[Remuneration distribution - should morbidity-dependent overall remuneration also be distributed after adjustments for morbidity?]. / Honorarverteilung - sollte die morbiditätsbedingte Gesamtvergütung auch morbiditätsadjustiert verteilt werden?

INTRODUCTION: In the 2009 reform of the German collective remuneration system for outpatient medical care, on the level of overall remuneration, the morbidity risk was transferred to the health funds fulfilling a long-term demand of physicians. Nevertheless not transferring morbidity adjustment to the levels of physician groups and singular practices can lead to budgets not related to patient needs and to incentives for risk selection for individual doctors. METHODS: The systematics of the distribution of overall remuneration in the German remuneration system for outpatient care are analysed focusing on the aspect of morbidity adjustment. Using diagnostic and pharmaceutical information of about half a million insured subjects, a risk adjustment model able to predict individual expenditures for outpatient care for different provider groups is presented. This model enables to additively split the individual care burden into several parts attributed to different physician groups. Conditions for the use of the model in the distribution of overall remuneration between physician groups are developed. A simulation of the use of diagnoses-based risk adjustment in standard service volumes then highlights the conditions for a successfull installation of standard service volumes representing a higher degree of risk adjustment. RESULTS: The presented estimation model is generally applicable for the distribution of overall remuneration to different physician groups. The simulation of standard service volumes using diagnosis-based risk adjustment does not provide a more accurate prediction of the expenditures on the level of physician practices than the age-related calculation currently used in the German remuneration system for outpatient medical care. CONCLUSION: Using elements of morbidity-based risk adjustment the current German collective system for outpatient medical care could be transformed towards a higher degree of distributional justice concerning medical care for patients and more appropriate incentives avoiding risk selection. Limitations of the applicability of risk-adjustment can be especially pointed out when a high share of lump-sum-payments is used for the remuneration of some physician groups.

Widely tunable photonic crystal fiber Fabry-Perot optical parametric oscillator.

We present a widely tunable low-threshold chi(3) optical parametric oscillator. The oscillator cavity is formed by butt coupling dichroic mirrors to either end of a highly nonlinear index-guiding photonic crystal fiber. This yields a singly resonant Fabry-Perot oscillator with a high feedback fraction for the resonant parametric sideband. The tuning range of the output parametric sideband stretches from 23 to 164 THz above the pump frequency. The threshold power of the oscillator is only 15 W.

Strong signal suppression in single-pump optical parametric amplifiers.

We show that the combined action of parametric gain and Raman scattering can lead to the complete suppression of an input optical signal in a single-pump parametric amplifier. This suppression is due to an interference between the two parametric gain modes. The interference occurs only at a set of discrete combinations of pump power, phase mismatch, and frequency detuning. Experimentally we are able to demonstrate over 95% (13 dB) suppression of an input signal in an amplifier with a peak parametric gain of only 6 dB.

Influence of Raman susceptibility on optical parametric amplification in optical fibers.

The real part of the Raman susceptibility is shown to have a strong influence on the peak parametric gain of single-pump parametric amplifiers. This results in a 35% variation in the peak parametric gain over the frequency range 0-30 THz. We are able to experimentally demonstrate this effect in a photonic crystal fiber and obtain good agreement between the experimentally measured and theoretically predicted gains.

High-conversion-efficiency widely-tunable all-fiber optical parametric oscillator.

A high-conversion-efficiency widely-tunable all-fiber optical parametric oscillator is described. It is based on modulation instability in the normal dispersion regime near the fiber's zero-dispersion wavelength. A 40 m long dispersion-shifted fiber is used in a synchronously pumped ring cavity. We demonstrate continuous sideband tuning from 1300 to 1500 nm and 1600 to 1860 nm by tuning the pump wavelength between 1532 and 1556 nm. Internal conversion efficiencies of up to 40% are achieved.

Combined effect of Raman and parametric gain on single-pump parametric amplifiers.

