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Abstract The author examines the role of the European Social Dialogue (ESD) in decision-making on social policy and labor relations at supranational level in the EU. The author looks into the history and distinctive features of the ESD, its formats, procedures, and legal framework. Based on a review of the institutionalization of social dialogue at the national level in the EU-27, the author draws two conclusions. The first is that the development of social dialogue is uneven across the Union because of the particularities of the social models of the member states and their political and socioeconomic development. The second is that, despite national differences, the coverage of workers by collective agreements in the EU as a whole and the entrenchment of social dialogue at the supranational level make it an integral and distinctive feature of the European social model. An analysis of the evolution of the ESD suggests that there has been a continual move towards a more autonomous status for the social partners. However, because of the 2008–2010 crisis, the ESD’s role has significantly weakened. “A New Start for Social Dialogue” announced by the Juncker’s Commission and several further initiatives are largely declarative. The Court of Justice’s 2021 decision limiting the scope for implementing autonomous agreements at the communitarian level could have a negative impact on the further development of the ESD. Finally, the author positively assesses the possible role of the ESD in overcoming the social consequences of internal and external challenges and the negative effects of transformation of the labor markets.

The artifact typology of Francois Bordes has been universally applied to European Middle Paleolithic assemblages for the past half-century. Although its utility as a common descriptive language is acknowledged, it is argued that Bordes' type definitions are inadequate for use in modern quantitatively and technologically oriented studies of lithics because they are overly subjective and are an uncontrolled mixture of technological and functional variables acted on by raw material constraints. They also incorporate untested assumptions about the cognitive abilities of Middle Paleolithic hominids. This paper proposes to replace the Bordes typology with a method based on attribute combinations in which artifact descriptions will contain more behaviorally significant information than is afforded by the current system.

BACKGROUND—Cystic fibrosis is the most common inherited disease with a fatal outcome in industrialised nations. With the improvement in life expectancy, supporting patients and their families in adapting to life with this chronic progressive disease has become increasingly important. The aim of the present study was to investigate the relationship between health related quality of life (HRQOL) in this population, severity of disease, and cognitive/behavioural factors such as subjective health perception and ways of coping. METHODS—A sample of 89 adolescent and adult patients with cystic fibrosis and 125 parents of younger patients with cystic fibrosis completed questionnaires on health related quality of life and on ways of coping with the illness. Parents were asked to fill out the questionnaires regarding their own quality of life and coping. Multiple regression analyses were performed to examine the relationship between different predictor variables and quality of life. RESULTS—After accounting for the impact of disease severity and hours of treatment per day, the subjective health perception of patients significantly explained variance in their quality of life. Ways of coping were also significantly correlated with HRQOL. In parents the most important factor in explaining variance of HRQOL seems to be the coping style, whereas disease severity of the child and subjective health perception did not show any influence. CONCLUSIONS—The findings support the important role of cognitive and behavioural factors in specific subjective health perception and ways of coping in the adaptation to this severe chronic disease, both in patients themselves and in parents. The results call for a careful assessment of issues of coping and professional support for families of patients with cystic fibrosis in the early course of disease.

