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Muscle wasting has been emerging as one of the principal components of cancer cachexia, leading to progressive impairment of work capacity. Despite early stages melanomas rarely promotes weight loss, the appearance of metastatic and/or solid tumor melanoma can leads to cachexia development. Here, we investigated the B16F10 tumor-induced cachexia and its contribution to muscle strength and locomotor-like activity impairment. C57BL/6 mice were subcutaneously injected with 5 × 104 B16F10 melanoma cells or PBS as a Sham negative control. Tumor growth was monitored during a period of 28 days. Compared to Sham mice, tumor group depicts a loss of skeletal muscle, as well as significantly reduced muscle grip strength and epididymal fat mass. This data are in agreement with mild to severe catabolic host response promoted by elevated serum tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and lactate dehydrogenase (LDH) activity. Tumor implantation has also compromised general locomotor activity and decreased exploratory behavior. Likewise, muscle loss, and elevated inflammatory interleukin were associated to muscle strength loss and locomotor activity impairment. In conclusion, our data demonstrated that subcutaneous B16F10 melanoma tumor-driven catabolic state in response to a pro-inflammatory environment that is associated with impaired skeletal muscle strength and decreased locomotor activity in tumor-bearing mice.

In der vorliegenden Studie wurden Kosten und Kosteneffektivitat von unterschiedlichen Zugangswegen zu russischsprachigen Migranten am Beispiel von Informationsveranstaltungen zur Suchtpravention untersucht: passive Kommstruktur, aktive Zugehstruktur sowie Mischstruktur (die aktive und passive Rekrutierungsstrategien kombiniert). Die Effektivitat der Zugangswege wurde uber die Anzahl der Teilnehmer sowie der erreichten Zielpersonen (mit praventiver Motivation) definiert. Die Erhebung der Effekt- und Kostendaten erfolgte bei Programmteilnehmern, Mediatoren sowie Programmkoordinatoren. Die Kommstruktur erwies sich als ineffektiv, es wurden nur 0,2 Teilnehmer je Veranstaltung erreicht. Die Kosten je Informationsveranstaltung waren bei Misch- und Zugehstruktur vergleichbar hoch (813 bzw. 792 EUR), jedoch erwies sich die Mischstruktur als effektiver und kosteneffektiver. Es wurden mehr Teilnehmer erreicht (18,9 gegenuber 15,2 Personen) und der Anteil der Zielpersonen war hoher (21% vs. 17% bei sekundarpraventiver Motivation). Bei den meisten Programmen in der Literatur sind die Rekrutierungskosten je Teilnehmer uber den passiven Zugang deutlich geringer als uber den aktiven Zugang. Die vorliegende Studie reproduziert diese Ergebnisse nicht. Eine mogliche Begrundung ist, dass die Rekrutierung bei dem sensiblen Thema Suchtpravention ein funktionierendes Netzwerk zu migrantenspezifischen Communities erfordert.

Purpose of the study The 9 (th) Revision of German Medical Licensing Regulations for Physicians has come into effect on October 1 (st) 2003. Social medicine was separated into the fields ""occupational health, social medicine" and the various cross-sectional modules: epidemiology, biometry, medical computer science; health economics, health-care system, public health; prevention, health promotion; rehabilitation, physical medicine, naturopathic treatment. This paper studies the realisation of teaching in the field social medicine at German medical faculties. Methods The survey was conducted in collaboration with the German Association for Social Medicine and Prevention (DGSMP). A survey was conducted at 38 institutes of 36 German medical faculties. The written questionnaire contained mostly selection items in which chances and barriers of the field were queried with supply items. Information about time scale, general conditions and resources was aked for. On the basis of the guidelines of the DGSMP, the topics to be taught were evaluated concerning their relevance and integration into education. Results The response rate was 68% (n=26). Social insurance, basic principles, responsibility in the Social Security Code and the different providers were judged as the most important topics. There was a strong demand for lecturing material. 82% (n=18) of the faculties wished to have specific material, for example e-learning, examples, lesson plans, curricula and also textbooks. 91% (n=19) of the faculties requested an exchange of information between the faculties concerning educational contents, motivation of students and e-learning. Discussion The realisation of teaching is different between the faculties concerning the number of hours, teaching methods and number of students per year. The motivation of the students is one of the problems, but also the lack of acceptance within the clinic. Specific resources and exchange between the faculties are necessary concerning e-learning, which is offered at only few faculties so far, but interest for a more intensive usage exists. Potentials of social medicine are the promotion of awareness among the students and the "identification of basics for medical acts in the social security system". Social medicine offers the possibility to connect the theoretical institutes with the clinic.

