Experiences and recommendations of veterinarians for the Dutch disciplinary system-a survey-based study

INTRODUCTION: In the Netherlands, the veterinary disciplinary system is governmentally executed and was originally designed to provide an educational effect on veterinarians as part of maintaining quality standards. METHODS: Over 900 veterinarians were questioned (20% of the total number of veterinarians working in veterinary medicine in the Netherlands). It was ascertained whether or not they were aware of the disciplinary system, if it affected their way of working and what impact it had on their way of working after having faced a disciplinary case. Respondents were given the opportunity to express their opinions about the system and possible improvements. RESULTS: The risk of complaints was found to be significantly greater when a veterinarian owned a practice compared to veterinarians who were employees. Veterinarians with their own practice were generally older (male) veterinarians. Whether this was a direct effect or just the effect of having a longer career could not be answered. Multiple disciplinary procedures appeared to have no influence. In 13%, veterinarians indicated that the disciplinary system had led to a more defensive way of practicing medicine to avoid complaints. DISCUSSION AND CONCLUSIONS: Most veterinarians supported a disciplinary system as a tool for maintaining and improving the integrity and reputation of the profession as a whole. Recommendations to improve were (1) shortening the length of the procedure, (2) screening for validity, (3) using online systems for communication with the disciplinary council, (4) the option of mediation before getting involved in a full procedure and (5) instituting a complaint fee

The views of farm animal veterinarians about their roles and responsibilities associated with on-farm end-of-life situations

Farm animal veterinarians are often involved in on-farm end-of-life (EoL) decisions and questions concerning euthanasia. These decisions can be challenging for the veterinarian, particularly if the interests of the animal and owner conflict. Moreover, the challenge is related to fundamental assumptions about roles and responsibilities veterinarians ascribe to themselves in EoL situations. Getting insight into what roles and responsibilities veterinarians perceive in these situations is important to understand the challenges veterinarians face and to explore ways to enable them to manage such situations. Existing literature and professional guidelines do not provide sufficient clarity and guidance in terms of the role conception and responsibilities of veterinarians in on-farm EoL situations. The objective of the current qualitative study was to better understand the views of farm animal veterinarians in the Netherlands regarding their roles and responsibilities associated with on-farm EoL situations. In-depth semi-structured interviews were conducted with 19 farm animal veterinarians. In terms of roles in EoL situations, our analysis shows that 1) seven roles can be distinguished based on the interviews, 2) two contextual dimensions influence role perception: a) the stage in which a veterinarian gets involved at the end of an animal’s life and b) the question of whose interests should be taken into consideration and how to prioritize (conflicting) interests by a veterinarian, 3) veterinarians enact a number of the identified roles and the combination of roles varies between individuals and 4) the individual veterinarian changes between roles depending on contextual aspects. In terms of responsibilities in EoL situations, analyses show that 1) individual veterinarians perceive a combination of five identified responsibilities, and 2) the perception of responsibilities relates predominantly to specific animal sectors. This insight into the roles and responsibility perceptions of veterinarians facilitates understanding the challenges veterinarians face in on-farm EoL situations and creates a starting point for how veterinarians can be supported to deal with potential conflicts of interest. These insights could also be valuable in the training of future veterinarians and lifelong learning of veterinarians as it provides a starting point to reflect on, and discuss, one’s role and responsibility in EoL situations

15 years of facts and figures on veterinary disciplinary measures in the Netherlands

In most countries, a veterinary disciplinary system is in force to ensure the quality of the veterinary profession and to offer an objective platform for complaints. We present an analysis of 15 years of veterinary disciplinary verdicts (2001-2016) to compare facts and figures and identify which factors are of major influence on the outcome of the verdicts. Rulings were collected from both paper files and the digital database of the veterinary disciplinary council (VDC), categorized, and used to create a database that enabled a statistical analysis. The results showed that complaints pertaining to companion animals are filed predominantly by owners, whereas complaints about livestock are mostly filed by the governmental civil servant (CS). CS complaints mostly address compliance issues. For the complaints made by owners (client complaints, CCs), reporting, communication, and veterinary mistakes appeared to be of statistical significance. Further studies are needed to investigate the impact of the complaints on veterinarians in general and how we can improve the veterinary disciplinary system

Coronary artery assessment by multidetector computed tomography in patients with prosthetic heart valves

