[Regulating the distribution of health professionals in Germany, Belgium, the United Kingdom, Quebec and the United states: monograph study]. / La régulation démographique de la profession médicale en Allemagne, Belgique, Royaume-Uni, Québec et Etats-Unis: étude monographique.

The Province of Quebec and the United Kingdom have both a strong system of medical manpower regulation. Growth of the number of doctors--and consequently of health expenditures--is kept under control. Shortage of supply of health services increases the queuing process. In the two countries, the main problem is not how to curb health costs but to cope with the unmet demand. In Germany, the control of medical school intake is very weak. However, agreement of young doctors by the Sickness Fund is strictly controlled, the Fund having the right to close the list of "agreed physicians" in areas or specialties where doctor surplus is observed. In Belgium, a numerus clausus system is established very recently for medical school intake. In the USA, the health care system is traditionally regulated by the market forces. The strong increase of health expenditures during the recent decades has shifted the power from the medical profession to the paying bodies (HMO, MCO...) who are now supporting the emergence of new health personnels, less costly.

Transpupillar laser phototherapy for retinal and choroidal tumors: a rational approach.

BACKGROUND: The physical laws are considered that need to be taken into account for optimal photothermal treatment of solid and vascular tumors, as well as other vascular anomalies of various etiology of the retina and choroid. Optimal irradiation therapy should take into account the distribution of both radiant and thermal energy in tumors, such as retinoblastomas, malignant melanomas and vascular malformations. Strict confinement of the extent of photothermal damage is critical since such pathological entities are frequently located close to the macula or optic nerve head. METHODS: A formal treatment of the optical quantities related to these requirements is presented. In this analysis we emphasize the following topics: Arrhenius' law, the kinetics of protein denaturation, the electromagnetic radiation field, wavelength, laser pulse duration (exposure time), optical properties of tissue, photocoagulation and thermotherapy. RESULTS: Generally, the conditions are best fulfilled when using radiation in the near-infrared range of the electromagnetic spectrum, such as that emitted from the diode (810 nm) and Nd:YAG (1064 nm) laser, because of the good optical penetration properties of this radiation in tissue. The xenon arc lamp was a very effective and particularly appropriate energy source for such purposes, and its withdrawal from the world market may have been untimely. Short wavelength sources of radiation, such as the argon ion (488, 514 nm) or the frequency-doubled Nd:YAG (532 nm) laser, are unsuitable for the irradiation of large vascular structures, as they have poor penetration depths. However, for vascular formations with a short path length (1 mm or less), short wavelength sources appear to be the most appropriate choice. Optical coupling of radiant energy to the eye by means of indirect ophthalmoscopic systems or contact lenses to the eye is crucial. Strong positive lenses may lead to severe constriction of the laser beam which leads to high irradiance within the anterior segment, increasing the chances of it being damaged; with negative contact lenses, such as the -64 D Goldmann type, this danger is reduced. CONCLUSIONS: Photothermotherapy is not without risk unless the temperature field can be well adapted to the tumorous structure, as temperature elevations outside a small therapeutic range that affect vital structures are considered to be a risk factor.

A new laser scalpel--a brief report.

One may consider the clad silica fibre cutting probe as a cheap alternative of the popular sapphire probe, sharing some of its properties. Made of silica, the scalpels have a fair heat tolerance and may be used without cooling by liquids or gas as is necessary with sapphire blades. The laser scalpel described here is driven (powered) with a 10 W cw Nd:YAG laser energy source (1064 nm) and possesses good cutting and haemostatic properties. It may also be used with lasers emitting other wavelengths. One may assume that a diode laser emitting in the near infrared (800-810 nm) may have very similar, although no analogous cutting properties when used with the described scalpel.

Lasers, optical systems and safety in ophthalmology: a review.

This is a review of optical methods related to biomicroscopy and laser treatment of the posterior segment of the eye. Contact lenses can be used to observe optical structures and couple laser radiation into the eye for a vast range of conditions and techniques. A small laser spot size is indispensable for photodisruptive work, though this requires a large beam diameter at the pupil and therefore optical systems and techniques such as scleral indentation which maximize the pupillary beam diameter are preferred. For coagulation work the choice of beam focusing optics is crucial for optimum safety. Vitreous replacement can be used to change the refractive power of the eye and permit new combinations of treatment and optical systems. This review covers many aspects of laser irradiation of the eye. It should be clear that, with the multitude of different procedures and optical systems involved, the laser surgeon is faced with a daunting task in assessing and meeting safety limits.

Optical and thermal mechanisms related to the design of laser sclerostomy.

Collateral, thermally induced structural damage during laser sclerostomy ab interno or ab externo was investigated theoretically and compared with experimental results. We show that collateral heat damage in contact strategies using fiber delivery is mainly due to heat conductivity following explosive ablation. Electron micrographs of perforated porcine eyes show that the damage is only weakly dependent on the laser wavelength. The experiments also demonstrate that simultaneous application of laser irradiation and pressure with the fiber tip yield efficient perforation of scleral tissue even when the weakly absorbed radiation of Nd:YAG or diode lasers is employed.

