Executive summary of the Hellenic Atherosclerosis Society guidelines for the diagnosis and treatment of dyslipidemias - 2023

Atherosclerotic cardiovascular disease (ASCVD) remains the main cause of death worldwide, and thus its prevention, early diagnosis and treatment is of paramount importance. Dyslipidemia represents a major ASCVD risk factor that should be adequately managed at different clinical settings. 2023 guidelines of the Hellenic Atherosclerosis Society focus on the assessment of ASCVD risk, laboratory evaluation of dyslipidemias, new and emerging lipid-lowering drugs, as well as diagnosis and treatment of lipid disorders in women, the elderly and in patients with familial hypercholesterolemia, acute coronary syndromes, heart failure, stroke, chronic kidney disease, diabetes, autoimmune diseases, and non-alcoholic fatty liver disease. Statin intolerance is also discussed.

Self-control is associated with health-relevant disparities in buccal DNA-methylation measures of biological aging in older adults

Self-control is a personality dimension that is associated with better physical health and a longer lifespan. Here, we examined (1) whether self-control is associated with buccal and saliva DNA-methylation (DNAm) measures of biological aging quantified in children, adolescents, and adults, and (2) whether biological aging measured in buccal DNAm is associated with self-reported health. Following preregistered analyses, we computed two DNAm measures of advanced biological age (principal-component PhenoAge and GrimAge Acceleration) and a DNAm measure of pace of aging (DunedinPACE) in buccal samples from the German Socioeconomic Panel Study (SOEP-G[ene], n = 1058, age range 0-72, Mage = 42.65) and saliva samples from the Texas Twin Project (TTP, n = 1327, age range 8-20, Mage = 13.50). We found that lower self-control was associated with advanced biological age in older adults (PhenoAge Acceleration β = - .34, [- .51, - .17], p < .001; GrimAge Acceleration β = - .34, [- .49, - .19], p < .001), but not young adults, adolescents or children. These associations remained statistically robust even after correcting for possible confounders such as socioeconomic contexts, BMI, or genetic correlates of low self-control. Moreover, a faster pace of aging and advanced biological age measured in buccal DNAm were associated with self-reported disease (PhenoAge Acceleration: β = .13 [.06, .19], p < .001; GrimAge Acceleration: β = .19 [.12, .26], p < .001; DunedinPACE: β = .09 [.02, .17], p = .01). However, effect sizes were weaker than observations in blood, suggesting that customization of DNAm aging measures to buccal and saliva tissues may be necessary. Our findings are consistent with the hypothesis that self-control is associated with health via pathways that accelerate biological aging in older adults.

Self-control is associated with health-relevant disparities in buccal DNA-methylation measures of biological aging in older adults

Self-control is a personality dimension that is associated with better physical health and a longer lifespan. Here we examined (1) whether self-control is associated with buccal and saliva DNA-methylation (DNAm) measures of biological aging quantified in children, adolescents, and adults, and (2) whether biological aging measured in buccal DNAm is associated with self-reported health. Following preregistered analyses, we computed two DNAm measures of advanced biological age (PhenoAge and GrimAge Acceleration) and a DNAm measure of pace of aging (DunedinPACE) in buccal samples from the German Socioeconomic Panel Study (SOEP-G[ene], n = 1058, age range 0-72, Mage = 42.65) and saliva samples from the Texas Twin Project (TTP, n = 1327, age range 8-20, Mage = 13.50). We found that lower self-control was associated with advanced biological age in older adults (β =-.34), but not young adults, adolescents or children. This association was not accounted for by statistical correction for socioeconomic contexts, BMI, or genetic correlates of low self-control. Moreover, a faster pace of aging and advanced biological age measured in buccal DNAm were associated with worse self-reported health (β =.13 to β = .19). But, effect sizes were weaker than observations in blood, thus customization of DNAm aging measures to buccal and saliva tissues may be necessary. Our findings are consistent with the hypothesis that self-control is associated with health via pathways that accelerate biological aging in older adults.

The Impact of Implementing a Diabetic Limb-Preservation Program on Amputation Outcomes at an Academic Institution in a Majority-Minority State

Background. Diabetic foot osteomyelitis may precede major limb amputations and lengthy hospital admission. These complications impact patients' morbidity and mortality. Healthcare institutions with dedicated limb-preservation teams realize reduced amputation rates and improved quality of care. This study evaluates the outcomes following the implementation of a rigorous diabetic limb-preservation program at an academic institution. Methods. Patients with diabetes admitted for osteomyelitis occurring below the knee were identified by ICD-10 codes and included for retrospective review. The number and type of amputations, bone biopsies, revascularizations, and hospital length of stay (LOS) were evaluated. Outcomes were compared using the high-low (Hi-Lo) amputation ratio for the 24 months preceding and the 24 months after the integration of a diabetic limb-preservation service. Results. The authors identified and included 337 patients admitted for diabetic foot osteomyelitis. In the 24-month period prior to program implementation, 140 patients were evaluated. In the 24-month period after program implementation, 197 patients were evaluated. The overall amputation rate decreased from 67.1% (n = 94) to 59.9% (n = 118) (P = .214). Major limb amputation rates significantly decreased from 32.9% (n = 46) to 12.7% (n = 25) (P = .001). Minor amputation rates significantly increased from 34.2% (n = 48) to 47.2% (n = 93) (P = .024). The Hi-Lo amputation ratio decreased from 0.96 to 0.27 (P < .001). The rate of obtaining bone biopsies increased from 32.1% (n = 45) to 72.1% (P < .001). The rate of revascularization increased from 10.7% (n = 15) to 15.2% (n = 30) (P = .299). Average hospital LOS decreased significantly from 11.6 days to 9.8 days (P = .044). Conclusion. After the implementation of a limb-preservation team, there was a precipitous drop in major limb amputations in favor of minor amputations. The average hospital LOS decreased. These findings demonstrated improved clinical care and outcomes in patients with lower extremity osteomyelitis and reinforce the importance of a diabetic foot-preservation service within healthcare institutions.

