Anoplin, a novel antimicrobial peptide from the venom of the solitary wasp Anoplius samariensis

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Preparação e caracterização de compósitos polímero/cerâmica com potencial de aplicações médicas

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Estudo sobre o uso do pentacloreto de nióbio, como ácido de Lewis, na síntese de enaminas através da reação de adição de Michael

The NbCl5 being a strong electrophile, is a potential candidate to act as a Lewis acid, and therefore it mediates various organic reactions. For this reason, it has received continuous attention by Brazilian researchers, especially in recent decades, since Brazil holds the largest reserves of niobium, besides being the largest producer of this element. The Michael addition reaction is one of the most widely used for forming carbon-carbon bonds and takes place by the addition of nucleophiles to activated olefins. Although this type of reaction is usually catalyzed by base, there are reports in the literature on the use of various Lewis acids in this type of reaction. The synthesis of enamines based acetilenodicarboxilates and amines, aromatic or alkyl, by Michael addition reaction is quite interesting, since these are valuable synthetic intermediates for the synthesis of heterocyclic and they are used in multicomponent reactions. The derivatives of anilino-fumarate also have a great potential for medical application. In this study we investigated the use of niobium pentachloride as Lewis acid to catalyze the Michael additions between the derivatives of aniline and acetilenodicarboxilates the synthesis of enamines

Caracterização da liga Ti-15Zr visando aplicações biomédicas

With advances in health care, has been na increase of demand for material that could replace the functions of the human body parts, thus evolved biomedic prosthesis which today are responsible for the constant improvement of the quality of life. The Titanium alloys are widely used as implants due to its properties, like high mechanical resistance, biocompatibility and corrosion resistance, and the addition alloying elements like Zirconium, may improve some of those properties. Such properties are related to the microstructure and consequently to the type of processing performed. The purpose of this dissertation was to characterize the experimental alloy Ti15Zr after route of processsing and heat treatment in order to extend the knowledge about this alloy. The latter has been abtained by fusion of pure metals in a arc melting furnace with an inert argon atmosphere. The material has been homogenized in a tube furnace at 950ºC for 24h and cold worked by swaging, after that, bars with 10 mm of diameter were obtained by the process of rotary forging. The samples were solubilized at 900º C for 2 hours and quenched in water. After that, 4 samples were submitted to the aging, at 400º C, 450º C, 500º C and 550º C. The microstructure and phase analysis was done by optical microscopy and X-rays diffraction (XRD), the mechanical characterization was carried out by microhardness test and finally, evaluation of corrosion resistance of the alloy by electrochemical tests. The XRD and the optical microscopy made it possible to analyze that the heat treatment influenced the phase shifting from α to α', and probably affected the alloy hardness, at the first aged sample at 500º Chas been a sudden increase in the value of hardness, probably by appearance of omega phase, unwanted phase to the medical application duo to great fragility, and finally ... (Complete abstract click electronic access below)

Caracterização da liga Ti-15Zr visando aplicações biomédicas

With advances in health care, has been na increase of demand for material that could replace the functions of the human body parts, thus evolved biomedic prosthesis which today are responsible for the constant improvement of the quality of life. The Titanium alloys are widely used as implants due to its properties, like high mechanical resistance, biocompatibility and corrosion resistance, and the addition alloying elements like Zirconium, may improve some of those properties. Such properties are related to the microstructure and consequently to the type of processing performed. The purpose of this dissertation was to characterize the experimental alloy Ti15Zr after route of processsing and heat treatment in order to extend the knowledge about this alloy. The latter has been abtained by fusion of pure metals in a arc melting furnace with an inert argon atmosphere. The material has been homogenized in a tube furnace at 950ºC for 24h and cold worked by swaging, after that, bars with 10 mm of diameter were obtained by the process of rotary forging. The samples were solubilized at 900º C for 2 hours and quenched in water. After that, 4 samples were submitted to the aging, at 400º C, 450º C, 500º C and 550º C. The microstructure and phase analysis was done by optical microscopy and X-rays diffraction (XRD), the mechanical characterization was carried out by microhardness test and finally, evaluation of corrosion resistance of the alloy by electrochemical tests. The XRD and the optical microscopy made it possible to analyze that the heat treatment influenced the phase shifting from α to α', and probably affected the alloy hardness, at the first aged sample at 500º Chas been a sudden increase in the value of hardness, probably by appearance of omega phase, unwanted phase to the medical application duo to great fragility, and finally ... (Complete abstract click electronic access below)

