iiinova — where your digital self keeps evolving

Jeffrey Wagner @jeffwagmd.bsky.social · 22/04/2026

5/5 To avoid becoming a "boutique" tool, VEXUS needs implementation science 🧪. We must ensure our competency standards are as implementable as they are precise. Read the full piece here: link.springer.com/article/10.1... #MedSky #POCUS #VEXUS #MedEd #HospitalMedicine

link.springer.com

The VExUS Precision Paradox: Navigating the Integration of High-Fidelity Hemodynamics into Generalist Practice - Journal of General Internal Medicine

Journal of General Internal Medicine -

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Jeffrey Wagner @jeffwagmd.bsky.social · 22/04/2026

4/5 Generalist adoption faces real hurdles 🚧: 🔹 Steep learning curves 🔹 15–20 min exam times 🔹 Handheld devices lacking ECG leads for temporal mapping Precision shouldn’t be a barrier to accessibility 🔓.

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Jeffrey Wagner @jeffwagmd.bsky.social · 22/04/2026

3/5 But here is the "Precision Paradox" ⚖️: Experts have proposed a 35-item competency rubric. While essential for fidelity, do granular checklists survive the "task creep" of a high-acuity environment?

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Jeffrey Wagner @jeffwagmd.bsky.social · 22/04/2026

2/5 VEXUS is a physiologic evolution, moving our gaze from the surface to the entire systemic watershed 🌊. By integrating Doppler across 4 vascular beds, we can visualize the pathologic backpressure compromising organ perfusion.

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Jeffrey Wagner @jeffwagmd.bsky.social · 22/04/2026

1/5 For a century, the Method of Lewis has defined bedside assessment of congestion 🫀. But IJV height is a unidimensional surrogate for a multidimensional hemodynamic problem. My new editorial in @jgim.bsky.social explores what comes next: VEXUS 🛰️. 🧵

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Reposted by Jeffrey Wagner

josh farkas 💊 @pulmcrit.bsky.social · 08/03/2026

New JAMA review attempts to equate pulmonary congestion with systemic congestion ("volume overload") This is sloppy & often wrong Pts w/ LV failure often have pulmonary congestion w/o systemic congestion Pts w/ RV failure usually have systemic congestion w/ dry lungs CVP isn't PCWP #EMIMCC

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Jeffrey Wagner @jeffwagmd.bsky.social · 02/03/2026

5/5 Ultimately, uJVP needs to move from a "cool hobby" to formal credentialing (looking at you, SHM POCUS Cert). It’s time to professionalize the probe so the next generation isn't left staring blankly at the neck. #MedSky #POCUS #MedEd #HospitalMedicine

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Jeffrey Wagner @jeffwagmd.bsky.social · 02/03/2026

4/5 However, a checklist validates the measurement, not the doctor. A resident might perfectly measure a uJVP of 12 cmH2O but fail to recognize the tamponade physiology driving it. We need to ensure we aren't just teaching image acquisition at the expense of clinical reasoning. 🧠

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Jeffrey Wagner @jeffwagmd.bsky.social · 02/03/2026

3/5 I dive into recent work by Franco et al., who used the Delphi & Angoff methods to create a standardized uJVP checklist. This moves us from arbitrary metrics ("I did 50 scans!") to criterion-referenced safety ("Can a minimally competent resident do this without error?"). 📉✅

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Jeffrey Wagner @jeffwagmd.bsky.social · 02/03/2026

2/5 Think of the JVP like a river. 🌊 The physical exam only looks at surface ripples (pulsations). POCUS lets us measure the actual depth (vessel diameter + collapse). But here’s the problem: A better tool is dangerous without better rules. We can’t keep using "vibes" to assess competency.

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Jeffrey Wagner @jeffwagmd.bsky.social · 02/03/2026

🧵 1/5. Raise your hand if you’ve ever stared at a patient’s neck with a penlight, pretending to see the JVP while your attending nodded enthusiastically. 🙋‍♂️🔦 We’ve all been there. But in the POCUS era, we can do better than "guessing at shadows." My latest editorial in JGIM: #MedSky #POCUS #MedEd

link.springer.com

From Flashlights to Probes: Do You See the JVP? - Journal of General Internal Medicine

Journal of General Internal Medicine -

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Reposted by Jeffrey Wagner

Atul Gawande @agawande.bsky.social · 06/11/2025

Today @TheNewYorker released our short documentary “Rovina’s Choice” online. It traces the ongoing effects of the sudden shutdown of US foreign aid through the story of one mother in Kenya as she seeks to save her daughter from sickness and starvation. 🎥 1/ www.newyorker.com/culture/the-...

newyorker.com

The Shutdown of U.S.A.I.D. Has Already Killed Hundreds of Thousands

The short documentary “Rovina’s Choice” tells the story of what goes when aid goes.

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Jeffrey Wagner @jeffwagmd.bsky.social · 26/10/2025

As medical advocate for the gut: ‘Anything’ is inadmissible—lacks nutrition and intent. Enter fruits/veg into evidence.