Nanoscale pores introduced into paper via mesoporous silica coatings using sol-gel chemistry

Mesopores, with diameters between 2 and 50 nm, not only increase the specific surface area, but also generate hierarchically porous materials with specific properties such as capillary fluid transport, ion specific pore accessibility, or size exclusion. Paper is a strongly hierarchical, porous material with specific properties, such as capillary force-driven fluid transport. However, paper fibers change their morphology during the initial step of wood disintegration. This results in changes of the porous fiber structure. In particular paper fibers loose their mesopores during the final drying step in the fabrication process. Here, we investigate silica mesopore formation in paper by sol-gel chemistry and evaporation induced self-assembly to specifically introduce and rationally design mesopore formation and distribution in cotton linter and eucalyptus sulfate paper sheets. We demonstrate the importance of synchronizing the solvent evaporation rate and capillary fluid velocity to ensure mesopore formation as well as the influence of the fiber type and sol-gel solution composition. The combination of argon and krypton sorption, SAXS, TEM and CLSM provides systematic analysis of the porous structure and the silica distribution along the cellulose paper fiber length and cross-section. These results provide a deeper understanding of mesopore formation in paper and how the latter is influenced by paper fluidic properties.

Associations of socioeconomic disparities with buccal DNA-methylation measures of biological aging

BACKGROUND

Individuals who are socioeconomically disadvantaged are at increased risk for aging-related diseases and perform less well on tests of cognitive function. The weathering hypothesis proposes that these disparities in physical and cognitive health arise from an acceleration of biological processes of aging. Theories of how life adversity is biologically embedded identify epigenetic alterations, including DNA methylation (DNAm), as a mechanistic interface between the environment and health. Consistent with the weathering hypothesis and theories of biological embedding, recently developed DNAm algorithms have revealed profiles reflective of more advanced aging and lower cognitive function among socioeconomically-at-risk groups. These DNAm algorithms were developed using blood-DNA, but social and behavioral science research commonly collect saliva or cheek-swab DNA. This discrepancy is a potential barrier to research to elucidate mechanisms through which socioeconomic disadvantage affects aging and cognition. We therefore tested if social gradients observed in blood DNAm measures could be reproduced using buccal-cell DNA obtained from cheek swabs.

RESULTS

We analyzed three DNAm measures of biological aging and one DNAm measure of cognitive performance, all of which showed socioeconomic gradients in previous studies: the PhenoAge and GrimAge DNAm clocks, DunedinPACE, and Epigenetic-g. We first computed blood-buccal cross-tissue correlations in n = 21 adults (GEO111165). Cross-tissue correlations were low-to-moderate (r = .25 to r = .48). We next conducted analyses of socioeconomic gradients using buccal DNAm data from SOEP-G (n = 1128, 57% female; age mean = 42 yrs, SD = 21.56, range 0-72). Associations of socioeconomic status with DNAm measures of aging were in the expected direction, but were smaller as compared to reports from blood DNAm datasets (r = - .08 to r = - .13).

CONCLUSIONS

Our findings are consistent with the hypothesis that socioeconomic disadvantage is associated with DNAm indicators of worse physical health. However, relatively low cross-tissue correlations and attenuated effect sizes for socioeconomic gradients in buccal DNAm compared with reports from analysis of blood DNAm suggest that in order to take full advantage of buccal DNA samples, DNAm algorithms customized to buccal DNAm are needed.

Quadriceps tendon autograft for anterior cruciate ligament reconstruction: state of the art

The ideal graft for anterior cruciate ligament reconstruction (ACLR) continues to be debated. Although first described in 1984, use of the quadriceps tendon (QT) autograft has only recently gained popularity. The biomechanical properties of the QT autograft are favourable compared to bone-patellar tendon-bone (BPTB) and doubled hamstring (HS) grafts with a higher load to failure and a modulus of elasticity that more closely approximates the native anterior cruciate ligament (ACL). The QT graft can be harvested with or without a bone plug, as either a full thickness or a partial thickness graft, and even through minimally invasive techniques. The surgeon must be aware of potential harvest risks including patellar fracture or a graft that is of insufficient length. Numerous short-term studies have shown comparable results when compared to BPTB or hamstring HS autografts with similar graft failure rates, patient-reported outcomes. A major advantage of QT ACLR is reduced donor site morbidity compared to BPTB. However, some persistent quadriceps weakness after QT ACLR has also been reported. The current literature shows that use of the QT autograft for ACLR provides equivalent clinical results compared to other autografts with less donor site morbidity. However, future studies with longer follow-up and higher level of evidence are needed to identify specific populations where the QT may have additional advantage.

Mental health-related communication in a virtual community: text mining analysis of a digital exchange platform during the Covid-19 pandemic

BACKGROUND

Virtual communities played an important role in mental health and well-being during the Covid-19 pandemic by providing access to others and thereby preventing loneliness. The pandemic has accelerated the urge for digital solutions for people with pre-existing mental health problems. So far, it remains unclear how the people concerned communicate with each other and benefit from peer-to-peer support on a moderated digital platform.

OBJECTIVE

The aim of the project was to identify and describe the communication patterns and verbal expression of users on the inCLOUsiv platform during the first lockdown in 2020.

METHODS

Discussions in forums and live chats on inCLOUsiv were analysed using text mining, which included frequency, correlation, n-gram and sentiment analyses.

RESULTS

The communication behaviour of users on inCLOUsiv was benevolent and supportive; and 72% of the identified sentiments were positive. Users addressed the topics of 'corona', 'anxiety' and 'crisis' and shared coping strategies.

CONCLUSIONS

The benevolent interaction between users on inCLOUsiv is in line with other virtual communities for Covid-19 and the potential for peer-to-peer support. Users can benefit from each other's experiences and support each other. Virtual communities can be used as an adjuvant to existing therapy, particularly in times of reduced access to local health services.

A prospective, multicenter, epidemiological study of the prevalence of cardiovascular risk factors in hypertensive patients in Greece, the WIN-HAZARD study

Background/Introduction

Arterial hypertension (AH) is a major, common, modifiable, risk factor for cardiovascular disease. It is strongly associated with cardiovascular disease (CVD), the leading cause of death globally, according to World Health Organization. In addition to elevated blood pressure (BP), many hypertensive patients have other risk factors that increase the overall cardiovascular risk. The calculation of the total cardiovascular (CV) risk is necessary for selecting the proper treatment strategy and guide timely treatment decisions and interventions.

