Search

Localized inflammatory or reactive overgrowths are quite more common clinical findings on human gingiva. Most of the lesions are benign and innocuous though some have potency to transfer in to a malignant lesion. These types of lesions are difficult to identify clinically as their appearance are quite similar so only Histopathological evaluation can detect their identity. In this case report we displayed a case of Peripheral Ossifying Fibroma in maxillary anterior tooth region in 32 year old female patient along with clinical, Histopathological evaluation along with present and future treatment details. Peripheral ossifying fibroma (POF) is usually a fibromatic, non neoplastic enlargement of the gingiva which shows areas of calcification or ossification. Synonyms for POF include Peripheral cementifying fibroma, Peripheral fibroma with calcification, Calcifying or ossifying fibrous epulis and Calcifying fibroblastic granuloma. Keywords: Gingival overgrowth, Ossifying fibroma, Peripheral ossifying fibroma, Peripheral cementifying fibroma

The presence of pulpal pathosis and inflammatory periodontal disease concomitantly can complicate diagnosis and treatment planning of any tooth. It requires a combined treatment approach involving endodontic, periodontic and prosthodontic intervention. Often, the periodontal and prosthodontic aspects are neglected by the clinicians after successful endodontic treatment resulting in failure. The present case report describes a multidisciplinary approach for the treatment of a tooth that presented with an endo-perio lesion; using non-surgical root canal treatment and periodontal regenerative surgery (non-incised papillae surgical approach, {NIPSA} long with GTR membrane and an alloplastic bone graft) which were then followed by the placement of a conservative tooth coverage restoration (endocrown). A significant gain in clinical attachment level was seen 6 months postoperatively. Radiographically also a significant amount of bone fill was observed. Keywords: Endo-perio lesion, NIPSA, Endocrown

Modern power sector requires grid observability under all scenarios for its ideal functioning. This enforces the operator to incorporate state estimation solutions based on a priori measurements to deduce the corresponding operating states of the grid. The key principle for such aforementioned algorithms lies on an occurrence of an over determined class of system having an ample redundancy in the measurements. Operators employ state forecasting solutions to counter the loss of real-time measurements. This work encompasses a critical comparison between several machine learning models along with ARIMA and time delayed neural network architecture for proper forecasting of operating states under normal as well as contingency scenarios. To showcase the efficacy of the proposed approach, this work incorporates a comprehensive comparison between them based on RMSE, MSE and MAE index. Copula-based synthetic data generation based on Gaussian multivariate distribution of the a priori measurements and operating states along with optimal hyper-parameter tuning of the models have shown the effectiveness of such algorithms in predicting future state estimates. The proposed machine learning models can be also seen to showcase an effective forecasting strategy under varying noise scenarios. This work also showcases the implementation of the models for real-time state forecasting strategy having computational times in the order of micro seconds. All the simulations have been carried out on the standard IEEE 14 bus test bench to support the former proposals.

With the recent advancement in smart grid technology, real-time monitoring of grid is utmost essential. State estimation-based solutions provide a critical tool in monitoring and control of smart grids. Recently there has been an increased focus on false data injection attacks which can circumvent the traditional statistical bad data detection algorithm. Most of the research methodologies focus on the presence of FDIA in measurement set, whereas their exact locations remain unknown. To cater this issue, this paper proposes a deep learning architecture for detection of the exact locations of data intrusions in real-time. This deep learning model in association with traditional bad data detection algorithms is capable of detecting both structured as well as unstructured false data injection attacks. The deep learning architecture is not dependent on statistical assumptions of the measurements, it emphasizes on the inconsistency and co-occurrence dependency of potential attacks in measurement set, thus acting as a multilabel classifier. Such kind of architecture remains model free without any prior statistical assumptions. Extensive research work on IEEE test-bench shows that this scheme is capable of identifying the locations for intrusion under varying noise scenarios. Such kind of an approach shows potential results also in detection of presence of falsified data.

Efficient maximum power point tracking (MPPT) is an important problem for renewable power generation from photovoltaic systems. In this work, a current sensor based MPPT algorithm using an adaptive step‐size for a single ended primary inductance converter (SEPIC) based solar photovoltaic system is proposed. Due to lower sensitivity of power to current perturbation as compared to the voltage one, such a scheme is shown to yield better efficiency at steady‐state. A new adaptation scheme is also proposed for faster convergence of the MPPT technique. Hence, the proposed scheme yields better transient as well as steady‐state performance. A prototype converter is used along with digital implementation of the proposed MPPT technique to demonstrate the superiority of the proposed algorithm over the fixed step‐size and voltage based ones. Simulation and experimental results corroborates the same.

