Once a certain type of nanoparticle can be identified unambiguously using microscopic methods it is desirable to quantify the particle distribution within a cell, an organ or the whole organism. Transmission electron microscopy provides an ideal tool to perform qualitative and quantitative analyses of particle-related structural changes of the respiratory tract, to reveal the localization of nanoparticles within tissues and cells and to investigate the 3D nature of nanoparticle-lung interactions.Nanotechnology in its widest sense seeks to exploit the special biophysical and chemical properties of materials at the nanoscale. While the potential technological, diagnostic or therapeutic applications are promising there is a growing body of evidence that the special technological features of nanoparticulate material are associated with biological effects formerly not attributed to the same materials at a larger particle scale. Therefore, studies that address the potential hazards of nanoparticles on biological systems including human health are required. Due to its large surface area the lung is one of the major sites of interaction with inhaled nanoparticles. One of the great challenges of studying particle-lung interactions is the microscopic visualization of nanoparticles within tissues or single cells both This article provides information on the applicability, advantages and disadvantages of electron microscopic preparation techniques and several advanced transmission electron microscopic methods including conventional, immuno and energy-filtered electron microscopy as well as electron tomography for the visualization of both model nanoparticles (e.g. polystyrene) and technologically relevant nanoparticles (e.g. titanium dioxide). Furthermore, we highlight possibilities to combine light and electron microscopic techniques in a correlative approach. Finally, we demonstrate a formal quantitative, i.e. stereological approach to analyze the distributions of nanoparticles in tissues and cells.This comprehensive article aims to provide a basis for scientists in nanoparticle research to integrate electron microscopic analyses into their study design and to select the appropriate microscopic strategy. With an epithelial surface area of approximately 140 m2 , airway 2 -8, the e2 ,10, and 2 .Particles can be classified according to their size which predominantly defines to which compartments of the lungs they gain access . In receWhere then is the justification to employ different transmission electron microscopic (TEM) tools for the analysis of the interaction of NP with cells of the respiratory system? First of all, it is of principal interest to investigate whether the morphology of the tissues and cells of interest changes following NP exposure. Usually, conventional light and electron microscopic methods will suffice to address these questions. Second, however, the localization and distribution of particles within tissues and cells needs to be studied to understand how and why NP cause cellular responses and whether a targeted particle has reached its target cell compartment ,29. UnfoThough the importance of TEM analyses in NP research is unquestionable the use of advanced imaging techniques and appropriate quantification is still rare. We are convinced that this may partly result from the unawareness of the pitfalls when applying conventional TEM to NP research and the possibilities to overcome these problems. Despite the great efforts to standardize and optimize the generation and exposure systems of NP  the apprA prerequisite for transmission electron microscopy is that all material entering the microscope has to be fixed in one way or another. Fixation of cells and tissues aims to preserve the specimens as close to the living state as possible. As further outlined, different electron microscopic techniques as well as specific questions of a particular study significantly influence the choice of the fixation and embedding method. Currently, there are two major approaches to fix biological samples, viz. chemical or physical fixation. For the lung as an entire organ, there is no routine alternative approach to chemical fixation to date but for restricted tissue samples, such as larger airways or cell cultures, physical fixation offers an excellent alternative. The following paragraphs as well as Figure Two basic routes exist for the delivery of chemical fixative to the lung: instillation via the airways ,37 and pVascular perfusion fixation via a cannula/catheter introduced into the pulmonary trunk fixes the lungs very quickly and thoroughly , but itsFirst, the preferred method of fixation for NP research depends on the actual scientific question. If the uptake of particles by alveolar macrophages or their interaction with surfactant is the subject of interest one will have to use vascular perfusion fixation. However, if the translocation of NP to the blood circulation is investigated it will be desirable not to wash out all the blood from the pulmonary circulation and one would therefore prefer to use instillation fixation. Second, however, the choice of the fixation method is also influenced by the experience and skills of a laboratory. If one is not familiar with the different aspects of vascular perfusion fixation and their interpretation this technique may lead to false conclusions because the relationship between the airway and vascular pressures determines the structural appearance of the parenchyma .Fixation of lung samples by immersion in the fixative is by far the least preferable technique because the lung tissue is collapsed and artefactual changes occur, which can not be controlled for . It shouThe fixative consists of a fixing agent in a suitable vehicle . The mosPhysical fixation is often referred to as physical immobilization, cryo-immobilization or cryofixation. The purpose is to solidify the water in the sample, thereby arresting the biological machinery. However, the formation of ice crystals induces severe damage to the cell . Cryo-imIn order to be useful for TEM studies, these segregation artefacts need to be prevented, or reduced below the resolution limit of the TEM. This can be achieved by vitrification: a phase transition of liquid water to the vitrified state, which is an amorphous , solid state of water -57. SuchIt has been recognized that high pressure (roughly 200 MPa) influences the physics of water in a way cryoprotectants do  which leThe vitrification of the water in the sample results in a highly increased preservation of the fine structure and an improved retention of the structural components compared to chemical fixation ,66,77-79After successful vitrification, a variety of follow-up procedures are available Figure . The fulAlternatively, the water can be removed from the sample either by freeze drying ,87 or byWe here for the first time present evidence that lung tissue can be fixed by HPF Figure . HoweverConventional TEM in NP research is frequently used to characterize particle structure ,91-93, tDespite its wide use in NP research, conventional TEM as a sole tool for the qualitative or quantitative evaluation of the cellular localization of NP needs to be carefully evaluated from case to case. With few exceptions , it needs to be accompanied by methods that increase the identification of every NP, independent of its size, shape or electron transmissibility. Nevertheless, the application of conventional TEM is justified by its suitability to detect potential effects of NP on cellular ultrastructure and to characterize NP structure.Once a specimen has undergone all fixation and embedding procedures, it has maintained its antigenicity, and preserved its ultrastructure, immuno TEM offers some useful applications for NP research: visualization, co-localization and quantification of NP and antigens -101. HowIf NP could be made visual by immunogold labeling their identification would be straightforward and unambiguous. The binding specificity could then be cross-checked by the co-localization of the particle (which cannot be performed with immunogold labeling of proteins). Once particles are undoubtedly detectable by TEM, it is possible to determine their exact localization within cellular organelles and to quantitatively assess their tissue or cellular distribution in an unbiased way . This approach requires that the particles have a surface coating which can be recognized by a specific antibody. As the surface coating is likely to influence the biological effects of the NP, this approach for NP detection might not be advantageous in toxicological studies. However, particles targeted to specific tissues, cells or organelles are designed with a specific coating that guides them their way. In these cases, immunogold labeling for detection may be feasible and very useful.If coated NP are labeled by immunogold particles it may be interesting to determine their exact localization. For example, early and late endosomes as well as lysosomes cannot be distinguished from each other by their morphology alone. The double-labeling technique (e.g. using 5 nm golds for the NP and 15 nm golds for the organelle) may represent an interesting approach to perform co-localization studies. In those cases where NP can be identified by EFTEM (see below) immunogold labeling of organelles or cytoskeletal proteins offers a detailed analysis of how NP are associated with cellular proteins. Finally, exposure of cells to NP may result in alterations of the cellular distribution of a particular antigen  which caAs shown above, the major problem in the investigation