Purpose

This prospective, multicenter, epidemiological, non-interventional, nationwide study aimed to evaluate the type and number of total CVD risk factors in hypertensive patients in Greece, according to the 2013 guidelines of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC), applicable at the time of the study conduct.

Methods

Overall, 3 Cardiology Hospital sites and 167 private Cardiologists, Internists, Endocrinologists and General Practitioners nationwide participated in the study, enrolling consecutive adult patients with hypertension under treatment. Total CV risk was assessed by 2013 ESH/ESC criteria, and the European Systematic Coronary Risk Evaluation (SCORE) algorithm. It involved a single visit, with no screening period for the patients. The study has been conducted in compliance with ICH/GCP standards, from March 2017 to April 2019.

Results

In total 1309 patients with AH under treatment were enrolled (59% male, mean age 60.6 years, mean BMI 28.2). The median time from AH diagnosis was 3.7 years. The most common CV risk factors were dyslipidaemia (76.4%), male gender (59%), advanced age (58.1%) and abdominal obesity (46.1%). The incidence of the remaining total CV risk factors per category was asymptomatic target organ damage (20.8%), diabetes (11.3%) and established CV or renal disease (5.8%). The majority of the study patients (71.6%) had concomitantly ≥3 total CV risk factors (table 1 and table 2).

The mean (±SD) systolic arterial pressure was 143.5±14.7 mmHg and the mean (±SD) diastolic 85.5±8.6 mmHg. More than half of the patients (51.8%) received one antihypertensive drug, with angiotensin II receptor blockers (ARBs) being the most commonly reported drug class (23.9%), followed by calcium channel blockers (15.8%).

Conclusion

This real-world study with its broad geographical coverage and phycisians' specialty range, contributed significant epidemiological data pertaining to prevalence of cardiovascular risk factors in adult hypertensive patients and their current treatment status in Greece. The value of this observational study lies in supporting the proper deployment of current guidelines, as well as, the implementation of future preventive healthcare programmes.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): WIN MEDICA S.A. Table 1Table 2

Ultrashort pulse written fiber Bragg gratings as narrowband filters in multicore fibers

We present the inscription of narrow-linewidth fiber Bragg gratings (FBGs) into different types of multicore fibers (MCFs) using ultrashort laser pulses and the phase mask technique, which can act as notch filters. Such filters are required, e.g., to suppress light emitted by hydroxyl in the Earth's upper atmosphere, which disturbs ground-based observation of extraterrestrial objects in the near infrared. However, the inscription into a commercially available seven-core fiber showed a quite large core-to-core deviation of the resonance wavelength of up to 0.45 nm. Two options are presented to overcome this: first, we present the photo-treatment of the FBGs to tune the resonance wavelength, which allows for sufficient resonance shifts. Second, adapted MCFs containing 12 cores, arranged on a circle, are fabricated. For this, two different fabrication procedures were investigated, namely, the mechanical drilling of the preform for a rod-in-tube version as well as a stack-and-draw approach. Both adapted MCFs yielded significant improvements with core-to-core wavelength variations of the FBGs of only about 0.18 nm and 0.11 nm, respectively, sufficient to fulfill the requirements for astronomical filter applications as discussed above.

Atmospheric Carbon and Transport - America (ACT-America) Data Sets: Description, Management, and Delivery

The ACT-America project is a NASA Earth Venture Suborbital-2 mission designed to study the transport and fluxes of greenhouse gases. The open and freely available ACT-America data sets provide airborne in situ measurements of atmospheric carbon dioxide, methane, trace gases, aerosols, clouds, and meteorological properties, airborne remote sensing measurements of aerosol backscatter, atmospheric boundary layer height and columnar content of atmospheric carbon dioxide, tower-based measurements, and modeled atmospheric mole fractions and regional carbon fluxes of greenhouse gases over the Central and Eastern United States. We conducted 121 research flights during five campaigns in four seasons during 2016-2019 over three regions of the US (Mid-Atlantic, Midwest and South) using two NASA research aircraft (B-200 and C-130). We performed three flight patterns (fair weather, frontal crossings, and OCO-2 underflights) and collected more than 1,140 h of airborne measurements via level-leg flights in the atmospheric boundary layer, lower, and upper free troposphere and vertical profiles spanning these altitudes. We also merged various airborne in situ measurements onto a common standard sampling interval, which brings coherence to the data, creates geolocated data products, and makes it much easier for the users to perform holistic analysis of the ACT-America data products. Here, we report on detailed information of data sets collected, the workflow for data sets including storage and processing of the quality controlled and quality assured harmonized observations, and their archival and formatting for users. Finally, we provide some important information on the dissemination of data products including metadata and highlights of applications of ACT-America data sets.

Cooperative Chain Dynamics of Tracer Chains in Highly Entangled Polyethylene Melts

By neutron spin echo spectroscopy, we have studied the center of mass motion of short tracer chains on the molecular length scale within a highly entangled polymer matrix. The center of mass mean square displacements of the tracers independent of their molecular weight is subdiffusive at short times until it has reached the size of the tube d; then, a crossover to Fickian diffusion takes place. This observation cannot be understood within the tube model of reptation, but is rationalized as a result of important interchain couplings that lead to cooperative chain motion within the entanglement volume ∼d^{3}. Thus, the cooperative tracer chain motions are limited by the tube size d. If the center of mass displacement exceeds this size, uncorrelated Fickian diffusion takes over. Compared to the prediction of the Rouse model we observe a significantly reduced contribution of the tracer's internal modes to the spectra corroborating the finding of cooperative rather than Rouse dynamics within d^{3}.

Self-Similar Dynamics of Large Polymer Rings: A Neutron Spin Echo Study

This work clarifies the self-similar dynamics of large polymer rings using pulsed-field gradient nuclear magnetic resonance and neutron spin echo spectroscopy. We find center of mass diffusion taking place in three dynamic regimes starting (i) with a strongly subdiffusive domain ⟨r^{2}(t)⟩_{com}∼t^{α} (0.4≤α≤0.65); (ii) a second subdiffusive region ⟨r^{2}(t)⟩_{com}∼t^{0.75} that (iii) finally crosses over to Fickian diffusion. While the t^{0.75} range previously has been found in simulations and was predicted by theory, we attribute the first to the effect of cooperative dynamics resulting from the correlation hole potential. The internal dynamics at scales below the elementary loop size is well described by ring Rouse motion. At larger scales the dynamics is self-similar and follows very well the predictions of the scaling models with preference for the self-consistent fractal loopy globule model.

