Veterinary Medical Specialization: Bridging Science and Medicine Volume 39 doc

Advances in Veterinary Science and Comparative Medicine Volume 39 Veterinary Medical Specialization: Bridging Science and Medicine Advances in Veterinary Science and Comparative Medicine Edited by Dr W Jean Dodds HEMOPET Santa Monica, California Advisory Board Kenneth C Bove( William S Dernell Carlton Gyles Robert O Jacoby Ann B Kier Raymond F Nachreiner Carl A Osborne Fred W Quimby Alan H Rebar Ronald D Schultz Advances in Veterinary Science and Comparative Medicine Volume 39 Veterinary Medical Specialization: Bridging Science and Medicine E d i t e d by W Jean Dodds Hemopet Santa Monica, California Academic Press San Diego New York Boston London Sydney Tokyo Toronto This book is printed on acid-free paper @ Copyright 1995 by ACADEMIC PRESS, INC All Rights Reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher Academic Press, Inc A Division of Harcourt Brace & Company 525 B Street, Suite 1900, San Diego, California 92101-4495 United Kingdom Edition published by Academic Press Limited 24-28 Oval Road, London NWI 7DX International Standard Serial Number: 0065-35 19 International Standard Book Number: 0-12-039240-2 PRINTED IN THE UNITED STATES OF AMERICA 95 96 9 99 0 E B CONTENTS CONTRIBUTORS PREFACE vii ix Overview: Bridging Basic Science and Clinical Medicine W J E A N DODDS I Background 11 Emergence of Veterinary Medical Specialization 111 Recommendations for the Future References 21 24 Estimating Disease Prevalence with Health Surveys and Genetic Screening W J E A N DODDS I IT 111 IV Background Health Surveys Current and Future Trends Recommendations References Thyroiditis-A 90 Model Canine Autoimmune Disease GEORGE HAPP M I Introduction and Background 11 Molecular Basis of Autoimmunity-The Failure of Self-Tolerance 111 Screening for Canine Genes That Might Predispose toward Thyroiditis IV Models of Autoimmune Disease V 97 102 108 113 vi CONTENTS V Autoimmune Thyroiditis in Humans and Animals VI Future Research Applications References 115 123 127 Ve t e rin ar y M e di c a1 Sp e c i ali z ati on CLINTON LOTHROP, R D J I Historical Reference to Human Medicine 11 Early Development of Veterinary Specialization 111 Future Trends and Recommendations References Appendix 141 143 153 160 163 Standards for Veterinary Clinical Trials DAWN BOOTHE N D MARGARET SLATER M A R I 11 111 IV V VI VII Introduction History of Clinical Trials in Human Medicine Early Veterinary Clinical Trials Designing Proper Clinical Trials Ethical Considerations in Clinical Trials Current Status of Clinical Trials in Veter Recommendations References 191 202 234 242 249 250 Benefits and Burdens: Legal and Ethical Issues Raised by Veterinary Specialization JERROLD TANNENBAUM I Veterinary Specialization and the Law 11 Ethical Issues Raised by Veterinary Specialization 111 Some Legal and Ethical Issues in Innovative Therapies and Clinical Trials IV Conclusion: Recommendations for the Future References INDEX 254 276 287 293 295 297 CONTRIBUTORS Numbers in parentheses indicate the pages on which the authors' contributions begin DAWN M BOOTHE, Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine, Texas A&M University, College Station, Texas 77843 (191) W JEAN DODDS,Hemopet, Santa Monica, California 90403 (1, 29) GEORGE M HAPP, Department of Biology, University of Vermont, Burlington, Vermont 05405 (97) CLINTON D LOTHROPJR., Scott-Ritchey Research Center and Department of Small Animal Surgery, College of Veterinary Medicine, Auburn University, Auburn, Alabama 36849 (141) MARGARET R SLATER, Department of Veterinary Anatomy and Public Health, College of Veterinary Medicine, Texas A&M University, College Station, Texas 77843 (191) Department of Environmental Studies, Tufts University School of Veterinary Medicine, North Grafton, Massachusetts 01536 (254) JERROLD TANNENBAUM, vii This Page Intentionally Left Blank PREFACE This volume is the first of the series for which I am privileged to serve in the capacity of Series Editor The subject, veterinary medical specialization, is the bridge between practicing clinical veterinarians and academic scientists that generates new knowledge to further the art of veterinary medicine Of course, much of the scientific discovery that benefits animal medicine is derived from the basic and applied sciences with the original purpose of benefitting human health This often includes biomedical research on animals along with in vitro alternatives to animal testing Much of the information gathered from the biomedical research effort can be applied equally to human and veterinary medicine It is not surprising that the veterinary profession has evolved a series of