OBJECTIVE: RESPONSIVENESS is a concept developed by the World Health Organisation (WHO) to evaluate health system performance. It measures how well a health system meets its users’ legitimate expectations in non-medical related service aspects. RESPONSIVENESS consists of the categories “patient orientation” and “respect for persons”. It is operationalised by nine (8+1) domains. This project aims to explore the RESPONSIVENESS concept as a possibility to evaluate the performance of mental health care. METHOD: Face to face interviews with users of outpatient and hostel mental health services by means of a standardised instrument, developed by WHO were carried out. RESULTS: Overall RESPONSIVENESS in outpatient care was rated by a lower proportion of users negative than RESPONSIVENESS in hostel care (15 vs. 20%). Socio-demographic characteristics were related only to RESPONSIVENESS ratings in hostel care when legal guardianship was considered. Domains indicated as most important (ATTENTION, PARTICIPATION) in out-patient care did not perform well there. In hostel care the domains ATTENTION and RESPECT were rated as most important. These domains performed well. DISCUSSION AND CONCLUSIONS: The results are in line with the literature and adequately reflect the realities in mental health care. The RESPONSIVENESS concept offers a systematic approach for considering the categories “patient orientation” and “respect for persons” as quality criteria in mental health care. Evaluating mental health service provision using the concept of RESPONSIVENESS, indicates where to launch reforms in health care.

The coming into effect of the 9 th Revision of German Medical Licensing Regulations for Physicians on October 1st 2003 saw prevention and health promotion become a cross-sectional module of medical training subject to compulsory assessments and a grading system. The individual medical faculties are responsible for content and teaching methods. An initial survey of all 36 German medical facilities shows the current implementation of the new cross-sectional area. In a partly standardised questionnaire these faculties were surveyed on the linking of coordination and realisation, the didactic methodology concept of teaching as well as potentials and difficulties in implementation. The implementation of the cross-sectional area differs in responsibility with regard to coordination and content, time provided, integration of practice in health care and forms of assessment. Whereas consensus exists regarding the relevance and integration of preventive themes in teaching, the picture for health promotion is very heterogeneous.

Objective: Angiotensin-converting enzyme inhibitors are an effective therapy for all stages of heart failure due to reduced systolic left ventricular function. Because sufficient data on intravenous angiotensin-converting enzyme inhibitors following coronary artery bypass surgery complicated by postoperative left ventricular dysfunction are unavailable, the efficacy and safety of intravenously administered enalaprilat were evaluated. Design: A placebo-controlled, randomized, double-blind protocol. Setting: Postoperative intensive care unit at the German Heart Institute Berlin. Patients: Forty patients with a left ventricular ejection fraction

EinleitungDie Interventionsmaßnahme „fit für pisa“ ergänzt während der gesamten 4-jährigen Grundschulzeit die obligatorischen zwei Schulstunden Sport/Woche durch drei weitere Sportstunden an fünf Grundschulen in Göttingen. Die von 2007-2010 BMBF-geförderte Evaluationsstudie soll Aufschluss darüber geben, inwieweit sich ein quantitativ gesteigerter und qualitativ verbesserter Sportunterricht auf Gesundheit und Bewegungsverhalten von Schülern nachhaltig auswirkt.

