Nick Germanov | Critical Signal

6) The Doubt We do not need Bayesian evangelism. Bayes is powerful, but dose makes the poison. A poor prior can turn elegance into bias. For ICU research, the real question is not whether Bayes is fashionable. It is whether it helps signal surface from the fog of uncertainty 🕳️ Follow the Doubt. #FOAMed #FOAMcc #MedTwitter #CritCare #Bayesian

4) The Prior Problem The main limitation is also the main responsibility – the prior. A bad prior can smuggle bias into the model. An opaque prior can make the analysis look objective while hiding assumptions. Bayesian work should not mean “trust the model.” It should mean: “show your assumptions”.

🕳️ Signal Drift #1: Bayesian Future I don’t think the future is “Bayesian statistics replacing frequentism” More likely, it belongs to hybrid clinical methodology: frequentist rigor + Bayesian update Especially in ICU research, that combination feels hard to ignore.

@YounisJoseph Completely agree I also wonder if AI may transiently increase vacancies in some clinical markets – not by replacing clinicians directly, but by accelerating the exit of older physicians who find it harder to adapt or simply do not want to...

#Medtwitter : don’t let the AI doomers dissuade you from pursuing medical careers. Most of them aren’t physicians and don’t really understand the clinical dynamic. They said AI will kill radiology, but it’s looking more like the golden age for them

@emcrit Btw great update, thanks! One question I keep thinking about: HI-PEITHO used 9-18 mg, STRATIFY – 20 mg alteplase. Given OPTALYSE and the apparent efficacy/safety balance with lower-dose USAT regimens, do you think 18-20 mg is optimal?

AHA PE Guidelines 2026 are here, so are STRATIFY and HI-PEITHO. I have new takeaways, updated risk stratification, treatment recs, and much more... emcrit.org/424

@emcrit the PE field now really feels like it is entering its uncomfortable phase 🤨

@IM_Crit_ no friendship is perfect, but it can survive many things haha

He is a good friend but he intubates with midazolam & fentanyl... #foamed #foamcc #meded #medtwitter

HI-PEITHO is a meaningful signal. But STRATIFY adds the uncomfortable counter-signal: if the same low-dose alteplase gives a similar CT effect IV, the next battle is not catheter vs heparin alone. I suppose, it is catheter-based complexity vs simpler IV thrombolytic strategies on patient-centered outcomes.

Ultrasound-Facilitated, Catheter-Directed Fibrinolysis for Acute Pulmonary Embolism In patients with acute, intermediate-risk pulmonary embolism, ultrasound-facilitated, catheter-directed fibrinolysis plus anticoagulation led to a lower risk of the composite of pulmonary embolism-related death, cardiopulmonary decompensation or collapse, or symptomatic recurrence of pulmonary embolism within 7 days than anticoagulation alone. nejm.org/doi/full/10.10…

@PulmCrit Also agree! Maybe guidelines should reduce chaos, not replace judgment. And if a consultant only transmits guideline text without interpreting physiology, uncertainty, and trajectory, then it time to rethink their necessity

Agree. Corrolary: If you’re a nonprocedural consultant who is unwilling to deviate from guidelines, you can & should be replaced by artifical intelligence.

10) The Critical Signal STRATIFY is not the end of the story. It is the moment the field should become uncomfortable. This is EKOS-agnostic critical care: technology should not win by narrative, elegance, or procedural beauty. It should win by outcomes. 📡 With gratitude to @merc_irina for helping trace the signal through the flood

9) The Bedside At the bedside, elegance has a cost. USAT is not only a way to deliver alteplase. It means: • catheter lab logistics • transfer delays • procedural resources • device cost • specialist availability If the IV route gives a similar signal, complexity must earn its place.

🌊 Evidence Flood #1: STRATIFY Low-dose systemic thrombolysis. USAT. Heparin alone. Is everything that glitters truly gold? The great battle is yet to come. For now, the armies are only setting up camp. A search for critical signal. #FOAMed #FOAMcc academic.oup.com/cardiovascres/…