The introduction of the integrated interventional radiology (IR) residency in 2017 marked a change in the way IRs are trained. However, pathways to IR are still offered after completing diagnostic radiology (DR) residency. This study aims to analyze trends in the integrated IR match alongside changes in the DR match following the introduction of the integrated pathway and assess the implications for aspiring IRs. The National Resident Matching Program (NRMP) data reports for the integrated IR and DR matches were compared, focusing on the 2018 dataset with the first integrated IR inclusion and the most recent dataset from 2022. The number of residency slots and candidates were trended, and candidate competitiveness via USMLE scores, extra-curriculars, additional degrees, Alpha Omega Alpha (AOA) honor society membership, and medical school ranking were evaluated. Chi-squared and paired t-tests were utilized for statistical analysis. Since 2018, applying to integrated IR has become significantly less popular than DR, with 35.8% (n=72) fewer integrated IR applicants in 2022 relative to the 2.9% (n=20) decrease seen for DR (χ2 test, p=.0009). In 2022, an applicant's chance for a successful match was 82.2% (n=106/129) for integrated IR and 95.0% (n=638/672) for DR. While more selective at baseline, integrated IR has seen a 23.4% (n=12) increase in matched applicants since 2018 relative to the 4.7% (n=17) increase seen for DR. Regarding applicant competitiveness, mean USMLE Step 1 and Step 2 scores for integrated IR and DR matched applicants have remained around the 70th percentile among all medical students. Matching in 2022 required a mean of 12 research items for integrated IR applicants and 8 for DR; a mean increase of 4 and 2 items respectively (p >.05). Integrated IR and DR programs continue to draw around 30% of their matches from medical schools with the top 40 National Institutes of Health funding, although the integrated IR match has seen a 9.7% (n=19) decrease in AOA honors society membership relative to the 3.5% (n=25) increase for DR since 2018. There was no significant change for matched IR applicants relative to DR regarding the mean number of volunteer and work experiences or percentage of those with graduate degrees. Applicant demand for the integrated IR has decreased since its introduction relative to DR. Both specialties maintain their commitment to academic excellence and demonstrate an increased emphasis on research. For students interested in IR, the integrated pathway is becoming more competitive but represents an increasingly viable option.

To categorize trends in the popularity of the integrated interventional radiology (IR) residency among medical school seniors and assess changes in the level of applicant competitiveness required to successfully match since the integrated pathway's inception. The National Resident Matching Program's (NRMP) match data was compared from its first inclusion of integrated IR outcomes in 2018 with the most recent report from the 2022 cycle. Number of residency slots and candidates were trended over time, and factors reflective of candidate competitiveness including USMLE exam scores, extra-curricular experiences (research, volunteer, and work), additional degrees, Alpha Omega Alpha (AOA) honor society membership, and medical school ranking were further evaluated. Chi-squared and paired t-tests were utilized for statistical analysis. The demand for integrated IR positions has declined among U.S. MD seniors, with the number of applicants in 2022 decreasing by 35.8% (n=72) from the 2018 peak of 201 applicants. Compared with 2018, applicants in 2022 had a significantly higher chance of matching (χ2 likelihood ratio, p< .0001). During this period there was no significant change in applicant competitiveness regarding mean number of volunteer experiences, work experiences, or research experiences. Mean USMLE Step 1 and Step 2 scores did not significantly change, but successfully matching in 2022 required 3.8 additional publications, presentations, and abstracts than in 2018. There was no significant change in the percentage of successfully matched applicants with PhD or master's degrees, remaining stably around 5% and 20%, respectively, between 2018 and 2022. Although the percentage of matched applicants who were AOA honors society members had decreased from 30.5% to 20.8%, integrated IR programs during that time period continued to draw around one-third of their matched applicants from the top 40 medical schools with the most National Institutes of Health (NIH) funding. Since the introduction of the integrated IR residency, there has been a decline in applicant demand and an increased likelihood of successfully matching for those who apply. While most aspects of applicant competitiveness remained stable, importance of research productivity has heightened and emphasis on medical school pedigree remain. This work underscores the dynamic nature of the integrated IR residency match and offers guidance for medical students applying to the specialty and for program administrators.