We compared the immunological functions of interferon-gamma (IFN-gamma)-induced, classically activated macrophages (caM phi) and of interleukin-4 (IL-4)- and glucocorticoid-induced, alternatively activated macrophages (aaM phi) in a human co-culture system in vitro. Proliferation of peripheral blood leucocytes (PBL) or CD4+ T cells mediated by optimal doses of phytohaemagglutinin (PHA) or concanavalin A (Con A) was only marginally influenced by caM phi, but was strongly inhibited by aaM phi. The degree of lymphocyte proliferation sustained in the presence of caM phi was gradually reduced in a dose-dependent fashion by the addition of aaM phi. Flow cytometric analysis revealed that expression of costimulatory molecules such as CD11a, CD40, CD54, CD58, CD80 and CD86 did not vary significantly between caM phi and aaM phi and was low for CD58, CD80 and CD86. As shown by reverse transcriptase-polymerase chain reaction (RT-PCR) analysis, IL-10 was expressed in caM phi, aaM phi and control macrophages; the level of expression of IL-10 was slightly enhanced in aaM phi. Neither neutralizing anti-IL-10 antibodies, indomethacin nor NG-monomethyl-L-arginine (NMMLA) was able to reverse aaM phi-mediated inhibition of lymphocyte proliferation. Of several agents interfering with various second messenger pathways, cAMP and the Ca(2+)-ionophore A23187 inhibited differentiation of cultured human monocytes into phenotypically mature aaM phi expressing MS-1 high molecular weight protein (MS-1-HMWP) and RM 3/1 antigen, and prevented the suppressive action of aaM phi on lymphocyte proliferation. In conclusion, these results who that aaM phi actively inhibit mitogen-mediated proliferation of PBL and CD4+ T cells independently of the expression of costimulatory molecules and of IL-10, NO or prostaglandin synthesis, and that inhibition of phenotypic differentiation of aaM phi is paralleled by a lack of functional maturation. Thus, fully matured aaM phi may be functional in down-regulating CD4+ T-cell-mediated immune reactions by an as yet unknown mechanism.

Trois datations radiocarbones, comprises entre 19280 ± 220 BP et 14110 ± 110 BP ont recemment ete obtenues grâce a la spectrometrie de masse d'os de mammiferes mis au jour dans la grotte de Barma Grande (Grottes de Grimaldi, nord-ouest de l'Italie) en 1883-1884. L'analyse des 379 objets lithiques collectes lors de ces fouilles indiquent que la sequence archeologique du Paleolithique superieur a Barma Grande s'etend de l'Epigravettien ancien a l'Epigravettien recent. Ces dates et leurs associations archeologiques demontrent que les figurines feminines provenant de ce site sont bien plus recentes qu'on ne le pensait, ce qui remet en question la chronologie communement acceptee des Venus d'Europe de l'Ouest, et leur interpretation en tant que phenomene unitaire

Sept objets detenus a Montreal se revelent etre des figurines. Elles proviennent de la Grotte Grimaldi, en Ligurie, un des sites les plus important du Paleolithique europeen. Le parcours fantaisiste qui aboutit a l'etude actuelle ne permet pas de connaitre leur contexte, neanmoins l'A. pense reconnaitre des particularites stylistiques qu'il attribue au Gravettien-Epigravettien

A 38-kD cell-surface glycoprotein (MH 99, KS 1/4) appears strongly elevated in epithelial malignancies, although it also occurs in a few immature, germ-cell phenotypic tissues in human epidermis. In this study, the expression and synthesis characteristics of the MH 99 antigen were examined in several transformed epithelial cell lines. Marked increase of MH 99 (by 100-200%) was found in highly proliferative cell populations, as demonstrated by radioimmunoprecipitation, fluorescence-activated cell sorter analysis, and proliferation experiments in cultures of spontaneously immortalized keratinocytes (HaCaT) squamous cell carcinoma lines (SCL 1 and SCL 2), and SV-40 transformed keratinocytes (130, 425, and HaSV). The relation of the MH 99 antigen to cell proliferation was underscored by a 70-75% decrease of synthesis in nonproliferating HaCaT cells treated with mitomycin C. Blocking of two distinct epitopes of the molecule with two different monoclonal antibodies (MH 99 and MM 104) decreased cell proliferation by approximately 25% (F = 519.6; df = 1,145; p < 0.0001), as compared to untreated cells and to cells treated with unrelated antibodies (BT 15 and J 143). Analysis of MH 99 synthesis in aging transformed keratinocytes cultured without passage revealed downregulation by approximately 50-60% after 60 d, indicating inverse correlation of the MH 99 antigen with increasing cell age. It seems, therefore, that the MH 99 antigen is directly correlated with cell proliferation and inversely correlated with increasing age of transformed epithelial cells, possibly playing an active role in the process of cell proliferation.