of interactions between NP and the lung is the fact that it is often not possible to distinguish unambiguously between cellular structures and NP, a fact that is often neglected or even unrecognized. Energy filtered TEM combines the high resolution of the TEM with the analytical capabilities of electron energy loss spectroscopy and imaging . This alNP often contain elements such as titanium, zinc or cadmium with no or low abundance in biological systems. This differential atomic composition allows for the distinguishing potential of elemental mapping, and therefore of the NP. If lungs or cell cultures are exposed to an aerosol containing NP of a known composition, it is possible to test whether and which cells or organelles contain the elements the NP are composed of.EFTEM is an advanced imaging technique that requires substantial technical know-how and a suitable microscope, which explains why it is not widely established in life sciences. If the elemental composition of the particles is not known beforehand, the analysis by electron energy loss spectroscopy may turn out cumbersome and frustrating. Furthermore, analysing NP within biological preparations using EFTEM may also be frustrating if the NP consists of elements that occur in large amounts in biological systems as well although recent progress in the EFTEM technique might improve this situation . ElectroSo far, the use of EFTEM in pulmonary research is limited to a few studies, e.g. analysing plasma membrane integrity by lanthanide tracers  or phospFortunately, EFTEM has witnessed a more frequent use in recent years for the study of NP localization in vitro ,95, in vUnderstanding the interactions of NP with cellular structures, especially with complex membrane-bound organelles requires information about the three-dimensional (3D) arrangement of the morphological components. Before the development of ET, high resolution 3D reconstruction was based on a sequence of serial sections -115, whiThe development of ET has made it possible to overcome these problems: A rotational relationship between detector (camera) and object is created by tilting the section inside the electron microscope at user defined increment intervals, usually 1° or 2°. This gives rise to a tilt series: a sequence of projections of the object, taken from different angles . SubsequDue to the nature of the electron beam and the increasing relative thickness of the section at increased tilting angles, the section can only be inclined between about ±70°. The remainder, between ±70° and ±90°  cannot be recovered from the sample and will result in artefact formation during digital reconstruction .For the moment, ET is not widely established for several reasons. First, the electron microscope must be equipped with a motorized goniometer and specialized software, and such instrumentation is resourceful, which, in turn currently limits their purchase to a number of central TEM labs worldwide. Second, ET requires advanced experience and know-how in electron microscopy, specimen preparation and interpretation of the TEM images. The principles and problems of ET are discussed in a number of excellent reviews -124.ET is only emerging to be part of the methodological repertoire in NP research and has already been applied on nanomaterials  as well Visualization by ET allows the analysis of NP shape, volume and surface in 3D. This greatly helps with the characterization of NP and the discrimination between genuine particles and agglomerated NP. Furthermore, ET is projected to become a useful tool to study contact sites between NP and macromolecules in detail. Such insights will potentially improve our understanding of NP entry mechanisms into cells, processing by the cellular machinery and where NP related toxicity originates. One exciting topic also relates to the fact that ET extends the application of a number of stereological tools  to the electron microscopic level . ParticuIn an ideal world, it would be possible to investigate the interactions of cells with NP combining the benefits of light microscopy, especially live cell microscopy, with the high resolution of transmission electron microscopy. However, in laser scanning microscopy the resolution is limited to 200 nm and 500–900 nm in the lateral and axial directions, respectively, although deconvolution algorithms may increase the resolution 2–3 fold ,128,129.Two highly promising ways for correlative light and electron microscopy have been described in detail recently. Using a linker molecule, the fluorescent signal recorded by the optical system of the light microscope is converted into a signal that can be picked up by the optical system of the TEM. In a first approach, a biotinylated antibody specifically directed against a particular antigen is applied and visualized with a streptavidin labeled quantum dot that contains fluorescent molecules at the surface and an electron dense core (CdSe) which can unambiguously be detected by EFTEM ,132. NisDirect ways denounce the use of linker molecules between the two microscopic modes. The idea rests on the comparison of images obtained by light and and electron microscopy of the same region of interest. In the case of labeling of specific probes, the signal is obtained by light microscopy  and superimposed on the high resolution micrographs generated by TEM. One simple way is to use a low-temperature embedded or frozen specimen and cut consecutive ultrathin sections, which can be used for immunofluorescence imaging and immunogold labeling, respectively ,136. ThiA solution of striking simplicity has surfaced recently. Based on the analysis of specific conjugated π-electrons, fluorochromes can be detected by improved EFTEM instrumentation. In this manner, Mhawi et al.  could reThe potential of correlative light and electron microscopic approaches is enormous and their application in NP research may greatly enhance our understanding of the entering mechanisms, the intracellular trafficking and their downstream beneficial or toxic properties. The combination of the different advanced techniques described above offers a methodological armamentarium suited to answer many of the inherent questions currently discussed in NP research.The significance of microscopic evaluations is directly associated with the extent and representativeness of the observations. Evaluation of the extent of a microscopic finding requires the use of unbiased quantitative methods which describe the structures in terms of number, length, area or volume. The representativeness of the observations is critical because the actual material that enters the microscopic stage is infinitesimally small in relation to what it is thought to represent. Therefore, the aim is to give every part of an organ or a cell culture an equal chance of being selected for the analysis. Stereology offers a wide range of unbiased methods that fulfil these requirements and are frequently used in pulmonary research, but their use in NP research is rare. There are, however, three basic scenarios that justify the use of stereology in NP research: (1) First, it is necessary to estimate the morphological changes that occur upon exposure to NP, e.g. the volume of fibrotic lesions in the lung or the number of inflammatory cells. (2) Second, changes in protein localization due to NP exposure can be estimated by relating immunogold particles to the relative volume of the organelles which results in relative labeling indices. (3) Third, the preferential distribution of NP within tissues or cells needs to be estimated and evaluated using appropriate statistical methods that are closely correlated to the methods for quantification of immunogold labeling. All of these methods require the use of sampling procedures that need to be followed consequently from the whole organ down to the microscopic test field under investigation. These methods include randomization of localization by systematic uniform random sampling  or fractUnfortunately, morphological changes associated with NP exposures are usually reported by micrographs showing "representative" lesions or are not investigated at all, a consequence from the fact that most studies focus on acute toxicity of NP rather than on chronic exposures. However, it will be necessary to assess these changes both in acute and chronic situations to evaluate the significance of the reported toxicological responses for pulmonary structural remodeling. To give some examples, stereology offers tools to investigate the number of cells or alveoli -147, theThe approaches to analyze immunogold or NP distributions using the comparison of observed and expected particle distributions in terms of indices  declare that they have no competing interests.CM planned the work presented in this article, performed parts of the experiments and electron microscopic analyses, and wrote major parts of the manuscript. BRR performed parts of the experiments, reviewed the manuscript critically and provided important intellectual content. DV performed parts of the experiments and electron microscopic analyses, wrote major parts of the manuscript and provided essential intellectual content. FB performed parts of the experiments and reviewed the manuscript critically. PG supervised the work on this article, made important suggestions, reviewed the manuscript critically and provided important intellectual content. MO participated in the development of this work, made important suggestions, reviewed the manuscript critically and provided essential intellectual content. All authors read and approved the manuscript.