Polykation-DNA-Komplexe : Eigenschaften und Anwendung in der Gentransfektion

Polykationen bilden mit DNA spontan Komplexe. Triebkraft ist der Entropiegewinn durch Freisetzung der Gegenionen auf den Polyelektrolyten. Solche Komplexe können in der Gentechnik verwendet werden, um fremde DNA in eine Zelle einzuschleusen. Dies bezeichnet man als Gentransfektion. In dieser Arbeit werden erstmals bürstenförmige Polykationen mit wurmförmiger Topologie zur Gentransfektion verwendet. Dazu wurde die Komplexierung von DNA mit Bürstenpolymeren mit Poly-L-Lysin- und Polyvinylpyridinium-Seitenketten und linearen Polykationen untersucht. Die Komplexbildung verläuft in allen Fällen kinetisch kontrolliert, alle Polykationen bilden sphärische Komplexe, die Topologie hat keinen Einfluss auf die Komplexgröße. Komplexe aus Bürstenpolymeren transfizieren mehr als 25% der gesamten Zellpopulation bei Schweinehirnendothelzellen. Gegenüber dem kommerziellen Transfektionsmittel Lipofektamin konnte eine deutliche Steigerung um bis zu 400% erreicht werden. Komplexe, die mit linearen Analoga gebildet wurden, zeigten bei gleicher Komplexgröße Transfektionsraten unter 5%. Freisetzungsversuche zeigen, dass die Komplexe, die gut transfizieren, recht labil sind, also die DNA unter Kompetitoreinfluss freisetzen können. Stabile Komplexe haben geringe Transfektionseffizienzen. Ebenso wichtig ist der Schutz der DNA vor Abbau durch DNase. Die PVP-Bürste bietet als einziges der untersuchten Polykationen diesen Schutz und zeigt auch die besten Transfektionsraten. Zusätzlich zu der medizinischen Anwendung wurde die Kinetik der Komplexbildung untersucht. Dazu wurde ein spezieller Aufbau entwickelt, der es ermöglicht die Streuintensität der Komplexlösung bei kleinen Streuwinkeln zeitaufgelöst im Millisekundenbereich zu detektieren. Die Komplexbildung verläuft diffusionskontrolliert, im Bereich von Ladungsverhältnissen (positive zu negativen Ladungen) von 1.8 bis 4.0 schließt sich ein fraktales Wachstum an.

Amphotericin B nano-formulations : development, characterisation and suitability for oral administration