Background Physicians are quite often surveyed with the aim to investigate their opinions regarding provision and improvement of health care. However, in many cases response rates tend to be rather low. The aim of the study is to reflect methodological aspects regarding survey conduction and to analyse factors that cause physicians to take part in a study on delivering end-of-life care for the elderly. Methods N = 4,727 physicians in Lower Saxony, Germany, received a standardised questionnaire on their attitudes about end-of-life care for the elderly. Non-responders were asked to state the reasons for non-participation. Comparison of the sociodemographic characteristics between responders and non-responders, and evaluation of the reasons for non-participation were made. Results The response rate to the questionnaire on end-of-life care for the elderly was 40% (n = 1,892). Of the non-responders to the questionnaire, 12.8% (n = 364) stated the reasons for non-participation. Overall, the response rate to the questionnaire varied with specialty and location of the practice: radiotherapists answered significantly more frequently than other categories of physician (e.g. general practitioners) and physicians in rural areas significantly more frequently than their colleagues in urban areas. The reasons most frequently given for non-participation were "Not concerned with the subject" and "No time". Conclusions The varying rates of response indicate that the survey was not sufficiently relevant to all groups of physicians, or that the awareness of the topic may be partly underdeveloped.

The Sado River Drainage Survey project (2004-2008) was designed to fill a significant gap in our knowledge of the prehistory of Portugal. Southern Alentejo constitutes nearly one third of the total land mass of continental Portugal, but has received comparatively little attention from Palaeolithic archaeologists. Practically nothing was known about the prehistory of the Sado River basin, which includes the southern Alentejo plain, before now. The results of the Sado River Drainage Survey (SRDS) indicate that the Sado River basin was likely occupied at low population densities during the Middle Palaeolithic. There is some evidence for a Lower Palaeolithic presence but little or no evidence of an Upper Palaeolithic occupation. The emerging pattern suggests either an occupational hiatus or a major shift in settlement pattern towards the end of the Middle Palaeolithic. Possible explanations for this pattern, including aridification driven by climate change, are explored here.El proyecto de prospección de la cuenca del río Sado (SRDS), llevado a cabo entre el 2004 y el 2008, se diseñó para suplir la carencia de información concerniente al conocimiento actual de la Prehistoria de Portugal. Aunque la cuenca del río Sado conforma casi un tercio de la superficie continental de Portugal, aún no había recibido la debida atención para el Paleolítico. Antes de este proyecto, prácticamente nada se conocía acerca de la Prehistoria de dicha cuenca, incluyendo la llanura de Alentejo. Nuestros resultados indican una baja densidad de población durante el Paleolítico Medio, rastro de ocupaciones del Paleolítico Inferior y casi ninguna evidencia de ocupaciones asociadas al Paleolítico Reciente. A partir de los datos obtenidos, se desprende un modelo en el que se evidencia que, hacia finales del Paleolítico Medio, hubo una discontinuidad en la ocupación, probablemente asociada a cambios climáticos o del uso del territorio.

This paper describes an intensive survey of the Luano stream drainage located near Chingola, Zambia. Deforestation combined with cultivation of this area allowed a complete picture of settlement sizes and distributions from the Middle Stone Age through the Iron Age to be discovered. Models of Stone and Iron Age site location strategies are developed and compared to the settlement pattern observed at Luano. Site location decisions were found to be identical in the Late Stone Age and Early and Middle Iron Ages, suggesting a possible source of conflict between early agriculturalists and hunter‐gatherers. Iron Age communities became larger over time but split into smaller hamlets after AD 1500. Possible economic and social causes of this fission are discussed.

This paper describes Late Stone Age assemblages of quartz tools and debitage from sites near Luano Hot Spring, Chingola, Zambia. Formal tools at the Luano rock shelter site suggest a ‘Nachikufan II’ to ‘Nachikufan III’ sequence according to the traditional terminology. However, analysis of the debitage demonstrates that all levels of the site represent a single Late Stone Age technological tradition. Differences in formal tool frequencies at this site are better explained as activity facies. The implications of these results for our understanding of local Late Stone Age-Iron Age contacts are discussed.