Introduction To assess if in adults with COVID‐19, whether those with diabetes and complications (DM+C) present with a more severe clinical profile and if that relates to increased mortality, compared to those with diabetes with no complications (DM‐NC) and those without diabetes. Methods Service‐level data was used from 996 adults with laboratory confirmed COVID‐19 who presented to the Queen Elizabeth Hospital Birmingham, UK, from March to June 2020. All individuals were categorized into DM+C, DM‐NC, and non‐diabetes groups. Physiological and laboratory measurements in the first 5 days after admission were collated and compared among groups. Cox proportional hazards regression models were used to evaluate associations between diabetes status and the risk of mortality. Results Among the 996 individuals, 104 (10.4%) were DM+C, 295 (29.6%) DM‐NC and 597 (59.9%) non‐diabetes. There were 309 (31.0%) in‐hospital deaths documented, 40 (4.0% of total cohort) were DM+C, 99 (9.9%) DM‐NC and 170 (17.0%) non‐diabetes. Individuals with DM+C were more likely to present with high anion gap/metabolic acidosis, features of renal impairment, and low albumin/lymphocyte count than those with DM‐NC or those without diabetes. There was no significant difference in mortality rates among the groups: compared to individuals without diabetes, the adjusted HRs were 1.39 (95% CI 0.95–2.03, p = 0.093) and 1.18 (95% CI 0.90–1.54, p = 0.226) in DM+C and DM‐C, respectively. Conclusions Those with COVID‐19 and DM+C presented with a more severe clinical and biochemical profile, but this did not associate with increased mortality in this study., As people with diabetes are disproportionately affected by COVID‐19, there is a need to identify diabetes sub‐groups who could be at high risk of adverse outcomes when presenting to hospitals.Our real world study of people with diabetes and laboratory confirmed diagnoses of COVID‐19 uses service level data including biochemical markers for initial assessment. We compared these values and mortality levels in people with and without diabetes and hyperglycaemic complications.We found people with COVID‐19 and diabetes with existing complications presented with a more severe clinical and biochemical profile.However, the association between diabetic/hyperglycemic state in COVID‐19 and all cause‐mortality was not statistically significant in this study.

Aims/hypothesis The aim of this work was to describe the clinical characteristics of adults with type 1 diabetes admitted to hospital and the risk factors associated with severe coronavirus disease-2019 (COVID-19) in the UK. Methods A retrospective cohort study was performed using data collected through a nationwide audit of people admitted to hospital with diabetes and COVID-19, conducted by the Association of British Clinical Diabetologists from March to October 2020. Prespecified demographic, clinical, medication and laboratory data were collected from the electronic and paper medical record systems of the participating hospitals by local clinicians. The primary outcome of the study, severe COVID-19, was defined as death in hospital and/or admission to the adult intensive care unit (AICU). Logistic regression models were used to generate age-adjusted ORs. Results Forty UK centres submitted data. The final dataset included 196 adults who were admitted to hospital and had both type 1 diabetes and COVID-19 on admission (male sex 55%, white 70%, with mean [SD] age 62 [19] years, BMI 28.3 [7.3] kg/m2 and last recorded HbA1c 76 [31] mmol/mol [9.1 (5.0)%]). The prevalence of pre-existing microvascular disease and macrovascular disease was 56% and 39%, respectively. The prevalence of diabetic ketoacidosis on admission was 29%. A total of 68 patients (35%) died or were admitted to AICU. The proportions of people that died were 7%, 38% and 38% of those aged Conclusions/interpretation In people with type 1 diabetes and COVID-19 who were admitted to hospital in the UK, higher BMI, poorer renal function and presence of microvascular complications were associated with greater risk of death and/or admission to AICU. Risk of severe COVID-19 is reassuringly very low in people with type 1 diabetes who are under 55 years of age without microvascular or macrovascular disease. In people with Type 1 diabetes and COVID-19 admitted to hospital in the UK, BMI and one or more microvascular complications had a positive association and low serum creatine levels had a negative association with death/admission to intensive care unit after adjusting for age.

Introduction: COVID-19 infection in people with diabetes is associated with a disproportionately increased risk of complications and mortality.1 Diabetic ketoacidosis (DKA) is an acute complication of diabetes.2,3 Little is known about DKA in the presence of COVID-19 infection. This study aimed to explore the effects of COVID-19 infection on presentation, clinical course and outcome in patients presenting with DKA. Methods: This retrospective cohort study included all patients treated for DKA between 1 March and 30 May 2020 at University Hospitals Birmingham. Patients were categorised as COVID-positive or negative based on PCR swab test. A pre-COVID group was established as external control. Data regarding demographics, diabetes type, admission pH, bicarbonate, lactate, glucose, serum electrolytes, urea, creatinine, time to resolution of acidosis and ketosis, complications and outcome were collected. DKA onset was defined as the presence of hyperglycaemia (serum glucose >11 mmol/L), ketosis (serum ketones >3 mmol/L or urine ketone >+++) and metabolic acidosis (pH 7.3 or bicarbonate >15 mmol/L) as per national guidelines in the UK.4 Results: A total of 88 episodes were included in the final analysis (20 COVID-positive, 31 COVID-negative, 37 pre-COVID). These were further sub-classified into type 1 (five COVID-positive, two COVID-negative, 29 pre-COVID) and type 2 diabetes (15 COVID-positive, two COVID-negative, eight pre-COVID). There was no significant difference in the severity of DKA at presentation (median for COVID positive, COVID negative and pre-COVID groups): pH (7.15 vs 7.2 vs 7.2), bicarbonate (11.4 mmol/L vs 11 mmol/L vs 13.3 mmol/L), glucose (25.85 mmol/L vs 30.9 mmol/L vs 29.1 mmol/L), lactate (2.7 mmol/L vs 3.2 mmol/L vs 2.8 mmol/L), serum osmolality (314.6 mmol/L vs 323.1 mmol/L vs 316.2 mmol/L). There was also no significant difference between the groups for the duration of DKA (from the time of admission to resolution of DKA: 12.5 hours vs 14.9 hours vs 17.9 hours for COVID-positive, COVID-negative and pre-COVID groups, respectively; Fig 1). COVID-positive patients with type 1 diabetes were more hyperglycaemic on admission compared to COVID-negative and pre-COVID patients. There was a significantly higher incidence of type 2 diabetes in COVID-positive patients than in pre-COVID or COVID-negative groups. COVID-negative patients had more episodes of hypokalaemia and hyperkalaemia during DKA compared to other two groups. There was no significant difference between the number of episodes of hypokalaemia in the COVID-positive compared to the pre-COVID group. In patients with type 2 diabetes, hypokalaemia was more common in COVID-negative patients. Conclusion: COVID infection appears to influence the natural history of DKA differently in type 1 and type 2 diabetes. Infection was associated with increased hyperglycaemia in type I diabetes and greater acidosis on presentation with DKA. People with type 2 diabetes were presenting unusually in DKA when infected with COVID. These patients also had higher mortality rates. There is need for a multi-centre approach to conduct larger cohort studies in this area.

