Do Socioeconomic Factors Influence Knowledge, Attitudes, and Representations of End-of-Life Practices? A Cross-Sectional Study.

OBJECTIVE: Access to palliative and end-of-life (EOL) care might be influenced by knowledge, attitudes, and representations of these practices. Socioeconomic factors might then affect what people know about EOL care practices, and how they perceive them. This study aims to compare knowledge, attitudes, and representations regarding EOL practices including assisted suicide, medical assistance in dying, and continuous palliative sedation of adults, according to socioeconomic variables. METHODS: A cross-sectional community-based questionnaire study featuring two evolving vignettes and five end-of-life practices was conducted in Quebec, Canada. Three sample subgroups were created according to the participants' perceived financial situation and three according to educational attainment. Descriptive analysis was used to compare levels of knowledge, attitudes, and representations between the subgroups. RESULTS: Nine hundred sixty-six (966) people completed the questionnaire. Two hundred and seventy participants (28.7%) had a high school diploma or less, and 42 participants (4.4%) were facing financial hardship. The majority of respondents supported all end-of-life options and the loosening of eligibility requirements for medical assistance in dying. Differences between subgroups were minor. While respondents in socioeconomically disadvantaged subgroups had less knowledge about EOL practices, those with lower educational attainment were more likely to be in favor of medical assistance in dying, and less likely to favor continuous palliative sedation. CONCLUSIONS: People living with situational social and economic vulnerabilities face multiple barriers in accessing health care. While they may have poorer knowledge about EOL practices, they have a positive attitude towards medical assistance in dying and assisted suicide, and a negative attitude towards continuous palliative sedation. This highlights the need for future research and interventions aimed at empowering this population and enhancing their access to EOL care.

[Cultural diversity in Montreal: a range of public health challenges]. / La diversité culturelle montréalaise: une diversité de défis pour la santé publique.

Increasing immigration to Quebec has brought to the surface the need for adapting its public health systems and services, particularly in the area of primary care. The challenge is to take the heterogeneous nature of the population into account and to integrate diverse values, experience and know-how into the development of programmes and delivery of services, whilst simultaneously respecting the values of the various care providers and the norms of the institutions in the host country. This article addresses the question of adaptation strategies for health services, and namely the development of prevention and heath promotion programmes in public health within the framework of primary health care services within the intercultural context of Montreal. The issue of adaptation falls within the perspective and mandate of the Quebec government's policy on health and well-being (La politique de santé et du bien-être, 1992). Furthermore, it is a response to frequent demands from various health professionals and groups concerned with the adaptation of public services with respect to intercultural relationships confronted with the emerging realities associated with immigration. The article provides a reflection on specific ways of adapting prevention and health promotion initiatives targeting cultural communities and those who are undergoing immigration procedures or transitions. It also examines the development of ethno-cultural or other indicators which make it possible to capture migration experiences and their health impact. Since the Quebec health and social services system is currently in the process of major reform, it is hoped that it will seize this opportunity in order to make health and social service centres accountable for the adaptation of their programmes and services to the diversity of the populations they serve.

Open antireflux repairs for simple reflux esophagitis: short- and long-term results.

This analysis of the results of open antireflux surgery clearly shows a benefit for antireflux surgery in most patients who have severe esophagitis with or without hiatal hernia. The authors of this article have found many variations in the methodology used to evaluate these results. Aside from these problems, however, the authors also have noticed the remarkably serious and honest work performed by most surgeons in trying to report the truth with the methodologies available to them. The principles of antireflux surgery can be found among the different studies that are reviewed in this article. These principles include: 1. The necessity of closing the crura; 2. The importance of repositioning the distal esophagus into the abdominal cavity; 3. The necessity of increasing the LES pressure by using the musculature of the fundus; 4. The preference for using a short and floppy fundoplication to avoid side effects; and 5. The need for long-term follow-up in evaluating results.

[Intercultural communication in the clinical context: a question of partnership]. / La communication interculturelle en contexte clinique: une question de partenariat.

This article is intended to promote reflection on the intercultural competence of nurses and other health professionals. It discusses the different types of interpretation used to communicate with patients who do not speak English or French, legal and ethical consequences, and impact on health-care quality. The authors offer recommendations for both research and clinical nursing, as well as the health-care system in general, and highlight the challenges faced by nurses in a pluralist society. The literature review reveals an inherent complexity in the use of diverse types of interpreters. Finally, the authors argue that the intricacy of the cross-cultural communication trio is intensified by a lack of adequate preparation of nurses and other health professionals and interpreters regarding cross-cultural communication.