Timing for the evaluation and listing of patients with cystic fibrosis who are candidates for lung transplantation is still uncertain. Our study goal was to determine the value of the 12-min walk test as a simple and easy-to-use adjunctive assessment tool for pre-transplant evaluation. A total of 34 cystic fibrosis patients (17 male, mean age 22 years) with end-stage lung disease were evaluated in this retrospective analysis. The 12-min walk test was carried out according to an established protocol. Before walking, body plethysmography was performed and a capillary sample was taken for blood gas analysis. Walking distance and SaO 2 via continuous pulse oximetry were recorded online. There was a strong correlation between survival time and walking distance ( r =0.7, P =0.003). No other single parameter, such as FEV 1 , SaO 2, p CO 2 or BMI, showed a statistically significant correlation with survival time. Subjects who walked ≤700 m had a lower cumulative survival ( P =0.02). There was a statistically significant positive correlation between walking distance and SaO 2 at rest and after 12 min of walking ( r =0.5, P =0.001; and r =0.5, P =0.04, respectively). There was no correlation between walking distance and p CO 2 at rest, BMI, FEV 1 , or degree of change in SaO 2 during the walk test. This study demonstrates that in CF patients with end-stage lung disease, walking distance during a 12-min walk test is more informative with respect to survival than single parameters such as SaO 2, p CO 2 , FEV 1 or BMI.

Having participated in the re-discovery in Montréal of seven nearly unpublished anthropomorphic figurines from the caves of Grimaldi (Liguria, Italy), the authors present a description and analysis that reunites these seven pieces from thejullien collection with those from the musée des Antiquités nationales at Saint-Germain-en-Laye. They attempt a seriation that yields a provisional chronology within the total collection of statuettes. They then seek an explanation for the statuettes which takes into account the cultural context of their fabrication, use and disposal. With the judicious use of ethnographic analogies, they hypothesize that these objects were used by women to ensure safe completion of pregnancies and safe deliveries of infants, rather than to ensure fertility., Les auteurs, qui ont participé à la découverte à Montréal de sept statuettes anthropomorphes quasi inédites des grottes de Grimaldi (Ligurie, Italie), présentent une description et une analyse réunissant ces sept statuettes de la collection Jullien à celles du musée des Antiquités nationales. Afin d'établir une chronologie provisoire de cette collection de statuettes, une sériation a été effectuée ; puis une explication, qui prend en compte le contexte culturel de fabrication, d'utilisation et de « l'abandon » de ces objets, est donnée. Avec le soutien des cas ethnographiques, les auteurs proposent une utilisation par les femmes pour s 'assurer de la bonne marche de leur grossesse et de leur accouchement, plutôt que d'assurer la fécondité., White Randall, Bisson Michael S. Imagerie féminine du Paléolithique : l'apport des nouvelles statuettes de Grimaldi. In: Gallia préhistoire, tome 40, 1998. pp. 95-132.

The local effects of silver-coated polyurethane catheters and Dacron ® material were compared to uncoated polyurethane catheters and Dacron ® material in a long-term implantation test using rabbits. The tissue-implant interaction was analysed by investigating the type and number of inflammatory cells, capillaries, fat tissue, the extent of fibrosis, thickness of the fibrous capsule, number and distribution of silver particles, and the size of giant cells. Silver-coated and uncoated materials displayed comparable signs of inflammation and tissue reaction. Biomaterials (1994) 15 , (10) 753–758

Gold. Copper. Iron. Metal working in Africa has been the subject of both popular lore and extensive archaeological investigation. In this volume, four leading archaeologists attempt to provide a complete synthesis of current debates and understandings: When, how and where was metal first introduced to the continent? How were iron and copper tools, implements, and objects used in everyday life, in trade, in political and cultural contexts? What role did metals play in the ideological systems of precolonial African peoples? Substantive chapters address the origins of African metal working and analyze the specific uses, technology, and ideology of both copper and iron. An ethnoarchaeological account in the words of a contemporary iron worker enriches the archaeological explanations. The volume will be of great value to scholars and students of archaeology, African history, and the history of technology.