We demonstrate that the upconversion nanoparticles (UCNPs) fluoresce 50 times more on a gold (Au) coated Cicada wing. UCNPs are attractive bioimaging, and therapeutic materials as it is excited in the infrared, limited only by the low fluorescence quantum yield. Here, a plasmonic effect, coupled with an anti-reflecting (AR) Cicada wing substrate coated with Au is demonstrated to enhance the fluorescence of the UCNPs. Silica (SiO2) coated Erbium doped green emitting core-shell UCNPs (NaYF4: Yb3+, Er3+@SiO2) show conventional metal enhanced fluorescence. The AR property of the Cicada wing (R ~0.2% @ 1000 nm) contributes >6-fold enhancement as compared to flat (silicon, and quartz) substrates (R~10–30% @ 1000 nm). Upon plasmon coupling, with an optimally sputtered Au coating, an unprecedented enhancement of >50-fold for the 520, and 655 nm emission was obtained on the Au coated Cicada wings, vis-a-vis planar uncoated (silicon, and quartz) substrates. The enhancement was also confirmed by direct fluorescence imaging of the photonic substrates used. The fluorescence lifetime of the core, and the core-shell UCNPs (~300 μs) decreased by ~30–40%, and 10–30%, respectively, when placed on Au coated substrates.

Objective COVID-19 in people with diabetes is associated with a disproportionately worse prognosis. DKA is an acute complication of diabetes with a mortality rate of approximately 0.67%. Little is known about the natural history of DKA in the presence of COVID-19. This study aimed to explore the effects of COVID-19 on presentation, clinical course and outcome in patients presenting with DKA. Design Retrospective cohort study. Methods All patients treated for DKA between 1 March 2020 and 30 May 2020 were included. Patients were categorised as COVID-positive or COVID-negative based on the swab test. A pre-COVID group was established using data from 01 March 2019 to 30 May 2019 as external control. Data regarding demographics, diabetes type, pH, bicarbonate, lactate, glucose, DKA duration, complications and outcome were collected. Results A total of 88 DKA episodes were included in this study. There was no significant difference in the severity or duration of DKA between the three groups. COVID-positive T1DM were more hyperglycaemic on admission compared to COVID-negative and pre-COVID patients. There was an over representation of T2DM in COVID-positive patients with DKA than in pre-COVID or COVID-negative groups. Conclusion COVID-19 appears to influence the natural history of DKA differently in T1DM and T2DM. Patients with T1DM and COVID-19 presented with more hyperglycaemia (60 mmol/L (35.9–60.0) vs 31.4 mmol/L (28.0–39.1) vs 24 mmol/L (20.2–33.75), respectively). Patients with T2DM were unusually presenting in DKA when infected with COVID-19 with greater ICU need and higher mortality rates. A collaborative, multi-centre study is needed to provide more definitive results.

Objective Diabetes has emerged as an important risk factor for mortality from COVID-19. Metformin, the most commonly prescribed glucose-lowering agent, has been proposed to influence susceptibility to and outcomes of COVID-19 via multiple mechanisms. We investigated whether, in patients with diabetes, metformin is associated with susceptibility to COVID-19 and its outcomes. Research Design and Methods We performed a propensity score–matched cohort study with active comparators using a large UK primary care dataset. Adults with type 2 diabetes patients and a current prescription for metformin and other glucose-lowering agents (MF+) were compared to those with a current prescription for glucose-lowering agents that did not include metformin (MF−). Outcomes were confirmed COVID-19, suspected/confirmed COVID-19, and associated mortality. A negative control outcome analysis (back pain) was also performed. Results There were 29 558 and 10 271 patients in the MF+ and MF− groups, respectively, who met the inclusion criteria. In the propensity score–matched analysis, the adjusted hazard ratios for suspected/confirmed COVID-19, confirmed COVID-19, and COVID-19-related mortality were 0.85 (95% CI 0.67, 1.08), 0.80 (95% CI 0.49, 1.30), and 0.87 (95% CI 0.34, 2.20) respectively. The negative outcome control analysis did not suggest unobserved confounding. Conclusion Current prescription of metformin was not associated with the risk of COVID-19 or COVID-19-related mortality. It is safe to continue prescribing metformin to improve glycemic control in patients with.