Helen Herrman discusses the implications of a new systematic review and meta-analysis of the prevalence of mental disorders in homeless people in Western countries. Much has been written in the scientific literature and the popular press about mental disorders among homeless people, and about its converse—homelessness among people living with mental disorders. Yet despite community concern about homelessness and mental illness, we have limited understanding in many places of the genesis of the problem, and limited evaluation of useful ways to tackle it . There iPLoS Medicine, Seena Fazel and colleagues note that “more reliable estimates of the prevalence of serious mental disorders in the homeless should help inform public policy and development of psychiatric services, particularly in urban centres” [In a new systematic review and meta-analysis published in this issue of centres” . They fiThe main mental health problems for homeless people in Fazel and colleagues' analyses were alcohol and drug dependence, with random effects pooled prevalence estimates of 38% and 24%, respectively. The proportionate excess for psychosis, however, was greater than for the other mental disorders, with a random effects pooled prevalence estimate of 13%. This finding is consistent with the attention given to psychosis in homeless people by mental health planners and community rights activists. Homeless people with psychotic disorders typically have multiple comorbidities, including substance use disorders, physical illnesses, and disabilities, and often experience a poorly coordinated response to complex needs .PLoS Medicine:This Perspective discusses the following new study published in 10.1371/journal.pmed.0050225Fazel S, Khosla V, Doll H, Geddes J (2008) The prevalence of mental disorders among the homeless in Western countries: Systematic review and meta-regression analysis. PLoS Med 5(12): e225. doi:Seena Fazel and colleagues show, through a systematic review and meta-regression analysis, that homeless people in Western countries have a higher prevalence of alcohol and drug dependence and mental disorders.Fazel and colleagues draw these conclusions from the studies available over the last 40 years in a set of Western countries. It is a stark finding that despite all that has been written about mental illness among homeless people, and all the speculation about the origin of the problem, the authors deemed only 29 studies relevant to their analysis. One of the reasons for this relatively small body of work is the absence of clear definitions of homelessness and mental disorders in many publications.Homelessness is defined in various ways, but studies need to include a clear definition, and as implied by Fazel and colleagues, one that is locally relevant. The term can include people living in marginal accommodation, as well as roofless people. Some studies include the former, while in others the definition includes only those sleeping in designated shelters or public spaces. The features of a definition of homelessness that are useful in any locality, however, are the lack of appropriate housing and the social marginalisation of the individual . Also imThe substantial heterogeneity between the studies included in Fazel and colleagues' systematic review is expected and was analysed carefully by the authors. This analysis supports the authors' contentions that the findings are useful for drawing broad conclusions about the need for policy and practice change in a range of countries, while emphasising that service planning should not use the summary estimates given in the paper but should rely instead on local studies of morbidity to quantify needs. Several technical factors are likely to contribute to variation in the findings, as the authors outline. In comparing information across studies and countries, the definitions of homelessness, sample selection, and diagnostic criteria all need to be considered, as well as other features of the studies such as participation rates. Some of the variation can also be ascribed to local factors such as housing and social service provision. Changes in the affordability of alcohol may contribute to increasing rates of alcohol dependence over time, as may variation in policing and community attitudes.Beyond local surveys of morbidity, countries or regions need relevant information collected in a consistent way over time. Qualitative studies are also needed that provide information from intimate observation or that record the views and comments of people who are homeless and living with mental disorders . The menThe solutions needed are likely to vary considerably by type of disorder, despite commonalities in some of the serious consequences such as victimisation, criminality, suicide, and death from other causes. Homelessness among people living with psychotic disorders, for instance, is often linked to deinstitutionalisation in Western countries, although the analysis of the apparent failure of community care does not support a causal role . An analDemonstration programmes in the United States concluded that homeless adults with severe mental illnesses, often thought to be beyond the reach of existing outreach services, are willing to accept psychiatric treatment and can remain in community-based housing with appropriate support. Housing stability, appropriate psychiatric treatment, and increased income can lead to an improved quality of life . AccessiThe rate of mental disorders among homeless people is useful information for advocacy and for monitoring policy and practice change in a community. However, it does not in itself give a good indication of service needs, and contact with psychiatric services does not necessarily imply that health needs are being met . To answ


Environmental Health is now firmly established as a major venue for publishing in the field of environmental health. While remaining selective in our acceptances – of the 217 manuscripts that we have processed by June 2007, 115 (53%) were accepted – the number of manuscripts continues to grow from year to year. Last year we published 33 articles (of 64 submitted) and the number of submissions by June this year has already reached 40. The journal has now been in existence for five years, so the time seems ripe for us to assess the health of our journal and the opportunities offered by open access publication on the Internet.Published articles are one of the main products of research. Digital technology is revolutionizing the reproduction, distribution and control of scientific publication while providing new and important opportunities for science. It also allows wider and more rapid diffusion of knowledge with lower barriers to access, stimulating further research and applications of new information. The Internet facilitates access to journals that would otherwise require a visit to many different libraries. The majority of scientific journals are now available online, and most of the 2.5 million scientific articles published per year can be accessed away from libraries that carry the print versions.For this reason, "pigeon-holing" of research areas has become less important for the researcher to reach the intended audience. 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We conducted a nested case–control study in a cohort of European asphalt workers in which an increase in lung cancer risk has been reported among workers exposed to airborne bitumen fume, although potential bias and confounding were not fully addressed.We investigated the contribution of exposure to bitumen, other occupational agents, and tobacco smoking to the risk of lung cancer among asphalt workers.Cases were cohort members in Denmark, Finland, France, Germany, the Netherlands, Norway, and Israel who had died of lung cancer between 1980 and the end of follow-up (2002–2005). Controls were individually matched in a 3:1 ratio to cases on year of birth and country. We derived exposure estimates for bitumen fume and condensate, organic vapor, and polycyclic aromatic hydrocarbons, as well as for asbestos, crystalline silica, diesel motor exhaust, and coal tar. Odds ratios (ORs) were calculated for ever-exposure, duration, average exposure, and cumulative exposure after adjusting for tobacco smoking and exposure to coal tar.A total of 433 cases and 1,253 controls were included in the analysis. The OR was 1.12  for inhalation exposure to bitumen fume and 1.17  for dermal exposure to bitumen condensate. No significant trend was observed between lung cancer risk and duration, average exposure, or cumulative exposure to bitumen fume or condensate.We found no consistent evidence of an association between indicators of either inhalation or dermal exposure to bitumen and lung cancer risk. A sizable proportion of the excess mortality from lung cancer relative to the general population observed in the earlier cohort phase is likely attributable to high tobacco consumption and possibly to coal tar exposure, whereas other occupational agents do not appear to play an important role. Bitumen is the residual product from distillation of crude oil and is being used mainly as binder in asphalt mixes and in roofing applications . Workersa)pyrene is classified as a lung carcinogen by the International Agency for Research on Cancer (IARC) and others are suspected carcinogens , of which benzo in the analysis of the whole cohort, in the nested case–control study, we also took into consideration the dermal route (exposure to bitumen condensate).The objective of this study was to test whether the risk of lung cancer among asphalt workers is positively associated with exposure to bitumen, while adjusting for tobacco smoking and exposure to other known and suspected occupational lung carcinogens.n = 38,296) consisted of male workers < 75 years of age who were included in the cohort study in Denmark, Finland, France, Germany, the Netherlands, Norway, and Israel; had been employed at least two full seasons in the companies included in the cohort  were members of the study population who died of lung cancer between 1980 and the end of follow-up, as well as incident cases identified through cancer registries during the same periods in Denmark, Finland, Norway, and Israel. For each case, a set of controls was selected randomly among members of the study population if they fulfilled the matching criteria  and were free of respiratory and ill-defined cancer . On the other hand, an association was suggested between lung cancer risk and cumulative exposure to coal tar and, to a lesser extent, duration of exposure .p-value of test of heterogeneity for ever-exposure to bitumen condensate was 0.8).For 277 cases (66.7%), information was available on histological type: 99 (35.7%) were squamous cell carcinomas, 73 (26.4%) were adenocarcinomas, 50 (18.1%) were small-cell carcinomas, and the remaining 55 cases (19.9%) had either other or mixed histology. Although results for squamous cell carcinoma tended to be slightly more positive than those for adenocarcinoma and small-cell carcinoma , none of the differences were statistically significant  to 1.21 . The corresponding ORs for ever-exposure to bitumen condensate ranged from 1.13  to 1.26 ; see Supplemental Material, Table S6 (doi:10.1289/ehp.0901800).We studied what characteristics were associated with participation in the current study. Case or control status and having been employed as a paver were