Continuous infusion of interleukin-2 and cyclophosphamide as treatment of advanced cancers: a National Biotherapy Study Group Trial.

We have evaluated the effect of Interleukin-2 [IL-2] after Cyclophosphamide (C) chemotherapy in 41 patients with metastatic cancer. IL-2 was given as a continuous infusion priming cycle 36 hours after C at 1 gm/m2 intravenously. In 39 evaluable patients, there were no complete remissions [CR], 2 partial remissions [PR], and 1 had a minor response [MR]. Stable disease for 30 days was seen in 16 patients whereas 20 progressed. The durations of partial and minor responses were brief, ranging from 1-6 months. Grade 3-4 neutropenia was seen in 41%. This was more severe than seen with IL-2 alone or IL-2 combined with lower doses of C. The marrow suppression was due to the chemotherapy. This combination of IL-2 and C appears to be reasonably well tolerated by patients, but toxicity is greater and the response rate is no better than results achieved by IL-2 alone. Responses of 26 patients with renal cancer appear to be inferior to our historical data using IL-2/LAK cells without C. Immune monitoring demonstrated changes expected with C chemotherapy (i.e., a non-selective decline in immune function). C induced no further differences in IL-2 induced changes in immune function.

Levamisole meets sulfhydryl requirements of CTLL-2 cells and mediates enhanced proliferative response to mitogen stimulation without increasing interleukin-2 production.

We examined the effect of levamisole (LMS) on the proliferative response and interleukin-2 (IL-2) concentration in OKT3-, phytohemagglutinin-, and concanavalin-A-stimulated lymphocyte cultures. Although proliferative response was enhanced in lymphocyte cultures stimulated in the presence of LMS, similar levels of IL-2 were observed in stimulated and unstimulated cultures. The mechanism of the enhancement effect of LMS on proliferative response was further characterized by studying its effects on the growth of IL-2-dependent CTLL-2 cells in culture. Since this cell line has been shown to require 2-mercaptoethanol (2-ME) for normal growth in recombinant IL-2, the effect of LMS on several parameters of its growth was compared with that of 2-ME. Unlike 2-ME, LMS did not enhance 35S-cystine uptake. Both compounds increased thiol concentration in the cell culture, but (oxidized) 2-ME induced a greater increase. Generally, the effects of LMS on CTLL-2 growth were quite similar to those of structurally unrelated compounds known to have antioxidant properties, and the demonstrated thiol requirement of this cell line for growth in recombinant IL-2 was met by substituting LMS for 2-ME. When the effect of LMS on IL-2 receptor (IL-2R) expression in CTLL-2 cells was examined by a receptor-ligand binding assay involving low levels (10-80 pM) of 125IL-2, a modest increase in the level of IL-2R expression was observed. The biologically active high-affinity IL-2R complex is believed to be preferentially bound at the low levels of 125IL-2 used here, suggesting a functional relevance for this effect of LMS. These observations should be useful in minimizing the cost and duration of in vitro expansion of lymphocytes for use in adoptive immunotherapy and should be applicable in improving the response of immunologically impaired patients to immunotherapy.

Patterns of cytokines released by peripheral blood leukocytes of normal donors and cancer patients during interleukin-2 activation in vitro.

We have examined the responsiveness to in vitro stimulation with high-dose recombinant interleukin-2 (IL-2) of peripheral blood leukocytes (PBLs), collected from normal donors, or from successive daily cytaphereses of cancer patients with a range of advanced malignancies, following 5 days of continuous infusion with IL-2 in vivo. Normal donor PBLs showed a transient release of tumor necrosis factor (TNF) (up to 400 pg/ml) during the first day, while factors including interferon-gamma (IFN-gamma), soluble IL-2 receptor, and soluble CD-8 showed a gradual increase to modest levels (at best) during the 4 day incubation with IL-2. In contrast, the cancer patients' PBLs, after 5 days of IL-2 activation in vivo, responded with one of two patterns of production of cytokines. In pattern I, exposure to the IL-2 resulted in a transient release of TNF during the first 48 h. The level of TNF released showed a progressive increase from PBLs harvested from the first cytapheresis (up to 50 pg of TNF/ml) through the fourth cytapheresis (up to 2,000 pg of TNF/ml). Additionally, pattern I PBLs showed significant levels of production of IFN-gamma, soluble IL-2 receptor, and soluble CD8. In pattern II, the patients' PBLs from each cytapheresis released only low levels of TNF (less than 300 pg/ml) and minimal levels of IFN-gamma, IL-2 receptor, and CD8. A pattern I response is considered to be consistent with an immunostimulatory role for IL-2, which induces a cooperative interaction of lymphocytes and macrophages that is mediated by other cytokines, while pattern II may reflect an immunosuppression in these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Phase I trial of mitomycin C immunoconjugates cocktails in human malignancies.