[The current status of sclerostomy procedures in treatment of open angle glaucoma]. / Der gegenwärtige Stand der Sklerostomieverfahren bei der Behandlung des Offenwinkelglaukoms.

METHODS: A number of ab interno and ab externo sclerostomy procedures have been described in recent years. CONCLUSION: At the present time, there is no clear indication that such interventions are superior to the classical fistulizing glaucoma operations, such as trabeculectomy.

[Surgery with the laser scalpel. Physical principles and clinical effectiveness]. / Chirurgie mit dem Laserskalpell. Physikalische Grundlagen und klinische Wirksamkeit.

BACKGROUND: The conventional surgical method for cutting vascularized tissue with scalpel and scissors may now be improved by use of the laser scalpel. In particular, the frequent interruption necessitated and the poor visibility caused by bleeding may be mitigated owing to the haemostatic properties of laser light. This instrument may be of particular value for tasks involving extrabulbar structures, such as extraocular muscles and lacrimal tissue, as well as for facial surgery. MATERIALS AND METHODS: The mode of action and physical properties of a new laser scalpel are described and its characteristics compared with those of other instruments on the market. The probe consists of a clad, sculptured silica fibre with a core diameter of 0.6 mm and a conical 0.15 mm-diameter cutting tip. Radiation generated by a low cw-Nd:YAG laser module is fed into the probe, at the exit point of which a maximal power density of 57 kW/cm2 is attained. Radiated laser energy penetrates the tissue as an incision is made, thereby inducing an efficient blood flow stasis which is amplified by thermal energy diffusing from the immediate surroundings of the scalpel tip. RESULTS: In this report, the laser scalpel is implemented for the excision of a vascularized, amelanotic, facial naevus. Both the cutting and haemostatic effects were found to be excellent, occurrence of the latter phenomenon being supported by ultrastructural findings. The healing response was comparable to that observed after conventional surgery. CONCLUSION: The new laser scalpel represents an inexpensive and effective cutting and haemostatic tool powered by a standard cw Nd:YAG laser module, with a wide spectrum of potential applications.

Optical principles related to optimizing sclerostomy procedures.

A simple probe, consisting of a 200-micrometer uncladded silica optical fiber, advanced from a protecting 22-gauge hypodermic needle, was used to create sclerostomy fistulas both ab interno and ab externo by means of a combined radiation/mechanical effect. Perforation was achieved by exerting gentle forward pressure on the fiber in synchrony with the delivery of radiation pulses. An irradiation protocol suitable for producing such canals in cadaver porcine eyes was delineated using Ho:YAG, Nd:YAG, and diode laser energy sources. Despite significant differences in the pulse energy required for perforation (0.25, 7, and 8 J for the Ho:YAG, diode, and Nd:YAG lasers, respectively), the extent of collateral damage was comparable for each type of laser. The physical mechanisms underlying these findings are discussed.

A new instrument for controlling pressure exerted on the sclera during contact Nd:YAG laser cyclodestruction.

We tested the device described by Rol et al in their article in this issue, designed to define and precisely control the pressure applied to the sclera during contact cyclodestruction with a cw-Nd:YAG laser. Since scleral transparency, and hence transmission of laser energy, depends on the pressure applied, control of this parameter represents an important advance toward the goal of standardizing the cyclodestructive procedure. In eight of nine cadaver pig eyes, pressure was exerted on the sclera using the pressure-controlling device, with a setting of 0.25 N for two of these eyes, and one of 0.4 N for the other six. In the remaining eye, pressure was controlled intuitively by an experienced surgeon. Applying forces of 0.25 or 0.4 N yielded similar success rates, although these fluctuated greatly even under constant pressure conditions (from 17% to 50% at 0.25 N; from 27% to 42% at 0.4 N). The highest success rate (55%) was achieved by the intuitively controlled pressure irradiations of the experienced surgeon. The variation in coagulation intensity that occurred despite constant pressure suggests that additional factors contribute to the results achieved. Nonetheless, this pressure-controlling probe represents an important achievement. It will permit not only the novice but even experienced operators to adhere unambiguously to a protocol of quantitative, reproducible parameters, and will also help researchers to better understand the relationship between energy delivered and intraocular pressure reduction achieved in contact cyclophotocoagulation.

Ligand-operated synthesis of 4-series and 5-series leukotrienes in human neutrophils: critical dependence on exogenous free fatty acid supply.