not associated, whereas long duration of employment and long duration of exposure to bitumen (as estimated in the cohort phase of the study) were associated with participation. There was no association between cumulative semiquantitative exposure to bitumen as assessed in the cohort study and participation in the case–control study (not shown).The proportion of smokers was higher among controls than among persons in the general population in almost all the countries. The estimated confounding ORs were 1.07 in the Netherlands, 1.12 in Israel, 1.14 in France, 1.24 in Norway, 1.25 in Germany, and 1.28 in Denmark and Finland.This case–control study of lung cancer nested in the cohort of European asphalt workers was designed to explore the role of bitumen exposure, other occupational exposures, and tobacco smoking in determining the increased mortality from lung cancer observed among pavers in the cohort , 2003b. a) no significant association between indicators of inhalation and dermal exposure to bitumen and lung cancer, (b) the lack of an effect of other known or suspected occupational lung carcinogens in the asphalt industry or in other jobs, with the possible exception of exposure to coal tar, and (c) a higher prevalence of tobacco smoking in the study population compared with national surveys, which might have biased the results of the cohort study away from the null.The main results of the study are Workers with less than two seasons of employmentSubjects who died before 1980Workers employed in the job classes representing administrative and office workSubjects who were not reached or did not want to participate in the case–control study.In addition, the case–control analysis included additional cases of lung cancer identified after the end of the follow-up in the cohort analysis; 217 (50%) of the current cases were included after the cohort study was completed. Occupational exposure levels of bitumen fume have decreased during the last decades ; therefoThis study has several strengths. The detailed assessment of exposure to bitumen by both inhalation and dermal routes and the assessment of exposure to other agents both within and outside the asphalt industry led to improvement in the quality of information on work histories compared with the cohort phase of the study and relative to other studies of cancer risk among bitumen-exposed workers . In partThe main limitations of the study are the lack of some of the elements needed for exposure assessment at the individual level and the semiquantitative nature of exposure estimation. Contrary to initial plans, the data collected from fellow workers were too sparse to allow the modulation of job-history–based exposure estimates at the individual level, for example, related to personal hygiene. Thus, we used this information by company, job, and time period, because living subjects providing this information were predominantly controls, whereas the corresponding information for deceased cases was obtained from NOK and fellow workers. Using this information at the individual level could have introduced bias.Other potential limitations of the study, such as the higher proportion of controls with in-person interviews compared with cases, the variable number of controls available for cases, and the low quality of a subset of interviews, were addressed in sensitivity analyses and did not appear to have affected the results. The low response rate in some of the countries  is an additional limitation; in sensitivity analyses, however, individual countries did not appear to influence the results.Exposure misclassification due to inaccuracy in individual exposure estimates might have occurred; if exposure misclassification was nondifferential, it most likely would have resulted in attenuation of risk estimates.The assessment of occupational exposures to agents other than those related to bitumen was rather crude, which is reflected by lack of effect for most of them. This can be explained by misclassification, but can also be attributed to the narrow range of exposure experienced by asphalt and construction workers and low levels as a result of declining exposure levels in the work sites . In addiThe confounding OR by smoking ranged from 1.07 to 1.28 among the participating countries. Therefore, the comparison of the distribution of smoking among living controls and national surveys may suggest that a sizable proportion of the excess mortality from lung cancer observed when the cohort of asphalt workers was compared with national mortality rates, can be explained by the higher prevalence of smoking among cohort members. However, the comparison of smoking prevalence between the case–control study and the national surveys is limited by several factors, including possible lack of correspondence of definition of smokers in the surveys and in the nested case–control study, a healthy survivor effect  among living controls, and the limited response rate among controls. The confounding ORs should therefore be interpreted only in qualitative terms.Tobacco smoking was not strongly correlated with cumulative or average exposure of the agents studied, but entailed some confounding effect and was controlled for in the analysis.Exposure to other lung carcinogens outside the occupational environment, such as indoor radon, would exert a confounding effect only if these factors are correlated with the agents under study , which is not very plausible.p-value of statistical significance at 0.003, a level that was not approached by any result. Although the Bonferroni correction might be too conservative because the exposure variables were not independent, chance remains a plausible explanation of the results for the slight increase in OR for some of the exposure variables.Sixteen comparisons were performed in the main analysis (four dimensions of exposure to four bitumen-related agents), and a Bonferroni correction would set the The results of this study are consistent with the recent evaluation of Two main conclusions can be drawn from the present study. First, a sizable proportion of the excess mortality from lung cancer relative to the general population observed during the cohort phase of the study is likely attributable to the high consumption of tobacco experienced by these workers and possibly to coal tar exposure, whereas other occupational agents do not appear to play important roles. Second, we found no consistent evidence of an association between indicators of inhalation or dermal exposure to bitumen and lung cancer risk. However, our study underscores the importance of the current trend in reducing inhalation and dermal exposure to bitumen in the workplace, as our study may have failed to detect weak yet important exposure–response associations.


Epigenetics & Chromatin published its first papers a year ago, together with an editorial in which we stated our aim to publish a high-quality journal with a broad scope. A year later we are happy to report that these aims are being achieved. Papers published so far represent a broad swath of research on chromatin-based processes and epigenetic mechanisms. We are also delighted with the quality and breadth of submissions from many of the leading laboratories in the field.E&C [Among the papers in our inaugural issue was one from Elizabeth Blackburn and co-workers on the use of novel 4D imaging describing how human telomeres behave in vivo . This laE&C .E&C, which have also been collated to form a special anniversary print issue. The most popular model systems for epigenetic research are represented among them, including mice, yeast and flies. The articles range from studies of classical epigenetic phenomena, such as X-chromosome inactivation [Here we review a collection of recent articles that we believe illustrate the scope and quality of articles published in tivation  and positivation , to bioctivation  and atomtivation . Below, E&C paper published in January, 2009 [Drosophila white locus PEV mutants. Surprisingly, they find that the distribution of HP1 is highly inhomogeneous, and that the white gene is unusually sensitive to heterochromatic silencing. These findings led the authors to propose a model that reconciles some of the most puzzling features of PEV.The classical phenomenon of PEV, the heritable "spreading" of the silent state into a gene by juxtaposition to heterochromatin, has intrigued geneticists for 80 years. But despite substantial progress in understanding the components of spreading, the mechanism has remained in doubt. In their ry, 2009 , Bas vanE&C paper published in October, 2009 [Pluripotency lies at the heart of reprogramming and stem cell biology, yet its molecular basis remains unknown. Mouse embryonic stem cells represent a favorite model for studying the relationship between epigenetics and chromatin, and this system was used by Azim Surani and colleagues to investigate the possible role of the ESET histone methyltransferase in regulating pluripotency. In their er, 2009 , they deE&C paper published in September, 2009 [Ultimately, understanding the role of chromatin in mediating epigenetic inheritance requires a more complete description of the process that occurs behind the replication fork, where old nucleosomes are transmitted to daughter strands and new nucleosomes are assembled. However, little is known about this process in vivo, and as a result, the chromatin basis for epigenetic inheritance remains the subject of much speculation. In their er, 2009 , JessicaE&C will become increasingly attractive for publication of the most exciting research in the field. Among the advantages of publishing in E&C are that upon acceptance, a paper is immediately published online in preliminary form, highlighted on the E&C web site and indexed on PubMed. A particular advantage of online publication is that papers can be made more readable by including crucial data and procedures as part of the main body of the paper, rather than being relegated to supplements. As co-Editors-in-chief with long experience in this field, we exercise our judgment concerning the necessity for additional experiments proposed by referees that would otherwise delay publication of an exciting result and/or represent an unreasonable amount of work. Should the circumstances merit it, we are glad to consider accelerated publication of a paper submitted with decision letters and complete peer reviews from a high-impact journal. This policy was proposed and approved at a recent meeting of the E&C Editorial Board, and we hope that potential authors will consider this option as a way of achieving very rapid publication in a highly competitive arena.The tremendous progress that we have witnessed in the chromatin and epigenetics field exemplified by these studies has led to an increasing appreciation for the importance of chromatin-based processes in biological regulation. As a result, many researchers are finding that their work is becoming more competitive for space in high-impact journals. We recognize that in these cases a journal such as ours may not be the first choice for submission. Nevertheless, we think that by maintaining the high quality of published work, E&C, we still need to increase the number of submissions and subsequent publication in order for this venture to succeed. Therefore, when trying to decide where to send your work for publication, we ask that you take into account the high editorial standards of E&C, the breadth and excellence of our Editorial Board, the rapid publication upon acceptance, and the advantages of open access in reaching your intended audience. On behalf of the E&C team and the Editorial Board, we hope that you will consider our journal for submitting your work for publication.As pleased as we are with the overall quality of manuscripts submitted to