Sodium-glucose co-transporter-2 (SGLT2) inhibitors are widely prescribed in people with type 2 diabetes. We aimed to investigate whether SGLT2 inhibitor prescription is associated with COVID-19, when compared with an active comparator. We performed a propensity-score-matched cohort study with active comparators and a negative control outcome in a large UK-based primary care dataset. Participants prescribed SGLT2 inhibitors (n = 9948) and a comparator group prescribed dipeptidyl peptidase-4 (DPP-4) inhibitors (n = 14 917) were followed up from January 30 to July 27, 2020. The primary outcome was confirmed or clinically suspected COVID-19. The incidence rate of COVID-19 was 19.7/1000 person-years among users of SGLT2 inhibitors and 24.7/1000 person-years among propensity-score-matched users of DPP-4 inhibitors. The adjusted hazard ratio was 0.92 (95% confidence interval 0.66 to 1.29), and there was no evidence of residual confounding in the negative control analysis. We did not observe an increased risk of COVID-19 in primary care amongst those prescribed SGLT2 inhibitors compared to DPP-4 inhibitors, suggesting that clinicians may safely use these agents in the everyday care of people with type 2 diabetes during the COVID-19 pandemic.

Effective management of diabetic ketoacidosis (DKA) in line with national guidelines improves clinical outcomes and may reduce length of hospital stay.1 Regular auditing and performance feedback are key to achieving sustained and significant improvement in the management of DKA.2,3 One of the major limitations for maximal impact of an audit is the delay from initiation to results as the latter may not be applicable to the then current practice. In order to overcome this, our department of diabetes collaborated with the hospital's health informatics team and created an automated auditing system called Digital Evaluation of Ketosis and Other Diabetes …

Diabetic ketoacidosis (DKA) is an acute endocrine emergency that requires immediate diagnosis and management. Effective management of DKA in accordance with national guidelines improves clinical outcomes and may reduce long hospital stays.[1][1] Recent studies have shown that frequent audit cycles

Sustainability of any production system is a key issue to address in modern context of environment friendly developments. It primarily depends on the continued human relationship with a given energy resource where the rate at which humans exploit it is compared to the rate at which nature renews again. If the resource is regenerated at a higher rate than it is used, it is considered renewable, but if it is exploited at a higher rate than it is regenerated, it is considered nonrenewable. Within various process of judging sustainability, the emergy approach is a unique method which encompasses all components of concerned resources in their renewable or nonrenewable form. It is a matter of concern to examine the sustainability of energy technologies that can be increased further for the ever increasing need of society. This paper deals with methods to judge sustainability of production systems using emergy approach applied to a case study.

In recent days power generation using renewable energy sources have gained more attention. In this context the most commonly used available energy sources are solar and wind. The work presented here is regarding the charging of low power electronic gadgets using the wind energy available during travelling. A DC generator with a single-ended primary-inductor converter provides voltage required for charging the gadgets. The device will get continuously charged by the external battery source which is connected to the proposed circuit. The device can be used as emergency source for charging electronic gadgets while travelling in a vehicle open to flow of air.

Aims To establish the prevalence of admission plasma glucose in 'diabetes' and 'at risk' ranges in emergency hospital admissions with no prior diagnosis of diabetes; characteristics of people with hyperglycaemia; and factors influencing glucose measurement. Methods Electronic patient records for 113 097 hospital admissions over 1 year from 2014 to 2015 included 43 201 emergencies with glucose available for 31 927 (74%) admissions, comprising 22 045 people. Data are presented for 18 965 people with no prior diagnosis of diabetes and glucose available on first attendance. Results Three quarters (14 214) were White Europeans aged 62 (43‐78) years, median (IQ range); 12% (2241) South Asians 46 (32‐64) years; 9% (1726) Unknown/Other ethnicities 43 (29‐61) years; and 4% (784) Afro‐Caribbeans 49 (33‐63) years, P 24 hours. Conclusions Hyperglycaemia was evident in 21% of adults admitted as an emergency; various aspects related to follow‐up and initial testing, age and ethnicity need to be considered by professional bodies addressing undiagnosed diabetes in hospital admissions., Glucose needs to be measured in all adults admitted as an emergency not just those over 40/30 years old, as younger people particularly South Asians and Afro‐Caribbeans are at risk of being admitted with undiagnosed diabetes. Overall, 5% of emergency admissions had glucose in the ‘diabetes’ range, 8% if South Asian and Afro‐Caribbean, with 16% of people in the ‘at risk’ range. One third of all emergency admissions were for 24 hours.

Wide-area power system stabilizers (WAPSSs) based on time-synchronized signals are known to be relatively effective in damping inter-area oscillations. However, the use of wide-area signals introduces time-delay in the feedback loop due to the time taken in fetching the feedback information. In general, delays in the feedback loop are detrimental to the performance of the controller and may lead to instability if the control is not sufficiently robust to tolerate the delay variation. It may be the case that one opts for using non-synchronized signals (not time-synchronized) for WAPSS. This paper investigates and compares the effect of delay in synchronized and non-synchronized feedback-based WAPSS. The analysis is carried out using eigenvalue computation for time-delay systems and applied to two study systems. It is shown that non-synchronized signals are less sensitive to delay from the systems stability viewpoint even though comparable damping can be achieved.

Dermatofibrosarcoma protuberans (DFSP) is a rare, locally aggressive soft tissue tumor commonly occurring in the trunk or extremities, lesser than 5% being located on the scalp. Surgery is the mainstay of management of this locally infiltrative cutaneous soft tissue sarcoma, with a high probability of recurrence if margin remains positive or inadequate. Adjuvant radiotherapy to a dose of 40–60 Gy decreases this chance of recurrence considerably. Radiotherapy is generally delivered by interstitial HDR brachytherapy, opposed photon or electron beam. We report a case of a 24 year old female, presenting with a small, painless nodule over right frontal area of scalp, diagnosed as DFSP post surgery with close margin that was treated with adjuvant radiation customized HDR surface mould brachytherapy with good local control and cosmesis.

