Joshua Niforatos, MD, MTS

It’s the person I sometimes think I am, but in reality I try to have positive energy at every patient encounter

I love it lol - also it’s exactly what I wear on shift 😍

CJEM debate: clinical decision rules–thinking beyond the algorithm - Canadian Journal of Emergency Medicine Canadian Journal of Emergency Medicine -

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

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?

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...

"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/...

Twitter / X is … spiraling.

CJEM debate: clinical decision rules–thinking beyond the algorithm - Canadian Journal of Emergency Medicine Canadian Journal of Emergency Medicine -

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...

Apparently the fad of using propensity matching is switching to the new fad of target trial emulation, regardless of the quality of data.

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...

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/

Right!?!

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.

It ain’t easy… :(

www.cbsnews.com/baltimore/ne...

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

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.

the authors do mention important limitations, especially how acute/emergent some of the diagnoses might actually be; regardless, worth a read

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

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/

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...

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

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...

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/#:~...

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

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/

Oh for sure!!! Decent literature showing practice variation across numerous specialties

I think looking at low value admissions is a very worthwhile endeavor — and every ED doc knows at their shop who the people are that admit and scan everyone :)

But I think that’s not the point because admissions are to reduce morbidity and mortality, and that’s hard to study.

I think the elephant in the room if we’re going to say that all these admits don’t change morality is… what is the point then of GIM / hospital medicine?

I guess the thing that needs to be addressed is why did over 80% require greater than 24 hour stay?

But that’s the point- the question is one of indication, not mortality. The former is harder to study but is what the relevant question is. Very few things influence mortality in medicine.

I think this study has a lot of issues and likely doesn’t capture the SDoH involved with caring for patients in a VA ED, at least based on my experience. Also the admit rate of 41.2% or CP, SOB, Abd pain tells me something isn’t being captured.

That’s not the central question. The central question is: By how much does the propensity to admit patients vary across physicians within a given emergency department (ED).

And there are many reasons for admission, many that improve morbidity and not mortality

the other question is: were admissions indicated? mortality is very rare event and not the sole or even the reason for admission. For patient's DC'd w/in 24h, what was the ED census that day? Was their boarding?

Sometimes when there's ED boarding, admissions are necessary if inpatient has beds.

If you publish a JAMA IM paper and make these conclusions, you at least need to do it correctly from a research perspective if the goal is to ascertain "provider practice variation".