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Nina Kimer,1 Aleksander Krag,2 Lise L Gluud1 1Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark; 2Department of Gastroenterology, Odense University Hospital, University of Southern Denmark, Odense, Denmark Abstract: Hepatic encephalopathy is a complex disease entity ranging from mild cognitive dysfunction to deep coma. Traditionally, treatment has focused on a reduction of ammonia through a reduced production, absorption, or clearance. Rifaximin is a nonabsorbable antibiotic, which reduces the production of ammonia by gut bacteria and, to some extent, other toxic derivatives from the gut. Clinical trials show that these effects improve episodes of hepatic encephalopathy. A large randomized trial found that rifaximin prevents recurrent episodes of hepatic encephalopathy. Most patients were treated concurrently with lactulose. Trials have varied greatly in design, outcomes, and duration of treatment regimes. Although a number of retrospective studies have indicated that long-term treatment with rifaximin is safe and possibly beneficial, high quality trials are needed to further clarify efficacy and safety of long-term treatment with rifaximin and evaluate effects of combination therapy with lactulose and branched-chain amino acids for patients with liver cirrhosis and hepatic encephalopathy. Keywords: prevention, lactulose, liver cirrhosis

Abstract Objectives This systematic review and meta-analysis aimed to assess the stroke detection performance of artificial intelligence (AI) in magnetic resonance imaging (MRI), and additionally to identify reporting insufficiencies. Methods PRISMA guidelines were followed. MEDLINE, Embase, Cochrane Central, and IEEE Xplore were searched for studies utilising MRI and AI for stroke detection. The protocol was prospectively registered with PROSPERO (CRD42021289748). Sensitivity, specificity, accuracy, and area under the receiver operating characteristic (ROC) curve were the primary outcomes. Only studies using MRI in adults were included. The intervention was AI for stroke detection with ischaemic and haemorrhagic stroke in separate categories. Any manual labelling was used as a comparator. A modified QUADAS-2 tool was used for bias assessment. The minimum information about clinical artificial intelligence modelling (MI-CLAIM) checklist was used to assess reporting insufficiencies. Meta-analyses were performed for sensitivity, specificity, and hierarchical summary ROC (HSROC) on low risk of bias studies. Results Thirty-three studies were eligible for inclusion. Fifteen studies had a low risk of bias. Low-risk studies were better for reporting MI-CLAIM items. Only one study examined a CE-approved AI algorithm. Forest plots revealed detection sensitivity and specificity of 93% and 93% with identical performance in the HSROC analysis and positive and negative likelihood ratios of 12.6 and 0.079. Conclusion Current AI technology can detect ischaemic stroke in MRI. There is a need for further validation of haemorrhagic detection. The clinical usability of AI stroke detection in MRI is yet to be investigated. Critical relevance statement This first meta-analysis concludes that AI, utilising diffusion-weighted MRI sequences, can accurately aid the detection of ischaemic brain lesions and its clinical utility is ready to be uncovered in clinical trials. Key Points There is a growing interest in AI solutions for detection aid. The performance is unknown for MRI stroke assessment. AI detection sensitivity and specificity were 93% and 93% for ischaemic lesions. There is limited evidence for the detection of patients with haemorrhagic lesions. AI can accurately detect patients with ischaemic stroke in MRI. Graphical Abstract

The ecological and evolutionary consequences of ploidy-driven trait variation, particularly for autopolyploids, remain poorly understood. Saxifraga oppositifolia L. (purple saxifrage), is a highly successful arctic-alpine plant species with significant genetic and phenotypic variation potentially related to autopolyploidy. Over the past decade, we have accumulated knowledge of S. oppositifolia through student projects at the University Centre in Svalbard. Building on this knowledge, we initiated the long-term “SO-field study” in 2018 including 768 permanently tagged plants screened for ploidy level, trait variation and environmental associations. Here we summarize main findings from unpublished student projects, consolidating and extending these findings with the available data from the ongoing SO-field study, containing 63% diploids, 16% triploids, and 21% tetraploids. Our results support that Svalbard is a mixed-ploidy contact zone, where ploidy is strongly associated with certain traits, including growth form, leaf mass area, flower investment, seed production and habitat. Autopolyploidy has significantly influenced both ecology and evolution of S. oppositifolia and needs to be accounted for when autopolyploids are used as a study species or evaluated for management purposes. Our findings suggest considerable re-interpretation of former research and pave the way for new inquiries and hypotheses to be tested within this framework.

