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The typical Western diet, high in processed and animal-based foods, is nutritionally and ethically problematic. Beyond the well-documented cruelty to animals that characterizes the practices of the factory-farming industry, current patterns of meat consumption contribute to medical and moral harm in humans on both an individual level and a public health scale. We aim to deconstruct, by highlighting their fallacies, the common positive and normative arguments that are used to defend current nutritional patterns. Animal-based foods promote the mechanisms that underlie chronic cardiometabolic disease, whereas whole-food plant-based nutrition can reverse them. Factory farming of animals also contributes to climate change, antibiotic resistance, and the spread of infectious diseases. Finally, the current allocation of nutritional resources in the United States is unjust. A societal shift toward more whole-food plant-based patterns of eating stands to provide significant health benefits and ethical advantages, and the medical profession has a duty to advocate accordingly. Although it remains important for individuals to make better food choices to promote their own health, personal responsibility is predicated on sound advice and on resource equity, including the availability of healthy options. Nutrition equity is a moral imperative and should be a top priority in the promotion of public health.

Injection drug use-related infective endocarditis (IDU-IE) is a complex disease with increasing incidence. Although universally recognized that IDU-IE requires antibiotics and often requires cardiac surgery, most patients do not receive addiction treatment which substantially increases their risk of recurrent IDU-IE from drug use recurrence. Accordingly, a multidisciplinary approach integrating addiction treatment may benefit patients with IDU-IE. We describe the format and structure of a team called the Multidisciplinary Endocarditis Evaluation Team (MEET) whose purpose is to optimize, formalize, and standardize the care of patients with IDU-IE. Given the complexity of IDU-IE, MEET is comprised of addiction medicine, anesthesia, cardiology, cardiac surgery, infectious disease, case management, nursing, and social work. MEET strived to be acceptable to patients and families to support their preferences and values. MEET focused treatment of IDU-IE on the patient's medical and surgical needs with attention to the patients' underlying substance use disorder as an essential component.

Telehealth has been a long-awaited advancement with the potential to improve efficiency, convenience, and quality in healthcare. However, as telehealth becomes integrated into routine clinical care, it is imperative to consider the practical and ethical implications that could undermine or devalue care delivery. The medical profession must ensure that it is implemented judiciously and with robust quality standards, guided by fair and equitable policies that balance patient autonomy with rigorous standards of care and access. Such a system must recognize the opportunity for more patient input as stakeholders to tailor care to their needs and preferences, while also acknowledging the risk of suboptimal care if convenience is prioritized over quality. More studies of optimal care models are needed to integrate data in terms of both stakeholder input and outcomes.

Physicians have a duty to present diagnostic and therapeutic choices with rational guidance that respects patient values and realizes patient goals. In cardio-oncology, we commonly encounter patients who understandably feel overwhelmed or feel that they have no favorable options, particularly in the context of advanced malignancy. Accordingly, a longitudinal multidisciplinary commitment to shared decision making (SDM) ensures that physicians and patients actively participate in this process to promote the best possible outcomes from the patient perspective. We propose a practical framework for approaching these difficult decisions in cardio-oncology drawing upon our experience in clinical practice.

By convention, the ascending aorta is measured by echo from leading edge to leading edge. “Leading edge” connotes the edge of the aortic wall that is closest to the probe (at the top of the inverted “V” of the ultrasound image). By transthoracic echo (TTE), the leading edges are the outer anterior wall and inner posterior wall. By transesophageal echo (TEE), the leading edges are the outer posterior wall and inner anterior wall. Aortic measurements should be taken (by convention) in diastole (when the aorta is moving least). Simple TTE is 70 to 85% sensitive in diagnosing ascending aortic dissection. TEE sensitivity approaches 100%, though the tracheal carina imposes a blind spot on TEE, impeding visualization of distal ascending aorta and proximal aortic arch. While computed tomography angiography may be superior for defining full anatomic extent of aortic dissection, echocardiography is superior in assessing functional consequences such as mechanism and severity of aortic regurgitation, evidence of myocardial ischemia when complicated by coronary dissection, or evidence of tamponade physiology when pericardial effusion is present. Reverberation artifact can mimic a dissection flap. A true flap moves independently of the outer aortic wall which can be confirmed by M-mode. Color flow respects a true flap but does not respect a reverberation artifact. Assessment for bicuspid aortic valve (BAV) morphology should be done in systole, not diastole. In diastole, when the valve is closed, the raphé can make a bicuspid valve appear trileaflet. Doming in the parasternal long axis (PLAX) view and an eccentric closure line on PLAX M-mode should also raise suspicion for BAV.