does not appear. First page follows. Introduction The fresh pea crop is of considerable economic importance in California. As most of it is shipped to distant markets, there is danger of the product’s being subject to conditions deleterious to edible quality. To a certain extent the continued success of the industry depends upon placing a high-quality commodity on the table of the consumer. In an effort to help in guiding commercial practices in this direction, studies have been made on the fundamental changes occurring in the peas and pods after harvest. As a rule the results of analyses presented by most investigators studying changes in stored material have been expressed as percentages of dry matter. When this method of expression is used, it is difficult to secure a true picture of the absolute changes that are taking place because the variables being studied, such as sugars and starches, are compared with another variable—total dry matter. Kertesz(5)5 has recently pointed out some of the errors commonly occurring in the accumulation and presentation of data on stored material. In these studies the authors have been interested in determining the absolute changes occurring in both pods and peas in storage and the transfer of material from one to the other.

does not appear. First page follows. During the 1936 season, growers in various districts in California were experiencing some difficulty in sulfuring the fruit to be dried. Long, Mrak, and Fisher5 found that the difficulties of that season were merely a recurrence of a series of yearly troubles. These investigators determined that some of the samples of sulfur in question burned 90 to 100 per cent, whereas many others burned anywhere from 10 to 50 per cent. With the poor-burning sulfurs the result was reduced quality of the product, delay in operations during the drying season, and an actual loss of sulfur through failure to burn.

Chemical studies on the garden pea were begun at the California Agricultural Experiment Station in 1924. The object of the work was to determine some of the changes that occur in the fruit during development and after harvest. This paper deals specifically with the changes in amounts of some of the components of the pods and peas during their development. The results on storage will be presented in another paper. The investigations were confined mainly to the carbohydrates as it was believed that these played a more important part than other components in the determination of quality. Experimental procedure The variety used was Dwarf Telephone. This is a large-podded wrinkled pea and is the variety used for the spring crop in the Imperial Valley. The seed was planted at the University Farm, Davis, California, on November 20, 1924. The plants were in full bloom on April 9, 1925, and on this date a large number of open flowers were labeled by tying strings around the peduncles. This was done to have fruit of the same age for study. The first picking was made on April 21 when the fruit was 12 days old. The peas at this time were still very small and it was necessary to harvest a large number of fruit to get enough peas for the analyses. A second picking was made on April 27. From this date harvesting was done at two-day intervals until May 15 and then at four-day intervals until May 27. The samples were collected each morning between 7 :30 and 8 :00. Several representative fruits were selected at each harvest and one specimen of each picking is shown in figure 1. A number of fruits were also counted from each day's picking to be used for samples for analysis. These were then immediately shelled and the peas and pods weighed separately. From these data the average fresh weight of the fruit, pods, and peas were calculated and are given in columns 4, 5, and 7 of table I. When weighings were completed the peas and pods were preserved immediately by placing them

does not appear. First page follows. Introduction Edible quality in watermelons is determined by several contributing chemical and physical factors. To be of high quality the flesh must be deep red in color, of crisp texture, and high in sugar content. Our American varieties manifest marked variation of these characters and foreign varieties are even more variable. While the relative intensity of these characters may vary slightly from season to season in a given locality, such variation is much less pronounced than the consistent differences among varieties. Many varieties have been grown at Davis annually since 1930, and yearly differences in these characters, while slight, could easily be due to a slight difference in genetic constitution of variety. For instance, Striped Klondike No. 11 has consistently contained more sugar than other varieties tested. Again, Tom Watson and Kleckley Sweet, annually have manifested pale-red rather than deep-red color. Thus, year after year, the varieties maintain a certain identity. It is not inferred here that these characters might not be influenced by environmental conditions, extent of foliage development, or total fruit yield expressed in pounds per plant. Varieties do vary in the amount of leaf surface and relative size of leaves. Certain small-fruited varieties characteristically produce six to ten fruits, while others, such as Tom Watson, rarely produce more than three fruits per plant.