Abstract In demersal trawl fisheries, the unavailability of the catch information until the end of the catching process is a drawback, leading to seabed impacts, bycatches and reducing the economic performance of the fisheries. The emergence of in-trawl cameras to observe catches in real-time can provide such information. This data needs to be processed in real-time to determine the catch compositions and rates, eventually improving sustainability and economic performance of the fisheries. In this study, a real-time underwater video processing system counting the Nephrops individuals entering the trawl has been developed using object detection and tracking methods on an edge device (NVIDIA Jetson AGX Orin). Seven state-of-the-art YOLO models were tested to discover the appropriate training settings and YOLO model. To achieve real-time processing and accurate counting simultaneously, four frame skipping ideas were evaluated. It has been shown that adaptive frame skipping approach, together with YOLOv8s model, can increase the processing speed up to 97.47 FPS while achieving correct count rate and F-score of 82.57% and 0.86, respectively. In conclusion, this system can improve the sustainability of the Nephrops directed trawl fishery by providing catch information in real-time.

Background:. Computer-aided design and manufacturing (CAD/CAM) is widely adopted for optimizing microsurgical reconstruction of mandibular defects. However, commercial solutions are hampered by costs and lengthy lead times, with the latter being problematic in cancer surgery. This study aimed to investigate the efficiency of an in-house CAD/CAM service for expeditious planning and execution of free fibula mandibular reconstruction in head and neck cancer patients. Methods:. This retrospective cohort study compared cancer patients undergoing segmental mandibulectomy and immediate free fibula flap reconstruction treated before and after implementation of in-house CAD/CAM. The primary endpoint was treatment delay from preoperative consultation to surgery. Cases in the two groups were matched on the number of fibula segments required for mandibular reconstruction. The control group underwent segmental mandibulectomy and fibula flap reconstruction by “freehand.” The CAD/CAM group underwent preoperative virtual surgical planning and CAD/CAM of intraoperative cutting guides for the mandibulectomy and fibula osteotomies. Outcomes were compared with the unpaired t test or Wilcoxon rank-sum test. Results:. Sixteen patients were included in both groups. Treatment delay did not increase after implementation of in-house CAD/CAM with a median 6 (range 6–20) days wait in the CAD/CAM group and 8 (6–20) days wait in the control group (P = 0.48). Utilization of CAD/CAM significantly reduced fibula flap ischemia time with a mean of 18.4 [95% confidence interval 2.8; 33.9] minutes (P = 0.022). Conclusions:. In-house CAD/CAM was implemented for free fibula flap mandibular reconstruction in head and neck cancer patients without causing treatment delay. Furthermore, CAD/CAM reduced fibula flap ischemia time.

Background: Physical activity has been associated with preventing the development of type 2 diabetes and atherosclerotic cardiovascular disease. However, our understanding of the precise molecular mechanisms underlying these effects remains incomplete and good biomarkers to objectively assess physical activity are lacking. Methods: We analyzed 3072 serum proteins in 26 men, normal weight or overweight, undergoing 12 weeks of a combined strength and endurance exercise intervention. We estimated insulin sensitivity with hyperinsulinemic euglycemic clamp, maximum oxygen uptake, muscle strength, and used MRI/MRS to evaluate body composition and organ fat depots. Muscle and subcutaneous adipose tissue biopsies were used for mRNA sequencing. Additional association analyses were performed in samples from up to 47,747 individuals in the UK Biobank, as well as using two-sample Mendelian randomization and mice models. Results: Following 12 weeks of exercise intervention, we observed significant changes in 283 serum proteins. Notably, 66 of these proteins were elevated in overweight men and positively associated with liver fat before the exercise regimen, but were normalized after exercise. Furthermore, for 19.7 and 12.1% of the exercise-responsive proteins, corresponding changes in mRNA expression levels in muscle and fat, respectively, were shown. The protein CD300LG displayed consistent alterations in blood, muscle, and fat. Serum CD300LG exhibited positive associations with insulin sensitivity, and to angiogenesis-related gene expression in both muscle and fat. Furthermore, serum CD300LG was positively associated with physical activity and negatively associated with glucose levels in the UK Biobank. In this sample, the association between serum CD300LG and physical activity was significantly stronger in men than in women. Mendelian randomization analysis suggested potential causal relationships between levels of serum CD300LG and fasting glucose, 2 hr glucose after an oral glucose tolerance test, and HbA1c. Additionally, Cd300lg responded to exercise in a mouse model, and we observed signs of impaired glucose tolerance in male, but not female, Cd300lg knockout mice. Conclusions: Our study identified several novel proteins in serum whose levels change in response to prolonged exercise and were significantly associated with body composition, liver fat, and glucose homeostasis. Serum CD300LG increased with physical activity and is a potential causal link to improved glucose levels. CD300LG may be a promising exercise biomarker and a therapeutic target in type 2 diabetes. Funding: South-Eastern Norway Regional Health Authority, Simon Fougners Fund, Diabetesforbundet, Johan Selmer Kvanes’ legat til forskning og bekjempelse av sukkersyke. The UK Biobank resource reference 53641. Australian National Health and Medical Research Council Investigator Grant (APP2017942). Australian Research Council Discovery Early Career Award (DE220101226). Research Council of Norway (Project grant: 325640 and Mobility grant: 287198). The Medical Student Research Program at the University of Oslo. Novo Nordisk Fonden Excellence Emerging Grant in Endocrinology and Metabolism 2023 (NNF23OC0082123). Clinical trial number: clinicaltrials.gov: NCT01803568.

