve done things differently.
January 3, 2025 at 5:09 AM
I wish someone would’ve told me as a medical student and as a resent that working your @$$ off for years with dozens and dozens of first author publications (study design, data analysis, writing, presentations) means nothing at the early career level … I would’ve done things differently.
This editorial by J. Broder on imaging utilization in the ED is the best piece I've ever read on the topic: when there are no CDRs for abdominal pain, no time to see patients, unreliable exam findings, high rates of (+) imaging, expectations of "zero miss culture"
pubmed.ncbi.nlm.nih.gov/39487590/
pubmed.ncbi.nlm.nih.gov/39487590/
a man standing in a parking lot with the words " what the hell am i supposed to do " above him
ALT: a man standing in a parking lot with the words " what the hell am i supposed to do " above him
media.tenor.com
January 1, 2025 at 7:14 PM
This editorial by J. Broder on imaging utilization in the ED is the best piece I've ever read on the topic: when there are no CDRs for abdominal pain, no time to see patients, unreliable exam findings, high rates of (+) imaging, expectations of "zero miss culture"
pubmed.ncbi.nlm.nih.gov/39487590/
pubmed.ncbi.nlm.nih.gov/39487590/
New paper from @abfriedman.com uses NHAMCS data from 2007-2019 for CT imaging rates of abdominal pain visits to the ED.
1. CT scan rates ⬆️ 26.2% to 42.6%! But...
2. Test positivity, i.e., an emergency general surgical diagnosis, ⬆️ increased 17.2% to 22.9%!
pubmed.ncbi.nlm.nih.gov/39313946
1. CT scan rates ⬆️ 26.2% to 42.6%! But...
2. Test positivity, i.e., an emergency general surgical diagnosis, ⬆️ increased 17.2% to 22.9%!
pubmed.ncbi.nlm.nih.gov/39313946
Trends in visits, imaging, and diagnosis for emergency department abdominal pain presentations in the United States, 2007-2019 - PubMed
Despite more abdominal pain ED visits and increased imaging rates per visit, test positivity continues to rise. Our findings do not support claims that CT and ultrasound are being used less appropriat...
pubmed.ncbi.nlm.nih.gov
January 1, 2025 at 6:22 PM
New paper from @abfriedman.com uses NHAMCS data from 2007-2019 for CT imaging rates of abdominal pain visits to the ED.
1. CT scan rates ⬆️ 26.2% to 42.6%! But...
2. Test positivity, i.e., an emergency general surgical diagnosis, ⬆️ increased 17.2% to 22.9%!
pubmed.ncbi.nlm.nih.gov/39313946
1. CT scan rates ⬆️ 26.2% to 42.6%! But...
2. Test positivity, i.e., an emergency general surgical diagnosis, ⬆️ increased 17.2% to 22.9%!
pubmed.ncbi.nlm.nih.gov/39313946
New paper from Johns Hopkins (radiology/EM) questioning the use of "age over 65" for C spine imaging in trauma patients
Of 9455 CTs performed in pts ≥ 65, 192 (2.0%) fractures were identified (113 females); 28 (0.30%) were in asymptomatic pts
pubmed.ncbi.nlm.nih.gov/38940447/#:~...
Of 9455 CTs performed in pts ≥ 65, 192 (2.0%) fractures were identified (113 females); 28 (0.30%) were in asymptomatic pts
pubmed.ncbi.nlm.nih.gov/38940447/#:~...
Is older age an appropriate criterion alone for ordering cervical spine computed tomography after trauma - PubMed
Cervical spine fractures in posttrauma patients ≥ 65 years are uncommon, with the lowest incidence in those 65 to 70 years old. Excluding asymptomatic individuals aged 65-70 from routine CSCT presents...
pubmed.ncbi.nlm.nih.gov
January 1, 2025 at 6:05 PM
New paper from Johns Hopkins (radiology/EM) questioning the use of "age over 65" for C spine imaging in trauma patients
Of 9455 CTs performed in pts ≥ 65, 192 (2.0%) fractures were identified (113 females); 28 (0.30%) were in asymptomatic pts
pubmed.ncbi.nlm.nih.gov/38940447/#:~...
Of 9455 CTs performed in pts ≥ 65, 192 (2.0%) fractures were identified (113 females); 28 (0.30%) were in asymptomatic pts
pubmed.ncbi.nlm.nih.gov/38940447/#:~...
Majoring on the minors: Regulatory organizations turn a blind eye to emergency department boarding in favor of rare conditions | #AcademicEmergencyMedicine
pubmed.ncbi.nlm.nih.gov/39034656/
pubmed.ncbi.nlm.nih.gov/39034656/
Majoring on the minors: Regulatory organizations turn a blind eye to emergency department boarding in favor of rare conditions - PubMed
Majoring on the minors: Regulatory organizations turn a blind eye to emergency department boarding in favor of rare conditions
pubmed.ncbi.nlm.nih.gov
January 1, 2025 at 5:59 PM
Majoring on the minors: Regulatory organizations turn a blind eye to emergency department boarding in favor of rare conditions | #AcademicEmergencyMedicine
pubmed.ncbi.nlm.nih.gov/39034656/
pubmed.ncbi.nlm.nih.gov/39034656/
Reposted by Joshua Niforatos, MD, MTS
This concerns me. A 2015 paper showed that < 50% of VA ED physicians were board certified EM physicians... I did a quick skim of the paper, and they did not break it down by IM vs EM, unless I missed it... which is a HUGE problem for this paper....