subspecialties over the past two decades that parallels specialization in h u m a n medicine This follows the explosion of knowledge in basic science and medicine from the 1960s to the era of molecular biology and gene therapy we have entered today My own career, which spans 30 years, attests to this change As a biomedical scientist who developed an interest and expertise in comparative hemostasis, I have seen the field develop from a clinical specialty with rather unsophisticated techniques for manually monitoring whole blood coagulation activity in glass and silicone-coated test tubes to the most advanced applications of biochemical and molecular techniques Today, scientists working in academia and private industry are cloning the genes that produce individual coagulation factors and sequencing the gene products They can even manipulate experimental animals through gene therapy to correct inherited bleeding disorders Coagulation factor concentrates are routinely produced by recombinant technology for treatment of diseases such as hemophilia to avoid the serious risk of transfusion-transmitted disease associated with the use of blood plasma concentrates To be able to see a particular medical specialty evolve during my career has been a stimulating and challenging experience During this time, scientific advances in hemostasis research have been translated ix 290 JERROLD T ~ i ~ ] ~ / ~ A veterinary specialist should ~i~]iĐ~ ~ifi irtfiO~iti~ÂOI}i~o~ttt]tlrefor a ~fiditi0~ 0nly if ther~ i~ ~o ~ffee~i¥~ ~uS~0~ai~y l ~ f ~ d u ~ foI~ d~al~ in~ ~ith this c0~dition dure 0niy if ~eiiabie data or inf0rmatiofi jti~tifle~ the condusi6fi tha~ the pi'ocedure might benefit the patient, and is no less likely to benefit the patient than a customary procediii~e Although data relevant to the scientific validity arid ~ff~e~iveness of the procedure can result from the recommended t~atm~fi~, rio i ~ o vative treatment should be performed in order to obtaiii such {]a~a, Benefiting the patient muSf b~ tl~B ~ r ~ t i ~ ~fi~ati0ti The client must exercise an informed c~nsefit ~0 th~ ~}f0e~t]~i~o, This means that the client must understand[ t ~ fi~ffif~ ~i~fh~ p ~ ~ dure, the nature and likely consequences of any other available proCe~ dures, the potential known risks of the procedure to the life and quality of life of the patient, the possibility of unknown risks if the C~h~equences of the procedure are especially unpredictable, and the f/i~ thfit this is an innovative procedure Although ~he law never requires authorizations by clients to be in writing, f~e ~ore innovative, complex, or risky the procedure, the greater the reason to have the client sign a written consent~not just to protect the doctor but to assure that the client's consent is made knowingly and voluntari][~: Except in extreme or unusual circumstances (e.g., in an emergency where a customary therapy would clearly be ineffective) generalists should not attempt innovative therapy without consulting with or referring the case to a specialist As a rule, specialists are more likely than generalists to know whether there already exists a potentially effective innovative procedure and whether a proposed inno~titi~¢~ pro-cedtire is likely to benefit the patient B, I~S~ES IN ACADEMIC VETERINARY MEDICINE Clinician members oi~veterinary school i'acultie~, most of whom are specialists, sometimes confront situations in which the ethical dilemmas posed by innovative procedures are intensi~d Ae~domi~ ~linicians often view as part of their function the finding of bett~i'~ l tii~ovative p~0eedures and the discovery of data regarding the effecti~efi~ of innovative pr0cedUr~s Academic veterinariang ~ill s o ~ t i m ~ se~ a patient as a eahdidate for a different medical 0~ s~t~ie~i ti~i'oach~ when a specialist in private p~actice who may await reports of l~flovative pi'ocedures by academic clinicians in tii~ joa~fials •ight not, The development of new treatments and techniques by speciaiist~ LEGAL AND ETHICAL ISSUES 291 in academic pr~t~c~ J~ ~sse~t~al for progress in veterinary medicine Therefore, academic veterinarians sometimes have a legitimate interest in recommending innovative procedures, and one reason it can be morally correct to perform such a procedure is that other animals and client~ may benefit from it Difficult ethical i~sues arise if the patient may experience distress or discomfort as ~ :result of the innovative proceduro, ~ith~r b ~ c a ~ it i~ not clear any treatment will help or because the p~oaed~re it~¢|f might ~Ou~ ~0re distress than would an existing customary one Also relevant is the fairness of a treatment that might cost the client more than a customary approach (such as euthanasia) and that ~ aimed at obtaining future benefits for other patient~ ~nd z!