IntroductionElite breath-hold divers (BHD) possess several oxygen conserving adaptations to endure long dives similar to diving mammals. During dives, Bottlenose Dolphins may increase the alveolar ventilation (VA) to perfusion (Q) ratio to increase alveolar oxygen delivery. We hypothesized that BHD possess similar adaptive mechanisms during apnea.Methods and resultsPulmonary blood volume (PBV) was determined by echocardiography, 15O-H2O PET/CT, and cardiac MRi, (n = 6) during and after maximum apneas. Pulmonary function was determined by body box spirometry and compared to matched controls. After 2 min of apnea, the PBV determined by echocardiography and 15O-H2O-PET/CT decreased by 26% and 41%, respectively. After 4 min of apnea, the PBV assessed by echocardiography and cardiac MRi decreased by 48% and 67%, respectively (n = 6). Fractional saturation (F)O2Hb determined by arterial blood-gas-analyses collected after warm-up and a 5-minute pool-apnea (n = 9) decreased by 43%. Compared to matched controls (n = 8), spirometry revealed a higher total and alveolar-lung-capacity in BHD (n = 9), but a lower diffusion-constant.ConclusionOur results contrast with previous studies, that demonstrated similar lung gas transfer in BHD and matched controls. We conclude that elite BHD 1) have a lower diffusion constant than matched controls, and 2) gradually decrease PBV during apnea and in turn increase VA/Q to increase alveolar oxygen delivery during maximum apnea. We suggest that BHD possess pulmonary adaptations similar to diving mammals to tolerate decreasing tissue oxygenation.New and noteworthyThis manuscript addresses novel knowledge on tolerance to hypoxia during diving, which is shared by elite breath-hold divers and adult diving mammals: Our study indicates that elite breath-hold divers gradually decrease pulmonary blood volume and in turn increase VA/Q, to increase alveolar oxygen delivery during maximum apnea to tolerate decreasing oxygen levels similar to the Bottlenose Dolphin.

Background: Comorbidity with type 2 diabetes (T2D) results in worsening of cancer-specific and overall prognosis in colorectal cancer (CRC) patients. The treatment of CRC per se may be diabetogenic. We assessed the impact of different types of surgical cancer resections and oncological treatment on risk of T2D development in CRC patients. Methods: We developed a population-based cohort study including all Danish CRC patients, who had undergone CRC surgery between 2001 and 2018. Using nationwide register data, we identified and followed patients from date of surgery and until new onset of T2D, death, or end of follow-up. Results: In total, 46,373 CRC patients were included and divided into six groups according to type of surgical resection: 10,566 Right-No-Chemo (23%), 4645 Right-Chemo (10%), 10,151 Left-No-Chemo (22%), 5257 Left-Chemo (11%), 9618 Rectal-No-Chemo (21%), and 6136 Rectal-Chemo (13%). During 245,466 person-years of follow-up, 2556 patients developed T2D. The incidence rate (IR) of T2D was highest in the Left-Chemo group 11.3 (95% CI: 10.4–12.2) per 1000 person-years and lowest in the Rectal-No-Chemo group 9.6 (95% CI: 8.8–10.4). Between-group unadjusted hazard ratio (HR) of developing T2D was similar and non-significant. In the adjusted analysis, Rectal-No-Chemo was associated with lower T2D risk (HR 0.86 [95% CI 0.75–0.98]) compared to Right-No-Chemo. Conclusions: This study suggests that postoperative T2D screening should be prioritised in CRC survivors with overweight/obesity regardless of type of CRC treatment applied. Funding: The Novo Nordisk Foundation (NNF17SA0031406); TrygFonden (101390; 20045; 125132).