Doping of traditional semiconductors has enabled technological applications in modern electronics by tailoring their chemical, optical and electronic properties. However, substitutional doping in two-dimensional semiconductors is at a comparatively early stage, and the resultant effects are less explored. In this work, we report unusual effects of degenerate doping with Nb on structural, electronic and optical characteristics of MoS2 crystals. The doping readily induces a structural transformation from naturally occurring 2H stacking to 3R stacking. Electronically, a strong interaction of the Nb impurity states with the host valence bands drastically and nonlinearly modifies the electronic band structure with the valence band maximum of multilayer MoS2 at the Γ point pushed upward by hybridization with the Nb states. When thinned down to monolayers, in stark contrast, such significant nonlinear effect vanishes, instead resulting in strong and broadband photoluminescence via the formation of exciton complexes tightly bound to neutral acceptors.

It is well known that PD controller, though yields good servo response, fails to provide satisfactory regulatory response for Integrating Plus Time-Delay (IPTD) processes. On the other hand, using an integral control action generally leads to large overshoot or settling time. To achieve good servo as well as regulatory response, a new all-PD control structure is proposed for IPTD processes in this paper. Design formulas are derived in terms of gain-margin and phase-margin specifications. Numerical examples on the design methodology are presented and experimentally validated on a temperature control process.

Pericardial constriction is a rare, but well documented complication following cardiac surgery. It has been reported following coronary artery bypass grafting (CABG), cardiac surgery for congenital heart diseases and very rarely following closed mitral commissurotomy. We hereby report a case of chronic constrictive pericarditis following closed mitral commissurotomy mimicking mitral restenosis with refractory heart failure.

BackgroundNasal fractures present in 39% of patients with facial trauma. These patients are assessed in the emergency department followed by outpatient review in the senior house officer-led emergency ear, nose and throat (ENT) clinic. Inadequate treatment of nasal trauma can result in debilitating functional and aesthetic problems. Inexperienced junior doctors may be apprehensive in assessing nasal trauma resulting in time pressured clinics and suboptimal management.MeasuresA retrospective review of clinical noting over 3 months was carried out to gauge the extent of the problem. Three baseline measurements for satisfactory quality of assessments included: (1) 3/5 key symptoms elicited by the clinician (epistaxis, rhinorrhoea, nasal airway obstruction, dental malocclusion and diplopia). (2) Presence/absence of ‘septal haematoma’ (SH) and ‘deviated nasal septum’ (DNS) documented. (3) Patient follow-up within 2 weeks after the initial injury. Three Plan-Do-Study-Act (PDSA) cycles were conducted with implementation of interventions (proforma, clinic poster, patient information leaflet and training) as visualised in our ‘driver diagram’.ResultsThe quality of nasal trauma assessments improved following each intervention. There was an increase from 86% to 100% patients being seen within 2 weeks of the injury. There was an improvement in quality of assessments following the teaching as two-thirds (PDSA cycle 2) followed by 100% (PDSA cycle 3) of clinical documentation included ‘rhinorrhoea’ and 83% (PDSA cycle 2) to 100% (PDSA cycle 3) included ‘nasal airway obstruction’. Similarly, two thirds (PDSA cycle 2) followed by 100% (PDSA cycle 3) examined and documented the presence/absence of SH and DNS. A 100% improvement in trainee confidence was reported. We are now conducting more comprehensive assessments of nasal trauma patients.ConclusionThe need to provide relevant training and support to ENT junior doctors is crucial in their development, as well as to ensure delivery of high-quality patient-centred care.

PN heterojunctions comprising layered van der Waals (vdW) semiconductors have been used to demonstrate current rectifiers, photodetectors, and photovoltaic devices. However, a direct or near-direct bandgap at the heterointerface that can significantly enhance optical generation, for high light absorbing few/multi-layer vdW materials, has not yet been shown. In this work, for the first time, few-layer group-6 transition metal dichalcogenide (TMD) $WSe_2$ is shown to form a sizeable (0.7 eV) near-direct bandgap with type-II band alignment at its interface with the group-7 TMD $ReS_2$ through density functional theory calculations. Further, the type-II alignment and photogeneration across the interlayer bandgap have been experimentally confirmed through micro-photoluminescence and IR photodetection measurements, respectively. High optical absorption in few-layer flakes, large conduction and valence band offsets for efficient electron-hole separation and stacking of light facing, direct bandgap $ReS_2$ on top of gate tunable $WSe_2$ are shown to result in excellent and tunable photodetection as well as photovoltaic performance through flake thickness dependent optoelectronic measurements. Few-layer flakes demonstrate ultrafast response time (5 $\mu$s) at high responsivity (3 A/W) and large photocurrent generation and responsivity enhancement at the heterostructure overlap region (10-100X) for 532 nm laser illumination. Large open-circuit voltage of 0.64 V and short-circuit current of 2.6 $\mu$A enables high output electrical power. Finally, long term air-stability and a facile single contact metal fabrication process makes the multi-functional few-layer $WSe_2$/$ReS_2$ heterostructure diode technologically promising for next-generation optoelectronic applications., Comment: Manuscript- 27 pages, 8 figures. Supporting Information- 17 pages, 17 figures