~ients For academic veterinarians engaged in the search for innovative proc~dqres, ! reiterate the five principles suggested above and would ~dcl the fo!!ow|ng remarks Clinicians must resist the temptation to pormit a de$ir~ to find innovative procedures or to evaluate a particular innovative procedure to lead them to ignore or disfavor a customary treatment that will likely be more beneficial to this patient Clients should always be informed when part of the clinician's motivation for recommending an innovative approach is to gather data that could be beneficial to other patients and clients Clients should be informed whether this procedure is likely to be more distressful to the patient or more costly than a customary procedure or another possible innovative procedure, Interns or residents who are required as part of their academic program to present or publish clinical research reports must never perform procedures based on their own educational interests rather than the needs of the patient and client C FROM INNOVATIVE THERAPY TO CLINICAL TRIALS" THE PATIENT AS MEANS RATHER THAN END? The use of an innovative procedure on a particular patient can eventuate in a clinical trial to test the procedure more rigorously by utilizing a statistically significant number of animals Conversely, practitioners may begin using an innovative approach after the completion of a clinical trial of the approach Clinical trials differ from innovative therapy in that the former involve, by definition, procedures that are part of a larger, systematic effort to test a scientific or medical hypothesis Clinical trials, especially randomized clinical trials (RCTs) in which subjects are assigned at random to experimental and control groups, have led to considerable controversy in human medicine (Levine, 1986) Among the many ethical questions that can be asked about 292 JERROLD TANNENBAUM clinical trials in h u m a n or veterinary medicine are when it is appropriate to begin a trial (e.g., whether a trial can ever be justified when there already exists an effective treatment); how far a trial should proceed when it becomes apparent that the treatment being evaluated will not work; whether a patient doing poorly should be removed from the experiment if some other treatment would benefit it more; whether subjects in control groups can be removed from the group and treated if it becomes clear that a treatment under investigation is effective; to what extent placebos may be ethically justifiable; and whether it is appropriate to charge clients for the trial or medical care necessitated by it Ethical issues raised by full-scale clinical trials are discussed in Chapter This chapter focuses on legal and ethical questions relating to specialization faced more commonly in practice by veterinarians, few of whom engage in conducting clinical trials Nevertheless, it is useful here to highlight the most serious ethical problem in clinical trials As has been discussed, this problem is already faced by specialists contemplating innovative therapies By looking at this problem in the context of clinical trials, one can appreciate more clearly why it is of crucial importance whenever an innovative procedure is considered The major ethical problem in clinical trials, and especially RCTs, is that helping the patient (and in veterinary medicine the client as well) is no longer the sole focus of the practitioner The patient is also a vehicle for achieving another goal: the testing of a procedure, product, or scientific hypothesis Philosopher Charles Fried has argued (Fried, 1974) that h u m a n RCTs deprive patients of one of the central values in the doctor-patient relationship: the "good of personal care." Medical patients believe that their doctor is loyal to them and their interests, and only to their needs and interests As Fried observes, RTCs deviate from this assumption, even when laws require that physicians who conduct such trials inform patients that part of the purpose of the investigation is to gather information of potential benefit to others Like h u m a n medical patients, veterinary clients assume that their practitioner will be loyal to them (Tannenbaum, 1995) This is why it is profoundly unethical for a veterinarian to utilize an innovative procedure on a patient without informing the client, and without assuring both himself and the client that the procedure is appropriate for this patient Innovative veterinary procedures pose the risk that the desire to obtain useful information will compromise the loyalty assumed by the client Full-scale clinical trials pose this risk even more strongly because they involve