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Individuals with Type 2 Diabetes (T2D) are at high risk of subclinical cardiovascular disease (CVD), potentially detectable through retinal alterations. In this single-centre, prospective cohort study, 255 asymptomatic adults with T2D and no prior history of CVD underwent echocardiography, non-contrast coronary computed tomography and cardiovascular magnetic resonance. Retinal photographs were evaluated for diabetic retinopathy grade and microvascular geometric characteristics using deep learning (DL) tools. Associations with cardiac imaging markers of subclinical CVD were explored. Of the participants (aged 64 ± 7 years, 62% males); 200 (78%) had no diabetic retinopathy and 55 (22%) had mild background retinopathy. Groups were well-matched for age, sex, ethnicity, CV risk factors, urine microalbuminuria, and serum natriuretic peptide and high-sensitivity troponin levels. Presence of retinopathy was associated with a greater burden of coronary atherosclerosis (coronary artery calcium score ≥ 100; OR 2.63; 95% CI 1.29–5.36; P  = 0.008), more concentric left ventricular remodelling (OR 3.11; 95% CI 1.50–6.45; P  = 0.002), and worse global longitudinal strain (OR 2.32; 95% CI 1.18–4.59; P  = 0.015), independent of key co-variables. Early diabetic retinopathy is associated with a high burden of coronary atherosclerosis and markers of early heart failure. Routine diabetic eye screening may serve as an effective alternative to currently advocated screening tests for detecting subclinical CVD in T2D, presenting opportunities for earlier detection and intervention.

Introduction The objective of the study was to determine the relative importance (RI) of treatment attributes psoriasis patients and physicians consider when choosing between biologic therapies based on psoriasis severity. Methods A discrete choice experiment (DCE) weighting preference for eight sets of hypothetical treatments for moderate or severe psoriasis was conducted. DCE hypothetical treatments were defined and varied on combinations of efficacy, safety, and dosing attributes [frequency/setting/route of administration (ROA)]. Results When assuming moderate psoriasis in the patient DCE, ROA (RI 29%) and efficacy (RI 27%) drive treatment choices. When assuming severe disease in the DCE, patients preferred treatments with higher efficacy (RI 36%); ROA was relatively less important (RI 15%). From the physician perspective, ROA (RI 32%) and efficacy (RI 26%) were most important for moderate psoriasis patients. In the physician model for severe psoriasis, efficacy (RI 42%) was the predominant driver followed by ROA (RI 22%). Regardless of severity, probability of loss of response within 1 year was the least important factor. Conclusions The severity of disease is a critical element in psoriasis treatment selection. There are high levels of alignment between physician- and patient-derived preferences in biologic treatment choice selection for psoriasis. Funding Janssen Pharmaceuticals.

We present a lithography-free technique for fabrication of clean, high quality graphene devices. This technique is based on evaporation through hard Si shadow masks, and eliminates contaminants introduced by lithographical processes. We demonstrate that devices fabricated by this technique have significantly higher mobility values than those obtained by standard electron beam lithography. To obtain ultra-high mobility devices, we extend this technique to fabricate suspended graphene samples with mobilities as high as 120 000 cm 2 /(V·s).

BackgroundMalnutrition in children is widely prevalent around the world. It has been observed that malnourished children with multiple anthropometric deficits have higher mortality. However, adequate studies are not available on the outcome and recovery of these children.Nandurbar, a tribal district from Maharashtra, India, shows high prevalence of all three forms of malnutrition, often occurring simultaneously. A project previously undertaken in Nandurbar from July 2014 to June 2016 studied the effect of various therapeutic feeds in treatment of children with uncomplicated severe acute malnutrition (SAM). In this study, we analyse secondary data from it to correlate effects of stunting, wasting and underweight on treatment recovery.MethodsAnalysis was done on 5979 children with SAM using linear and logistic regression on R software for recovery rates and weight gain in children with SAM with single versus multiple anthropometric deficits, their relation to age, sex, and recovery from severe stunting by gain in height.ResultsThe mean age of children was 35 months and 53.1% of the children were males. 2346 (39.2%) children recovered at the end of the 8-week treatment. 454 (7.6%) had single anthropometric deficit (SAM only), 3164 (52.9%) had two anthropometric deficits (SAM and severe underweight (SUW)) and 2355 (39.4%) children had three anthropometric deficits (SAM, SUW and severe stunting). Out of the 5979 children with SAM, only 52 (0.9%) of children were not underweight (severe or moderate).44.94% of children with SAM who were severely stunted recovered, compared with 35.52% of children who were not (p<0.001). After controlling for confounders, severe stunting was found to increase the odds of recovery by 1.49. Severely stunted children with SAM also showed faster recovery and weight gain by 1.93 days (p<0.012) and 0.29 g/kg/day (p<0.001), respectively. Recovery was higher in females and younger age group. Recovery was also found to depend on the therapeutic feed, with children receiving medical nutrition therapy showing better recovery for severely stunted children.ConclusionOur findings corroborate previous literature that stunting is a way for the body to deal with chronic stress of nutritional deprivation and provides a survival advantage to a child.