The American health care system increasingly conflates physician "productivity" with true clinical efficiency. In reality, inordinate time pressure on physicians compromises quality of care, decreases patient satisfaction, increases clinician burnout, and costs the health care system a great deal in the long term even if it is financially expedient in the short term. Inadequate time to deliver care thereby conflicts with the core principles of biomedical ethics, including autonomy, beneficence, nonmaleficence, and justice. We propose that the health care system adjust its focus to recognize the nonmonetary value of physician time while still realizing the need to deploy resources as effectively as possible, a concept we describe as "ethical efficiency."

The COVID-19 pandemic and its sequelae have created scenarios of scarce medical resources, leading to the prospect that health care systems have faced or will face difficult decisions about triage, allocation, and reallocation. These decisions should be guided by ethical principles and values, should not be made before crisis standards have been declared by authorities, and, in most cases, will not be made by bedside clinicians. Do not attempt resuscitation and withholding and withdrawing decisions should be made according to standard determination of medical appropriateness and futility, but there are unique considerations during a pandemic. Transparent and clear communication is crucial, coupled with dedication to provide the best possible care to patients, including palliative care. As medical knowledge about COVID-19 grows, more will be known about prognostic factors that can guide these difficult decisions.

Shortages of life-saving medical resources caused by COVID-19 have prompted hospitals, healthcare systems, and governmentsto develop crisis standards of care, including 'triage protocols' to potentially ration medical supplies during the public health emergency. At the same time, the pandemic has highlighted and exacerbated racial, ethnic, and socioeconomic health disparities that together constitute a form of structural racism. These disparities pose a critical ethical challenge in developing fair triage systems that will maximize lives saved without perpetuating systemic inequities. Here we review alternatives to 'utilitarian' triage, including first-come first-served, egalitarian, and prioritarian systems of allocating scarce medical resources. We assess the comparative advantages and disadvantages of these allocation schemes. Ultimately, we argue that while triage protocols should not exacerbate disparities, they are not an adequate mechanism for redressing systemic health inequities. Entrenched health disparities must be addressed through broader social change.

This Yale Aortic Institute lecture provides “tips and pitfalls” regarding echocardiographic assessment of the aorta.

Ventricular assist device (VAD) care offers a distinctive lens through which we can explore unjust gender norms. This is a resource-intensive intervention, one in which increasingly sophisticated technology brings with it the need for more long-term care. This care work is demanding, involving device maintenance, medication and appointment management, household work, and emotional support. Most patients eligible for receiving VADs are men, so it is not surprising that it is more often women who are responsible for the care of patients with VADs. Still, there is room to question why so much of this labor is expected of and taken on by female caregivers, when it could be shared with male caregivers and even patients themselves. To the extent that gender difference in the distribution of this labor is avoidable and inequitable, it becomes in part a disparity resulting from unjust social norms. In order to unpack some of this injustice, the authors utilize empiric data and theoretical work in feminist ethics to articulate some of the mechanisms of the gender disparity in VAD care labor and to offer communitarian decision-making and redistribution of care labor as potential routes toward greater justice for women with respect to VAD therapy.

BackgroundImmune checkpoint inhibitors (ICIs) are highly effective in treating cancer; however, cardiotoxicity can occur, including myocarditis. Cardiac magnetic resonance (CMR) imaging is useful for evaluation of myocarditis, although it has not been well studied in ICI cardiotoxicity.MethodsWe identified patients referred for CMR evaluation of ICI cardiotoxicity from September 2015 through September 2019. We assessed structural and functional parameters, feature tracking (FT) left ventricular and atrial strain, T2- weighted ratios and quantitative late gadolinium enhancement (LGE). We also applied the Updated Lake Louise Criteria for diagnosis of myocarditis.ResultsOf the 20 patients referred, the median left ventricular ejection fraction (LVEF) was 52.5% ± 19.1 and 50% had a normal LVEF (≥53%). FT strain analysis revealed an average abnormal global longitudinal strain (GLS) of −9.8%± 4.2%. In patients with a normal LVEF, the average GLS remained depressed at −12.3%± 2.4%. In all patients, GLS demonstrated a significant negative correlation with LVEF (rs= −0.64, p 0.002). Sixteen patients (80%) had presence of LGE (14 non-ischemic pattern and 2 ischemic). Percent LGE did not correlate with any CMR parameters and notably did not correlate with LVEF (rs= −0.29, p = 0.22) or GLS (rs= 0.10, p = 0.67), highlighting the value of tissue characterization beyond functional assessment. Nine patients (45%) met full Updated Lake Louise Criteria and 85% met at least one criterion, suggestive of myocarditis in the correct clinical context. Thirteen patients (65%) were treated for ICI-associated myocarditis and, of these, 54% (n = 7) had recovery of LVEF to normal. There was no correlation between LVEF (p = 0.47), GLS (0.89), or % LGE (0.15) and recovery of LVEF with treatment.ConclusionIn patients with suspected ICI cardiotoxicity, CMR is an important diagnostic tool, even in the absence of overt left ventricular dysfunction, as abnormalities in left ventricular strain, T2 signal and LGE can identifying disease.