treating each patient as a vehicle to obtain benefits for other patients or other clients LEGAL AND ETHICAL ISSUES 293 However defensible they might sometimes be, clinical trials, like innovative procedures, raise a warning for all veterinarians: in the typical professional relationship, in which a client brings a patient to you for its care, both the law and the fundamental principles of normative ethics assume that your sole aim is to serve the patient and client before you If you deviate from this goal without good medical justification, and without full disclosure to the client and informed consent by the client, you endanger the good of personal care and proceed at your legal peril IV Conclusion: R e c o m m e n d a t i o n s for the Future Legal and ethical issues raised by veterinary specialization cannot be eliminated or made easy The more specialization can provide effective treatments, the more generalists will have to know when they should refer to specialists; the more specialists and generalists will have to cooperate in the overall care of patients; and the more specialists will be able to offer complex, expensive, and innovative procedures A key element in all these legal and ethical issues is the importance and value of animals The law would not obligate generalists to refer patients to specialists unless people thought that animals can merit specialty veterinary care in the first place Nor would anyone be troubled about the morality of subjecting animals to difficult advanced t r e a t m e n t s unless it was believed that they deserve not to suffer unjustifiable pain or distress Specialization generates legal and ethical questions not just because specialists develop advanced procedures that themselves raise ethical questions Specialization also plays a central role in the elevation of the value of veterinary patients As specialization makes possible more effective veterinary care, clients become more eager to obtain such care The very ability to help an animal one wants to value allows the emotional or economic bonds to strengthen and grow These bonds nourish the demand for advanced veterinary services, which in turn, drives the profession to provide them As veterinary patients are valued ever more highly, the more the law will seek to protect them and their owners, and the more doctors and clients will be compelled to confront difficult ethical dilemmas The following recommendations are offered to assist veterinarians to prepare for the inescapable legal and ethical problems associated with specialization 294 JERROLD TANNENBAUM All veterinarians must appreciate that advances in veterinary medicine, often developed by the specialties, generate difficult legal and moral questions All veterinarians should make the continuing study of veterinary law and ethics an important part of their professional activity State veterinary licensing boards should prevent false, deceptive, and misleading representations about specialization by generalists and specialists States that not have explicit regulations prohibiting generalists from representing themselves as specialists should adopt and enforce such rules The boards should also guard against statements by specialists or facilities employing specialists that falsely claim the superiority of specialty over general care Generalists should strive to keep current with advances in the specialties so that they know when cases should be referred and when a new or advanced procedure is appropriately done, or expected, in general practice States that not yet require continuing education as a condition of licensure should so, and the licensing boards should encourage all doctors to attend education sessions that will keep them informed about developments in the specialties Specialists who give instructional talks at continuing education classes or professional meetings should make clear when they are informing generalists about the latest developments in their specialty, when they are indicating conditions for which a referral is advisable, and when they are describing techniques appropriate for general practice The process of the recognition of new specialties must include consideration of legal burdens such recognition can impose on generalists Qualified candidates for certification must never be subjected to exclusionary barriers that can have the effect of protecting someone else's income or professional status To protect the public, animals, specialists, and generalists, groups of practitioners should be recognized by the AVMA as specialties only if they provide services that are distinctive in some way from those provided by generalists or existing specialties The veterinary