Interventional radiologists often provide treatment and palliation for patients near the end of life (1Cyphers E. Silberstein S. Keller E.J. Suspending do not resuscitate/do not intubate orders for image-guided procedures.Semin intervent Radiol. 2022; 39: 338-340Crossref PubMed Scopus (1) Google Scholar). These patients often have do not resuscitate and/or do not intubate (DNR/DNI) orders or other advance directives that express their preferences to refuse resuscitative measures in the event of a cardiac or respiratory arrest or the loss of a protected airway. For example, up to 79% of patients with advanced cancer have a DNR/DNI order (2Cheng M.T. Shih F.Y. Tsai C.L. Tsai H.B. Tsai D.F.C. Fang C.C. Impact of major illnesses and geographic regions on do-not-resuscitate rate and its potential cost savings in Taiwan.PLoS One. 2019; 14e0222320Crossref Scopus (7) Google Scholar). Historically, surgeons have required patients to suspend DNR/DNI orders in the perioperative setting, allowing for resuscitation if unexpected emergencies occur intraoperatively. However, surgery and anesthesiology guidelines have since discouraged this behavior, citing that the forcing of patients and families to choose between their preferences and an indicated procedure does not sufficiently support a patient’s right to self-determination (3American College of SurgeonsStatement on advance directives by patients: “do not resuscitate” in the operating room. ACS, 2014Google Scholar,4American Society of Anesthesiologists Committee on EthicsEthical guidelines for the anesthesia care of patients with do-not-resuscitate orders or other directives that limit treatment. ASA, 2018Google Scholar). Moreover, these updated guidelines advocate for code status discussions during consent conversations (3American College of SurgeonsStatement on advance directives by patients: “do not resuscitate” in the operating room. ACS, 2014Google Scholar,4American Society of Anesthesiologists Committee on EthicsEthical guidelines for the anesthesia care of patients with do-not-resuscitate orders or other directives that limit treatment. ASA, 2018Google Scholar). Interventional radiologists are also called upon to provide an intervention while respecting patient preferences to avoid resuscitative measures. Nonetheless, some interventional radiology (IR) practices require suspension of DNR/DNI orders, although there are no published data on the frequency of such policies or IR-specific guidelines on these practices. This work aimed to evaluate the status of required periprocedural suspension of DNR/DNI in IR. An institutional review board–approved cross-sectional survey–based study was conducted using a 5-question survey (Qualtrics XM; Provo, Utah) and distributed through social media (Twitter and SIR Connect) and emails to interventional radiologists and IR trainees practicing in the United States from April 2022 through June 2022. Questions collected demographic information such as the participant’s role and years in practice and type of practice, addressed whether the participant’s practice requires the suspension of DNR/DNI orders during procedures, and addressed how often the physician discusses code status during the consent process. Numerical data analysis was primarily descriptive. Where applicable, statistical analysis was performed using Medcalc 20.114 (MedCalc Software, Ostend, Belgium). Odds ratio and χ2 were reported to 95% confidence intervals. The Stanford University institutional review board approved this study (Protocol Number 63751). A total of 159 participants responded, with demographic information provided in Table 1. The frequency of participants holding code status discussions during the consent process is presented in Table 2. Although 35% (n = 56) of participants reported that their practices required the suspension of DNR/DNI orders, 11% (n = 17) of participants were unaware of whether their institutions required suspension (Fig). There were no statistically significant differences across practice type, role, years of experience, or requiring suspension requirement. Trainees were more likely to not know if their practices required suspension of DNR/DNI orders compared with faculty (χ2(1, N = 142) = 6.16, P = .01).Table 1Participant demographics according to practice type and current positionCharacteristicn (%)Practice type Teaching107 (67) Nonteaching44 (28) Hybrid8 (5)Current position Junior trainee (postgraduate year 1–4 or equivalent)26 (16) Senior trainee (postgraduate year 5 or higher or equivalent)20 (13) Attending posttraining < 10 y45 (28) Attending posttraining ≥10 y61 (38) Advanced practice provider (eg, nurse practitioner and physician assistant)7 (4) Open table in a new tab Table 2Code status discussions during consent conversationsHow often do you have a discussion with a patient about their code status during the consent process?n (%)Always23 (15)Very often25 (16)Sometimes48 (30)Rarely42 (26)Never10 (6)Did not respond10 (6) Open table in a new tab This brief survey-based analysis demonstrated variation in approaches to suspension of DNR/DNI orders for IR procedures and demonstrated that trainees were less likely to know their institution’s policy. Because trainees are often tasked with having consent conversations and helping coordinate care, this presents a potential problem. Therefore, it may be helpful for training programs to consider the inclusion of didactics exploring these clinical challenges faced by interventionalists-in-training. Interventional radiologists may consider adopting a similar approach to what is recommended in surgery and anesthesiology guidelines, in which code status is reconsidered during consent conversations and suspension is not a strict or unilateral requirement (3American College of SurgeonsStatement on advance directives by patients: “do not resuscitate” in the operating room. ACS, 2014Google Scholar,4American Society of Anesthesiologists Committee on EthicsEthical guidelines for the anesthesia care of patients with do-not-resuscitate orders or other directives that limit treatment. ASA, 2018Google Scholar). In this study, the frequency with which participants reported discussing code status during consent conversations was variable: 30% (n = 48) reported always or very often discussing code status, whereas 63% (n = 100) reported discussing code status sometimes, rarely, or never. A key pillar of the consent process is discussing the procedure’s risks (3American College of SurgeonsStatement on advance directives by patients: “do not resuscitate” in the operating room. ACS, 2014Google Scholar,4American Society of Anesthesiologists Committee on EthicsEthical guidelines for the anesthesia care of patients with do-not-resuscitate orders or other directives that limit treatment. ASA, 2018Google Scholar); although many procedures performed in IR are associated with minimal risk, possible adverse events span a gamut from easily reversible to fatal. Interventional radiologists should consider discussing code status before procedures to obtain robust informed consent and best understand and respect their patients’ wishes in the event of a code. Limitations to this analysis include the small sample size and response rate, which may introduce sampling and selection bias, and the survey’s distribution through social media, which precludes accurate determination of response rate, limiting generalizability across interventional radiologists. These results suggest that DNR/DNI suspension practices vary among interventional radiologists, although more than one-third of participants require suspension. Code status was inconsistently addressed during consent conversations. To best respect our patients’ rights to self-determination near the end of life, to navigate these challenging situations, and to encourage more consistent approaches as a specialty, further study should be aimed toward establishing IR-specific guidelines for best practices. This work was supported by the Applied Ethics in Interventional Radiology working group.