Femtosecond inscription of semi-aperiodic multi-notch fiber Bragg gratings using a phase mask

We present an innovative concept of a semi-aperiodic phase mask design that enables the realization of multi-notch fiber Bragg gratings (FBG). This design utilizes the overlap and interference of near-infrared ultrashort laser pulses diffracted by short sequenced phase mask sections, which not only allows for a highly stable and reproducible inscription of a large number of wavelength filters but also paves the way towards full aperiodic phase masks. The semi-aperiodic FBG inscribed by this phase mask enables versatile notch filters showing multiple non-equidistant resonances. Those filters target applications, for instance in ground-based telescopes, where a large number of hydroxyl emission lines emitted in the upper atmosphere at near-infrared wavelengths restrict the observation of faint extraterrestrial objects.

Prophylactic Fixation and Arthroscopic Bone Grafting of Large Femoral Neck Cyst During Hip Labral Repair and Femoral Osteochondroplasty: A Case Report

CASE

We describe a case of hip impingement in an 18-year-old woman in association with a large cyst at the femoral neck equal to a resection level of approximately 40%. There was great concern of femoral neck fracture. At the time of hip arthroscopy, this was prophylactically treated with cannulated screws in the femoral head and neck, and the cyst was arthroscopically bone grafted using a novel technique with instruments included in standard the arthroscopy trays.

CONCLUSION

Prophylactic femoral neck fixation with arthroscopic bone grafting of large bone cysts is a viable treatment option with minimal added morbidity.

Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity

BACKGROUND AND PURPOSE

We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores < 6 points.

METHODS

The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0-2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-month favorable functional outcome (mRS scores 0-1) and mRS score distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding.

RESULTS

We evaluated 336 AIS patients with large vessel or distal occlusions and mild stroke severity (mean age 63 ± 15 years, 45% women). Patients treated with IVT (n = 162) had higher FI (85.6% vs. 74.8%, P = 0.027) with lower mRS scores at hospital discharge (P = 0.034) compared with the remaining patients. No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality. IVT was associated with higher likelihood of 3-month FI [odds ratio (OR), 2.19; 95% confidence intervals (CI), 1.09-4.42], 3-month favorable functional outcome (OR, 1.99; 95% CI, 1.10-3.57), functional improvement at discharge [common OR (per 1-point decrease in mRS score), 2.94; 95% CI, 1.67-5.26)] and at 3 months (common OR, 1.72; 95% CI, 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders, including mechanical thrombectomy.

CONCLUSIONS

Intravenous thrombolysis is independently associated with higher odds of improved discharge and 3-month functional outcomes in AIS patients with large vessel or distal occlusions and mild stroke severity. IVT appears not to increase the risk of systemic or symptomatic intracranial bleeding.

A practical method to account for random phase approximation effects on the dynamic scattering of multi-component polymer systems

Investigations of polymer systems that rely on the interpretation of dynamical scattering results as, e.g., the structure factor S(Q, t) of single chains or chain sections may require the inclusion of effects, as described within the framework of the random phase approximation (RPA) for polymers. To do this in practice for the dynamic part of S(Q, t) beyond the initial slope is a challenge. Here, we present a method (and software) that allows a straightforward assessment of dynamical RPA effects and inclusion of these in the process/procedures of model fitting. Examples of applications to the interpretation of neutron spin-echo data multi-component polymer melts are shown.

Visual Immunoprecipitate Assay (VIP) for Listeria monocytogenes and Related Listeria Species Detection in Selected Foods: Collaborative Study

Six foods representing a variety of food products were analyzed by the Assurance Listeria polyclonal enzyme immunoassay (EIA) and by either the Bacteriological Analytical Manual or the U.S. Department of Agriculture culture method for detecting Listeria monocytogenes and related Listeria species. Samples of each food type, at each inoculation level, were analyzed simultaneously by both methods. A total of 19 laboratories representing federal government agencies and private industry in the United States and Canada participated. Food types were inoculated with Listeria species including L. monocytogenes, with the exception of 3 lots of green beans, which were naturally contaminated. During this study, 1764 samples and controls were analyzed and confirmed, of which 492 were positive and 947 were negative by both methods. There were 159 samples that were positive by culture method but negative by the EIA and 188 that were negative by culture method but positive by EIA. Twenty-two samples were negative by EIA and by culture method but confirmed positive when Assurance selective enrichment broths were subcultured to selective agar. The Assurance polyclonal EIA for detecting L. monocytogenes and related Listeria species in foods has been adopted first action by AOAC INTERNATIONAL.

Assurance Enzyme Immunoassay for Detection of Enterohemorrhagic Escherichia coli 0157:H7 in Selected Foods: Collaborative Study

Five foods types were analyzed by the Assurance EHEC (Escherichia coli 0157:H7) enzyme immunoassay (EIA) and by the Bacteriological Analytical Manual (BAM) culture method. Each sample of each food type at each inoculation level was simultaneously analyzed by both methods. A total of 21 laboratories representing state and federal government agencies and private industry in the United States and Canada participated. Samples were inoculated with E. coli 0157:H7, except for one lot of poultry that was naturally contaminated. A total of 1304 samples and controls were analyzed and confirmed, of which 473 were positive and 818 were negative by both methods. Thirteen samples were positive by BAM but negative by EIA. Because of the study design, it was not possible for the BAM method to produce false-negative or falsepositive results. The Assurance method for detection of E. coli OI57:H7 in selected foods has been adopted first action by AOAC INTERNATIONAL.