profession should engage in serious discussion of legal and ethical problems presented by innovative therapies and clinical trials There is nothing in the Principles of Veterinary Medical Ethics that addresses this topic By contrast, there is an extensive and growing literature relating to experimentation in human medicine, and the medical profession has authored several official ethical codes and guidelines dealing with experimentation on human subjects (Capron, 1986; Annas and Grodin, 1992) The importance of their patients requires that veterinarians also deliberate seriously about how the LEGAL AND ETHICAL ISSUES 295 need to develop newer, more effective therapies can be reconciled with the interests of c u r r e n t p a t i e n t s and clients REFERENCES American Dental Association (1989) "Rebate and split-fees," Principles of ethics and code of professional conduct In "Codes of Professional Responsibility," 2nd ed (R A Gorlin, Ed.), p 163 Bureau of National Affairs, Washington, DC American Medical Association (1989) "Fee-splitting," Principles of medical ethics and current opinions of the Council on Ethical and Judicial Affairs In "Codes of Professional Responsibility," 2nd ed (R A Gorlin, Ed.), p 211 Bureau of National Affairs, Washington, DC American Medical Association Law Department (1957) "Advisory Opinion: American Medical Association Principles of Medical Ethics" (pamphlet) Chicago American Psychiatric Association (1981) "Section 2," Principles of medical ethics with annotations especially applicable to psychiatry In "Codes of Professional Responsibility," 2nd ed (R A Gorlin, Ed.), p 241 Bureau of National Affairs, Washington, DC American Veterinary Medical Association (1995) Guidelines on alternative therapies In "AVMA Directory," 44th ed., p 52 Schaumburg, IL American Veterinary Medical Association (1995) Guidelines for use of specialty titles In "AVMA Directory," 44th ed., p 86 Schaumburg, IL Ames, E R (1993a) Specialty credentialing: Ensuring fairness and reasonability J A m Vet Med Assoc 202, 519 Ames, E R (1993b) Specialties in behavior and feline practice approved by ABVS J A m Vet Med Assoc 202, 1797 Ames, E R (1995) Specialty board continues recognitions J Am Vet Med Assoc 20{}, 1297 Annas, G J., and Grodin, M A (1992) "The Nazi Doctors and the Nuremberg Code." Oxford Univ Press, New York AVMA Directory (1995a) American Veterinary Medical Association, pp 52-92 Schaumburg, IL AVMA Directory (1995b) American Veterinary Medical Association, pp 241-245 Schaumburg, IL AVMA Principles (1988) "Professional relationships with new clients," Principles of veterinary medical ethics [pamphlet] American Veterinary Medical Association, Schaumburg, IL AVMA Principles (1990) " Fees for service," Principles of veterinary medical ethics [pamphlet] American Veterinary Medical Association, Schaumburg, IL AVMA Principles (1994) "Referrals, consulations, and relationships with clients," Principles of veterinary medical ethics (pamphlet) American Veterinary Medical Association, Schaumburg, IL Bates v State Bar of Arizona 433 U.S 350 (1977) Board of Medical Registration v Kaadt, 76 N.E.2d 689 (Ind 1948) Brook v St John's Hickey Memorial Hospital, 368 N.E.2d 264 (Ind Ct App 1st Dist 1977), appeal after remand, 380 N.E.2d 72 (Ind 1978) Capron, A (1986) Human experimentation In "Biolaw," (J Childress, P King, K Rothenberg, W Wadlington, and R Gaare, eds.), pp 217-252 University Publications of America, Frederick, MD 296 JERROLD TANNENBAUM Council Recommends Revision of Commission and Rebate Principle (1993) J A m Vet Med Assoc 202, 1799 Fried, C (1974) "Medical Experimentation: Personal Integrity and Social Policy." American Elsevier, New York Gelatt, K (1993) Letter: Ophthalmologists Need to Focus on Extra-Label Drug Use Initiative J A m Vet Med Assoc 203, 497 Levine, R J (1986) "Ethics and Regulation of Clinical Research," 2nd ed Urban & Schwarzenberg, Baltimore, MD Rhodes, M A (1989) Recent trends and new causes of action In "Medical Malpractice, Release 29" (D W Louisell and H Williams, Eds.), pp - - - , Bender, New York Tannenbaum, J (1993a) Ethics: The why and wherefore of veterinary law Vet Clin N America: Sm A n i m a l Pract 23, 921-935 Tannenbaum, J (1993b) Veterinary medical ethics: A focus of conflicting interests J Soc Issues 49, 143-155 Tannenbaum, J (1995) "Veterinary Ethics: Animal Welfare, Client Relations, Competition and Collegiality," 2nd ed Mosby-Year Book, St Louis, MO Trantafello v Medical Center of Tarzana, 182 Cal App 3d (1986) Valentine v Kaiser Foundation Hospital, 15 Cal Rptr 26 (Dist Ct App., 1st Dist 1961), disapproved on other grounds, Siverson v Weber, 23 Cal.Rptr 337, 372 P.2d 97 Waltz, J R., and Inbau, F E (1971) "Medical Jurisprudence," pp 179-202 Macmillan, New York Zeller v Greater Baltimore Medical Center, 506 A.2d 646 (Md App 1986) 7physician who had completed one-third of his residency training held to the higher specialty standard in lawsuit alleging negligence arising out of defendant's performance of a circumcision operation, which led to gangrene and the necessity of removal of the patient's glans penis The court held that the defendant had "held himself out as a specialist" by virtue of his having performed between six and eight hundred such operations and his own testimony that he considered his residency a program one in which he "specialized" in these procedures Index Animal welfare, see also Ethics clinical trials experimental animals, 235-236 quality of life, 222 Antigens canine thyroid disease model characteristics, 119-121 von Willebrand factor, in Irish wolfhounds, 67-70 Antioxidants, synthetic, immune system effects, 12-15 Autoimmune disease, see Thyroiditis Basenjis, disease prevalence, 72-74 Bearded collies, disease prevalence, 6264 Behavior problems, prevalence, Old English sheepdogs, 56 Biochemical markers, disease recognition, 83-87 Bleeding disorders, prevalence, Old English sheepdogs, 59-60 Blood diseases, prevalence, Old English sheepdogs, 59 Bone disorders, prevalence, Old English sheepdogs, 48 Bovine granulocytopathy, future specialization trends, 154-155 Cancer, prevalence, Old English sheepdogs, 50 Canines, see also specific b r e e d s thyroid disease model, 97-127 disease characteristics, 115-123 autoantigens, 119-121 disease process, 117-119 environmental factors, 122-123 major histocompatibility complex polymorphism, 121-122 normal thyroid, 115-117 T-cell receptor polymorphism, 121122 future research applications, 123127 autoimmune pathogenesis, 126 breed improvement, 124-125 diagnostic criteria improvement, 124 DLA histotyping, 123-124 endangered species, 125 genetic defect correction, 126 therapeutic immunosuppression, 125-126 genetic screening, 108-113 immunogenetics, 108-109 major histocompatibility complex genes, 109-113 IDDM model, 113-115 overview, 97-102 self-tolerance failure, 102-108 HLA gene polymorphism, 105-108 major histocompatibility complex genes, 102-105 T-cell receptor complex, 102-108 Chronic infections, prevalence, Old English sheepdogs, 50-52 Clinical medicine basic science bridge, 1-24 future recommendations, 21-24 gene therapy, 22-23 297 298 INDEX molecular approaches, 22-23 research funding, 23-24 research integration, 21-22 historical overview, 1-3 animal research, 1-2 early practices, 2-3 specialization, see Specialization Clinical trials basic science bridge future recommendations funding, 23-24 integration, 21-22 historical overview, animal research, 1-2 current status, 242-249 five-year study, 242-246 assessment, 246 methodology deficiencies, 245 reporting deficiencies, 245-246 summary, 243-245 single issue review, 247-249 design strategies, 202-234 data analysis, 226-229 analytical methods, 228-229 exclusions, 227-228 withdrawals, 227-228 data reporting, 229-234 publication, 229-233 trial review, 233-234 follow-up, 220-226 adverse effects, 221-222 closeout, 225-226 data collection, 223-224 data monitoring, 225 losses, 225 outcome measurements, 220-221 post-trial follow-up, 226 quality of life, 222 subject compliance, 223 trial length, 225 intervention design, 211-220 bias control, 211-219 dosing regimen, 219-220 question proposal, 202-205 objectives, 202-203 planning, 203-205 study group selection, 205-211 inclusion criteria, 208-209 power estimates, 209-211 recruitment methods, 206-208 sample size, 209-211 ethics, 234-242 animal welfare, 222, 235-236 human subject rights, 234-235 informed consent, 238-242 history human medicine, 193-197 veterinary medicine, 197-202 legal issues, innovative therapies, 287293 academic medicine, 290-291 liability, 287-290 patient rights, 291-293 overview, 191-193 recommendations, 249-250 Consultations, specialization legal issues, 267-268 Dalmatians, disease prevalence, 79-82 deafness, 80-82 urate urolithiasis, 79-80 Data analysis, see Clinical trials Deafness, prevalence, dalmatians, 80-82 Disease, see also specific d i s e a s e biochemical markers, 83-87 molecular genetic markers, 87-88 physical characteristics, 82-83 prevalence estimation, see Health surveys registries, 89-90 DLA genes diversity, 125 histotyping, 123-124 types, 124 Dogs, see Canines; specific b r e e d s Dosing regimens, clinical trial design, 219-220 Endangered species, future research applications, 125 Endocrine disease, prevalence, Old English sheepdogs, 59 299 INDEX Ethics animal welfare, 222, 235-236 human subject rights, 234-235 informed consent, 238-242 specialization, 