does not appear. First page follows. Introduction Concurrently with the 1931-1932 hydrologic investigation of Putah Creek basin, reported by Huberty and Johnston in the accompanying paper (3),4 studies of water quality were being made.5 The purpose of the study was to determine, from analytical data, the classification of waters of the area as to their chemical composition; the seasonal variation in the character and amount of dissolved salts; and to determine the boron content of the waters, since this element is highly toxic to most plants when present even in minute quantities (1),(2),(4). Methods of Procedure Samples were obtained from the pump discharge of wells penetrating water-bearing formations of various depths. Figure 1 shows the locations of the wells, from which water samples were collected in glassstoppered bottles for analysis. From a small number of wells, perforated at only one water-bearing stratum, water samples were collected at intervals of from one day to one week to determine the seasonal variation in salt content. Water samples of from 2 to 4 liters, collected in glass-stoppered bottles were placed in wooden containers and immediately taken to the laboratory where determinations were made for pH, bicarbonate, carbon dioxide, and nitrate. Later analyses were made for calcium, magnesium, sodium, potassium, iron, carbonate, sulfate, chloride, phosphate, nitrate, silicon, aluminum, and boron. The total solids were determined at 105° c. Results of the Analyses The results of the determinations of bicarbonate and chloride ions on samples collected to show seasonal changes in the dissolved salt content are recorded in table 1. Table 2 contains the analyses of well waters obtained within Putah Creek lower basin, and the results are reported in parts per million. The pH values reported. in the second column were obtained soon after the samples reached the laboratory. For the convenience of those not accustomed to interpreting water analysis in parts per million, table 3 is introduced.

Reverse transcriptase polymerase chain reaction for the detection of tyrosinase-mRNA-positive cells in peripheral blood of melanoma patients, as a possible marker of hematogenous dissemination, has demonstrated varying detection rates. This study examined the sensitivity and reproducibility of the technique using a protocol of multiple polymerase chain reaction to determine circulating melanocytic cells. For each of the 123 melanoma patients included in this study, four nested polymerase chain reactions were performed from two blood specimens requiring both polymerase chain reactions from at least one blood sample to be positive to consider a patient as positive. Thus, a definitive result was obtained in 98% of the cases, whereas only 1.6% lacked conclusive findings. Thus, we found a correlation between the tyrosinase detection rate and the clinical stage. Circulating tyrosinase-mRNA-positive cells were detected in 13% of patients with primary tumor, 17% with regional skin/lymph node metastasis, and 44% with distant metastasis. Positivity also correlated with known melanoma progression markers such as gender, tumor thickness, and histologic type. Positive results were obtained more frequently in (i) men compared with women, (ii) patients with thick primary melanomas (4 mm: 38%) compared with those with thinner tumors (1.1-4 mm, 22%;or = 1 mm, 5%), and (iii) patients with nonclassifiable (38%), nodular (34%), and occult primary melanomas (30%) compared with those with acrolentiginous (17%), superficial spreading (9%), or lentigo maligna melanoma (0%). These findings suggest that detection of tyrosinase-mRNA-positive cells in peripheral blood is not an adequate marker for identifying melanoma patients with distant metastasis. Reverse transcriptase polymerase chain positivity in early melanoma stages, however, as corresponding to other prognostic parameters, may indicate increased risk for the development of hematogenous metastasis and may be of value as a progression marker.

M. S. Bisson — Commerce et tribut. Documents archéologiques sur l'origine des États du sud de VAfrique centrale. Cet article examine le rapport du négoce et du tribut avec le développement d'États préhistoriques en Afrique sud-centrale, à l'aide de données historiques et archéologiques. L'hypothèse selon laquelle le négoce organisé sur de longues distances aurait été la cause première de la formation des États est examinée en ce qui concerne les Yeke, le Monomatapa et les Lunda du Sud et de l'Est. Les données archéologiques porteraient à conclure que le commerce au long cours fut un facteur important dans la croissance de l'État. Toutefois, il y a aussi trace d'une formation d'État antérieure, et qui aurait été provoquée par le développement d'un réseau tributaire, avant l'apparition du négoce s'étendant aux littoraux., Bisson Michael S. Trade and Tribute. Archaeological Evidence for the Origin of States in South Central Africa. In: Cahiers d'études africaines, vol. 22, n°87-88, 1982. systèmes étatiques africains. pp. 343-361.