We investigate the combined effect of Raman and parametric gain on single-pump parametric amplifiers. The phasematched parametric gain is shown to depend strongly on the real part of the complex Raman susceptibility. In fused silica fibers this results in a significant reduction in the available parametric gain for signal detunings beyond 10 THz. We are able to experimentally measure this effect for signal detunings ranging from 7 to 22 THz. Finally we discuss the implications of these results for the design of broadband optical parametric amplifiers.

Cross-phase modulation instability in photonic crystal fibers.

We report on the observation of cross-phase modulation instability in a highly nonlinear photonic crystal fiber. In such fibers the presence of higher orders of dispersion results in a complex phase-matching curve. We are able to observe this behavior experimentally and obtain excellent agreement between the measured and predicted shifts.

Polarization modulation instability in photonic crystal fibers.

Polarization modulation instability (PMI) in birefringent photonic crystal fibers has been observed in the normal dispersion regime with a frequency shift of 64 THz between the generated frequencies and the pump frequency. The generated sidebands are orthogonally polarized to the pump. From the observed PMI frequency shift and the measured dispersion, we determined the phase birefringence to be 5.3 x 10(-5) at a pump wavelength of 647.1 nm. This birefringence was used to estimate the PMI gain as a function of pump wavelength. Four-wave mixing experiments in both the normal and the anomalous dispersion regimes generated PMI frequency shifts that show good agreement with the predicted values over a 70 THz range. These results could lead to amplifiers and oscillators based on PMI.

Effect of dispersion fluctuations on widely tunable optical parametric amplification in photonic crystal fibers.

The effect of dispersion fluctuations on the conversion efficiency of large frequency shift parametric sidebands is studied by numerical simulation and experiment. Numerical results based on periodic and random dispersion models are used to fit the experimental results. The fitting parameters provide a measure of the uniformity of the photonic crystal fiber used in the experiment. This allows us to place limits on the required uniformity of a photonic crystal fiber for strong frequency conversion.

Widely tunable optical parametric generation in a photonic crystal fiber.

We report on the observation of widely tunable optical parametric generation in a photonic crystal fiber. The frequency shift of the generated sidebands that arise from modulational instability is strongly dependent on the detuning of the pump from the fiber's zero-dispersion wavelength. We are able to demonstrate experimentally more than 450 nm of sideband tunability as we tune the pump wavelength over 10 nm. Excellent agreement has been found between the experimentally measured and theoretically predicted shifts.

Characterization of chromatic dispersion in photonic crystal fibers using scalar modulation instability.

A simple and accurate method is proposed for characterizing the chromatic dispersion of high air-filling fraction photonic crystal fibers. The method is based upon scalar modulation instability generated by a strong pump wave propagating near the zero-dispersion wavelength. Measuring the modulation instability sideband frequency shifts as a function of wavelength gives a direct measurement of the fiber's chromatic dispersion over a wide wavelength range. To simplify the dispersion calculation we introduce a simple analytical model of the fiber's dispersion, and verify its accuracy via a full numerical simulation. Measurements of the chromatic dispersion of two different types of high air-filling fraction photonic crystal fibers are presented.

Experimental investigation of early-time diffusion in the quantum kicked rotor using a Bose-Einstein condensate.

We report measurements of the early-time momentum diffusion for the atom-optical delta-kicked rotor. In this experiment a Bose-Einstein condensate provides a source of ultracold atoms with an ultranarrow initial momentum distribution, which is then subjected to periodic pulses (or "kicks") using an intense far-detuned optical standing wave. We characterize the effect of varying the effective Planck's constant for the system, while keeping all other parameters fixed. The observed behavior includes both quantum resonances (ballistic energy growth) and antiresonances (re-establishment of the initial state). Our experimental results are compared with theoretical predictions.

Diffusion resonances in action space for an atom optics kicked rotor with decoherence.