Immune checkpoint inhibitors are highly effective in the treatment of cancer. Unfortunately they can result in variety of side effects, including life threatening myocarditis. A 52-year-old male with a history of hypertension and metastatic non-small cell lung cancer previously treated with

The purpose of this article is to investigate how cultural meanings associated with the left ventricular assist device (LVAD) inform acceptance and experience of this innovative technology when it is used as a destination therapy. We conducted open-ended, semistructured interviews with family caregivers and patients who had undergone LVAD-DT procedures at six U.S. hospitals. A grounded theory approach was used for the analysis. Thirty-nine patients and 42 caregivers participated. Participants described a sense of obligation to undergo the procedure because of its promise for salvation. However, once the device was implanted, patients described being placed into a liminal state of being neither sick nor healthy, with no culturally scripted role. Consideration of end-of-life decisions was complicated by the uncertainties about how patients with LVADs die. Pre-implantation communications among patient, family, and clinicians should take into account the impact of the technology on meaning, identity, and patient experience.

Vaccination policy in the case of human papillomavirus (HPV) has remained a constant source of controversy ever since Gardasil, Merck’s vaccine against HPV, received US Food and Drug Administration approval in the summer of 2006. This controversy has centered on the risks and benefits of vaccinating girls and women in rich and poor nations alike. However, despite all of the attention created by this important policy question, relatively little has been focused on another key public health question: should boys be vaccinated against HPV as well? If herd immunity against the most carcinogenic strains of HPV could be more rapidly and efficiently achieved by vaccinating everyone at risk for being a carrier, it logically follows that vaccine policy should expand to include boys and men.

The quality of life (QOL) of caregivers of patients with LVAD-DT (Left Ventricular Assist Device as Destination Therapy) has not been well explored.We used a concurrent mixed methods design. Caregivers (n = 42; average 60 years old, 82% female, 75% white) of patients (n = 39; average 68.3 years old, 83% male, 90% white) and providers (n = 27) from 6 LVAD-DT programs were recruited. We used the City of Hope Quality of Life Family Caregiver instrument, modified for LVAD-DT. Lower scores indicate poorer QOL. We analyzed open-ended questions with the use of Nvivo 10.0, using a modified grounded theory approach.The Psychologic subscale had the lowest average QOL score, followed by Social, Spiritual, and then Physical subscales. The composite mean average QOL score across the subscales was highest in caregivers40 years of age and ≥70 years of age. There was a nonsignificant trend toward better QOL in male caregivers (P = .06). We sorted QOL items into tertiles based on the percentage of responses5 (10-point Likert scale). Scores5 in the 2nd tertile (items from Social and Spiritual subscales) were reported by many fewer respondents than the 1st tertile (items from the Psychologic subscale). In the 3rd tertile,10% of respondents scored5 on 15 of the items. In qualitative interviews psychologic and social themes predominated in discussing requisites for competent caregivers, stress in pre-implantation decision making, lack of psychologic preparation, impact on freedom/independence, daily worry about pump performance, and value of psychologic and social support.Support interventions for caregivers of patients with LVAD-DT should address the psychologic and social aspects that lead to poor QOL.

s we continue to make advances in medicine that Apromise to treat more people more effectively, we face rising pressures of cost containment and the imperative to allocate resources judiciously. Accordingly, physicians are increasingly confronted with the challenge of where to draw the line at providing care. At first glance this idea may seem akin to Hippocratic blasphemy; as physicians we are never supposed to stop caring for our patients. Nonetheless, it may not always be medically or ethically appropriate to provide ever-escalating care to patients whose illnesses continue to ravage them despite our best efforts, especially when self-destructive behavior lies at the root of their disease. Mr X was a longstanding intravenous heroin user who initially presented with bacterial endocarditis requiring mitral valve replacement. Six months later, he re-presented with severe sepsis and prosthetic fungal endocarditis leading to severe mitral stenosis. Another valve replacement was deemed necessary to achieve cure given the level of valve destruction and persistent positive blood cultures despite appropriate antifungal therapy. However, three consultations with three different cardiothoracic surgeons yielded three nearly identical assessments: Mr X’s recidivism was a contraindication to repeat valve replacement. In case there had been any doubt as to whether he was still using, a nurse found used needles hidden in his clothes. Despite his worsening mental status in the setting of multiple embolic strokes, Mr X expressed that he did not want to die. The ethics committee was consulted and found no medical contraindication to surgery, and in the absence of guidelines they deferred to a senior cardiothoracic surgeon. Although he reinforced the precedent that recurrent prosthetic endocarditis associated with continued active intravenous drug use sufficiently justified his colleagues’ declining to offer a reoperation, he agreed to perform one. After a predictably complicated postoperative course, Mr X was discharged to a physical rehabilitation facility. It was not clear whether there was an effort to enroll him in substance rehabilitation as well. Shortly thereafter, his family brought him to the emergency department after finding him confused and disheveled at home. He had reportedly signed out of