276-287 euthanasia, 286-287 fees, 285-286 general practitioner relationship, 27~ 284 cOn~l~etition, 283-284 critic~m~ 281-283 fee-splitt~ng~ 279-280 patient retentior~, 280-281 overview, 277-279 service overutilization, 284-285 Euthanasia, ethical issues, 286-287 Eye diseases, prevalence, Old English sheepdogs, 50 Fees, ethical issues f~'6~-~plitting, 279-280 speciaiiz~i~iort~ 255-286 (}a~trointestinal disorders, prevalence, Old English sheepdogs, 60-61 General practitioners, specialist relationship ethical issues, 279 -284 competition, 283-284 criticism, 281-283 fee-splitting, 279-280 patient retention, 280-281 legal issues, 267-274 boundary development, 272-273 generalist legal duties, 268-271 overlapping specialties, 273-274 referrals verses consultations, 267268 specialist legal duties, 271 Gene therapy canine thyroid disease model future research applications, 126 immunogenetics, 108-109 major histocompatibility complex genes, 109-113 disease registries, 89-90 DLA gene histotyping, 123-124 future specialization trends, 154-160 bovine granulocytopathy, 154-155 gene delivery, 157-160 progressive retinal atrophy, 155-156 pyruvate kinase deficiency, 156-157 molecular approaches, 22-23 screening biochemical markers, 83-87 canine thyroid disease model, 108113 immunogenetics, 108-109 major histocompatibility complex genes, 109-113 health surveys, 8-9, 31-32 molecular genetic markers, 87-88 Granulocytopathy, bovine, future specialization trends, 154-155 H Health surveys, disease prevalence estimation, 29-90 basenjis, 72-74 bearded collies, 62-64 dalmatians, 79-82 deafness, 80-82 urate urolithiasis, 79-80 Irish setters, 74-76 Irish wolfhounds, 64-72 age, 65 familial influence, 65 health history, 65-67 sex, 65 thyroid profile, 70-72 von Willebrand factor antigen, 6770 Newfoundlands, 76-79 Old English sheepdogs, 37-61 age, 45-46 demographic variables, 40-43 disease categories, 47-61 frequencies, 43 genetic influences, 46-47 neutered animals, 43-45 300 INDEX response rate, 39 results, 39 sex ratios, 40, 43 study design, 38-39 overview genetic screening, 31-32 historical perspective, 8-9, 29-31 methods, 32-37 recommendations, 88-90 genetic disease registries, 89-90 molecular probes, 88-89 trends, 82-88 biochemical markers, 83-87 molecular genetic markers, 87-88 physical characteristics, 82-83 Hip dysplasia, prevalence, Old English sheepdogs, 48-49 HLA gene, in canine autoimmune disease models, self-tolerance failure, 105-108 IDDM, autoimmune disease models, 113115 Immunology autoimmune disease, s e e Thyroiditis disease prevalence, Old English sheepdogs, 52-56 immunogenetics, canine models, 108109 nutrition effects, 9-15 immune-suppressant viruses, 10 nutritional factors, 10-11 synthetic antioxidants, 12-15 thyroid me£abolism, 11-12 scientific advances, 5-7 vaccines, 7-8 Informed consent, specialization legal issues, 256-258 Innovative therapies, legal issues, 287293 academic medicine, 290-291 liability, 287-290 patient rights, 291-293 Irish setters, disease prevalence, 74-76 Irish wolfhounds, disease prevalence, 6472 age, 65 familial influence, 65 health history, 65-67 sex, 65 thyroid profile, 70-72 von Willebrand factor antigen, 67-70 Joint disorders, prevalence, Old English sheepdogs, 48 Lawsuits, malpractice, s e e Malpractice lawsuits Legal issues, specialization general practitioner relationship, 267274 boundary development, 272-273 generalist legal duties, 268-271 overlapping specialties, 273-274 referrals verses consultations, 267268 specialist legal duties, 271 innovative therapies, 287-293 academic medicine, 290-291 liability, 287-290 patient rights, 291-293 malpractice lawsuits, 275-276 overview, 254-258 competence, 255-256 informed consent, 256-258 intentional wrongs, 254-255 negligence, 254-256 standards, 258-266 competence, 258-260 false representation, 265 imposition, 259-260 practitioners affected, 261-266 quasi-specialties, 266 M Major histocompatibility complex genes, canine autoimmune disease models genetic screening, 109-113 INDEX polymorphisms, 121-122 self-tolerance failure, 102-105 Malpractice lawsuits innovative therapies, liability, 287-290 specialization, 275-276 Markers, disease recognition biochemical, 83-87 genetic, 87-88 Molecular medicine, future trends, 153 Molecular probes, 88-90 N Negligence, specialization legal issues, 254-256 Newfoundlands, disease prevalence, 7679 Nutrition, immune system effects, 9-15 immune-suppressant viruses, 10 nutritional factors, 10-11 synthetic antioxidants, 12-15 thyroid metabolism, 11-12 Old English sheepdogs, disease prevalence, 37-61 age, 45-46 demographic variables, 40-43 disease categories, 47-61 behavior, 56 bleeding disorders, 59-60 blood diseases, 59 bone disorders, 48 cancer, 