Medical student exposure to interventional radiology (IR) through dedicated rotations represents a vital component for students to consider IR as a career and to ensure a successful match into the integrated residency pathway. Students from osteopathic medical schools have historically been underrepresented in integrated IR positions. During the 2022 match, 84.1% of successfully matched applicants overall were from U.S. allopathic medical schools, whereas 15.9% were from osteopathic medical schools. This brief report aims to categorize the landscape of IR rotation exposure at osteopathic medical schools and proposes a framework to increase student access to IR.

Artificial intelligence (AI) encompasses computational algorithms that, partially or completely, autonomously perform beneficial tasks usually considered representative of human intelligence.[1] This revolutionary technology has the potential to shape the scope of healthcare in incredible ways. From data-driven treatment recommendations, real-time intraprocedural support, predicting outcomes, and more, there are vast possibilities for implementing AI in interventional radiology (IR) to help maximize patient care.[2] [3] [4] [5] While there exists much enthusiasm for integrating this cutting-edge technology in IR, there are many ethical issues to consider in its use, such as questions about data ownership and distribution, culpability in the setting of AI-associated adverse events, and amplification of inequities and bias. This article explores some of these challenges and suggests a framework for navigating them.

The integrated interventional radiology (IR) residency requires sufficient exposure for medical students to consider IR as a career pathway and to become successful applicants. Osteopathic students are underrepresented in the IR match. The purpose of this study is to categorize the landscape of IR at osteopathic medical schools and propose a framework to increase student access to IR. The Commission on Osteopathic College (COCA) website was utilized to create a list of accredited colleges of osteopathic medicine. School websites were searched, and offices of clinical education were contacted for the availability of IR and diagnostic radiology (DR) rotations. Rotation curricula were reviewed. The Society of Interventional Radiology’s Residents, Fellows, and Students section was utilized to generate a list of interventional radiology interest groups (IRIG) at osteopathic medical schools. 31 COCA-accredited colleges of osteopathic medicine had curriculum information available. Of those schools, 29% (n = 9) had IR rotations available for students while 71% (n = 21) had student-run IRIGs. 67% (n = 6) of IR rotations were available to all clinical students and 33% (n = 3) were available for seniors only; none were available to preclinical students. These rotations were electives in 89% (n = 8) of cases while 11% (n = 1) were listed as subinternships. Most rotations were 4 weeks in length (56%, n = 5). Of schools without available IR rotations, 55% (n = 12) had DR rotations available for students; 75% of these DR rotations had IR exposure in their curricula. Medical student exposure to IR is of paramount importance for a successful integrated IR residency match. It has been previously shown that a majority of allopathic schools offer their students IR rotations. However, only 29% of osteopathic schools provide such rotations despite 71% of institutions having student-run IRIGs. IR rotations varied in category, length, and student level availability. There is significant need to improve and standardize access to IR at osteopathic medical schools and this can be achieved through establishing dedicated IR experiences at existing clinical sites and radiology partner groups.