High-Sensitivity Dry Rehydratable Film Method for Enumeration of Coliforms in Dairy Products: Collaborative Study

A dry-film coliform count plate that is inoculated with 5 mL sample was compared with the Violet Red Bile Agar plate method in a collaborative study by 18 laboratories. Products analyzed were 2% milk, chocolate milk, cream, vanilla ice cream, cottage cheese, and cheese. Collaborators tested blind duplicate uninoculated samples and samples inoculated at low, medium, and high level. Significantly (P&lt; 0.05) higher numbers of coliforms were recovered by the dry-film method from 2% milk samples at the 3 inoculum levels, the chocolate milk at the low- and high-inoculum levels, and the cream at the high-inoculum level. Significantly higher counts were obtained by the agar method for cottage cheese samples at the low-inoculum level. The repeatability standard deviation for the dry-film method was significantly higher for the high-inoculum level chocolate milk sample and the medium-inoculum level cottage cheese. The same statistic was significantly higher for the agar method at all 3 inoculum levels in the 2% milk and the medium-inoculum level cream. The high-sensitivity dry rehydratable film method for enumeration of coliforms in dairy products has been adopted first action by AOAC INTERNATIONAL.

Visual Immunoprecipitate Assay (VIP) for Detection of Enterohemorrhagic Escherichia coli (EHEC) 0157:H7 in Selected Foods: Collaborative Study

Five foods representative of a variety of food products were analyzed by the Visual Immunoprecipitate Assay (VIP) and the Bacteriological Analytical Manual (BAM) culture method for the presence of Escherichia coli 0157: H7. A total of 21 laboratories representing state and federal government agencies, as well as private industry, in the United States and Canada participated. Food types were inoculated with strains of E. coli 0157:H7, with the exception of one lot of poultry, which was naturally contaminated. During this study, a total of 1377 samples and controls were analyzed and confirmed, of which 508 were positive and 867 were negative by both methods. Two samples were positive by BAM and negative by VIP. Because of the study design, it was not possible for the BAM method to produce false-negative or false-positive results. The VIP assay for detection of EHEC in selected foods has been adopted first action by AOAC INTERNATIONAL.

Assurance Polyclonal Enzyme Immunoassay for Detection of Listeria monocytogenes and Related Listeria Species in Selected Foods: Collaborative Study

Six foods representing a variety of food products were analyzed by the Assurance Listeria polyclonal enzyme immunoassay (EIA) and by either the Bacteriological Analytical Manual or the U.S. Department of Agriculture culture method for detecting Listeria monocytogenes and related Listeria species. Samples of each food type, at each inoculation level, were analyzed simultaneously by both methods. A total of 19 laboratories representing federal government agencies and private industry in the United States and Canada participated. Food types were inoculated with Listeria species including L. monocytogenes, with the exception of 3 lots of green beans, which were naturally contaminated. During this study, 1764 samples and controls were analyzed and confirmed, of which 492 were positive and 947 were negative by both methods. There were 159 samples that were positive by culture method but negative by the EIA and 188 that were negative by culture method but positive by EIA. Twenty-two samples were negative by EIA and by culture method but confirmed positive when Assurance selective enrichment broths were subcultured to selective agar. The Assurance polyclonal EIA for detecting L. monocytogenes and related Listeria species in foods has been adopted first action by AOAC INTERNATIONAL.

Elective, Non-urgent Procedures and Aesthetic Surgery in the Wake of SARS-COVID-19: Considerations Regarding Safety, Feasibility and Impact on Clinical Management

BACKGROUND

The worldwide spread of a novel coronavirus disease (COVID-19) has led to a near total stop of non-urgent, elective surgeries across all specialties in most affected countries. In the field of aesthetic surgery, the self-imposed moratorium for all aesthetic surgery procedures recommended by most international scientific societies has been adopted by many surgeons worldwide and resulted in a huge socioeconomic impact for most private practices and clinics. An important question still unanswered in most countries is when and how should elective/aesthetic procedures be scheduled again and what kind of organizational changes are necessary to protect patients and healthcare workers when clinics and practices reopen. Defining manageable, evidence-based protocols for testing, surgical/procedural risk mitigation and clinical flow management/contamination management will be paramount for the safety of non-urgent surgical procedures.

METHODS

We conducted a MEDLINE/PubMed research for all available publications on COVID-19 and surgery and COVID-19 and anesthesia. Articles and referenced literature describing possible procedural impact factors leading to exacerbation of the clinical evolution of COVID-19-positive patients were identified to perform risk stratification for elective surgery. Based on these impact factors, considerations for patient selection, choice of procedural complexity, duration of procedure, type of anesthesia, etc., are discussed in this article and translated into algorithms for surgical/anesthesia risk management and clinical management. Current recommendations and published protocols on contamination control, avoidance of cross-contamination and procedural patient flow are reviewed. A COVID-19 testing guideline protocol for patients planning to undergo elective aesthetic surgery is presented and recommendations are made regarding adaptation of current patient information/informed consent forms and patient health questionnaires.

CONCLUSION

The COVID-19 crisis has led to unprecedented challenges in the acute management of the crisis, and the wave only recently seems to flatten out in some countries. The adaptation of surgical and procedural steps for a risk-minimizing management of potential COVID-19-positive patients seeking to undergo elective aesthetic procedures in the wake of that wave will present the next big challenge for the aesthetic surgery community. We propose a clinical algorithm to enhance patient safety in elective surgery in the context of COVID-19 and to minimize cross-contamination between healthcare workers and patients. New evidence-based guidelines regarding surgical risk stratification, testing, and clinical flow management/contamination management are proposed. We believe that only the continuous development and broad implementation of guidelines like the ones proposed in this paper will allow an early reintegration of all aesthetic procedures into the scope of surgical care currently performed and to prepare the elective surgical specialties better for a possible second wave of the pandemic.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Method Extension Study to Validate Applicability of AOAC Official Method 996.14 Assurance® Polyclonal Enzyme Immunoassay for Detection of Listeria monocytogenes and Related Listeria spp. from Environmental Surfaces: Collaborative Study

Test portions from 3 environmental surface types, representative of typical surfaces found in a food production facility, were analyzed by the Assurance®Listeria Polyclonal Enzyme Immunoassay (EIA) and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) culture method for Listeria monocytogenes and related Listeria species. In all cases, naturally contaminated environmental test samples were collected from an actual food production facility by sponge or swab. Test samples from concrete surfaces were collected by both swab and sponge; sponge test samples were collected from rubber surfaces, and swabs were used to sample steel surfaces. Test portions from each surface type were simultaneously analyzed by both methods. A total of 23 collaborators, representing government agencies, as well as private industry in both the United States and Canada, participated in the study. During this study, a total of 550 test portions and controls was analyzed and confirmed, of which 207 were positive and 336 were negative by both methods. Six test portions were positive by culture, but negative by the EIA. Three test portions were negative by culture, but positive by the EIA. Two test portions were negative by EIA and by culture, but confirmed positive when EIA enrichment broths were subcultured to selective agars. The data reported here indicate that the Assurance®Listeria EIA method and the USDA/FSIS culture method are statistically equivalent for detection of L. monocytogenes and related Listeria species from environmental surfaces taken by sponges or swabs.