Objectives Patients with prosthetic heart valves may require assessment for coronary artery disease. We assessed whether valve artefacts hamper coronary artery assessment by multidetector CT. Methods ECG-gated or -triggered CT angiograms were selected from our PACS archive based on the presence of prosthetic heart valves. The best systolic and diastolic axial reconstructions were selected for coronary assessment. Each present coronary segment was scored for the presence of valve-related artefacts prohibiting coronary artery assessment. Scoring was performed in consensus by two observers. Results Eighty-two CT angiograms were performed on a 64-slice ( = 27) or 256-slice ( = 55) multidetector CT. Eighty-nine valves and five annuloplasty rings were present. Forty-three out of 1160 (3.7%) present coronary artery segments were non-diagnostic due to valve artefacts (14/82 patients). Valve artefacts were located in right coronary artery (15/43; 35%), left anterior descending artery (2/43; 5%), circumflex artery (14/43; 32%) and marginal obtuse (12/43; 28%) segments. All cobalt-chrome containing valves caused artefacts prohibiting coronary assessment. Biological and titanium-containing valves did not cause artefacts except for three specific valve types. Conclusions Most commonly implanted prosthetic heart valves do not hamper coronary assessment on multidetector CT. Cobalt-chrome containing prosthetic heart valves preclude complete coronary artery assessment because of severe valve artefacts. Key Points Most commonly implanted prosthetic heart valves do not hamper coronary artery assessment Prosthetic heart valve composition determines the occurrence of prosthetic heart valve-related artefacts Bjork-Shiley and Sorin tilting disc valves preclude diagnostic coronary artery segment assessmen

Computed tomography segmental calcium score (SCS) to predict stenosis severity of calcified coronary lesions

To estimate the probability of ≥50 % coronary stenoses based on computed tomography (CT) segmental calcium score (SCS) and clinical factors. The Institutional Review Board approved the study. A training sample of 201 patients underwent CT calcium scoring and conventional coronary angiography (CCA). All patients consented to undergo CT before CCA after being informed of the additional radiation dose. SCS and calcification morphology were assessed in individual coronary segments. We explored the predictive value of patient’s symptoms, clinical history, SCS and calcification morphology. We developed a prediction model in the training sample based on these variables then tested it in an independent test sample. The odds ratio (OR) for ≥50 % coronary stenosis was 1.8-fold greater (p = 0.006) in patients with typical chest pain, twofold (p = 0.014) greater in patients with acute coronary syndromes, twofold greater (p < 0.001) in patients with prior myocardial infarction. Spotty calcifications had an OR for ≥50 % stenosis 2.3-fold (p < 0.001) greater than the absence of calcifications, wide calcifications 2.7-fold (p < 0.001) greater, diffuse calcifications 4.6-fold (p < 0.001) greater. In middle segments, each unit of SCS had an OR 1.2-fold (p < 0.001) greater than in distal segments; in proximal segments the OR was 1.1-fold greater (p = 0.021). The ROC curve area of the prediction model was 0.795 (0.95 confidence interval 0.602–0.843). Validation in a test sample of 201 independent patients showed consistent diagnostic performance. In conjunction with calcification morphology, anatomical location, patient’s symptoms and clinical history, SCS can be helpful to estimate the probability of ≥50 % coronary stenosis

Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data

OBJECTIVE: To determine whether coronary computed tomography angiography (CTA) should be performed in patients with any clinical probability of coronary artery disease (CAD), and whether the diagnostic performance differs between subgroups of patients. DESIGN: Prospectively designed meta-analysis of individual patient data from prospective diagnostic accuracy studies. DATA SOURCES: Medline, Embase, and Web of Science for published studies. Unpublished studies were identified via direct contact with participating investigators. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Prospective diagnostic accuracy studies that compared coronary CTA with coronary angiography as the reference standard, using at least a 50% diameter reduction as a cutoff value for obstructive CAD. All patients needed to have a clinical indication for coronary angiography due to suspected CAD, and both tests had to be performed in all patients. Results had to be provided using 2×2 or 3×2 cross tabulations for the comparison of CTA with coronary angiography. Primary outcomes were the positive and negative predictive values of CTA as a function of clinical pretest probability of obstructive CAD, analysed by a generalised linear mixed model; calculations were performed including and excluding non-diagnostic CTA results. The no-treat/treat threshold model was used to determine the range of appropriate pretest probabilities for CTA. The threshold model was based on obtained post-test probabilities of less than 15% in case of negative CTA and above 50% in case of positive CTA. Sex, angina pectoris type, age, and number of computed tomography detector rows were used as clinical variables to analyse the diagnostic performance in relevant subgroups. RESULTS: Individual patient data from 5332 patients from 65 prospective diagnostic accuracy studies were retrieved. For a pretest probability range of 7-67%, the treat threshold of more than 50% and the no-treat threshold of less than 15% post-test probability were obtained using CTA. At a pretest probability of 7%, the positive predictive value of CTA was 50.9% (95% confidence interval 43.3% to 57.7%) and the negative predictive value of CTA was 97.8% (96.4% to 98.7%); corresponding values at a pretest probability of 67% were 82.7% (78.3% to 86.2%) and 85.0% (80.2% to 88.9%), respectively. The overall sensitivity of CTA was 95.2% (92.6% to 96.9%) and the specificity was 79.2% (74.9% to 82.9%). CTA using more than 64 detector rows was associated with a higher empirical sensitivity than CTA using up to 64 rows (93.4% v 86.5%, P=0.002) and specificity (84.4% v 72.6%, P<0.001). The area under the receiver-operating-characteristic curve for CTA was 0.897 (0.889 to 0.906), and the diagnostic performance of CTA was slightly lower in women than in with men (area under the curve 0.874 (0.858 to 0.890) v 0.907 (0.897 to 0.916), P<0.001). The diagnostic performance of CTA was slightly lower in patients older than 75 (0.864 (0.834 to 0.894), P=0.018 v all other age groups) and was not significantly influenced by angina pectoris type (typical angina 0.895 (0.873 to 0.917), atypical angina 0.898 (0.884 to 0.913), non-anginal chest pain 0.884 (0.870 to 0.899), other chest discomfort 0.915 (0.897 to 0.934)). CONCLUSIONS: In a no-treat/treat threshold model, the diagnosis of obstructive CAD using coronary CTA in patients with stable chest pain was most accurate when the clinical pretest probability was between 7% and 67%. Performance of CTA was not influenced by the angina pectoris type and was slightly higher in men and lower in older patients. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42012002780

Prevalence of anatomical variants and coronary anomalies in 543 consecutive patients studied with 64-slice CT coronary angiography

The aim of our study was to assess the prevalence of variants and anomalies of the coronary artery tree in patients who underwent 64-slice computed tomography coronary angiography (CT-CA) for suspected or known coronary artery disease. A total of 543 patients (389 male, mean age 60.5 ± 10.9) were reviewed for coronary artery variants and anomalies including post-processing tools. The majority of segments were identified according to the American Heart Association scheme. The coronary dominance pattern results were: right, 86.6%; left, 9.2%; balanced, 4.2%. The left main coronary artery had a mean length of 112 ± 55 mm. The intermediate branch was present in the 21.9%. A variable number of diagonals (one, 25%; two, 49.7%; more than two, 24%; none, 1.3%) and marginals (one, 35.2%; two, 46.2%; more than two, 18%; none, 0.6%) was visualized. Furthermore, CT-CA may visualize smaller branches such as the conus branch artery (98%), the sinus node artery (91.6%), and the septal branches (93%). Single or associated coronary anomalies occurred in 18.4% of the patients, with the following distribution: 43 anomalies of origin and course, 68 intrinsic anomalies (59 myocardial bridging, nine aneurisms), three fistulas. In conclusion, 64-slice CT-CA provides optimal visualization of the variable and complex anatomy of coronary arteries because of the improved isotropic spatial resolution and flexible post-processing tool

Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: Meta-analysis of individual patient data