It has been shown that socioeconomic status (SES) is associated with adherence to treatment of patients with several chronic diseases. However, there is a controversy regarding the impact of SES on adherence among patients with the human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS). Thus, we sought to perform a systematic review of the evidence regarding the association of SES with adherence to treatment of patients with HIV/AIDS.We searched the PubMed database to identify studies concerning SES and HIV/AIDS and collected data regarding the association between various determinants of SES  and adherence.We initially identified 116 potentially relevant articles and reviewed in detail 17 original studies, which contained data that were helpful in evaluating the association between SES and adherence to treatment of patients with HIV/AIDS. No original research study has specifically focused on the possible association between SES and adherence to treatment of patients with HIV/AIDS. Among the reviewed studies that examined the impact of income and education on adherence to antiretroviral treatment, only half and less than a third, respectively, found a statistically significant association between these main determinants of SES and adherence of patients infected with HIV/AIDS.Our systematic review of the available evidence does not provide conclusive support for existence of a clear association between SES and adherence among patients infected with HIV/AIDS. There seemed to be a positive trend among components of SES  and adherence to antiretroviral treatment in many of the reviewed studies, however most of the studies did not establish a statistically significant association between determinants of SES and adherence. Suboptimal adherence to medical treatment with antiretroviral agents has been associated with increased morbidity and mortality, potential transmission of drug-resistant virus, drug resistance, and failure to achieve viral suppression -4. AdherIt is suggested that SES is consistently associated with higher adherence to medical treatment in patients suffering from chronic diseases, such as asthma, diabetes, and post-myocardial infarction ,7,10-12.Although adherence is higher in patients with HIV/AIDS than in other chronic diseases  ,14, it iIt is noteworthy that despite the fact that SES is a commonly used term, it is rather difficult to define and measure it . AccordiTwo independent reviewers performed the literature search, study selection, and data extraction. Disagreements between these reviewers were resolved in meetings of all authors. We performed a systematic search of the literature to identify reviews and original studies that reported data regarding the impact of SES on adherence in HIV/AIDS patients. The relevant studies were identified by the use of the PubMed database (articles written in English), published until 2006. In addition, we performed additional searches of various Internet resources on HIV/AIDS ,17,18. AThe inclusion and exclusion criteria used for the studies reviewed, were set before the literature search. Studies included in our study concerned only individual HIV-infected adult patients and their adherence to antiretroviral treatment. Reviews and editorials were not included in our systematic review. We excluded studies focused on HIV prevention, quality of life, attitude, and health status of patients. We also excluded studies, which compared the outcomes of treatment with different antiretroviral drugs without reporting specific data for the SES of the studied patients. Additionally, we excluded studies that focused on HIV-infected illicit drug users, as such users have specific psychosocial characteristics  and are From the studies that were included in our systematic review we extracted data regarding the date of publication, the setting of the study, the patient population, details of the medical treatment , data relevant to SES, the measure of adherence, the overall adherence and findings regarding the association between major determinants of SES and adherence. In this study we assessed three parameters as major factors contributing to SES, namely, income, education, and occupation, and we examined their association with adherence to treatment of HIV infected patients.In Figure We did not identify a study focused directly on the association between SES or its main determinants analyzed as a group and adherence. In Table In Table In this systematic review we found that SES was not consistently associated with adherence to treatment among HIV infected patients. Since there was no study directly examining the association between SES and adherence in patients with HIV/AIDS, we evaluated the available data regarding the possible association between the major separate determinants of SES  and adherence. Although someone would have expected a clear association between SES and adherence to treatment based on data from studies on patients with chronic diseases other than HIV/AIDS infection, the evidence from the available studies does not fully support the existence of such an association in this patient population. However, a positive trend of association between levels of various SES components and levels of adherence to antiretroviral treatment is present among many of the studies.By taking a close look at the data presented, it is noteworthy that among the reviewed studies that examined some of the main components of SES, most did not find a statistically significant association between these factors and adherence to antiretroviral treatment. It should be emphasized that a statistically significant association between income and education, two main determinants of SES, and adherence was found in only half and less than a third of the studies that examined income and education, respectively.The existence of a possible association between income and adherence to treatment in HIV/AIDS patients was examined in 14 of the reviewed studies. Among the 7 studies in which income was found to be significantly associated with adherence, 4 concluded that the cost of antiretroviral treatment and/or poor living conditions were factors preventing patients from complying with treatment. If this financial obstacle was overcome, adherence was expected to reach considerably higher levels ,28,30,31The existence of a possible association between level of education and adherence to treatment in HIV/AIDS patients was examined in 13 of the reviewed studies. Among the 13 studies that considered education as a probable factor affecting adherence to antiretroviral treatment, only 4 original studies ,16,24,29Employment status was either not assessed or not found to be an independent factor associated with adherence, in the majority of the studies that we reviewed. Specifically, employment was found to have a significant impact on adherence in only 1 of 8 studies that examined this factor. The authors of that study postulated that having a busy workload might be an impediment to the patients' ability to adhere to antiretroviral treatment , therefoOur systematic review has several limitations. First, it was not possible to make a synthesis of the data using the principles of meta-analysis due to the fact that there was considerable heterogeneity among the reviewed studies. Adherence was measured by different methods in each of the studies and the cutoff percentage of adherence to treatment between 'adherent' and 'non-adherent' varied among the studies, depending on the authors' estimate. Furthermore, while most of the studies included patients generally following the model of life prevailing in the industrialized countries, some of the studies focused on populations having special economic, cultural, and social structures. Moreover, the studied patients received different antiretroviral regimens, ranging from monotherapy to HAART; the complexity of the treatment schedule affects the level of a patient's adherence. Second, SES was not focused upon as a homogenous group of specific factors in any of the reviewed studies, but was rather dispersed among its components, which were regarded as socio-demographic information. Therefore, we were forced to collect partial data regarding the association of such SES components, and adherence to antiretroviral treatment, where – and if – such an association was assessed. Occupation was only assessed in terms of employment status, as no data were given on status of occupation or working position of the patients. Additionally, we could not analyze the possible association between other SES proxy variables, such as the neighborhood, and adherence to treatment because the included studies did not report relevant data. Third, patients supposed to have lower SES, as perceived by the treating physician, are generally more likely to receive less complex antiretroviral regimens, and more information on how to maintain a satisfying adherence level. We cannot exclude that such an inequity could have occurred in the reviewed studies, as most studies were not set in a randomized controlled trial (RCT) environment, and include random HIV patients, therefore impeding our effort to find an association between levels of SES, and adherence to antiretroviral treatment.Adherence is a complex, dynamic process that influences the outcome of HIV treatment and the patient's health status ,36. It mOn the other hand, it has been noted before that physicians' choice regarding the medication they prescribe to their HIV patients is often influenced by their own estimates of expected level of patients' adherence to treatment, based on social stereotypes . In thisUnlike SES, there were other factors, which were found to influence greatly and consistently HIV patients' adherence in the reviewed studies. Specifically, psychosocial factors such as depression ,26,28,31In several studies it has been shown that SES is significantly associated with adherence to treatment in patients with chronic diseases -12. DespIn order for HIV patients to achieve higher levels of adherence to treatment, interventions regarding the patient, the clinician and the treatment have to be made ,6. SpeciConclusively, the available evidence suggests that SES is not consistently associated with adherence to therapy among patients infected with HIV and it does not seem to be a major determinant of adherence to antiretroviral treatment. Many available studies suggest a positive trend among factors contributing to patients' SES and adherence to medical treatment among patients with HIV/AIDS, however such an association cannot be statistically consolidated throughout most of the studies included in our systematic review. It should be emphasized that it appears that there is a confusion regarding the accurate meaning of the term "SES" and thus it has been assessed in various ways. Future studies may further explain the different impact of SES to adherence to treatment between patients infected with HIV and patients suffering from other chronic diseases.The author(s) declare that they have no competing interests.