Method Extension Study to Validate Applicability of AOAC Official Method 997.03 Visual Immunoprecipitate Assay (VIP®) for Listeria monocytogenes and Related Listeria spp. from Environmental Surfaces: Collaborative Study

Test portions from 3 environmental surface types, representative of typical surfaces found in a food production facility, were analyzed by the Visual Immunoprecipitate assay (VIP®) and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) culture method for Listeria monocytogenes and related Listeria species. In all cases, naturally contaminated environmental test samples were collected from an actual food production facility by sponge or swab. Test samples from concrete surfaces were collected by both swab and sponge; sponge test samples were collected from rubber surfaces, and swabs were used to sample steel surfaces. Test portions from each surface type were simultaneously analyzed by both methods. A total of 27 laboratories, representing government agencies as well as private industry in both the United States and Canada, participated in the study. During this study, a total of 615 test portions and controls was analyzed and confirmed, of which 227 were positive and 378 were negative by both methods. Nine test portions were positive by culture, but negative by the VIP. Five test portions were negative by culture, but positive by the VIP. Four test portions were negative by VIP and by culture, but confirmed positive when VIP enrichment broths were subcultured to selective agars. The data reported here indicate that the VIP method and the USDA/FSIS culture method are statistically equivalent for detection of L. monocytogenes and related Listeria species from environmental surfaces taken by sponges or swabs.

Equivalence of Assurance® Gold Enzyme Immunoassay for Visual or Instrumental Detection of Motile and Nonmotile Salmonella in All Foods to AOAC Culture Method: Collaborative Study

Six foods representative of a wide variety of processed, dried powder processed, and raw food types were analyzed by the Assurance® Gold Salmonella Enzyme Immunoassay (EIA) and AOAC INTERNATIONAL culture method. Paired samples of each food type were simultaneously analyzed; one sample by the Assurance method and one by the AOAC culture method. The results for Assurance method were read visually and instrumentally with a microplate reader. A total of 24 laboratories representing federal government agencies and private industry, in the United States and Canada, participated in this collaborative study. Food types were inoculated with species of Salmonella with the exception of raw ground chicken, which was naturally contaminated. No statistical differences (p &lt; 0.05) were observed between Assurance Gold Salmonella EIA with either visual or instrumental interpretation and the AOAC culture method for any inoculation level of any food type or naturally contaminated food. The Assurance visual and instrumental options of reading sample reactions produced the same results for 1277 of the 1296 sample and controls analyzed.

Is the global prevalence rate of adult mental illness increasing? Systematic review and meta-analysis

OBJECTIVES

The question whether mental illness prevalence rates are increasing is a controversially debated topic. Epidemiological articles and review publications that look into this research issue are often compromised by methodological problems. The present study aimed at using a meta-analysis technique that is usually applied for the analysis of intervention studies to achieve more transparency and statistical precision.

METHODS

We searched PubMed, PsycINFO, CINAHL, Google Scholar and reference lists for repeated cross-sectional population studies on prevalence rates of adult mental illness based on ICD- or DSM-based diagnoses, symptom scales and distress scales that used the same methodological approach at least twice in the same geographical region. The study is registered with PROSPERO (CRD42018090959).

RESULTS

We included 44 samples from 42 publications, representing 1 035 697 primary observations for the first time point and 783 897 primary observations for the second and last time point. Studies were conducted between 1978 and 2015. Controlling for a hierarchical data structure, we found an overall global prevalence increase in odds ratio of 1.179 (95%-CI: 1.065-1.305). A multivariate meta-regression suggested relevant associations with methodological characteristics of included studies.

CONCLUSIONS

We conclude that the prevalence increase in adult mental illness is small, and we assume that this increase is mainly related to demographic changes.

[Adequate anti-infective treatment : Importance of individual dosing and application]

Sepsis-induced changes in pharmacokinetic parameters are a well-known problem in intensive care medicine. Dosing of antibiotics in this setting is therefore challenging. Alterations to the substance-specific kinetics of anti-infective substances have an effect on the distribution and excretion processes in the body. Increased clearance and an increased distribution volume (V_d) and particularly compromized organ function with reduced antibiotic elimination are often encountered in patients with sepsis. Renal replacement treatment, which is frequently used in intensive care medicine, represents a substantial intervention in this system. Current international guidelines recommend individualized dosing strategies and adaptation of doses according to measured serum levels and pharmacokinetic/pharmacodynamic (PK/PD) parameters as concepts to optimize anti-infective therapy in the critically ill. Likewise, the recommendation to adjust the administration form of beta-lactam antibiotics to prolonged or continuous infusion can be found increasingly more often in the literature. This article reviews the background of the individual dosing in intensive care patients and their applicability to the clinical routine.

Reduction of Premature Aging Markers After Gastric Bypass Surgery in Morbidly Obese Patients

Background

Obesity is considered to be a major comorbidity. Obese patients suffer from an increased proinflammatory state associated with a premature aging phenotype including increased secretion of senescence-associated secretory proteins (SASP) and reduced telomere length. Micro-ribonucleic acids (miRNAs) are non-coding RNA molecules that could modify the post-transcriptional process. Several studies have reported associations between miRNAs and metabolic unhealthy conditions.

Aim

To determine if bariatric surgery and the resulting weight loss could reverse the premature aging phenotype.

Methods

We enrolled 58 morbidly obese patients undergoing bariatric surgery. Markers of premature aging including the SASP IL-6, CRP and PAI-1, 7 miRNAs, as well as telomere length and telomere oxidation in mononuclear cells were evaluated.