We numerically investigate momentum diffusion rates for the pulse kicked rotor across the quantum to classical transition as the dynamics are made more macroscopic by increasing the total system action. For initial and late time rates we observe an enhanced diffusion peak which shifts and scales with changing kick strength, and we also observe distinctive peaks around quantum resonances. Our investigations take place in the context of a system of ultracold atoms which is coupled to its environment via spontaneous emission decoherence, and the effects should be realizable in ongoing experiments.

White-light supercontinuum generation with 60-ps pump pulses in a photonic crystal fiber.

The generation of a spatially single-mode white-light supercontinuum has been observed in a photonic crystal fiber pumped with 60-ps pulses of subkilowatt peak power. The spectral broadening is identified as being due to the combined action of stimulated Raman scattering and parametric four-wave-mixing generation, with a negligible contribution from the self-phase modulation of the pump pulses. The experimental results are in good agreement with detailed numerical simulations. These findings demonstrate that ultrafast femtosecond pulses are not needed for efficient supercontinuum generation in photonic crystal fibers.

Vitamin E enhances Ca(2+)-mediated vulnerability of immature cerebellar granule cells to ischemia.

The effects of vitamin E on lipid peroxidation, intracellular free Ca2+ concentration ([Ca2+]i), and cell death were investigated in the postischemic immature cerebellum. Deprivation of oxygen and glucose for 10-min in a suspension of freshly dissociated granule cells from the cerebellum of 9-day-old male rat pups resulted in a recovery-induced consumption of cell nonenzymatic antioxidants (ascorbic acid, glutathione, and alpha-tocopherol) and development of membrane lipid peroxidation as measured by the thiobarbituric acid method. The rate of lipid peroxidation of the postischemic cells was stimulated, not reduced, by treatment of the cells with vitamin E (5-30 microM alpha-tocopherol phosphate). In flow-cytometric studies a 10-min period of ischemia resulted in a small increase in intracellular calcium concentration, lipid peroxidation products and cell death, but in the presence of alpha-tocopherol the same treatment caused a dramatic increase in cell death, accompanied by a large increase in [Ca2+]i and lipid peroxidation products. Pretreatment of the cells with a mixture of three antioxidants (vitamin C/rutin/ubiquinol-10, 10/5/1) or nickel (Ni2+) reduced the alpha-tocopherol-induced increases in [Ca2+]i, and cell death. Hydrogen peroxide (1 mM) and the water-soluble analogue of vitamin E, trolox (50 microM), mimicked the effect of vitamin E on lipid peroxidation in the postischemic cells. Pretreatment of the cells with the intracellular Ca2+ chelator BAPTA-AM, reduced both the alpha-tocopherol-induced increase in [Ca2+]i and cell death. The effect of vitamin E on [Ca2+]i was age dependent and decreased abruptly during maturation of the cerebellum between the first and second weeks of life. Results of in vitro treatment of the immature cerebellar cells with the water-soluble form of vitamin E (alpha-tocopherol phosphate) suggest that, after consumption of cellular co-antioxidants, vitamin E may be converted to an alpha-tocopheroxyl radical, which act as a toxic prooxidant as cellular bioenergetics deteriorate.

Voltage-activated calcium channel currents of rat dorsal root ganglion cells are reduced by trimethyl lead.

Using the conventional whole-cell patch-clamp recording technique with cultured neurones of rat dorsal root ganglions (DRG), we analysed the effects of trimethyl lead (TML) on voltage-activated calcium channel currents. TML reduces voltage-activated calcium channel currents in a dose-dependent manner, with a threshold concentration below 0.5 microM and a total reduction of the current ( > or =80% of the control current) at concentrations above 50 microM. Half of the current is abolished at TML concentrations between 1 and 5 microM. The action is irreversible and is not voltage dependent. After application of TML the current decreases with each activation of the channel until a steady state is reached after 8-12 min, when the channel was activated every 10 s. The channel had to be in the open state for TML to act. TML is a potent compound for reducing voltage activated calcium channel currents. These effects of TML must be taken into account in explaining the neurotoxic effects of this organic metal compound.