Objective To determine whether coronary computed tomography angiography (CTA) should be performed in patients with any clinical probability of coronary artery disease (CAD), and whether the diagnostic performance differs between subgroups of patients. Design Prospectively designed meta-analysis of individual patient data from prospective diagnostic accuracy studies. Data sources Medline, Embase, and Web of Science for published studies. Unpublished studies were identified via direct contact with participating investigators. Eligibility criteria for selecting studies Prospective diagnostic accuracy studies that compared coronary CTA with coronary angiography as the reference standard, using at least a 50% diameter reduction as a cutoff value for obstructive CAD. All patients needed to have a clinical indication for coronary angiography due to suspected CAD, and both tests had to be performed in all patients. Results had to be provided using 2×2 or 3×2 cross tabulations for the comparison of CTA with coronary angiography. Primary outcomes were the positive and negative predictive values of CTA as a function of clinical pretest probability of obstructive CAD, analysed by a generalised linear mixed model; calculations were performed including and excluding non-diagnostic CTA results. The no-treat/treat threshold model was used to determine the range of appropriate pretest probabilities for CTA. The threshold model was based on obtained post-test probabilities of less than 15% in case of negative CTA and above 50% in case of positive CTA. Sex, angina pectoris type, age, and number of computed tomography detector rows were used as clinical variables to analyse the diagnostic performance in relevant subgroups. Results Individual patient data from 5332 patients from 65 prospective diagnostic accuracy studies were retrieved. For a pretest probability range of 7-67%, the treat threshold of more than 50% and the no-treat threshold of less than 15% post-test probability were obtained using CTA. At a pretest probability of 7%, the positive predictive value of CTA was 50.9% (95% confidence interval 43.3% to 57.7%) and the negative predictive value of CTA was 97.8% (96.4% to 98.7%); corresponding values at a pretest probability of 67% were 82.7% (78.3% to 86.2%) and 85.0% (80.2% to 88.9%), respectively. The overall sensitivity of CTA was 95.2% (92.6% to 96.9%) and the specificity was 79.2% (74.9% to 82.9%). CTA using more than 64 detector rows was associated with a higher empirical sensitivity than CTA using up to 64 rows (93.4% v 86.5%, P=0.002) and specificity (84.4% v 72.6%, P<0.001). The area under the receiver-operating-characteristic curve for CTA was 0.897 (0.889 to 0.906), and the diagnostic performance of CTA was slightly lower in women than in with men (area under the curve 0.874 (0.858 to 0.890) v 0.907 (0.897 to 0.916), P<0.001). The diagnostic performance of CTA was slightly lower in patients older than 75 (0.864 (0.834 to 0.894), P=0.018 v all other age groups) and was not significantly influenced by angina pectoris type (typical angina 0.895 (0.873 to 0.917), atypical angina 0.898 (0.884 to 0.913), non-anginal chest pain 0.884 (0.870 to 0.899), other chest discomfort 0.915 (0.897 to 0.934)). Conclusions In a no-treat/treat threshold model, the diagnosis of obstructive CAD using coronary CTA in patients with stable chest pain was most accurate when the clinical pretest probability was between 7% and 67%. Performance of CTA was not influenced by the angina pectoris type and was slightly higher in men and lower in older patients. Systematic review registration PROSPERO CRD42012002780

The views of farm animal veterinarians about their roles and responsibilities associated with on-farm end-of-life situations

Farm animal veterinarians are often involved in on-farm end-of-life (EoL) decisions and questions concerning euthanasia. These decisions can be challenging for the veterinarian, particularly if the interests of the animal and owner conflict. Moreover, the challenge is related to fundamental assumptions about roles and responsibilities veterinarians ascribe to themselves in EoL situations. Getting insight into what roles and responsibilities veterinarians perceive in these situations is important to understand the challenges veterinarians face and to explore ways to enable them to manage such situations. Existing literature and professional guidelines do not provide sufficient clarity and guidance in terms of the role conception and responsibilities of veterinarians in on-farm EoL situations. The objective of the current qualitative study was to better understand the views of farm animal veterinarians in the Netherlands regarding their roles and responsibilities associated with on-farm EoL situations. In-depth semi-structured interviews were conducted with 19 farm animal veterinarians. In terms of roles in EoL situations, our analysis shows that 1) seven roles can be distinguished based on the interviews, 2) two contextual dimensions influence role perception: a) the stage in which a veterinarian gets involved at the end of an animal’s life and b) the question of whose interests should be taken into consideration and how to prioritize (conflicting) interests by a veterinarian, 3) veterinarians enact a number of the identified roles and the combination of roles varies between individuals and 4) the individual veterinarian changes between roles depending on contextual aspects. In terms of responsibilities in EoL situations, analyses show that 1) individual veterinarians perceive a combination of five identified responsibilities, and 2) the perception of responsibilities relates predominantly to specific animal sectors. This insight into the roles and responsibility perceptions of veterinarians facilitates understanding the challenges veterinarians face in on-farm EoL situations and creates a starting point for how veterinarians can be supported to deal with potential conflicts of interest. These insights could also be valuable in the training of future veterinarians and lifelong learning of veterinarians as it provides a starting point to reflect on, and discuss, one’s role and responsibility in EoL situations