On the basis of experience gained from 6,000 laparoscopies (73% cholecystectomies) at the Moabit Hospital in Berlin, we carried out a cohort study to analyze the failure rate and decontamination of labeled "tracer" instruments processed in three test trays that were each subjected to 100 cycles. The majority of repairs focused on the functional parts of separable scissors and damaged or lost components. At 4%, the repair index after laparascopic use was less than that of a previously documented investigation period covering 1990 to 1996. A comparison of the costs of disposable and reusable instruments showed that reusable instruments were more cost-effective by a factor ofor =10, indicating that the price gap reported in our previous calculation for 1992 and 1994 has closed only slightly. After 100 cycles, we found traces of proteinaceous material in the eluate on every fourth instrument inspected (eight of 32); half of them (four) gave a positive reading when tested with a hemoglobin pseudoperoxidase test stick. It must be said, however, that similar residual contamination has been found on instruments used in conventional open surgery, with no indication of clinical relevance. This study was designed to examine the clinical suitability of laparoscopic instruments in terms of function and hygiene. Improvements in instrument design and cleanability must focus in particular on the reproducibility of cleaning results, because cleaning is the most important step in processing sterile supplies. As the number of minimally invasive operations has risen considerably, a mere visual check no longer meets the requirements prescribed by modern quality assurance. A multicenter study of residual proteins found on tracer instruments in all surgical fields is now in progress.

AIM: In order to investigate the potential of Helicobacter pylori (HP) to induce dyspepsia, we performed a randomized prospective study on the long-term effect of HP-eradication on symptoms of HP-positive dyspeptic patients in whom other organic causes for dyspepsia were carefully ruled out. PATIENTS: 201 patients referred to our endoscopy unit with dyspeptic symptoms for at least six months entered the study. Patients with previous peptic ulcer were excluded. METHODS: After endoscopy of the upper alimentary tract and 13C-urea breath test, patients with active peptic ulcer, hiatal hernia, macroscopic evidence for esophagitis and negative HP-status were excluded. The remaining patients underwent abdominal sonography, H2-exhalation test with lactose, and 24-h pH monitoring in order to exclude other organic causes for dyspepsia. In 20 patients, dyspepsia was assumed to be due to HP-gastritis. Patients received eradication therapy and were controlled as assessed by the 13C-urea breath test six weeks and six months after completion of the therapy. Dyspeptic symptoms were monitored by means of a validated symptom score. RESULTS: Out of 20 patients with HP-gastritis the first eradication treatment was successful in 13, while seven patients remained HP-positive after antibiotic treatment. Six months after completion of therapy the symptoms of HP-eradicated patients improved considerably (score values 17.4 +/- 1.5 and 10.2 +/- 0.8, respectively, p < 0.01) whereas symptoms of patients with persistent infection remained unchanged (21.1 +/- 1.7 and 20.4 +/- 1.5, n.s.) and only improved after successful retherapy (20.4 +/- 1.5 and 11.7 +/- 2.1, p < 0.05). In total, 17 of 20 patients (85%) improved after successful eradication. Also, neutrophil infiltration in the gastric mucosa correlated to both dyspeptic symptoms before therapy (r = 0.85) and the decrease in symptom score after HP-eradication (r = 0.61). In contrast, the symptoms of eight patients with gastroesophageal reflux disease were not improved after eradication (20.0 +/- 1.1 and 18.2 +/- 1.0, n.s.) CONCLUSIONS: HP-infection per se contributes to dyspepsia. 17 of 20 (85%) HP-positive dyspeptic patients improved after HP-eradication, when other potential organic causes for dyspepsia had been ruled out. However, many patients did not completely recover but the symptoms only partly decreased which parallels the persistence of part of the inflammatory infiltration in the gastric mucosa. This emphasizes the importance of HP-gastritis as an organic disease causing dyspeptic symptoms.

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.