Background: Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy.Methods: RESTART was a prospective, randomised, open-label, blinded-endpoint, parallel-group trial at 122 hospitals in the UK that assessed whether starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. For this prespecified subgroup analysis, consultant neuroradiologists masked to treatment allocation reviewed brain CT or MRI scans performed before randomisation to confirm participant eligibility and rate features of the intracerebral haemorrhage and surrounding brain. We followed participants for primary (recurrent symptomatic intracerebral haemorrhage) and secondary (ischaemic stroke) outcomes for up to 5 years (reported elsewhere). For this report, we analysed eligible participants with intracerebral haemorrhage according to their treatment allocation in primary subgroup analyses of cerebral microbleeds on MRI and in exploratory subgroup analyses of other features on CT or MRI. The trial is registered with the ISRCTN registry, number ISRCTN71907627.Findings: Between May 22, 2013, and May 31, 2018, 537 participants were enrolled, of whom 525 (98%) had intracerebral haemorrhage: 507 (97%) were diagnosed on CT (252 assigned to start antiplatelet therapy and 255 assigned to avoid antiplatelet therapy, of whom one withdrew and was not analysed) and 254 (48%) underwent the required brain MRI protocol (122 in the start antiplatelet therapy group and 132 in the avoid antiplatelet therapy group). There were no clinically or statistically significant hazards of antiplatelet therapy on recurrent intracerebral haemorrhage in primary subgroup analyses of cerebral microbleed presence (2 or more) versus absence (0 or 1) (adjusted hazard ratio [HR] 0·30 [95% CI 0·08–1·13] vs 0·77 [0·13–4·61]; pinteraction=0·41), cerebral microbleed number 0–1 versus 2–4 versus 5 or more (HR 0·77 [0·13–4·62] vs 0·32 [0·03–3·66] vs 0·33 [0·07–1·60]; pinteraction=0·75), or cerebral microbleed strictly lobar versus other location (HR 0·52 [0·004–6·79] vs 0·37 [0·09–1·28]; pinteraction=0·85). There was no evidence of heterogeneity in the effects of antiplatelet therapy in any exploratory subgroup analyses (all pinteraction>0·05).Interpretation: Our findings exclude all but a very modest harmful effect of antiplatelet therapy on recurrent intracerebral haemorrhage in the presence of cerebral microbleeds. Further randomised trials are needed to replicate these findings and investigate them with greater precision.Funding: British Heart Foundation.

ObjectivesWe postulate that performance feedback is a prerequisite to ensure sustained improvement in diabetic ketoacidosis (DKA) management.DesignThe study was based on ‘theory of change’ concept that suggests changes of primary drivers determine the main outcome. A set of secondary drivers can be implemented to achieve improvements in these primary drivers and thus the main outcome.SettingThis study was conducted at a large tertiary care center in the West Midlands, UK. The region has above average prevalence of diabetes and DKA admissions in the country.ParticipantsAll participants diagnosed with DKA as per national guidelines, except those managed in intensive care unit from April 2014 to March 2018, were included in this study.InterventionsMonthly feedback of performance was the main intervention. Development of a real-time live DKA audit tool, automatic referral system of DKA to the specialist team, electronic monitoring of blood gas measurements and education and redesigning of local (trust) guidelines were the other interventions in this study.Main outcome measuresTotal DKA duration, appropriateness of fixed rate intravenous insulin infusion, fluid prescription, glucose monitoring, ketone monitoring and referral to specialists.ResultsThere was a significant reduction in the duration of DKA postintervention compared with baseline results. However, in the absence of regular feedback, the duration of DKA showed an upward trend nearing baseline values. Similar trends were noted in secondary drivers influencing DKA duration.ConclusionBased on these results, we recommend regular audit and feedback is required to sustain improvements in DKA management.

Objective: Glucose is measured on hospital admission as an emergency as elevated glucose is associated with an eight-fold risk of dying in hospital. This study reports on admission plasma glucose by ethnicity in people without prior diabetes. Research Design and Methods: A clinical audit CARMS-12031 of electronic patient records for 113,097 admissions to hospital over 1 year from April 2014 to March 2015 identified 43,201 emergency admissions with glucose unavailable for 11,274 (26%). Of 5,867 admissions with prior diabetes coding, 5,523 (94%) had glucose recorded. First attendances were analyzed for emergency admissions with no record of diabetes. Results: Of these 18,965 people admitted, 75% were White Europeans WE who were older than South Asians SA 12%, unknown/other ethnic groups U 9%, and Afro-Caribbeans AC 4%. 1,003 people admitted as an emergency had glucose in ‘diabetes range’ (≥11.1mmol/L) and 3,042 in ‘at risk’ range (7.8 to 11.0mmol/L). More SA 8% had glucose in diabetes range than WE 5% and also than U 5%; there were significantly more WE 17% in ‘at risk’ range than U 14% or AC 11%. Higher glucose was observed in SA and U men than women, p = 0.005 and p = 0.018, respectively. Conclusions: Protocols should target people requiring additional HbA1c testingto diagnose undiagnosed diabetes on hospital admission especially younger SA and AC individuals, and outline appropriate clinical intervention. Disclosure S. Ghosh: Advisory Panel; Self; Abbott. Other Relationship; Self; Mylan. R. Susarla: None. R.A. Round: None. P. Nightingale: None. J.A. Williams: None. I.M. Stratton: Consultant; Self; Novo Nordisk A/S. Research Support; Self; Bayer AG, Boehringer Ingelheim International GmbH. G. Gkoutos: None. J. Webber: None. W. Hanif: Advisory Panel; Self; Boehringer Ingelheim International GmbH. Consultant; Self; Novo Nordisk A/S. Research Support; Self; AstraZeneca, Janssen Diagnostics, Sanofi. Speaker's Bureau; Self; AstraZeneca, Novartis AG, Novo Nordisk A/S. G. Roberts: None. S.E. Manley: None.