Inadequate reporting is problematic for several reasons. If authors do not provide sufficient details concerning the conduct of their study, readers are left with an incomplete picture of what was done. As such, they are not able to judge the merits of the results and interpret them. The EQUATOR Network is a new initiative aimed at improving the clarity and transparency of reporting health research. Mental health continues to be a major health concern in many parts of the world. It is estimated that 5% to 10% of people are affected by depression  examinedIn the late 1970s the International Committee of Medical Journal Editors (ICMJE) published reporting guides for authors. These were limited only to formatting issues . Other eThe last decade has witnessed considerable activity in developing reporting guidelines: more than 80 of them now exist. They cover a broad spectrum; examples include recommendations for specific study designs , types Enhancing the QUAlity and Transparency Of health Research) Network [To help improve the quality of reporting health research, we established the EQUATOR .In working to achieve these goals the EQUATOR Network will help ensure that the clarity and transparency of healthcare research is optimal for decisions made by healthcare professionals, funders, editors, peer reviewers, and readers.DM, IS, KFS, JH, and DGA all conceived the paper. DM drafted the initial text and all authors helped edit it. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Emerging trends and new policies suggest that more cancer patients might die at home in the future. However, not all have equal chances of achieving this. Furthermore, there is lack of evidence to support that those who die at home experience better care and a better death than those who die as inpatients. The QUALYCARE study aims to examine variations in the quality and costs of end-of-life care, preferences and palliative outcomes associated with dying at home or in an institution for cancer patients.Mortality followback survey  conducted with bereaved relatives of cancer patients in four Primary Care Trusts in London. Potential participants are identified from death registrations and approached by the Office for National Statistics in complete confidence. Data are collected via a postal questionnaire to identify the informal and formal care received in the three months before death and the associated costs, relatives' satisfaction with care, and palliative outcomes for the patients and their relatives. A well-established questionnaire to measure relatives' views on the care integrates four brief and robust tools - the Client Service Receipt Inventory, the Palliative Outcome Scale, the EQ-5 D and the Texas Revised Inventory of Grief. Further questions assess patients and relatives' preferences for place of death. The survey aims to include 500 bereaved relatives . Bivariate and multivariate analyses will explore differences in place of death and place of end-of-life care, in preferences for place of death, patients' palliative outcomes and relatives' bereavement outcomes, in relation to place of death. Factors influencing death at home and the costs of end-of-life care by place of death will be identified.Collecting data on end-of-life care retrospectively from bereaved relatives has ethical, practical and scientific challenges. QUALYCARE has been carefully designed to address these challenges in a robust and ethically sound population-based survey. By discovering variations in the underlying individual reality of place of death for people dying from cancer and their families, this study will advance our understanding of end-of-life care and, we hope, improve care for cancer patients and their families in the future.National Institute of Health Research (NIHR) Clinical Research Network Portfolio. UKCRN7041. Extensive evidence shows that most members of the public and patients prefer to be cared for and to die at home -3. HowevNot all people with terminal cancer have equal chances of dying at home, and some of the inequities are well known. For example, patients living in deprived areas are less likely to die at home. This and another 16 factors are part of a robust international model of factors influencing death at home in cancer, derived from findings of 58 studies relating to 1.5 million patients . This moEnabling more patients to die in the place of their choice is important. However, the real issue is at what quality, and secondly, at what cost. There is little evidence to support that those who die at home and their relatives experience better care than those who die in institutions such as hospitals, hospices or nursing homes. There is a dearth of comparative studies on the associated costs.The QUALYCARE study has been designed to address the lack of evidence on the quality and costs of end-of-life care for people with cancer in relation to place of death. Its primary aim is to examine variations in the quality and costs of end-of-life care, preferences and palliative outcomes associated with home vs. institutional death in cancer. Secondary aims are to examine whether the care, costs, preferences and outcomes associated with death at home are the same in areas with high vs. low home death rates and in areas with high vs. low deprivation levels. Table Mortality followback postal survey with bereaved relatives of people who died from cancer, with a nested case-control study of home vs. hospital deaths, and informed by a pilot study .Finding out the views of bereaved relatives is important for three main reasons. Firstly, because this is the only way to get a population-based perspective on end-of-life care, and an understanding of the use and experiences of care  relatingNotwithstanding, bereaved relatives are a vulnerable group and engaging in research can be distressing and difficult for them. Few would currently accept the position that bereavement research is unethical per se, particularly in light of research findings showing benefits as perceived by bereaved relatives-21. ThesA postal approach was chosen as the most appropriate and practical data collection method, given the large size of the study population and robust postal research methodologies with bereaved relatives developed in the UK. An RCT of postal vs. face-to-face methods using an adapted version of the same questionnaire found that response rates (52% vs. 56%) and respondents' characteristics did not differ significantly . AlthougThe nested case-control study will identify people who die at home (defined as the "cases") and compare their past exposure to suspected risk factors (for dying at home) with that of patients who die in hospital (the "controls"). The definition of cases in relation to place of death is not as clear as in studies measuring disease frequency, where those affected by the disease are considered the cases. Our approach was therefore to take home deaths as the "cases", given that these are rarer than hospital deaths. The QUALYCARE case-control study will compare the care received, preferences and other risk factors for dying at home, rather than costs or outcomes . Because the association will be determined for each individual case-control pair, the study will determine more accurately than cross-sectional studies the potential for a causal link between risk factors and death at home.Finally, the study includes an economic evaluation of costs and consequences. This takes a health service perspective but voluntary sector costs and informal care are also valuated, at the market price that would have to be paid by the NHS to provide these. The cost component is the more exploratory part of the study, focused on estimation rather than hypothesis testing, as so little is known about the topic.The survey takes place in four Primary Care Trust (PCT) areas within London. London has the lowest home death rates of all nine strategic health authorities in England (18.5% in 2008) . This isBereaved relatives of people aged 18 years or over who died from cancer in a one year period (March 2009-March 2010), and who lived in one of the PCTs in study.Bereaved relatives are identified from death registrations, as the people who registered a cancer-related death (informant). In a similar study across eight cancer networks in the UK (2002-03), this was found to be a spouse or relative in 93% of the cases . This idIn each wave, the ONS team first identifies all cases of death registered four to ten months prior to the date invitation letters are planned to be sent out; they then screen for further eligibility criteria Table . There iAfter eligible people are identified, a sample is then drawn by the ONS team. This is stratified by PCT and place of death - 1) home, 2) hospice, 3) nursing home, and 4) NHS hospital. The sample in each PCT includes: all deaths that take place at home; all hospice deaths; all nursing home deaths; and a random sample of NHS hospital deaths.Invitation letters are sent by the ONS team to the informants in death registrations sampled for the study, inviting them to take part and explaining how they had been identified. Letters to potential participants in Wave 1 were sent in January 2010; letters for Wave 2 were sent in July 2010.http://www.kcl.ac.uk/qualycare). Contact points are given if people wish to talk about the study. The information leaflet, the study questionnaire, a reply slip (for people to decline to take part if they wish so), two freepost envelopes (one for the reply slip to be sent to the ONS and one for the questionnaire to be sent to the research team) and a leaflet with information about bereavement  are also enclosed.The invitation letter first apologises in advance for any distress caused. It then assures potential participants that their contact details were not released and that instead the ONS agreed to contact them on behalf of the research team for the purposes of the study. Each letter is enclosed with an information leaflet signed by the Principal Investigator and the Director of Public Health from the local Primary Care Trust (PCT), explaining why the work is important and how it will be used to help improve care  may also take place, although this is entirely optional, and only if participants write in the questionnaire they agree and provide their contact details. The interview aims to clarify information if appropriate  and to talk about the questionnaire, so the researcher ascertains the impact and effect of the questionnaire on the participant (to screen for distress and serious concerns). The period of data collection is planned to be eight months, including time for the second and last wave of questionnaires to be returned and follow-up telephone interviews to be made.The study uses an adapted short form of a questionnaire developed by Ann Cartwright in the late 1960's to measure patients' experiences of the last year of life from the perspective of their bereaved relatives . Since tCompleting the questionnaire takes about 60 minutes. Participants are given the contact details of the research team, should they need assistance.Once identified, all sampled