In 2023, the radiology community will experience the beginning of a generational change by matching its first class of Generation Z residents. To best welcome and embrace the changing face of the radiology workforce, this Viewpoint highlights the values that this next generation will bring, how radiologists can improve the way they teach the next generation, and the positive impact that Generation Z will have on the specialty and the way radiologists care for patients.

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS l. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[1] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[2] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. ll. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[3] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[4] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[5] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[6] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[7] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[8] In democratic societies, one must take into consideration community morals and values.[9] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[10] lll. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[11] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[12] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[13] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[14] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. lV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[15] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[16] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[17] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[18] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[19] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[20] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[21] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. Vl. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[22] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[23] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[24] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. Vll. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [1] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [2] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [3] Moss, p. 1295-1298. [4] Moss, p. 1296. [5] Moss, p. 1295-1298. [6] Moss, p. 1295-1298. [7] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [8] Cohen, p. 1299-1301. [9] Moss, p. 1297. [10] Cohen, p. 1300. [11] Cappelen, p. 478-480. [12] Cappalen, p. 478-480. [13] Cappelen, p.479. [14] Cappelen, p. 479. [15] Cappelen, p. 479 [16] Cohen, p. 1301. [17] Cappelen, p. 478. [18] Cohen, p. 1299-1301. [19] Cohen, p. 1301. [20] Cappelen, p. 476-480. [21] Cappelen, p. 476-480. [22] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [23] Kawachi, p. 18-33. [24] Kawachi, p. 18-33.

Medical business ethics are the ethical principles and values that guide the conduct of business in healthcare.[1] Medicine is unique in the business sense because people tend to believe that patient outcomes should be the primary focus over monetary gains, such that a less lucrative course should be taken if it is better for the patient.[2] In interventional radiology (IR), concerns regarding medical business ethics often surround the relationships between IRs and industry partners, competition among providers, and other situations where there is lack of alignment between motivations to do what is best for one's patients, one's practice, and personal gains.

3. Highlight the strengths and future direction of endovascular robotics to reshape interventional therapy.

Medical trainees face unique challenges as they transition from medical outsiders to primary operators.[1] This tends to be a rapid socialization process where they are continually evolving both consciously and unconsciously to meet the demands of changing roles and expectations from service to service and team to team.[2] Likewise, the senior trainees and faculty responsible for training them face unique challenges poised between a need to educate and support the next generation of clinicians and not jeopardize patient care through the involvement of less experienced operators. The authors believe these collective set of unique dilemmas surrounding medical education can collectively be termed "medical trainee ethics"—what are the distinct set of values and virtues that govern acceptable behavior related to trainees' education and involvement in healthcare?

AIM: To characterise the current landscape of informed consent practices for image-guided procedures, including location of consent, guideline availability, and utility of decision-aid resources. MATERIALS AND METHODS: A survey of 159 interventional radiologists was conducted from April through June 2022. The survey evaluated participant demographics (gender, practice type, and level of training) and consent practices. Fifteen questions investigated discussion of benefits, risks, and alternatives, who obtained consent, location of consent conversations, how decision-making capacity is assessed, availability of formal guidance on consent discussions, and if and how decision-aids are used. RESULTS: Most respondents (93.7%) were "extremely" or "very" comfortable discussing the benefits and risks of image-guided procedures during informed consent. Most respondents were "very" comfortable discussing alternative treatments within radiology (86.8%) while fewer felt confident regarding alternatives outside radiology (46.5%). Most respondents indicated obtaining consent in a pre-procedure area (89.9%), while 12.7% of respondents obtained consent in the procedure room. Of the respondents, 66.7% did not have formal education or documented guidance on what providers should disclose during consent. Ninety-two respondents (57.9%) reported using decision aids. The type of decision aid varied, with most reporting using illustrations or drawings (46.6%). Decision aid utility was more prevalent in non-teaching/academic (71.4%) versus academic (61%) institutions (p1/40.02).CONCLUSION: Regardless of demographics, interventionalists are confident in discussing benefits, risks, and alternative image-guided therapies, but are less confident discussing alternative treatment options outside of radiology. Formal education on informed consent is less common, and the use of decision aids varies between teaching and non-teaching institutions.(c) 2023 Published by Elsevier Ltd on behalf of The Royal College of Radiologists.