pubmed.ncbi.nlm.nih.gov/25936477/
pubmed.ncbi.nlm.nih.gov/25936477/
Emergency medicine in the Veterans Health Administration-results from a nationwide survey - PubMed
Veterans Health Administration emergency physicians have primarily clinical responsibilities, and less than half have formal emergency medicine board certification. Despite most VHA EDs having univers...
pubmed.ncbi.nlm.nih.gov
December 24, 2024 at 12:31 PM
This concerns me. A 2015 paper showed that < 50% of VA ED physicians were board certified EM physicians... I did a quick skim of the paper, and they did not break it down by IM vs EM, unless I missed it... which is a HUGE problem for this paper....
pubmed.ncbi.nlm.nih.gov/25936477/
pubmed.ncbi.nlm.nih.gov/25936477/
I think the idea that admissions are to solely reduce mortality doesn’t make any sense tbh…. sure, sometimes an admission may do that. The real question is: was the admission indicated or not indicated.
Haven’t read the paper yet but… did it stratify by IM and EM docs in the ED?
Haven’t read the paper yet but… did it stratify by IM and EM docs in the ED?
🚨New paper🚨The emergency department (ED) is like a box of chocolates; you never know which doc you're gonna get. What happens when you get a doc that admits patients more often? Are you less likely to die? @stephencoussens and I explore this question in @JAMAInternalMed.🧵1/
December 24, 2024 at 12:14 PM
I think the idea that admissions are to solely reduce mortality doesn’t make any sense tbh…. sure, sometimes an admission may do that. The real question is: was the admission indicated or not indicated.
Haven’t read the paper yet but… did it stratify by IM and EM docs in the ED?
Haven’t read the paper yet but… did it stratify by IM and EM docs in the ED?
Reposted by Joshua Niforatos, MD, MTS
Part of being anti-RFK Jr. is calling out doctors who spread pro-RFK Jr. propaganda.
If you partner with and/or support these doctors in any way, you are enabling RFK Jr no matter what you say about him yourself.
Sorry.
If you partner with and/or support these doctors in any way, you are enabling RFK Jr no matter what you say about him yourself.
Sorry.
December 11, 2024 at 4:34 PM
Part of being anti-RFK Jr. is calling out doctors who spread pro-RFK Jr. propaganda.
If you partner with and/or support these doctors in any way, you are enabling RFK Jr no matter what you say about him yourself.
Sorry.
If you partner with and/or support these doctors in any way, you are enabling RFK Jr no matter what you say about him yourself.
Sorry.
Reposted by Joshua Niforatos, MD, MTS
Never underestimate the POWER of a Vaccine Scientist. If RFK Jr. is voted DOWN for head of HHS (and he should NOT be confirmed), it's not because of Congress, it will be because people like Dr. Peter Hotez spoke out.🙏💜
December 14, 2024 at 12:35 AM
Never underestimate the POWER of a Vaccine Scientist. If RFK Jr. is voted DOWN for head of HHS (and he should NOT be confirmed), it's not because of Congress, it will be because people like Dr. Peter Hotez spoke out.🙏💜
Fml ….
RFK Jr’s transition team lawyer is currently petitioning the US government to pause distribution of vaccines for polio, hepatitis A, diphtheria, tetanus and nine others.
America is on the brink of the Middle Ages.
America is on the brink of the Middle Ages.
December 14, 2024 at 12:04 AM
Fml ….
Reposted by Joshua Niforatos, MD, MTS
#ADAPTtrial released & the results are interesting…
Compared to SOC, Procalcitonin guided antibiotics in sepsis resulted in:
- FEWER antibiotic days: 10.7 vs 9.8 (p=0.01) BUT
- HIGHER 28 day mortality: 19.4% vs 20.9% (p=0.02) though this did not meet the pre-specified non-inferiority margin
🤔
1/
Compared to SOC, Procalcitonin guided antibiotics in sepsis resulted in:
- FEWER antibiotic days: 10.7 vs 9.8 (p=0.01) BUT
- HIGHER 28 day mortality: 19.4% vs 20.9% (p=0.02) though this did not meet the pre-specified non-inferiority margin
🤔
1/
December 9, 2024 at 10:58 PM
#ADAPTtrial released & the results are interesting…
Compared to SOC, Procalcitonin guided antibiotics in sepsis resulted in:
- FEWER antibiotic days: 10.7 vs 9.8 (p=0.01) BUT
- HIGHER 28 day mortality: 19.4% vs 20.9% (p=0.02) though this did not meet the pre-specified non-inferiority margin
🤔
1/
Compared to SOC, Procalcitonin guided antibiotics in sepsis resulted in:
- FEWER antibiotic days: 10.7 vs 9.8 (p=0.01) BUT
- HIGHER 28 day mortality: 19.4% vs 20.9% (p=0.02) though this did not meet the pre-specified non-inferiority margin
🤔
1/