In this paper data are presented showing some of the changes that occur in the fruit of the garden pea after harvest, when held at different temperatures. The object of this study was to determine the changes in at least a few of the components that were thought to be so altered after harvest as to affect the edible quality. In this study the changes in only a few of the carbohydrates were determined, but no doubt a large number of other chemical as well as structural changes occur that are to some extent responsible for the rapid loss of edible quality when held under certain conditions after harvest.

Background Health systems increasingly try to make their services more responsive to users' expectations. In the context of the World Health Report 2000, WHO developed the concept of health system responsiveness as a performance parameter. Responsiveness relates to the system's ability to respond to service users' legitimate expectations of non-medical aspects. We used this concept in an effort to evaluate the performance of mental health care in a catchment area in Germany. Methods In accordance with the method WHO used for its responsiveness survey, responsiveness for inpatient and outpatient mental health care was evaluated by a standardised questionnaire. Responsiveness was assessed in the following domains: attention, dignity, clear communication, autonomy, confidentiality, basic amenities, choice of health care provider, continuity, and access to social support. Users with complex mental health care needs (i.e., requiring social and medical services or inpatient care) were recruited consecutively within the mental health services provided in the catchment area of the Hanover Medical School. Results 221 persons were recruited in outpatient care and 91 in inpatient care. Inpatient service users reported poor responsiveness (22%) more often than outpatients did (15%); however this was significant only for the domains dignity and communication. The best performing domains were confidentiality and dignity; the worst performing were choice, autonomy and basic amenities (only inpatient care). Autonomy was rated as the most important domain, followed by attention and communication. Responsiveness within outpatient care was rated worse by people who had less money and were less well educated. Inpatient responsiveness was rated better by those with a higher level of education and also by those who were not so well educated. 23% of participants reported having been discriminated against in mental health care during the past 6 months. The results are similar to prior responsiveness surveys with regard to the overall better performance of outpatient care. Where results differ, this can best be explained by certain characteristics that are applicable to mental health care and also by the users with complex needs. The expectations of attention and autonomy, including participation in the treatment process, are not met satisfactorily in inpatient and outpatient care. Conclusion Responsiveness as a health system performance parameter provides a refined picture of inpatient and outpatient mental health care. Reforms to the services provided should be orientated around domains that are high in importance, but low in performance. Measuring responsiveness could provide well-grounded guidance for further development of mental health care systems towards becoming better patient-orientated and providing patients with more respect.

Background Statements on potential measures to improve palliative care in Germany predominantly reflect the points of view of experts from specialized palliative care organizations. By contrast, relatively little is known about the views of representatives of organizations and institutions that do not explicitly specialize in palliative care, but are involved to a relevant extent in the decision-making and policy-making processes. Therefore, for the first time in Germany, we carried out a representative study of the attitudes of a broad range of different stakeholders acting at the national or state level of the health care system. Methods 442 organizations and institutions were included and grouped as follows: patient organizations, nursing organizations, medical associations, specialized palliative care organizations, political institutions, health insurance funds and others. Using a standardized questionnaire, the participants were asked to rate their agreement with the World Health Organization's definition of palliative care (five-point scale: 1 = completely agree, 5 = completely disagree) and to evaluate 18 pre-selected improvement measures with regard to their general meaningfulness and the feasibility of their introduction into the German health care system (two-point scale: 1 = good, 2 = poor). Results The response rate was 67%. Overall, the acceptance of the aims of palliative care in the WHO definition was strong. However, the level of agreement among health insurance funds' representatives was significantly less than that among representatives of the palliative care organizations. All the improvement measures selected for evaluation were rated significantly higher in respect of their meaningfulness than of their feasibility in Germany. In detail, the meaningfulness of 16 measures was evaluated positively (70–100% participants chose the answer "good"); for six of these measures feasibility was evaluated negatively (0–30% "good"), while for the remaining ten measures feasibility was evaluated inconsistently (31–69% "good"). Conclusion The reason why potentially meaningful improvement measures are considered to be not very feasible in Germany may be the existence of barriers resulting from the high degree of fragmentation of health care provision and responsibilities. In overcoming these barriers and further improving palliative care it may be helpful that the basic understanding of the palliative care approach seems to be quite homogenous among the different groups.

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