cases are assigned study identification (ID) numbers by the ONS team, who then provides the research team with a spreadsheet of these numbers . The spreadsheet enables the ONS team and the research team to communicate using study ID numbers with a view to prepare the questionnaire packs, conduct the mailings and monitor recruitment. Questionnaire packs are prepared by the research team using the spreadsheet to personalised each pack by PCT and gender of the deceased . Questionnaires and reply slips are also marked with the respective study ID number. The packs are then delivered to the ONS, where address labels and personalised invitation letters are included and postage is organised. The research team manages the questionnaire returns and notifies the ONS of study ID numbers to prevent follow-up mailings to people who decline participation; ONS reports back to the research team all declinations to participate (made either by phone or post) with reasons if people volunteer them, as well as any complaints received.Upon receipt of a completed questionnaire, the research team records arrival into the spreadsheet, checks completion, levels of distress and grief intensity, and safely store the questionnaire in a locked cabinet in a locked office in the team's department. Access to the data is restricted and controlled. If there is need for clarifications regarding the questionnaire or follow-up to assess the impact of the questionnaire on the participant and potential distress, and provided the participant has agreed to be contacted and provided contact details, a member of the research team makes contact to arrange a telephone interview.At the end of each wave, the ONS provides the research team with an anonymised and encrypted dataset of all eligible cases of deaths in each of the PCTs (including participants and non-participants) with individual information on study ID numbers, PCT of residence, age, date of death occurrence, date of death registration, underlying cause of death, other causes of death, place of death, gender, place of birth, electoral ward of last residence of the deceased and their relationship to the informant. These data are important to understand what population is excluded from the study and who decides not to take part. All information is treated confidentially, following ONS regulations and the data management guidelines of the research team's department. The study has been approved by an NHS Research Ethics Committee (REC ref no.: 09/H0808/85).Receiving the invitation letter and completing the questionnaire can lead to a reawakening of bereavement and any associated distress or anger. It can also lead to disclosure of information by the participants which may require follow-up action by the research team. For example, it may prompt unresolved issues about bereavement and grief in the participant. Published guidelines by Colin Murray Parkes on how to conduct ethical bereavement research are being followed  and a seAnswers to the questionnaire are entered into a pre-designed SPSS database (version 17.0). This excludes any personal information that might have been provided by the participant, such as contact details; these are kept only in the paper questionnaire, which is securely stored in a locked cabinet. Data entry is continuously monitored through supervision meetings where a set of rules develops and exceptions are discussed. A decision diary with rules, exceptions and decisions constructs an audit trail to enable transparency. Ten percent of the data are double-entered and cross-checks identify the percentage of items with discordances, missing data and systematic errors (percentage of double-checked data to be adjusted according to outcome of cross-checks). Once completed and checked, the questionnaire database will then link with the anonymised dataset provided by the ONS (using study ID numbers).2 tests will be used with categorical variables (significance level set at 0.05).Numbers of all cancer deaths, participants and non-participants, including those ineligible and those who decline to participate or do not reply will be reported in a flowchart. Participants and non-participants will be compared in terms of clinical and socio-demographic variables of both the deceased and their relatives, to investigate possible selection bias. The influence of place of death and timing from death to first contact will also be investigated. T-tests will be used to compare continuous data which are normally distributed, Mann-Whitney tests will be used with non-parametric continuous or ordinal data, and χThe data allow reporting the place of death for both participants and non-participants. For participants, comparisons will be made between place of death as reported in the death registrations and as reported by the bereaved relatives, examining percentage and type of disagreements. Place of death will also be compared with the place where the patients spent most part of the three months before death, as reported by their relatives  - of patients and of their relatives, and for the latter at three months prior to death, changes in the three months before death (reported retrospectively) and post-death. Numbers and percentages (with 95% CIs) where the patient and the relative disagreed regarding place of death and the type of disagreements will also be reported. χ2 tests to compare categorical variables.Frequency tables and descriptive statistics will report outcomes by place of death (objective 1.3). These will show numbers and percentages of patients who experienced pain, anxiety/depression, confusion, and other symptoms, and more severe levels of each symptom in the week of death. Symptom scores in the POS and EQ-5 D will be compared for pain and anxiety/depression and percentage and type of disagreements reported. We will also compare item responses and total scores in the POS, EQ-5 D and TRIG, satisfaction with the different types of formal care  and attainment of preferred place of death for patients and relatives, between home and hospital, hospice and nursing home deaths. Differences between home and hospital, hospice or nursing home deaths will be tested using independent-samples t-tests to compare normally distributed continuous data, Mann-Whitney tests to compare non-parametric continuous or ordinal data, and χ2 tests to compare categorical variables. Continuous data on service use are expected to be skewed but we will examine histograms and box plots to confirm this.Frequency tables and descriptive statistics with numbers and percentages (95% CIs), medians (with IQ ranges) or means (with SDs) will report the use of informal and formal care in the three months before death, by place of death (objectives 1.4 and 1.5). Use will be examined both as categorical (yes/no) and ordinal or continuous data . Home deaths will be compared with the three other places of deaths (one-to-one) using independent-samples t-tests to compare normally distributed continuous data, Mann-Whitney tests to compare non-parametric continuous or ordinal data, and χData on service use in the last three months before death, collected using the CSRI, will be combined with appropriate unit costs to calculate service costs. Unit costs will be mostly obtained from the 2009 Unit Costs for Health and Social Care publication. We planSimilar analyses will be conducted to compare home vs. institutional deaths  (objective 2), to compare areas with high vs. low home death rates and areas with high vs. low deprivation levels (objective 3).2 statistic will be calculated to determine the amount of variance accounted for in the models.Following bivariate analyses comparing home with other places of death, logistic regressions will be conducted to determine the relative influence of different factors on death at home , place of death being the dependent categorical variable (home - yes/no) (objective 4). Potential predictors of death at home identified in bivariate analyses will be entered in the regression. These will be grouped in three categories - illness related, personal (including preferences), and environmental factors (including care components), following a model of factors influencing death at home in cancer . Odds raRegression analyses will be performed for areas with high and low home death rates separately  and results will be compared in terms of factors retained in the models and those that lose significance or strength to others, and the amount of variance explained. In the same way, regressions will also be performed within areas with high and low social deprivation levels.Regression analyses will be conducted to determine the relative influence of death at home  on the costs  and on each outcome (dependent variables), controlling for other factors (objective 5). First, bivariate analyses will be undertaken to identify predictors of each of the palliative outcomes and cost-drivers, other than death at home; these will be entered in the regression, alongside death at home. Different multivariate approaches will be undertaken including logistic regression and linear regression. We plan to use bootstrapping with cost data as these are expected to be skewed, to generate more robust 95% CIs; results The odds ratios and 95% CIs for death at home will be compared with those for other factors, to assess its strength and significance relative to others. Results will be compared with bivariate analyses to examine whether death at home lost or gain significance or strength. Similar regression analyses will be performed for areas with high and low home death rates separately  and results will be compared in terms of the influence of death at home. Regressions will also be performed within areas with high and low social deprivation levels.Sample size calculations were carried out following Altman's methods for the Lack of data on the magnitude of differences on patients and relatives' outcomes and costs precluded further calculations. Measuring the costs of care usually requires relatively large sample sizes due to high variance in costs (large SDs) but the Based on responses achieved in a recent survey, we have accommodated a scenario of 38% response rate with an extra 10% of missing data . To get Based on the estimated figures by place of death, a sampling strategy was drawn. We decided to include all eligible home deaths, hospice deaths and nursing home deaths in all four PCTs, and a random sample of 150 NHS hospital deaths in each PCT. The number of people to be sent questionnaires was projected to approximate 1,450, of which we expected ~550 returned questionnaires, ~500 with complete data.Prior to commencing the study, it was decided that if response rates were lower than 30% or if there were serious complaints that could not be addressed, we would stop the study. Results from Wave 1 were reviewed with the project steering group in March 2010. The response rate achieved by then was higher than 40% and there were no serious complaints that could not be addressed. Therefore, the study progressed to Wave 2.This consists of an independent group responsible for data-monitoring. The