Ventilated post-mortem computed tomography (VPMCT) has been shown to achieve lung expansion in cadavers and has been proposed to enhance the diagnosis of lung pathology. Two key problems of the method of ventilation have been identified: firstly, the presence of head and neck rigor making airway insertion challenging and, secondly, air leak, if there is not a good seal around the airway, which diminishes lung expansion and causes inflation of the stomach. Simple procedures to insert a ‘definitive’ cuffed airway, which has a balloon inflated within the trachea, are therefore desirable. This study aims to test different procedures for inserting cuffed airways in cadavers and compare their ventilation efficacy and to propose a decision algorithm to select the most appropriate method. We prospectively tested variations on two ways of inserting a cuffed airway into the trachea: firstly, using an endotracheal tube (ET) approach, either blind or by direct visualisation, and, secondly, using a tracheostomy incision, either using a standard tracheostomy tube or shortened ET tube. We compare these approaches with a retrospective analysis of a previously reported series using supraglottic airways. All techniques, except ‘blind’ insertion of ET tubes, were possible with adequate placement of the airway in most cases. However, achieving both adequate insertion and a complete tracheal seal was better for definitive airways with 56 successful cases from 59 (95 %), compared with 9 cases from 18 (50 %) using supraglottic airways ( p  < 0.0001). Good lung expansion was achieved using all techniques if the airway was adequately positioned and achieved a good seal, and there was no significant chest pathology. We prefer inserting a shortened ET tube via a tracheostomy incision, as we find this the easiest technique to perform and train. Based on our experience, we have developed a decision algorithm to select the most appropriate method for VPMCT.

Laparoscopic adrenalectomy (LA) has become the procedure of choice to treat benign functioning and non-functioning adrenal tumours. With improving experience, large adrenal tumours (> 5 cm) are being successfully tackled by laparoscopy. This study aims to present our single unit experience of LA performed for large adrenal masses. Forty-six laparoscopic adrenalectomies performed for large adrenal lesions more than 5 cm during the period 2001 to 2010 were reviewed. A total of 46 adrenalectomies were done in 42 patients. The mean tumour size was 7.03 cm (5-15 cm). Fourteen patients had tumour size more than 8 cm. The lesions were localised on the right side in 17 patients and on the left side in 21 patients with bilateral tumours in 4 patients. Functioning tumours were present in 32 of the 46 patients. The average blood loss was 112 ml (range 20-400 ml) with the mean operating time being 144 min (range 45 to 270 min). Five patients required conversion to open procedure. Three of the 46 patients (6.52%) on final histology had malignant tumours. LA is safe and feasible for large adrenal lesions. Mere size should not be considered as a contraindication to laparoscopic approach in large adrenal masses. Graded approach, good preoperative assessment, team work and adherence to anatomical and surgical principles are the key to success.

A 42-year-old patient presented with right-sided abdominal discomfort. Investigations revealed a 19 × 21 centimetres large cystic lesion occupying nearly the entire right side of the abdomen. It was situated between ascending colon and right kidney and extended from the liver to the pelvic inlet supero-inferiorly. Laparoscopic excision was planned. The cyst was aspirated completely and dissected from the surrounding structures. It was eventually found to be arising from the right free edge of the greater omentum. Due to its size and weight it was lodged behind the ascending colon. Post-operative course was uneventful. Histology revealed a mesothelial omental cyst. Omental cysts are rare abdominal tumours. Complete excision is the treatment advised to prevent recurrence. Laparoscopic excision can be safely performed taking care to ascertain diagnosis and not to damage any structures intra-operatively.

Using boron nitride as a substrate for graphene has been suggested as a promising way to reduce the disorder in graphene caused by space fluctuations. It is now shown by scanning tunnelling microscopy that graphene conforms perfectly to boron nitride and the charge fluctuations are minimal compared with the conventionally used substrate, silica. Boron nitride could really be the natural graphene substrate. Graphene has demonstrated great promise for future electronics technology as well as fundamental physics applications because of its linear energy–momentum dispersion relations which cross at the Dirac point 1 , 2 . However, accessing the physics of the low-density region at the Dirac point has been difficult because of disorder that leaves the graphene with local microscopic electron and hole puddles 3 , 4 , 5 . Efforts have been made to reduce the disorder by suspending graphene, leading to fabrication challenges and delicate devices which make local spectroscopic measurements difficult 6 , 7 . Recently, it has been shown that placing graphene on hexagonal boron nitride (hBN) yields improved device performance 8 . Here we use scanning tunnelling microscopy to show that graphene conforms to hBN, as evidenced by the presence of Moiré patterns. However, contrary to predictions 9 , 10 , this conformation does not lead to a sizeable band gap because of the misalignment of the lattices. Moreover, local spectroscopy measurements demonstrate that the electron–hole charge fluctuations are reduced by two orders of magnitude as compared with those on silicon oxide. This leads to charge fluctuations that are as small as in suspended graphene 6 , opening up Dirac point physics to more diverse experiments.

Clinical introductionA 17-year-old boy with primary cardiac diagnosis of cor triatriatum, atrial septal defect (ASD) and patent ductus arteriosus (PDA) was referred for a cardiac MRI. He was operated on at 3 months of age with correction of the above-mentioned defects. During follow-up, on echocardiogram, he gradually developed moderate right ventricular dilation with preserved systolic function and a trace of tricuspid regurgitation. The interatrial septum was intact and the left chambers looked normal in size (see online supplementary video 1). Clinically, he was active and asymptomatic with saturations of 99% on air. Consequently, he was referred for an MRI scan to look for possible causes. The images are seen in figure 1.QuestionWhat diagnosis would you suspect from figure 1?Arteriovenous malformationLeft superior vena cavaLevoatriocardinal veinMeandering pulmonary vein