Introduction: As HbA1c is now widely used for the diagnosis of diabetes with WHO cut-off ≥ 48 mmol/mol/6.5%, it is debatable whether the value should vary by ethnicity. Aim: This study compares plasma glucose and HbA1c in white European WE, South Asian SA, unknown/other U and Afro-Caribbean AC people admitted as an emergency. Methods: Electronic patient records were interrogated over 1 year (2014/5) for a clinical audit, CARMS-12031R. Glucose was measured on wards with meters/gas machines or the laboratory along with HbA1c on Tosoh G8 HPLC analysers if haemoglobin normal. Results: There were 30,664 people of whom 22,045 (72%) had glucose recorded and 2,083 (7%) HbA1c. 1,904 (6%) had both glycaemic markers and were aged 64 (50-78) years, median (IQ range); 839 (44%) female; 560 (29%) prior diabetes diagnosis; 1,405 (74%) WE, 296 (16%) SA, 112 (6%) U and 91 (5%) AC. Glucose was 7.4 (5.8-10.6), 8.6 (6.2-12.3), 8.1 (5.9-10.7), 7.0 (5.9-11.6) mmol/L and HbA1c 42 (37-55), 50 (41-70), 42 (38-60), 46 (39-70) mmol/mol/6.0 (5.5-7.2), 6.7 (5.9-8.6), 6.0 (5.6-7.6), 6.4 (5.7-8.6)%, respectively. HbA1c was higher relative to glucose in SA and AC compared to WE and U, p Conclusions: Haematological differences related to red blood cell turnover may account for the variance; this should be recognised by those involved in producing protocols/guidelines for diagnosis. More research is required on using HbA1c to confirm undiagnosed diabetes in admissions. Disclosure S.E. Manley: None. R. Susarla: None. R.A. Round: None. P. Nightingale: None. J.A. Williams: None. I.M. Stratton: Consultant; Self; Novo Nordisk A/S. Research Support; Self; Bayer AG, Boehringer Ingelheim International GmbH. J. Webber: None. G. Gkoutos: None. W. Hanif: Advisory Panel; Self; Boehringer Ingelheim International GmbH. Consultant; Self; Novo Nordisk A/S. Research Support; Self; AstraZeneca, Janssen Diagnostics, Sanofi. Speaker's Bureau; Self; AstraZeneca, Novartis AG, Novo Nordisk A/S. G. Roberts: None. S. Ghosh: Advisory Panel; Self; Abbott. Other Relationship; Self; Mylan.

To study the effect of a quality improvement programme (QIP) on the overall care for patients admitted with diabetic ketoacidosis (DKA). Patients aged ≥17 years admitted with DKA from April 2014 to September 2016 at a large teaching hospital in the West Midlands were included in the study.

A quality improvement project undertaken at University Hospital Birmingham to improve the management of patients on variable rate intravenous insulin infusions (VRIII) to allow a consistent standard of care in keeping with Joint British Diabetes Societies guidelines. An initial baseline of data was identified from the database; any episode where a patient was started on a VRIII over a 10-week period from 1 September to 10 November 2016. ITU patients and those on a scale for less than 1 hour were excluded. …

Renewability of a system can be expressed on the basis of continued human relationship with a given energy resource i.e. the rate at which humans exploit it compared to the rate at which nature renews again. If the resource is regenerated at a higher rate than it is used, it is considered renewable, but if it is exploited at a higher rate than it is regenerated, it is considered nonrenewable. The more renewable an energy resource is that is, the faster it can be regenerated at the level it is being used, the less of an environmental impact it has. It is a matter of concern to examine energy technologies having intermittent renew ability that can be realistically increased. While an efficient use of a resource can increase renew ability, an innovation in the process of turning a non-resource renewable material into a useful resource can be more proficient. In this paper energy method has been discussed to judge the renew ability of a power production plant.

Background: Nonalcoholic fatty liver disease (NAFLD), a feature of metabolic syndrome is a highly prevalent condition worldwide. Patients with NAFLD have a higher mortality when compared to general population. Many investigators have shown a close relationship between NAFLD and cardiovascular disease which contributes to the total mortality associated with NAFLD particularly in Western population. This study was therefore conducted to evaluate whether NAFLD independently affects angio-graphically proven coronary artery disease in Asians. Methods: The severity assessment of fatty liver disease was done by ultrasonography and was graded with increased severity from 0 to 4. Coronary angiography was performed to detect the presence or absence of significant coronary artery disease and modified Gensisni score, which determines the severity of coronary atherosclerotic involvement in individual patients was calculated. Results: Statistical analysis showed that Fatty liver disease was significantly higher in patients with significant coronary artery disease than in non-significant coronary artery disease group. When analyzed on basis on severity of fatty liver disease, modified Gensini score was significantly higher in group with fatty liver grade 2-3 than in group with fatty liver grade 0 or 1. Logistic regression analysis further showed that severity of fatty liver disease had independent effect on coronary atherosclerotic involvement. Conclusions: From our current study it can be reasonably said that NAFLD may be an independent risk factor for developing arteriosclerosis. This hypothesis should be verified with larger studies in different population groups.