OBJECTIVES: The importance of caregivers for destination left ventricular assist device (LVAD-DT) patients is generally recognized, but there is little focus on how to select and prepare the caregiver for this role. METHODS: LVAD-DT patients, caregivers, physicians, social workers and coordinators from 3 institutions participated in qualitative interviews. There were 12 providers (5 VAD coordinators, 3 social workers, 2 surgeons , 2 medical directors) and 13 patients/caregiver pairs (all patients are male; all but 1 caregiver are female, 6 caregivers are over 70). Seven of the 13 patients did not have Advance Directives. Caregivers completed the City of Hope Caregiver Quality of Life (CHQOL-C) survey. Interviews were analyzed using grounded theory. Mean subscale scores on the CHQOL-C were used to contrast caregivers’ responses above and below the mean. RESULTS: Providers emphasized that caregivers must be physically able, emotionally stable and committed. They stated that family members with a health care background are ideal candidates and used phrases such as “meticulous with care” and “serene” to describe competent caregivers. However, they also acknowledged that caregivers can become “overwhelmed” or “anxious,” with the “reality of the daily grind.” They were critical of family members who do not “step up.” Providers did not acknowledge that caregivers’ roles might change over time and did not identify many social supports outside of the LVAD-DT community. Caregivers and patients emphasized effects of LVAD-DT on the nature of their relationships, daily activities and social lives. Caregivers described concerns about the patient’s limited stamina and mobility. Several mentioned that they no longer have an intimate relationship with their spouse. Some described a profound sense of isolation. Caregivers described many home management tasks and for some, almost total physical care of the patient. Caregivers balanced comments such as “of course I love him” with the fact that caregiving is “very trying.” Some described difficulties with patients who have become “more demanding.” Several contrasted the volume of information they received about what to expect with the sense that they were unprepared for the magnitude of the changes. Caregivers were unprepared for discussions about advance directives. Caregivers whose CHQOL-C social subscale score fell above the mean of 6.2 (SD 2.23) on a 10 point Likert scale tended to express more positive coping strategies. By contrast, caregivers with worse quality of social life expressed more financial concerns and more concerns about their own health. Some caregivers described the LVAD as “a blessing” but others referred to it as a curse. For some, the LVAD becomes less of an external machine and, at some point becomes part of the person. DISCUSSION: While clinicians do extensive teaching about life with an LVAD-DT, caregivers still express a sense of unpreparedness and highlight multiple domains of concern, including relationship issues with the patient, and with the device, isolation, and home and family management. This initial qualitative analysis reflects a need for greater emphasis on quality of life for LVAD-DT caregivers.

Resistance to the stimulatory effects of insulin on glucose utilization is a key feature of type 2 diabetes, obesity, and the metabolic syndrome. Recent studies suggest that insulin resistance is primarily caused by a defect in glucose transport. GLUT4 is the main insulin-responsive glucose transporter and is expressed predominantly in muscle and adipose tissues. Whereas GLUT4 has been shown to play a critical role in maintaining systemic glucose homeostasis, the mechanisms regulating its expression are incompletely understood. We have cloned the murine homologue of KLF15, a member of the Krüppel-like family of transcription factors. KLF15 is highly expressed in adipocytes and myocytes in vivo and is induced when 3T3-L1 preadipocytes are differentiated into adipocytes. Overexpression of KLF15 in adipose and muscle cell lines potently induces GLUT4 expression. This effect is specific to KLF15 as overexpression of two other Krüppel-like factors, KLF2/LKLF and KLF4/GKLF, did not induce GLUT4 expression. Both basal (3.3-fold, p0.001) and insulin-stimulated (2.4-fold, p0.00001) glucose uptake are increased in KLF15-overexpressing adipocytes. In co-transfection assays, KLF15 and MEF2A, a known activator of GLUT4, synergistically activates the GLUT4 promoter. Promoter deletion and mutational analyses provide evidence that this activity requires an intact KLF15-binding site proximal to the MEF2A site. Finally, co-immunoprecipitation assays show that KLF15 specifically interacts with MEF2A. These studies indicate that KLF15 is an important regulator of GLUT4 in both adipose and muscle tissues.