50 chronic infections, 50-52 endocrine disease, 59 eye diseases, 50 gastrointestinal disorders, 60-61 hip dysplasia, 48-49 immune problems, 52-56 joint disorders, 48 reproductive disorders, 49-50 skin disorders, 49 thyroid disease, 56-59 disease frequencies, 43 genetic influences, 46-47 neutered animals, 43-45 301 response rate, 39 results, 39 sex ratios, 40, 43 study design, 38-39 Patient rights, s e e a l s o Ethics legal issues, innovative therapies, 291293 retention, 280-281 Polymerase chain reaction, major histocompatibility complex screening, 110-113 Probes, molecular, 88-90 Progressive retinal atrophy, future specialization trends, 155-156 Pyruvate kinase deficiency, future specialization trends, 156-157 Referrals, specialization legal issues, 267-268 Registries, genetic disease, 89-90 Reproductive disorders, prevalence, Old English sheepdogs, 49-50 Research, s e e Clinical trials Restriction fragment length polymorphism, major histocompatibility complex screening, 110-112 Retinal atrophy, progressive, future specialization trends, 155-156 Skin disorders, prevalence, Old English sheepdogs, 49 Specialization basic science bridge, 4-21 clinical trials, 15-21 genetic screening, 8-9 health surveys, 8-9 immunology, 5-7, 9-15 nutrition, 9-15 scientific advances, 5-8 vaccines, 7-8 302 INDEX ethical issues, 276-287 euthanasia, 286-287 fees, 285-286 general practitioner relationship, 279-284 competition, 283-284 criticism, 281-283 fee-splitting, 279-280 patient retention, 280-281 overview, 277-279 service overutilization, 284-285 future trends, 153-160 gene therapy, 154-160 bovine granulocytopathy, 154-155 gene delivery, 157-160 progressive retinal atrophy, 155156 pyruvate kinase deficiency, 156157 molecular medicine, 153 history current status, 144-147 human medicine reference, 141-143 overview, 143 qualifications, 147-149 research integration, 149-153 scientific advances, 144-147 standards, 147-149 legal issues general practitioner relationship, 267-274 boundary development, 272-273 generalist legal duties, 268-271 overlapping specialties, 273-274 referrals verses consultations, 267-268 specialist legal duties, 271 innovative therapies, 287-293 academic medicine, 290-291 liability, 287-290 patient rights, 291-293 malpractice lawsuits, 275-276 overview, 254-258 competence, 255-256 informed consent, 256-258 intentional wrongs, 254-255 negligence, 254-256 standards, 258-266 competence, 258-260 false representation, 265 imposition, 259-260 practitioners affected, 261-266 quasi-specialties, 266 specialty boards, 163-190 Standards, specialization early history, 147-149 legal issues, 258-266 competence, 258-260 false representation, 265 imposition, 259-260 practitioners affected, 261-266 quasi-specialties, 266 T-cell receptors, in canine autoimmune disease models disease characteristics, 121-122 self-tolerance failure, 102-108 Thyroiditis canine autoimmune disease model, 97127 disease characteristics, 115-123 autoantigens, 119-121 disease process, 117-119 environmental factors, 122-123 major histocompatibility complex polymorphism, 121-122 normal thyroid, 115-117 T-cell receptor polymorphism, 121122 future research applications, 123127 autoimmune pathogenesis, 126 breed improvement, 124-125 diagnostic criteria improvement, 124 DLA histotyping, 123-124 endangered species, 125 genetic defect correction, 126 therapeutic immunosuppression, 125-126 genetic screening, 108-113 immunogenetics, 108-109 major histocompatibility complex genes, 109-113 IDDM model, 113-115 INDEX overview, 97-102 self-tolerance failure, 102-108 HLA gene polymorphism, 105-108 major histocompatibility complex genes, 102-105 T-cell receptor complex, 102-105 T-cell receptor gene polymorphism, 105-108 disease prevalence Irish wolfhounds, 70-72 Old English sheepdogs, 56-59 nutrition effects, 11-12 Trials, s e e Clinical trials 303 Urate urolithiasis, prevalence, dalmatians, 79-80 Vaccines, immunological effects, 7-8 Veterinarians, s e e General practitioners; Specialization von Willebrand factor antigen, disease prevalence, Irish wolfhounds, 67-70 This Page Intentionally Left Blank ...Advances in Veterinary Science and Comparative Medicine Volume 39 Veterinary Medical Specialization: Bridging Science and Medicine Advances in Veterinary Science and Comparative Medicine Edited... Alan H Rebar Ronald D Schultz Advances in Veterinary Science and Comparative Medicine Volume 39 Veterinary Medical Specialization: Bridging Science and Medicine E d i t e d by W Jean Dodds Hemopet... cardiology, internal medicine, neurology, veterinary medical oncology, and anesthesiology New specialties continue to be added and these are approved and governed by the American Veterinary Medical Association