Hybrid or composite nanomaterials have emerged that demonstrates superior optoelectronic performance over pure nanomaterials that lacks broadband usage, or responsivity, or both, mainly because of the limitation of the collection of photogenerated carriers. We have addressed this problem by using a composite of MoS2 and a multi-photon absorbing lanthanide doped upconversion nanoparticles (UCNPs), that emits in the visible, to make a photodetector (PD) device with ultrahigh broadband responsivity. Single flake MoS2 electrostatically conjugated with UCNPs were used to fabricate the PD device with platinum, and gold contacts. The device was irradiated with UV-to-NIR illumination, at different power density, to study its broadband photosensitivity. Photoresponsivities in excess of 100 A W-1 is easily obtained; a highest responsivity of 1254 A W-1 is reported for 980 nm at 1.0 V bias. An unprecedented normalized gain of 7.12 × 10−4 cm2 V−1, and Detectivity of 1.05 × 1015 Jones (@980 nm, 1 V) was obtained which is, to the best of our knowledge, the highest reported till date for this device class. Under vacuum conditions even higher values of these device parameters were obtained, while losing on the response speeds. The photoresponsivity in the nanocomposite followed the trend of the convoluted optical absorption of the individual components. Real application of the PD device was demonstrated using non-laser domestic appliances such as sodium vapour lamp, mobile phone flash light, and air-condition remote controller.

Pulmonary arteriovenous malformation first presenting with platypnea and orthodeoxia in the 3rd trimester of pregnancy is an extremely rare entity and poses a great diagnostic challenge to the treating physician. We hereby report a patient with pulmonary arteriovenous malformation presenting for the first time in third trimester of pregnancy diagnosed by pulmonary angiogram with subsequent improvement in symptoms post-delivery. Key words: Pulmonary Arteriovenous Malformation, Pregnancy, Platypnea, Orthodeoxia, Pulmonary Angiogram.

Aim To temporally and externally validate our previously developed prediction model, which used data from University Hospitals Birmingham to identify inpatients with diabetes at high risk of adverse outcome (mortality or excessive length of stay), in order to demonstrate its applicability to other hospital populations within the UK. Methods Temporal validation was performed using data from University Hospitals Birmingham and external validation was performed using data from both the Heart of England NHS Foundation Trust and Ipswich Hospital. All adult inpatients with diabetes were included. Variables included in the model were age, gender, ethnicity, admission type, intensive therapy unit admission, insulin therapy, albumin, sodium, potassium, haemoglobin, C-reactive protein, estimated GFR and neutrophil count. Adverse outcome was defined as excessive length of stay or death. Results Model discrimination in the temporal and external validation datasets was good. In temporal validation using data from University Hospitals Birmingham, the area under the curve was 0.797 (95% CI 0.785-0.810), sensitivity was 70% (95% CI 67-72) and specificity was 75% (95% CI 74-76). In external validation using data from Heart of England NHS Foundation Trust, the area under the curve was 0.758 (95% CI 0.747-0.768), sensitivity was 73% (95% CI 71-74) and specificity was 66% (95% CI 65-67). In external validation using data from Ipswich, the area under the curve was 0.736 (95% CI 0.711-0.761), sensitivity was 63% (95% CI 59-68) and specificity was 69% (95% CI 67-72). These results were similar to those for the internally validated model derived from University Hospitals Birmingham. Conclusions The prediction model to identify patients with diabetes at high risk of developing an adverse event while in hospital performed well in temporal and external validation. The externally validated prediction model is a novel tool that can be used to improve care pathways for inpatients with diabetes. Further research to assess clinical utility is needed.

Problem considered Anaemia, associated with lower productivity and higher sickness rate and absenteeism. Adolescent health has inter-generational effect. Morbidity status during adolescent has implication on future safe motherhood, optimum growth and development of foetus and children. Aims To assess, prevalence and determinants of anaemia and effect of different interventions amongst tea tribe adolescent girls. Methods A community based intervention study was conducted covering 16 tea estates of Dibrugarh district, Assam. Variables includes socio-demographic, environmental, anthropometry, history of present and past illness, clinical examination and laboratory investigation including haemoglobin, serum ferritin, sickling test and routine stool examination. Interventions like weekly IFA supplementation, dietary diversification, health promotion by monthly NHED, cooking demonstration, cooking competition and kitchen garden promotion was done. SPSS and EpiInfo software, used to calculate of rates, ratios, chi-square test, Fisher Exact test. Results Enrolments were 802, with mean age, 14.8 years. Anaemia prevalence was 96.3% with median serum ferritin, 22.9 ng/ml. Prevalence of sickle cell anaemia was, 12% and helminthiasis 84.20%. Health related complaints, significantly more frequent amongst older adolescents ( p Conclusions High anaemia prevalence requires urgent attention to avoid preventable morbidities. Integrated different intervention implementation found effective in reducing the burden of anaemia and associated factor.

Symmetrical peripheral gangrene is an ischemic necrosis simultaneously involving the distal portions of two or more extremities without any proximal arterial obstruction or vasculitis. It may occur as a result of a large number of infectious and non-infectious causes. A few cases of symmetrical peripheral gangrene associated with cardiac disease have been described in the literature. We describe a case of symmetrical peripheral gangrene complicating ventricular pseudoaneurysm, probably a hitherto unreported occurrence. In this report, we sought to emphasize the importance of cardiac evaluation while dealing with a case of symmetrical peripheral gangrene.