In der Form von Nanokapseln (AmB-HST), Nanoemulsion beziehungsweise multilamellaren Vesikeln (MLV) wurden drei Amphotericin-B-Formulierungen für die orale Applikation entwickelt, charakterisiert und verglichen. Die neuartige homogene Nanokapsel-Formulierung des hydrophoben Polyen-Antimykotikums Amphotericin B wurde in Analogie zu einem für Simvastatin und andere Arzneistoffe etablierten Prozess aus der Reinsubstanz, Lezithin und Gelatine mit Hilfe des HST-Verfahrens hergestellt. Photometrische Untersuchungen zeigten, dass das Endprodukt aus Monomeren aufgebaut ist. Mittels Mikroskopie ließen sich die Aggregate vor der Umhüllung mit Lezithin und Gelatine im Ausgangsmaterial als individuelle kugelförmige Arzneistoffpartikel darstellen. Strukturuntersuchungen mit dynamischer licht streuung (DLS) zeigten eine enge Größenverteilung der verkapselten Partikel von ca. 1 µm. Die Struktur der Hülle der HST-Partikel wurde erstmalig mit Neutronenstreuung unter Verwendung der Deuterium-basierten Lösungsmittel kontrastmethode aufgeklärt. Durch die teilweise Kontrastmaskierung des Partikelkerns bei der Neutronenstreuung konnte die Lezithin-Gelatine-Hülle als eine dünne, 5,64 ± 0.18 nm dicke Schicht aufgelöst werden, welche der biologischen Lipidmembran ähnlich, im Vergleich aber geringfügig größer ist. Dieses Resultat eröffnet Wege für die Optimierung der Formulierung von pharmazeutischen Nanopartikeln, z.B. durch Oberflächenmodifizierungen. Weitere Untersuchungen mittels Kleinwinkelneutronenstreuung unter Verwendung der D-Kontrastvariation deuten darauf hin, dass die Komponenten der Nanokapseln nicht den gleichen Masseschwerpunkt haben, sondern asymmetrisch aufgebaut sind und dass die stärker streuenden Domänen weiter außen liegen. Die Partikel sind im Vergleich zu Liposomen dichter. In-Vitro Freisetzungsstudien belegen das Solubilisierungsvermögen des HST-Systems, wonach die Freisetzung des Arzneistoffes aus der Formulierung zu allen gemessenen Zeitpunkten höher als diejenige der Reinsubstanz war. rnDie Nanoemulsion-Formulierung von Amphotericin B wurde mit einem Öl und Tensid system, jedoch mit unterschiedlichen Co-Solvenzien, erfolgreich entwickelt. Gemäß der Bestimmung der Löslichkeit in verschiedenen Hilfsstoffen erwies sich der Arzneistoff Amphotericin B als nicht-lipophil, gleichzeitig aber auch als nicht-hydrophil. Die zur Ermittlung der für die Emulsionsbildung notwendigen Hilfstoffkonzentrationen erstellten ternären Diagramme veranschaulichten, dass hohe Öl- und Tensidgehalte zu keiner Emulsionsbildung führten. Dementsprechend betrug der höchste Ölgehalt 10%. Die Tröpfchengröße wuchs mit zunehmender Tensidkonzentration, wobei die Co-Solventmenge der Propylenglykol-haltigen Nanoemulsion indirekt verringert wurde. Für die Transcutol®P-haltige Nanoemulsion hingegen wurde das Gegenteil beobachtet, nämlich eine Abnahme der Tröpfchengröße bei steigenden Tensidkonzentrationen. Durch den Einschluss des Arzneistoffes wurde nicht die Viskosität der Formulierung, sondern die Tröpfchengröße beeinflusst. Der Wirkstoffeinschluss führte zu höheren Tröpfchengrößen. Mit zunehmender Propylenglykolkonzentration wurde der Wirkstoffgehalt erhöht, mit zunehmender Transcutol®P-Konzentration dagegen vermindert. UV/VIS-spektroskopische Analysen deuten darauf hin, dass in beiden Formulierungen Amphotericin B als Monomer vorliegt. Allerdings erwiesen sich die Formulierungen Caco-2-Zellen und humanen roten Blutkörperchen gegenüber als toxisch. Da die Kontrollproben eine höhere Toxizität als die wirkstoffhaltigen Formulierungen zeigten, ist die Toxizität nicht nur auf Amphotericin, sondern auch auf die Hilfsstoffe zurückzuführen. Die solubilisierte Wirkstoffmenge ist in beiden Formulierungen nicht ausreichend im Hinblick auf die eingesetzte Menge an Hilfsstoff nach WHO-Kriterien. Gemäß diesen Untersuchungen erscheinen die Emulsions-Formulierungen für die orale Gabe nicht geeignet. Dennoch sind Tierstudien notwendig, um den Effekt bei Tieren sowie die systemisch verfügbare Wirkstoffmenge zu ermitteln. Dies wird bestandskräftige Schlussfolgerungen bezüglich der Formulierung und Aussagen über mögliche Perspektiven erlauben. Nichtsdestotrotz sind die Präkonzentrate sehr stabil und können bei Raumtemperatur gelagert werden.rnDie multilamellar-vesikulären Formulierungen von Amphotericin B mit ungesättigten und gesättigten neutralen Phospholipiden und Cholesterin wurden erfolgreich entwickelt und enthielten nicht nur Vesikel, sondern auch zusätzliche Strukturen bei zunehmender Cholesterinkonzentration. Mittels Partikelgrößenanalyse wurden bei den Formulierungen mit gesättigten Lipiden Mikropartikel detektiert, was abhängig von der Alkylkettenlänge war. Mit dem ungesättigten Lipid (DOPC) konnten hingegen Nanopartikel mit hinreichender Verkapselung und Partikelgrößenverteilung gebildet werden. Die Ergebnisse der thermischen und FTIR-spektroskopischen Analyse, welche den Einfluss des Arzneistoffes ausschließen ließen, liefern den Nachweis für die mögliche, bereits in der Literatur beschriebene Einlagerung des Wirkstoffs in lipid- und/oder cholesterinreiche Membranen. Mit Hilfe eines linearen Saccharosedichtegradienten konnte die Formulierung in Vesikel und Wirkstoff-Lipid-Komplexe nach bimodaler Verteilung aufgetrennt werden, wobei der Arzneistoff stärker mit den Komplexen als mit den Vesikeln assoziiert ist. Bei den Kleinwinkelneutronenstreu-Experimenten wurde die Methode der Kontrastvariation mit Erfolg angewendet. Dabei konnte gezeigt werden, dass Cholesterol in situ einen Komplex mit Amphotericin B bildet. Diesen Sachverhalt legt unter anderem die beobachtete Differenz in der äquivalenten Streulängendichte der Wirkstoff-Lipid- und Wirkstoff-Lipid-Cholesterin-haltigen kleinen unilamellaren Vesikeln nahe. Das Vorkommen von Bragg-Peaks im Streuprofil weist auf Domänen hin und systematische Untersuchungen zeigten, dass die Anzahl der Domänen mit steigendem Cholesteringehalt zunimmt, ab einem bestimmten Grenzwert jedoch wieder abnimmt. Die Domänen treten vor allem nahe der Außenfläche der Modellmembran auf und bestätigen, dass der Wirkstoff in den Cholesterinreichen Membranen vertikal eingelagert ist. Die Formulierung war sowohl Caco-2-Zellen als auch humanen roten Blutkörperchen gegenüber nicht toxisch und erwies sich unter Berücksichtigung der Aufnahme in Caco-2-Zellen als vielversprechend für die orale Applikation. Die Formulierung zeigt sich somit aussichtsreich und könnte in Tabletten weiterverarbeitet werden. Ein Filmüberzug würde den Wirkstoff gegen die saure Umgebung im Magen schützen. Für die Bestimmung der systemischen Verfügbarkeit der Formulierung sind Tierstudien notwendig. Die entwickelten multilamellaren Formulierungen einschließlich der Wirkstoff-Cholesterin-Komplexe bieten somit gute Aussichten auf die mögliche medizinische Anwendung. rnrn