group comprises representatives of the ONS, the PCTs in the study, local palliative care services, the Department of Heath End-of-Life Care Team, and a user representative (bereaved relative). Progress is reported to the group every three months.The QUALYCARE study faces two main challenges. First, ethical and data protection issues and practicalities are prominent in the study and have strongly determined its design. The sensitivity of the topic requires complicated procedures, compassion and attention to detail from all the staff involved. Secondly, there is a lack of evidence in the emerging area of cost measurement at the end of life to inform study design and procedures, thus methods and conclusions relating to costs will be in essence exploratory. Recall bias and use of caregivers as proxies for evaluating service use and palliative outcomes are important aspects to consider when interpreting the data ,36.Despite limitations, the QUALYCARE study is one of the most detailed population-based surveys of our time about the end-of-life care provided to people with cancer. Being carefully designed to be ethically and scientifically sound, it contributes to advancing the science in end-of-life care research. Case-control studies such as the one nested in QUALYCARE are rare in end-of-life care research despite More importantly, the QUALYCARE study could discover variations in the underlying individual reality of place of death for people dying from cancer and their families. This may include differences in the preferences, in palliative outcomes for patients, in bereavement outcomes for relatives, and in the costs of caring for people dying at home as compared to institutional settings, not just for the health care system but for families. Our findings will, we hope, help improve care for cancer patients and their families locally, and in comparable settings across the UK and beyond.CI: Confidence Interval; CSRI: Client Service Receipt Inventory; GP: General Practitioner; IQ: Inter-Quartile; NHS: National Health Service; ONS: Office for National Statistics; PCT: Primary Care Trust; POS: Palliative Outcome Scale; SD: Standard Deviation; TRIG: Texas Revised Inventory of GriefThe authors have received funding in the past five years from the Department of Health (partner in the study) for conducting end-of-life care research and, although unlikely, it is possible this organisation may gain or lose financially from the publication of this manuscript. The authors declare that they have no other competing interests.BG and IJH conceived the study, and PMcC, SH and JK made substantial contributions to its conception and design. BG and IJH negotiated the collaboration and acquisition of anonymised mortality data from the Office for National Statistics. BG coordinates the study fieldwork including sampling, data collection and data entry, supported by IJH, JK and SH. All authors are expected to make substantial contributions to the analysis and interpretation of the data. BG drafted this manuscript and PMcC, SH, JK and IJH revised it for important intellectual content. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/10/400/prepubTable A.Click here for file


Back in 1987, the World Health Organization (WHO) concluded that the screening of international travellers was an ineffective way to prevent the spread of HIV. However, some countries still restrict the entrance and/or residency of foreigners with an HIV infection. HIV-related travel restrictions have serious implications for individual and public health, and violate internationally recognized human rights. In this study, we reviewed the current situation regarding HIV-related travel restrictions in the 53 countries of the WHO European Region.hivtravel.org. We simplified and standardized the database information to enable us to create an overview and compare countries. Where data was outdated, unclear or contradictory, we contacted WHO HIV focal points in the countries or appropriate non-governmental organizations. The United States Bureau of Consular Affairs website was also used to confirm and complement these data.We retrieved the country-specific information chiefly from the Global Database on HIV Related Travel Restrictions at Our review revealed that there are no entry restrictions for people living with HIV in 51 countries in the WHO European Region. In 11 countries, foreigners living with HIV applying for long-term stays will not be granted a visa. These countries are: Andorra, Armenia, Cyprus (denies access for non-European Union citizens), Hungary, Kazakhstan, Moldova, the Russian Federation, Tajikistan, Turkmenistan, Ukraine and Uzbekistan. In Uzbekistan, an HIV-positive foreigner cannot even enter the country, and in Georgia, we were not able to determine whether there were any HIV-related travel restrictions due to a lack of information.In 32% of the countries in the European Region, either there are some kind of HIV-related travel restrictions or we were unable to determine if such restrictions are in force. Most of these countries defend restrictions as being justified by public health concerns. However, there is no evidence that denying HIV-positive foreigners access to a country is effective in protecting public health. Governments should revise legislation on HIV-related travel restrictions. In the meantime, a joint effort is needed to draw attention to the continuing discrimination and stigmatization of people living with HIV that takes place in those European Region countries where such laws and policies are still in force. We read the article, "Fear of foreigners: HIV-related restrictions on entry, stay and residence", in thisThe United Nations Human Rights Committee has stated, "Liberty of movement is an indispensable condition for the free development of a person" . EarlierThe [International] Covenant [on Civil and Political Rights] does not recognize the right of aliens to enter or reside in the territory of a State party. It is in principle a matter for the State to decide who it will admit to its territory. However, in certain circumstances an alien may enjoy the protection of the Covenant even in relation to entry or residence, for example, when considerations of non-discrimination, prohibition of inhuman treatment and respect for family life arise .Governments do, of course, have the right to control entry to their borders and have a certain margin of appreciation to justify differential treatment compatible with international human rights law. But the measures must pursue a legitimate aim and need to be proportional to the achievement of this aim .Back in 1987, the World Health Organization (WHO) concluded that the screening of international travellers was an ineffective way to prevent the spread of HIV . In 2002Since then, travel restrictions connected with communicable diseases in general and HIV in particular have often been discussed -9, incluThis important discussion prompted us to review the current situation in the 53 countries of the WHO European Region, given that restrictions on entry, residence and stay affect a wide range of PLHIV, including not only students and employees, but also members of vulnerable groups, such as refugees, asylum seekers and other migrants.In this study, which we carried out in April and May 2009, our concern was to map formal entry and residence restrictions that required an HIV test or a medical certificate of HIV status. It should be noted that in practice, however, some of the countries did not apply the rules that were legally valid at this time. We also reviewed whether people can be denied entry when applying for long-term stay (but not residence) or be deported if authorities obtain evidence of HIV infection.hivtravel.org based on suspected or real HIV status alone, including HIV screening of international travelers, are discriminatory and cannot be justified by public health concerns"  because Additional considerations arise with respect to travel within the 27 countries of the European Union because free movement of people within the EU is one of its founding principles, a principle acknowledged not only in its founding and subsequent treaties, but also in the European Convention of Human Rights. For example, Council Directive 2004/38/EC  states tWithout prejudice to the provisions on travel documents applicable to national border controls, all Union citizens with a valid identity card or passport ... shall have the right to leave the territory of a Member State to travel to another Member State [Article 4.1].And similarly:Without prejudice to the provisions on travel documents applicable to national border controls, Member States shall grant Union citizens leave to enter their territory with a valid identity card or passport .... [Article 5.1].The directive later notes that:Subject to the provisions of this Chapter, Member States may restrict the freedom of movement and residence of Union citizens ... on grounds of public policy, public security or public health. These grounds shall not be invoked to serve economic ends [Article 27.1].However, it goes on to place narrow limits on public health arguments for such restrictions:The only diseases justifying measures restricting freedom of movement shall be the diseases with epidemic potential as defined by the relevant instruments of the World Health Organization and other infectious diseases or contagious parasitic diseases if they are the subject of protection provisions applying to nationals of the host Member State [Article 29.1].For example, travel restrictions can be used to limit the spread of highly contagious diseases, such as cholera or acute respiratory syndrome (SARS), but such measures tend to be short-term and are most likely not very effective. Even in these cases, authorities must still consider human rights and the broad social, economic and public health consequences of initiating travel restrictions of any kind.In general, WHO does not support travel restrictions in relation to communicable diseases, and the recent case of influenza A (H1N1) was no exception . AccordiIn contrast to HIV, the highly contagious diseases that we have mentioned have short incubation periods and are transmitted through casual contact. While HIV transmission is mostly due to risk behaviours like sharing needles or unsafe sex, these diseases are transmitted much more readily, through droplets in the air or contaminated food or water. In the light of these differences, as well as the potential for discrimination and stigmatization, the public health justification for HIV-related travel restrictions is inadequate and even irrational.The authors declare that they have no competing interests.NC drafted the article based on an idea from JVL and SM. JVL fully revised the first draft and MW reviewed and added additional material. NC fact checked the changes. SM fully reviewed and edited the next draft. JVL and MW addressed the reviewer's comments. All authors read and approved the final manuscript.Table S1. Overview of travel restrictions in the countries of the WHO European Region.Click here for file