Interventional radiologists (IRs) often care for critically ill patients, providing both treatment and palliation. For example, a recent study found that patients died within 30 days of 9% of inpatient image-guided procedures and within 6 months of 7% of outpatient image-guided procedures.[1] It is also not uncommon for these patients to have do not resuscitate and/or do not intubate (DNR/DNI) orders or other advance directives expressing patients' wishes to refuse resuscitation and/or intubation in the event of a cardiac arrest or the loss of a protected airway.[2] When asked to perform a procedure for these patients, IRs can face a few different ethical dilemmas: the patient may want to keep the DNR/DNI order in place for their procedure, the documented code status may conflict with patient or family preferences, or respecting such preferences in the face of a code can be disturbing for the IR and/or members of their team. This article considers each of these issues with suggestions of how to best navigate them.

The action potential (AP) waveform controls the opening of voltage-gated calcium channels and contributes to the driving force for calcium ion flux that triggers neurotransmission at presynaptic nerve terminals. Although the frog neuromuscular junction (NMJ) has long been a model synapse for the study of neurotransmission, its presynaptic AP waveform has never been directly studied, and thus the AP waveform shape and propagation through this long presynaptic nerve terminal are unknown. Using a fast voltage-sensitive dye, we have imaged the AP waveform from the presynaptic terminal of male and female frog NMJs and shown that the AP is very brief in duration and actively propagated along the entire length of the terminal. Furthermore, based on measured AP waveforms at different regions along the length of the nerve terminal, we show that the terminal is divided into three distinct electrical regions: A beginning region immediately after the last node of Ranvier where the AP is broadest, a middle region with a relatively consistent AP duration, and an end region near the tip of nerve terminal branches where the AP is briefer. We hypothesize that these measured changes in the AP waveform along the length of the motor nerve terminal may explain the proximal-distal gradient in transmitter release previously reported at the frog NMJ. SIGNIFICANCE STATEMENT The AP waveform plays an essential role in determining the behavior of neurotransmission at the presynaptic terminal. Although the frog NMJ is a model synapse for the study of synaptic transmission, there are many unknowns centered around the shape and propagation of its presynaptic AP waveform. Here, we demonstrate that the presynaptic terminal of the frog NMJ has a very brief AP waveform and that the motor nerve terminal contains three distinct electrical regions. We propose that the changes in the AP waveform as it propagates along the terminal can explain the proximal-distal gradient in transmitter release seen in electrophysiological studies.

The influence of antigenic stimulation on the early development of the “spontaneously” occurring (“background”) IgM-, IgG-, and IgA-secreting cells has been studied in mice. To evaluate the effect of such exogenous stimulation by an evolving microbial microflora. the young of BALB/c mice that were kept under germ-free conditions and fed a low molecular weight chemically defined synthetic diet (GF-CD) were compared with the young of conventional BALB/c mice fed natural ingredients (CV-NI). The young were first suckling maternal milk and between Days 15 and 18 changed to the same diet as their parents. Background Ig-secreting cells in the spleen were enumerated in the protein A plaque assay. The specificity repertoire of the IgM-secreting cells was determined with plaque assays specific for sheep red blood cells (SRBC) that were haptenized with different concentrations of nitroiodophenyl (NIP). 4-hydroxy-3.5-dinitrophenyl (NNP), and 2,4,6-trinitrophenyl (TNP). The results show that during the first few weeks of life the numbers of background IgM-, IgG-, and IgA-secreting cells in the spleen develop faster in CV-NI mice than in GF-CD mice. At 4 weeks of age equal numbers of IgM-and IgG-secreting cells were found in both groups of mice, but the number of IgA-secreting cells remained reduced in GF-CD mice during the whole period of observation. The frequencies of IgM-secreting cells specific for the differently haptenized SRBC were the same in both groups of mice during the observation period of 10 weeks. This suggests that the ontogenetic appearance of IgM-, IgG-, and IgA-secreting cells in the spleen, and the specificity repertoire of the IgM-secreting cells, as far as was tested in our panel, is independent of exogenous antigenic and/or mitogenic stimulation. However, during neonatal development the rate of development of the background Ig synthesis is enhanced by environmental antigenic stimulation.