Studio e valutazione del legame tra rimodellamento elettrico e strutturale in Fibrillazione Atriale

La Fibrillazione Atriale (FA) è una delle aritmie più frequentemente riscontrate nella pratica clinica, ma i meccanismi che la generano e che la sostengono non sono ancora oggi ben chiari. L’obiettivo di questo lavoro di tesi è indagare il substrato aritmogeno della FA con particolare attenzione al legame tra rimodellamento elettrico e strutturale. La tecnica di riferimento per la valutazione della fibrosi è la risonanza magnetica con iniezione di mezzo di contrasto e acquisizione ritardata. Tipicamente, però, la presenza di fibrosi viene valutata durante la procedura di ablazione transcatetere mediante l’analisi dei potenziali elettrici rilevati, considerando le zone a basso potenziale indicative della presenza di alterazioni strutturali. In questo lavoro sono stati elaborati dati di Risonanza Magnetica (RM), in particolare sequenze Angio-RM e DE-RM. Dalle sequenze Angio-RM è stato ricostruito un modello 3D paziente-specifico dell’atrio, mentre dalle sequenze DE-RM sono state ricavate informazioni relative alla presenza di tessuto atriale fibrotico. Al modello 3D è stata poi sovrapposta l’informazione sull’intensità di grigio del dato DE-RM per poter visualizzare la localizzazione delle zone di fibrosi sulla superficie 3D dell’atrio.
 Sono stati anche esportati dal sistema di mappaggio elettroanatomico EnSite NavX (St. Jude Medical) i dati relativi alla geometria dell’atrio e ai potenziali registrati durante lo svolgimento della procedura di ablazione. Da questi dati è stato possibile ricostruire in ambiente Matlab le mappe di voltaggio raffiguranti i potenziali registrati durante la procedura. Per poter studiare e valutare il legame esistente tra rimodellamento elettrico e strutturale, sono state confrontate le mappe di voltaggio e le superfici raffiguranti fibrosi.
 Questo lavoro di tesi è stato svolto in collaborazione con l’U.O. di Cardiologia dell’Ospedale Bufalini di Cesena e la St. Jude Medical.