Results

Patients showed a significant drop of body mass index (BMI; 43.98 ± 3.5 versus 28.02 ± 4.1, p < 0.001). We observed a significant reduction in SASP including a reduction of 55% of plasma IL-6 levels (p = 0 < 0.001), 83% of CRP levels (p = 0.001) and 15% of plasma PAI-1 levels (p < 0.001). Telomere length doubled in the patient cohort (p < 0.001) and was accompanied by a reduction in the telomere oxidation index by 70% (p < 0.001). Telomere length was inversely correlated with telomere oxidation. The aging-associated miRNA miR10a_5p was upregulated significantly (p = 0.039), while the other tested miRNAs showed no difference.

Conclusion

Our data indicate a significant reduction of the proinflammatory SASP after bariatric surgery. We observed an increase in telomere length and reduced oxidative stress at telomeres. miR10a_5p which is downregulated during aging was upregulated after surgery. Overall, bariatric surgery ameliorated the premature aging phenotype.

J-NSE-Phoenix, a neutron spin-echo spectrometer with optimized superconducting precession coils at the MLZ in Garching

A novel set of superconducting main precession coils has been built and installed in the Jülich-neutron spin-echo (J-NSE) spectrometer at the Heinz Maier-Leibnitz Zentrum (MLZ) in Garching. These unique new coils comprise a field-integral optimizing field shape, fringe field compensation, and high stability. They yield an enhancement of a factor of 2.5 in the intrinsic field-integral homogeneity, i.e., the resolution. The coil concept has been developed for the ESSENSE instrument proposal for the European Spallation Source. We report on the construction of and on the first results from the new superconducting neutron spin-echo spectrometer at the MLZ in Garching where the coils are the main part of a refurbishment of the J-NSE spectrometer after twenty years of operation.

Direct Assessment of Tube Dilation in Entangled Polymers

A key ingredient within theories focusing on the rheology of entangled polymers is the way how the topological constraints of an entangled chain are lifted by unconstrained segments, i.e., how the constraining tube is dilated. This important question has been addressed by directly measuring the tube diameter d at the scale of the tube by neutron spin echo spectroscopy. The tube diameter d and plateau modulus G_{N}^{0} of highly entangled polyethylene oxide (PEO) chains of volume fraction c that are diluted by low molecular PEO show a concentration dependence d∝c^{a/2} and G_{N}^{0}∝c^{1+a} with an exponent a close to 4/3. This result allows the clear discrimination between different theoretical models that predict 4/3 or other values between 1 and 2 and provides an important ingredient to tube model theories.

Atmospheric implications of large C2-C5 alkane emissions from the U.S. oil and gas industry

Emissions of C₂-C₅ alkanes from the U.S. oil and gas sector have changed rapidly over the last decade. We use a nested GEOS-Chem simulation driven by updated 2011NEI emissions with aircraft, surface and column observations to 1) examine spatial patterns in the emissions and observed atmospheric abundances of C₂-C₅ alkanes over the U.S., and 2) estimate the contribution of emissions from the U.S. oil and gas industry to these patterns. The oil and gas sector in the updated 2011NEI contributes over 80% of the total U.S. emissions of ethane (C₂H₆) and propane (C₃H₈), and emissions of these species are largest in the central U.S. Observed mixing ratios of C₂-C₅ alkanes show enhancements over the central U.S. below 2 km. A nested GEOS-Chem simulation underpredicts observed C₃H₈ mixing ratios in the boundary layer over several U.S. regions and the relative underprediction is not consistent, suggesting C₃H₈ emissions should receive more attention moving forward. Our decision to consider only C₄-C₅ alkane emissions as a single lumped species produces a geographic distribution similar to observations. Due to the increasing importance of oil and gas emissions in the U.S., we recommend continued support of existing long-term measurements of C₂-C₅ alkanes. We suggest additional monitoring of C₂-C₅ alkanes downwind of northeastern Colorado, Wyoming and western North Dakota to capture changes in these regions. The atmospheric chemistry modeling community should also evaluate whether chemical mechanisms that lump larger alkanes are sufficient to understand air quality issues in regions with large emissions of these species.

Evaluation of later morphologic alterations in renal artery wall and renal nerves in response to catheter-based renal denervation in sheep: comparison of the single-point and multiple-point ablation catheters

This study evaluated the subacute morphologic alterations in renal artery wall and renal nerves in response to catheter-based renal denervation (RDN) in sheep and also compared the efficiency of single-point and multiple-point ablation catheters. Effect of each ablation catheter approved for the clinical use (Symplicity Flex(TM), Medtronic, Inc., or EnligHTN(TM), St. Jude Medical, INC.) was compared to intact contralateral renal artery in 12 sheep by histopathology and immunohistochemistry evaluation after a 10-day period post-RDN procedure. The safety was verified by extensive evaluation of kidney morphology. Vascular wall lesions and nerve injuries were more pronounced in those animals treated with multi-point EnligHTN catheter when compared with animals treated with single-point Symplicity Flex catheter. However, neither RDN procedure led to complete renal nerve ablation. Both systems, tested in the present study, provided only incomplete renal nerve ablation in sheep. Moreover, no appreciable progression of the nerve disintegration in subacute phase post-RDN procedure was observed. This study further supports the notion that the effectiveness remains fully dependent on anatomical inter-individual variability of the sympathetic nerve plexus accompanying the renal artery. Therefore, new systems providing deeper penetrance to targeted perivascular structure would be more efficient.

Inscribing diffraction gratings in bulk silicon with nanosecond laser pulses

Diffraction gratings are transversally inscribed in the bulk of monolithic crystalline silicon with infrared nanosecond laser pulses. Nanoscale material analyses of the modifications composing the gratings show that they rely on laser-induced stress associated with a positive refractive index change as confirmed with phase-shift interferometry. Characterizations of the optical properties of the gratings, including the diffraction angles and the efficiency of the different orders, are carried out. The refractive index change obtained from these measurements is in good agreement with the phase-shift measurements. Finally, we show that the grating diffraction efficiency depends strongly on the laser writing speed.

Primary Anterolateral Ligament Rupture in Patients Requiring Revision Anterior Cruciate Ligament Reconstruction: A Retrospective Case-Control Magnetic Resonance Imaging Review

PURPOSE

To compare the initial rate of anterolateral ligament (ALL) injury at the time of anterior cruciate ligament (ACL) rupture in patients who subsequently experienced ACL reconstruction graft failure versus patients who did not experience subsequent ACL reconstruction graft failure.