Nineteen patients with refractory solid malignancies received individualized combinations of mitomycin C conjugated murine monoclonal antibodies selected by immunohistochemical and flow cytometric screening of tumor specimens. There were no responses in this Phase I study. Thrombocytopenia precluded escalation above a mitomycin C dose of 60 mg per treatment cycle. Preclinical, clinical, and toxicity experiences with this investigational approach to the treatment of cancer are discussed.

Detection of a tumor-associated nucleoprotein antigen in mink lung cells transformed by two different viral oncogenes.

Salt-precipitated chromatin was prepared from cultured MvlLu line mink lung cells and from these cells transformed by either of the oncogenes v-mos (MIMS-102 line) or v-fes (F3C7 line). Xenoantisera were raised to chromatin from each of the three cell types and cross-tested in microcomplement fixation assays to determine immunospecificity. Chromatin from cells transformed by either v-mos or v-fes revealed antigenic profiles statistically indistinguishable (P less than 0.2 to 0.5) from one another with their respective cross-tested antisera, but did not react significantly with antisera to chromatin from the untransformed parental cell line. Likewise, little cross-reaction was observed with chromatin from the untransformed cells and antisera raised to chromatin from either of the oncogenically transformed lines (P less than 0.001), although each chromatin demonstrated high reactivity with its homologous antiserum preparation. These immunological data are consistent with the observed normal or transformed characteristics for each cell type, including morphology, anchorage-independent growth, and growth in the absence of serum.

Phase I clinical trial of recombinant human tumor necrosis factor.

A phase I and pharmacokinetic study of recombinant tumor necrosis factor (rH-TNF Asahi) was carried out in 29 patients, who received a total of 72 courses with doses ranging from 1 to 48 X 10(4) units/m2. Drug was given as 1-h i.v. infusions. Acute toxicities, taking the form of fever, chills, tachycardia, hypertension, peripheral cyanosis, nausea and vomiting, headache, chest tightness, low back pain, diarrhea and shortness of breath were seen, but were not dose-limiting or dose-related. Some early rise in SGOT, without any change in serum bilirubin, was noted at the highest doses. Eosinophilia, monocytosis, mild hypocalcemia and an increase in fibrin degradation products were seen in a few patients. The dose-limiting toxicity was hypotension, which occurred after the end of the drug infusion and was seen in all 5 patients treated at the highest dose. There was no mortality or long-term morbidity. There were no responses. Pharmacokinetic studies indicated a rapid plasma clearance and a short plasma half-life, generally less than 0.5 h.

Effects of divalent metal cations on composition and neoplasia-specific antigenicity of chromatins.

The antigenicity and composition of chromatins differ markedly in chromatin preparations obtained by different procedures. Rat Novikoff hepatoma chromatin (NC) obtained by the "salt precipitation" and the micrococcal nuclease digestion procedures using significant levels of EDTA and NaCl each shows a common complement fixation (CF) capacity, exceeding chromatin preparations obtained from normal rat liver when tested with rabbit antisera raised to dehistonized NC. In contrast, "structured" NC preparations, which have been postulated to retain a native physical conformation, show minimal CF capacity when tested with the same antiserum but show high CF following elution of histones. While further progressive elution of non-histone proteins (NHPs) did not alter the CF capacity per unit DNA, the completely separated DNA and NHP fractions each showed minimal CF. The data suggest that the antigens detected in the CF assay predominantly represent an artifactual but specific complex of DNA and NHP arising from a denaturation of the native chromatin following elution of metal ions or histones. A qualitatively similar profile of NHPs in salt-precipitated NCs shows a range of total protein/DNA ratios, suggesting that the NHPs found in chromatin preparations may not be intrinsic to the native chromatin structure.