Background: Isotretinoin for oral therapy in severe acne conglobata and acne nodulocystica represents a significant achievement; however, the drug exerts several mucocutaneous and systemic adverse effects, besides its teratogenic potency. Objective: The aim of this study was to investigate the plasma levels of isotretinoin and of 4-oxo-isotretinoin over long-term treatment of severe acne and to assess any correlation with the given dose, the clinical improvement and the occurrence of side effects. Methods: Forty-one patients with severe acne and acne-related disorders were studied under long-term oral intake of isotretinoin. Therapeutic effects and side effects were evaluated prior, during and at the end of therapy. The plasma levels of isotretinoin and of its major metabolite 4-oxoisotretinoin were measured by reversed-phase HPLC and were correlated with the administered oral dose and the number and frequency of side effects. Results: Dose-dependent plasma levels of isotretinoin and its metabolite were observed. At a mean dosage of 0.75–1.0 mg/kg/day, 404 ± 142 ng/ml were measured, whereas the plasma levels of 4-oxo-isotretinoin were 1–2 × higher. The plasma levels correlated well with the orally administered dose of isotretinoin and the observed mucocutaneous side effects. Conclusion: The study demonstrates that measuring of the plasma levels may be a helpful tool to monitor the individual therapeutic dose regimen in patients with severe acne in order to minimize undesired side effects and to control oral intake.

Interleukin-8 (IL-8), a 72 amino acid peptide secreted by cells of the immune system and of the amnion, chorion and decidua, was measured in women in late pregnancy. IL-8 was detected in the urine of 91 of 104 women with premature rupture of the fetal membranes, with values exceeding 1000 ng/L in cases of severe intra-amniotic infection. Women with urinary tract infections were excluded. The routine measurement of IL-8 in urine, together with C-reactive protein in serum, thus provides a low risk and technically simple approach to the assessment of intra-amniotic infection.

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.

Objectives To study the views of a wide range of representatives from organizations and institutions at the meso and macro level of the health system regarding palliative care in Germany. Methods 442 organizations and institutions were included (e.g. medical associations, political boards, health insurances). Using a standardized questionnaire, the main topics included the most recent health care reform, quality in palliative care and living will. Results The response rate was 67%. Most of the respondents (69.9%) rated the recently introduced specialist outpatient palliative care positively. The majority of the interviewees agreed that the effectiveness (74.2%) and efficiency (56.4%) of palliative care services need to be further evaluated. Two-thirds believed that political regulations of living wills could help minimize uncertainties concerning end-of-life decisions; palliative care specialists were less likely to be of that opinion compared to the other groups. Conclusions The recent political measures go into the right direction in order to further improve health care of severely ill and dying people in Germany. However, the effects on the health care system and on the routine delivery of care are uncertain. It is important to further develop palliative care on a broad societal, political and scientific base.

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.

Summary Several therapeutic methods have been employed in the management of localized granuloma annulare (GA), with varying degrees of success. We performed a prospective trial to evaluate the efficacy, cosmetic results, and safety of cryosurgical treatment in GA. Thirty-one patients with localized GA were treated by cryosurgery, using the contact method. Nitrous oxide (−86°C) or liquid nitrogen (–196°C) were used as refrigerants, and were applied with closed probes; each lesion was treated with one freeze-thaw cycle of 10–60s per session. If necessary, treatment was repeated after 20–30 days. Resolution of the lesions was obtained in all patients, and in 25 of 31 patients (80.6%) they resolved after a single freeze-thaw cycle. Relapse occurred in only one of 11 patients who were followed for more than 2 years, and this occurred 16 months after treatment. Excellent cosmetic results were obtained in 14 of 28 patients who were eligible for evaluation (50%), and good results in 11 (39.3%). The cosmetic result obtained by cryosurgery with nitrous oxide was independent of the size of the lesion, whereas in the group of patients treated with liquid nitrogen a better cosmetic result was obtained with smaller lesions (comparison of lesions 2.40 cm2 with those >2.40 cm2; P = 0.04). The duration of the lesion, its location, previous treatment with another method, and the number of treatment sessions, did not have any influence on the cosmetic result. The treatment was generally well tolerated. Blister formation occurred in all patients. Atrophic scars occurred in four of 19 patients (21.1%), all of whom had been treated with liquid nitrogen. Cryosurgery is effective and safe in the treatment of localized GA, and excellent cosmetic results may be achieved. We propose that the use of nitrous oxide as a refrigerant, with a single freeze-thaw cycle of 20 s, covering the entire surface of small lesions and the active rim of larger lesions (4 cm in diameter) is the optimal therapeutic regimen.

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.

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.