METHODS

Our institution's electronic medical record database was queried for patients who underwent primary ACL reconstruction with subsequent ACL graft rupture. Exclusion criteria included unavailable MRI scan, chronic ACL injury, multi-ligamentous injury, previous ACL reconstruction, and age younger than 13 or older than 50 years. Each patient was paired with an age-, gender-, and graft-matched control who underwent ACL reconstruction without subsequent graft rupture. Each patient was diagnosed with an intact, partially injured, or fully ruptured ALL on initial MRI. The location of ALL injury was also noted. The incidence and location of ALL rupture were compared using χ² analysis.

RESULTS

1,967 patients underwent primary ACL reconstruction. 128 patients experienced ACL graft rupture, and 55 patients (43%) had MRI scans available for review. 39 of these patients fulfilled inclusion criteria and were matched with a control patient. In the revision group, the ALL was diagnosed as intact, partially torn, and completely torn in 17, 14, and 8 patients, respectively, compared to 18, 13, and 8 patients, respectively in the control group. No difference was found in frequency of ALL rupture (Pearson χ² = 0.066; P = .968) or rupture location (Pearson χ² = 4.00, P = 0.135).

CONCLUSIONS

The incidence of initial ALL injury as documented on MRI was not different in patients who experienced subsequent ACL graft rupture compared with patients who did not experience ACL graft rupture after primary ACL reconstruction. The ALL was more commonly injured on the tibial side in patients with ACL graft rupture and femoral-sided lesions were more common in control patients.

LEVEL OF EVIDENCE

Level III, prognostic case-control study.

Management of injuries in snowboarders: rehabilitation and return to activity

Snowboarding has seen a continuous increase in popularity, leading to an increase in the number of snowboarding injuries seen in orthopedic practice. Upper-extremity injuries are more common than lower-extremity, spine, and pelvis injuries. In this review, we focus on the most common snowboarding injuries of the extremities, spine, and pelvis and provide an overview of their respective rehabilitation and return-to-sport protocols. Despite many of the injuries seen in snowboarding also occurring in other sports, objective data about rehabilitation and return to sport are lacking for many injuries. This provides an opportunity for research in the area with regard to many sports and many different injuries.

Psychosocial and demographic factors influencing pain scores of patients with knee osteoarthritis

BACKGROUND

Pain levels in patients with osteoarthritis (OA) of the knee are commonly assessed by using a numeric scoring system, but results may be influenced by factors other than the patient's actual physical discomfort or disease severity, including psychosocial and demographic variables. We examined the possible relation between knee-pain scores and several psychosocial, sociodemographic, disease, and treatment variables in 355 patients with knee OA.

METHODS

The pain-evaluation instrument was a 0- to 10-point rating scale. Data obtained retrospectively from the patients' medical records were demographic characteristics, body mass index (BMI), concomitant disorders, illicit and prescription drug use, alcohol use, smoking, knee OA treatment, and severity of knee OA indicated by Kellgren-Lawrence (KL) radiographic grade. Univariate and multivariate analyses were performed to determine whether these variables correlated with reported pain scores.

RESULTS

On univariate analysis, higher pain scores were significantly associated with Native American or Hispanic ethnicity; a higher BMI; current prescription for an opioid, antidepressant, or gabapentinoid medication; depression; diabetes mellitus; fibromyalgia; illicit drug use; lack of health insurance; smoking; previous knee injection; and recommendation by the clinician that the patient undergo knee surgery. Neither the patient's sex nor the KL grade showed a correlation. On multivariate analysis, depression, current opioid prescription, and Native American or Hispanic ethnicity retained a significant association with higher pain scores.

CONCLUSIONS AND IMPLICATIONS

Our results in a large, ethnically diverse group of patients with knee OA suggest that psychosocial and sociodemographic factors may be important determinants of pain levels reported by patients with knee OA.

Observation of the Self-Modulation Instability via Time-Resolved Measurements

Self-modulation of an electron beam in a plasma has been observed. The propagation of a long (several plasma wavelengths) electron bunch in an overdense plasma resulted in the production of multiple bunches via the self-modulation instability. Using a combination of a radio-frequency deflector and a dipole spectrometer, the time and energy structure of the self-modulated beam was measured. The longitudinal phase space measurement showed the modulation of a long electron bunch into three bunches with an approximately 200  keV/c amplitude momentum modulation. Demonstrating this effect is a breakthrough for proton-driven plasma accelerator schemes aiming to utilize the same physical effect.

A Note on the Ammonia and Glutamine Content of the Cerebrospinal Fluid

Tashiro (1922) showed that the isolated frog nerve liberates ammonia on stimulation, and Richter and Dawson (1948) have recently found that ammonia is liberated on stimulation by the brain. Ammonia is very toxic to the brain, on which it has an irritant action; but the brain may be protected to some extent by the enzyme system described by Krebs (1935), which can detoxicate ammonia by combination with glutamic acid to form glutamine. Sapirstein (1943) obtained evidence that this system is active in vivo by showing that glutamic acid increases the resistance of animals to convulsions produced by injecting ammonium chloride. The toxic action of ammonia on the brain is also of interest in connection with the view that it may be concerned in certain forms of epilepsy (Harris, 1945). This view is supported by the observations of Price, Waelsch and Putnam (1943) on the inhibitory action of glutamic acid on petit mal attacks.

Independent housing and support for people with severe mental illness: systematic review

OBJECTIVE

To systematically explore the outcomes of Independent Housing and Support (IHS) for people with severe mental disorders when compared to other residential settings.

METHOD

Systematic review of Randomised and Non-Randomised Controlled Trials of publications that analyse the outcomes of living in independent settings versus institutionalised accommodation. Risk of bias assessment was adapted from the Cochrane Collaboration's ACROBAT-Tool. The analysis was conducted separately for publications with homeless and non-homeless people.

RESULTS

Twenty-four publications from studies with homeless people and eight publications from studies with non-homeless people were included. Risk of bias was much lower in studies with the homeless. No RCT was found in the sample of publications with the non-homeless. Overall, results from Independent Housing and Support-settings are not inferior to results from institutionalised settings.

CONCLUSION

The results indicate that Independent Housing and Support-settings provide at least similar outcomes than residential care. We propose that clients' preferences should determine the choice of housing setting.