CT data-based navigation for post-mortem biopsy-a feasibility study

INTRODUCTION: Recent advances in medical imaging have brought post-mortem minimally invasive computed tomography (CT) guided percutaneous biopsy to public attention. AIMS: The goal of the following study was to facilitate and automate post-mortem biopsy, to suppress radiation exposure to the investigator, as may occur when tissue sampling under computer tomographic guidance, and to minimize the number of needle insertion attempts for each target for a single puncture. METHODS AND MATERIALS: Clinically approved and post-mortem tested ACN-III biopsy core needles (14 gauge x 160 mm) with an automatic pistol device (Bard Magnum, Medical Device Technologies, Denmark) were used for probe sampling. The needles were navigated in gelatine/peas phantom, ex vivo porcine model and subsequently in two human bodies using a navigation system (MEM centre/ISTB Medical Application Framework, Marvin, Bern, Switzerland) with guidance frame and a CT (Emotion 6, Siemens, Germany). RESULTS: Biopsy of all peas could be performed within a single attempt. The average distance between the inserted needle tip and the pea centre was 1.4mm (n=10; SD 0.065 mm; range 0-2.3 mm). The targets in the porcine liver were also accurately punctured. The average of the distance between the needle tip and the target was 0.5 mm (range 0-1 mm). Biopsies of brain, heart, lung, liver, pancreas, spleen, and kidney were performed on human corpses. For each target the biopsy needle was only inserted once. The examination of one body with sampling of tissue probes at the above-mentioned locations took approximately 45 min. CONCLUSIONS: Post-mortem navigated biopsy can reliably provide tissue samples from different body locations. Since the continuous update of positional data of the body and the biopsy needle is performed using optical tracking, no control CT images verifying the positional data are necessary and no radiation exposure to the investigator need be taken into account. Furthermore, the number of needle insertions for each target can be minimized to a single one with the ex vivo proven adequate accuracy and, in contrast to conventional CT guided biopsy, the insertion angle may be oblique. Navigation for minimally invasive tissue sampling is a useful addition to post-mortem CT guided biopsy.

Development and optimisation of photonic crystal based nanosensors

This thesis involved the development of two Biosensors and their associated assays for the detection of diseases, namely IBR and BVD for veterinary use and C1q protein as a biomarker to pancreatic cancer for medical application, using Surface Plasmon Resonance (SPR) and nanoplasmonics. SPR techniques have been used by a number of groups, both in research [1-3] and commercially [4, 5] , as a diagnostic tool for the detection of various biomolecules, especially antibodies [6-8]. The biosensor market is an ever expanding field, with new technology and new companies rapidly emerging on the market, for both human [8] and veterinary applications [9, 10]. In Chapter 2, we discuss the development of a simultaneous IBR and BVD virus assay for the detection of antibodies in bovine serum on an SPR-2 platform. Pancreatic cancer is the most lethal cancer by organ site, partially due to the lack of a reliable molecular signature for diagnostic testing. C1q protein has been recently proposed as a biomarker within a panel for the detection of pancreatic cancer. The third chapter discusses the fabrication, assays and characterisation of nanoplasmonic arrays. We will talk about developing C1q scFv antibody assays, clone screening of the antibodies and subsequently moving the assays onto the nanoplasmonic array platform for static assays, as well as a custom hybrid benchtop system as a diagnostic method for the detection of pancreatic cancer. Finally, in chapter 4, we move on to Guided Mode Resonance (GMR) sensors, as a low-cost option for potential use in Point-of Care diagnostics. C1q and BVD assays used in the prior formats are transferred to this platform, to ascertain its usability as a cost effective, reliable sensor for diagnostic testing. We discuss the fabrication, characterisation and assay development, as well as their use in the benchtop hybrid system.

Comment mettre en application des recommandations de pratique clinique? L'exemple des dyslipidémies [How to apply clinical guidelines in medical practice? The example of dyslipidemia]

How to summarize and facilitate the implementation of national and international guidelines in clinical practice? To adress these issues, we present a summary of dyslipidemia management for general practitioners. To achieve these aims, we adopted strategies based on international and national guidelines and focused on clinical applications which implies to choose specific options, such as the use of cardiovascular risk score and specific therapies as first options.