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Jeffrey Wagner @jeffwagmd.bsky.social · 26/10/2025

Indeed which has been fascinating to see. A great example of how broadly applied dichotomous thresholds (Hgb<7 =transfuse) miss nuances. Certainly if risk profile is lower argument more could benefit is reasonable. Unfortunately donor supply is decreasing www.bbc.com/news/article...

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Jeffrey Wagner @jeffwagmd.bsky.social · 24/10/2025

Oh yeah, thanks for the reminder to get that done

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Jeffrey Wagner @jeffwagmd.bsky.social · 23/10/2025

It’s an odd term. There ref says it is “as an unanswerable question”… that is not what most docs are doing IME. Clinical medicine is humbling. I try to preface my ? of trainers w/ these are ? I ask myself to probe thinking and understanding. IMO, it’s instructive to ?

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Jeffrey Wagner @jeffwagmd.bsky.social · 23/10/2025

This is spicy indeed 🌶️ 🔥

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Jeffrey Wagner @jeffwagmd.bsky.social · 23/10/2025

Fantastic work here! Very much agree with accounting for pretest of bacteremia given heterogeneity of sepsis as a clinical entity and that quality sepsis metrics play a role in diagnostic testing over clinical judgement more than it likely should. Bravo!

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Jeffrey Wagner @jeffwagmd.bsky.social · 18/10/2025

Important to note, even with 3 findings, the LR tells you the test result is x7 more likely in those with cholecystitis versus those without. Reiterates the point we all know, the story of the patient going into scanner matters ALOT more

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Jeffrey Wagner @jeffwagmd.bsky.social · 18/10/2025

Such a great thread and clinical pearl! Conceptually, sensitivity and specificity # s get confused. Retrospective case series illustrates why I prefer LR. With more findings of cholecystitis, LR+ 4.5→6→7 (more=⬆️ prob of sure Dx) but at same time LR– 0.1→0.4→0.7 (more=⬆️ prob of missing some)

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Jeffrey Wagner @jeffwagmd.bsky.social · 18/10/2025

I prefer to think in terms of interval likelihood ratios, and account for pretest prob. Agree that the above language anchors to broadly in description & highlights how “test-centric” decision making has become. A common pearl is the story/history is (probably) the best performing test we have

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Jeffrey Wagner @jeffwagmd.bsky.social · 12/10/2025

Definitely applies to HFrEF, but I haven’t seen reimbursement tied to HFpEF-specific GDMT. Here’s a summary of current therapies. With cost/access issues around GLP-1 RAs and SGLT2is, curious how implementation will go—most patients unlikely to get both.

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Jeffrey Wagner @jeffwagmd.bsky.social · 11/10/2025

I really worry about this use of AI/LLMs in peer review, specifically for methods review. The brakes analogy is apt. All for pursuing progress, but how this does not spin out of control seems unlikely in the current climate #pumpthebrakes

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Jeffrey Wagner @jeffwagmd.bsky.social · 11/10/2025

Efficiencies?! 🤦 Providing public health through a lens of scalable business is short sighted and, well, counter to the mission. Much worse in 🇺🇸. the pulling back of public safety net in larger society (housing, education, etc) coincides with move to align care models based on ROI

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Jeffrey Wagner @jeffwagmd.bsky.social · 11/10/2025

🙋🏻‍♂️I have seen the same. it has been a common teaching of mine to correct with learners on service. Unfortunately I am seeing it in cardiologist notes now too.🤦 data does not support outcomes beyond improvement in NT-pro BNP and HF hosp. we need docs to push back against this

too.data

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Jeffrey Wagner @jeffwagmd.bsky.social · 10/10/2025

Prevalence statistics inform pre-test probability. These numbers are staggering and reflect my anecdotal experience. When considering interventions, Kaiser's PHASE program implements an effective intervention but prevention efforts will be key. www.amjmed.com/article/S000...

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Jeffrey Wagner @jeffwagmd.bsky.social · 30/08/2025

Anecdotal, though hypothesize the correlation coefficient for a patient who asks to start testosterone for low energy despite normal levels who will subsequently ask me to empirically treat for parasites/cancer unspecified with ivermectin is 0.84

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Jeffrey Wagner @jeffwagmd.bsky.social · 15/08/2025

The Bible of Medicine. Spreading the gospel of Longo, Fauci, et al.

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Jeffrey Wagner @jeffwagmd.bsky.social · 05/08/2025

I have wondered why no LLM for UTD? They have content with nuance, which seems ripe for a partnership with AI (such as NEJM and JAMA with Open Evidence). Indeed, fewer trainees are using it too

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Jeffrey Wagner @jeffwagmd.bsky.social · 05/08/2025

10/12 Thanks to my amazing co-authors and the broader infection prevention community working to make indoor spaces safer! 🙏Shout out to @cudeptofmedicine.bsky.social #InfectionPrevention #IndoorAirQuality #PublicHealth #EngineeringControls #COVID19 #RespiratoryInfections #Evidence #SystematicReview

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Jeffrey Wagner @jeffwagmd.bsky.social · 05/08/2025

9/12 🎯 MOVING FORWARD: We need: ✅ More human outcome studies ✅ Standardized intervention classifications ✅ Better reporting of both benefits AND harms ✅ Real-world effectiveness trials The framework is there - now we need better evidence.