The influence of exogenously supplied free arachidonic acid (AA) and eicosapentaenoic acid (EPA) on the 5-lipoxygenase metabolism in human neutrophils (PMN) was investigated. Simultaneous application of A23187 with incremental concentrations of free AA caused a dose-dependent augmentation of the ionophore-elicited eicosanoid generation [release of leukotriene B4 and its omega-oxidation products, nonenzymatic hydrolysis products of leukotriene A4, and 5-hydroxyeicosatetraeneoic acid (5-HETE)]. A23187 challenge in the presence of free EPA resulted in the dose-dependent appearance of corresponding n - 3-derived metabolites, parallelled by a decrease in 4-series leukotrienes and 5-HETE. The inflammatory ligands formyl-methionyl-leucyl-phenylalanine and platelet-activating factor evoked no substantial eicosanoid generation in the absence of exogenously supplied polyunsaturated fatty acids (PUFAs). Addition of free AA or EPA in parallel with the ligand challenge evoked exclusive and dose-dependent generation of the respective leukotrienes and 5-HETE or 5-hydroxyeicosapentaenoic acid. Total amounts of 5-lipoxygenase products elicited under these conditions approached those in ionophore-stimulated PMN, with platelet-activating factor challenge surpassing the formyl-methionyl-leucylphenylalanine-evoked effect by approximately 50%. Two thirds of the maximum effect was obtained in the presence of only 10 microM free PUFA. Use of labeled fatty acids suggested exclusive origin of the eicosanoids from the exogenously provided precursor PUFA. Critical dependence on timing was noted; maximum response occurred upon simultaneous application of PUFA and ligand, and only 5 min of delay between AA or EPA addition and ligand challenge sufficed to reduce the formation of respective metabolites to less than 20%. EPA competed with AA and was noted to be the preferred substrate for ligand-evoked eicosanoid synthesis. In contrast to the simultaneous addition of free PUFAs, preloading of PMN with AA or EPA for 60 min revealed only very moderate or even no influence on ionophore- or ligand-evoked eicosanoid synthesis. We conclude that inflammatory ligands induce marked stimulation of PMN eicosanoid synthesis, with critical dependence on the presence of free precursor PUFAs. Preference of EPA over AA is observed under these conditions.

Lithotripsy of gallstones by means of a quality-switched giant-pulse neodymium:yttrium-aluminum-garnet laser. Basic in vitro studies using a highly flexible fiber system.

The quality-switched neodymium:yttrium-aluminum-garnet laser represents a new instrument for athermal fragmentation of gallstones by transformation of optical energy into mechanical energy in the form of shock waves via local plasma formation. A highly flexible 300-micron fiber transmission system was used in basic investigations to determine the influence of varying pulse repetition rates (5-30 Hz) and pulse energies (15 and 20 mJ) on shock wave intensity and stone fragmentation in vitro for 105 biliary calculi of known size and chemical composition. After performance of 1200 shock wave pressure measurements using polyvinylidenefluoride hydrophones, stone fragmentation was analyzed by determination of fragment removal rates (volume of fragments removed per fragmentation time), ablation rates (mean volume removed per laser pulse), and median fragment sizes for each laser setting. With the quality-switched neodymium:yttrium-aluminum-garnet laser system, all concrements could be reliably disintegrated into small fragments (median diameter, 0.7-1.7 mm). Compared with pure cholesterol stones, a significantly higher fragment removal rate was achieved in cholesterol stones containing 30% calcium phosphate (P = 0.039), in cholesterol stones containing 20% pigment (P = 0.015), and in pure pigment stones (P = 0.007). Fragment removal rates, local shock wave pressures, and median grain sizes were significantly higher at a pulse energy of 20 mJ than with 15 mJ. Shock wave pressures showed a distinct dependence on pulse repetition rates at 20 mJ, yet not at 15 mJ. Because there is no evident hazard of thermal damage to tissue using the quality-switched neodymium:yttrium-aluminum-garnet laser, it appears to be a promising device for nonsurgical biliary stone therapy.

Epulides in dogs.

Eighty-one cases of canine epulides are described clinically and histologically; 73 cases were diagnosed as inflammatory, fibrous hyperplasias of which 37% showed metaplastic bone formation and 22% demonstrated so-called plexiform epithelial hyperplasia which seems to have no human counterpart. There is no indication that metaplastic bone formation or plexiform epithelial hyperplasia influences the biologic behavior of the lesion. A distinction between these two histologic variants carries no prognostic significance. Six cases of epulides proved to be pyogenic granulomas and two were malignant tumors. It is stressed that the term epulis is non-specific giving no indication as to the true nature of the lesion.

Room-temperature operation of the vibronic KZnF(3):Cr(3+) laser.

True cw laser operation was achieved with the vibronic KZnF(3):Cr(3+) laser at room temperature. The laser is optically pumped with a krypton laser at 647 and 676 nm. With 1 W of absorbed power the laser is tunable between 785 and 865 nm. A 14% power-output slope efficiency was observed with longitudinal pumping in a folded three-mirror resonator.