Mophological analysis of the human vasculature from medical imaging. Application to cerebral and coranary arteries

In this project, we have investigated new ways of modelling and analysis of human vasculature from Medical images. The research was divided in two main areas: cerebral vasculature analysis and coronary arteries modeling. Regarding cerebral vasculature analysis, we have studed cerebral aneurysms, internal carotid and the Circle of Willis (CoW). Aneurysms are abnormal vessel enlargements that can rupture causing important cerebral damages or death. The understanding of this pathology, together with its virtual treatment, and image diagnosis and prognosis, includes identification and detailed measurement of the aneurysms. In this context, we have proposed two automatic aneurysm isolation method, to separate the abnormal part of the vessel from the healthy part, to homogenize and speed-up the processing pipeline usually employed to study this pathology, [Cardenes2011TMI, arrabide2011MedPhys]. The results obtained from both methods have been also compared and validatied in [Cardenes2012MBEC]. A second important task here the analysis of the internal carotid [Bogunovic2011Media] and the automatic labelling of the CoW, Bogunovic2011MICCAI, Bogunovic2012TMI]. The second area of research covers the study of coronary arteries, specially coronary bifurcations because there is where the formation of atherosclerotic plaque is more common, and where the intervention is more challenging. Therefore, we proposed a novel modelling method from Computed Tomography Angiography (CTA) images, combined with Conventional Coronary Angiography (CCA), to obtain realistic vascular models of coronary bifurcations, presented in [Cardenes2011MICCAI], and fully validated including phantom experiments in [Cardene2013MedPhys]. The realistic models obtained from this method are being used to simulate stenting procedures, and to investigate the hemodynamic variables in coronary bifurcations in the works submitted in [Morlachi2012, Chiastra2012]. Additionally, another preliminary work has been done to reconstruct the coronary tree from rotational angiography, and published in [Cardenes2012ISBI].

Consensus interdisciplinaire CHUV-HUG sur la prise en charge des douleurs du dos. Son application lausannoise dans la filière du dos [Inter-hospital CHUV-HUG medical consensus of back pain management. Its application in care pathways within CHUV of Lausanne].

Back pain is a considerable economical burden in industrialised countries. Its management varies widely across countries, including Switzerland. Thus, the University Hospital and University of Lausanne (CHUV) recently improved intern processes of back pain care. In an already existing collaborative context, the two university hospitals in French-speaking Switzerland (CHUV, University Hospital of Geneva), felt the need of a medical consensus, based on a common concept. This inter-hospital consensus produced three decisional algorithms that bear on recent concepts of back pain found in literature. Eventually, a fast track was created at CHUV, to which extern physicians will have an organised and rapid access. This fast track aims to reduce chronic back pain conditions and provides specialised education for general practitioners-in-training.

Incorporating priorities for waiting customers in the hypercube queuing model with application to an emergency medical service system in Brazil

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Forecasting the need for medical specialists in Spain: application of a system dynamics model

[EN] Background: Spain has gone from a surplus to a shortage of medical doctors in very few years. Medium and long-term planning for health professionals has become a high priority for health authorities. Methods: We created a supply and demand/need simulation model for 43 medical specialties using system dynamics. The model includes demographic, education and labour market variables. Several scenarios were defined. Variables controllable by health planners can be set as parameters to simulate different scenarios. The model calculates the supply and the deficit or surplus. Experts set the ratio of specialists needed per 1000 inhabitants with a Delphi method. Results: In the scenario of the baseline model with moderate population growth, the deficit of medical specialists will grow from 2% at present (2800 specialists) to 14.3% in 2025 (almost 21 000). The specialties with the greatest medium-term shortages are Anesthesiology, Orthopedic and Traumatic Surgery, Pediatric Surgery, Plastic Aesthetic and Reparatory Surgery, Family and Community Medicine, Pediatrics, Radiology, and Urology. Conclusions: The model suggests the need to increase the number of students admitted to medical school. Training itineraries should be redesigned to facilitate mobility among specialties. In the meantime, the need to make more flexible the supply in the short term is being filled by the immigration of physicians from new members of the European Union and from Latin America.