Quasi-phase-matched modulation instability in birefringent fibers.

The phase-sensitive nature of polarization modulation instability has been demonstrated in optical fibers whose birefringence has been manipulated to generate phase mismatches. Quasi-phase-matched modulation instability has been demonstrated, and the gain of the quasi-phase-matched sidebands has been investigated. The results are in good agreement with experiment.

Direct measurement of pulse distortion near the zero-dispersion wavelength in an optical fiber by frequency-resolved optical gating.

The technique of frequency-resolved optical gating is used to characterize the intensity and the phase of picosecond pulses after propagation through 700 m of fiber at close to the zero-dispersion wavelength. Using the frequency-resolved optical gating technique, we directly measure the severe temporal distortion resulting from the interplay between self-phase modulation and higher-order dispersion in this regime. The measured intensity and phase of the pulses after propagation are found to be in good agreement with the predictions of numerical simulations with the nonlinear Schrödinger equation.

Methyl mercury reduces voltage-activated currents of rat dorsal root ganglion neurons.

Methyl mercury (MeHg) is a widespread toxicant with major actions on the nervous system. Since the function of neurons depends on voltage gated ion channels, we examined the effects of micromolar concentrations of methyl mercury on voltage-activated calcium, potassium and sodium channel currents of cultured rat dorsal root ganglion (DRG) neurons. The cells, which were obtained from 2-4 day old rat pups, were whole-cell patch-clamped. Currents were separated by selective intra- and extracellular solutions as well as specific depolarizing voltage steps. We did not distinguish between different calcium, potassium or sodium channel subtypes. All three types of voltage-activated currents were irreversibly reduced by MeHg in a concentration dependent manner. Voltage-activated calcium and potassium channel currents were more sensitive to MeHg (Calcium: IC50 = 2.6 +/- 0.4 microM; Potassium: IC50 = 2.2 +/- 0.3 microM) than voltage-activated sodium channels (IC50 = 12.3 +/- 2.0 microM). The Hill coefficients for the reduction of the currents were calculated as approximately 1 for calcium and potassium channel currents and as 1.7 for sodium currents. In the cases of the voltage-activated calcium and sodium channel currents the reduction was clearly use dependent. Higher concentrations of MeHg (> or = 5 microM) resulted in a biphasic change in the holding membrane current at the potential of -80 mV in approximately 25% of the cases.

Voltage-activated calcium channel currents of rat DRG neurons are reduced by mercuric chloride (HgCl2) and methylmercury (CH3HgCl).

The actions of bath applied mercuric chloride (HgCl2) and methylmercury (CH3HgCl) on voltage-activated calcium channel currents (VACCCs) were tested, using the whole cell patch clamp recording technique with cultured dorsal root ganglion (DRG) neurons from 2-4 day old rat pups. Both metal compounds reduced the current irreversibly in a concentration dependent fashion, reaching a new (lower) steady state within 3 to 5 min after application. Inorganic mercury was more effective in reducing the VACCCs with an IC50 of 1.3 microM, while the IC50 for methylmercury was 2.6 microM. But the threshold concentrations were below 0.25 microM for both metal compounds and the calcium channel currents were reduced by more than 90% with concentrations of 5 microM and 20 microM, respectively. The Hill coefficient for both dose-response relationship was calculated as approximately 1. Calcium channel currents were reduced over the entire voltage range, but the current-voltage relation shifted to more positive potentials in a concentration dependent manner, the effect being more pronounced with HgCl2 than with CH3HgCl (1 microM HgCl2: 10 mV shift, 5 microM CH3HgCl: 5 mV shift). At higher concentrations (> or = 2 microM for HgCl2, and > or = 10 microM for CH3HgCl) an unidentified membrane current was observed. The inorganic mercury caused an inward current, while the organic mercury compound generated a biphasic current with a transient inward and a long lasting outward component. Our results suggest that mercury compounds affect the electrical properties of neurons and thereby decrease cognitive and motor performance.