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Jeffrey Wagner @jeffwagmd.bsky.social · 05/08/2025

8/12 💡 WHY THIS MATTERS: Indoor air quality affects everyone. Post-COVID, there's huge interest in engineering controls, but our review shows the evidence base has significant limitations. We're making policy decisions with incomplete information.

media.tenor.com

a cartoon of a man sitting at a desk with the words everyone has to follow protocol below him

ALT: a cartoon of a man sitting at a desk with the words everyone has to follow protocol below him

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Jeffrey Wagner @jeffwagmd.bsky.social · 05/08/2025

7/12 🏥 REAL-WORLD IMPACT: The heterogeneity in study designs makes it challenging to give clear guidance to healthcare facilities, schools, and offices about which engineering controls to prioritize. We need more standardized approaches to evaluation.

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Jeffrey Wagner @jeffwagmd.bsky.social · 05/08/2025

6/12 ⚠️ SAFETY BLIND SPOT: Studies rarely measured harms like toxic byproducts from disinfection systems. We need to know not just "does it work?" but "is it safe for continuous human exposure?" This gap is especially important for occupied spaces.

media.tenor.com

a group of nurses are dancing in a hospital room

ALT: a group of nurses are dancing in a hospital room

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Jeffrey Wagner @jeffwagmd.bsky.social · 05/08/2025

5/12 🧪 WHAT DO STUDIES ACTUALLY MEASURE? Most commonly: Non-pathogenic organisms in air (332 studies) Non-biological particles (197 studies) Actual pathogens (149 studies) Translation: We're often measuring proxies, not the bugs that actually make us sick.

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Jeffrey Wagner @jeffwagmd.bsky.social · 05/08/2025

4/12 ⚙️ WHAT INTERVENTIONS WORK? We found 3 main categories: 🦠 Pathogen INACTIVATION (405 studies) - UV-C, heat, chemicals 🌪️ Pathogen REMOVAL (200 studies) - filtration, air cleaning 💨 Air EXCHANGE/DILUTION (143 studies) - ventilation systems

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Jeffrey Wagner @jeffwagmd.bsky.social · 05/08/2025

3/12 🔬 Of those 672 studies, only 57 (8.5%) included human participants. Most research (90%) only looked at environmental samples - not actual infection outcomes in people. This is a major evidence gap! 🚨

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Jeffrey Wagner @jeffwagmd.bsky.social · 05/08/2025

2/12 📊 THE SCOPE: We systematically reviewed 672 studies published between 1929-2024 examining engineering interventions to reduce indoor respiratory infection transmission. That's almost a CENTURY of research on making indoor air safer! 🕰️

media.tenor.com

Purifiers Air GIF

ALT: Purifiers Air GIF

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Jeffrey Wagner @jeffwagmd.bsky.social · 08/07/2025

Where does lung POCUS fit here? I have found lung POCUS + uJVP to be easier to obtain and clinically useful. Perhaps a new paradigm? This 2016 article juxtaposes PAWP with extravascular lung water (EVLW), which may reflect the clinical utility of lung POCUS in this space

ncbi.nlm.nih.gov

Ultrasound of extravascular lung water: a new standard for pulmonary congestion

Extravascular lung water (EVLW) is a key variable in heart failure management and prognosis, but its objective assessment remains elusive. Lung imaging has been traditionally considered off-limits for...

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Jeffrey Wagner @jeffwagmd.bsky.social · 04/07/2025

💯 I find the mechanism elegant. hope outcomes will support adoption

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Jeffrey Wagner @jeffwagmd.bsky.social · 04/07/2025

Just had a case of this. The question is good but the enrollment # is small. Subgroup analysis has even smaller numbers. Hard to anchor on these findings IMO, especially when many of the recurrent cases I see fit a higher risk profile than the inclusion criteria. Maybe my own intervention bias 🤷🏻‍♂️

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Jeffrey Wagner @jeffwagmd.bsky.social · 20/05/2025

Of the writing I have done, this was the most personal and special. A dedication to all parents who are doctors, and of course my baby girl. Out today in @annalsofim.bsky.social, “Doctor Dad”. Thank you, Dr. Lacomb for the beautiful reading www.acpjournals.org/doi/10.7326/...

acpjournals.org

Doctor Dad | Annals of Internal Medicine

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Jeffrey Wagner @jeffwagmd.bsky.social · 27/04/2025

🤯 this is so life changing. Thank you!!

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Jeffrey Wagner @jeffwagmd.bsky.social · 19/04/2025

Would like to see an assessment of bias for the attorney alleging medical journals are biased Also, curious about the logic of pulling NIH funding for many researchers while spending tax dollars on…well, this 🤔

nytimes.com

Trump-Allied Prosecutor Sends Letters to Medical Journals Alleging Bias

An interim U.S. attorney is demanding information about the selection of research articles and the role of N.I.H. Experts worry this will have a chilling effect on publications.

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