This research presents a multi-channel phase shift inductor-inductor-capacitor (LLC) resonant converter with a wide input and output voltage range that has been specially optimized for fuel cell applications. The worst-case minimum stack voltage and the battery voltage range were used to determine the optimal parameters of the LLC converter. The voltage gain of the converter operating at a constant power was considered, and an algorithm for such a calculation is proposed. Current balancing is implemented using channel temperature measurements, circumventing the need for expensive current sensors. A natural self-balancing mechanism is investigated for converters operating at high frequencies exceeding the series resonance frequency of a resonant converter. Efficiency optimization recommendations for the transformer turn ratio of the converter are illustrated. Multi-object optimization is implemented to achieve an optimized design so that both the minimum and maximum voltage gains can be realized; simultaneously, the transformer turn ratio is kept at a minimum to maintain high efficiency. An experimental prototype of a four-channel converter is implemented and verified at a 5-kW power level. Active content and the C language code files for converter calculations are also provided in this paper.

Abstract Neutrophils play a significant role in sustaining chronic inflammation in Inflammatory Bowel Disease. The intestinal basement membrane acts as a barrier for immunological homeostasis, where the α3 and α4 chains of type IV collagen are expressed on the mucosal surface. We wanted to develop a biomarker reflecting early tissue injury, providing an opportunity for intervention. Two competitive enzyme-linked immunosorbent assays (ELISAs) quantifying human neutrophil elastase (HNE) degraded neo-epitopes of COL4A3 and COL4A4 were developed and investigated in two observational cohorts (n = 161, n = 100). A biomarker of MMP-mediated degradation of COL4A1 (C4M) was used for comparison. In Cohort 1, patients with mild endoscopic ulcerative colitis showed elevated levels of C4A3-HNE compared to those with severe disease. C4M had a strong positive correlation with disease activity. C4A3-HNE/C4M provided superior discrimination between mild and severe endoscopic disease and negatively correlated to disease activity. In Cohort 2, C4A4-HNE and C4A4-HNE/C4M showed similar trends. C4A3-HNE and C4A4-HNE possibly reflect early intestinal tissue injury. Combining the markers with a biomarker of another α-chain of the same collagen provides information on two distinct stages of mucosal damage. These biomarkers may be used to monitor disease flare-up in patients in remission, reducing the need for frequent endoscopic procedures.

Abstract Stoat (Mustela erminea) and weasel (M. nivalis) are hard to monitor as they are elusive of nature and leave few identifying marks in their surroundings. Stoat and weasel are both fully protected in Denmark and are thought to be widely distributed throughout the country. Despite this stoat and weasel were listed on the Danish Red List as Near Threatened in 2019, as their densities and population trends are unknown. Using a modified novel camera trapping device, the Double‐Mostela, a wooden box comprising a tracking tunnel and two camera traps, we attempted to obtain density estimates based on identification of individual stoats and weasels. We deployed camera traps both inside Double‐Mostela traps and externally in three different study areas in northern Zealand, Denmark, and tested commercial, American scent‐based lures to attract stoat and weasel. We obtained very low seasonal trapping rates of weasel in two study areas, but in one study area, we obtained a seasonal trapping rate of stoat larger compared to another study using the Mostela. In one study area, both species were absent. We observed no effect of scent‐based lures in attracting small mustelids compared to non‐bait traps. Potential reasons behind low capture rates of weasel and stoat are suboptimal habitat placement and timing of deployment of the Double‐Mostelas, land‐use changes over the last 200 years, predation from larger predators, as well as unintended secondary poisoning with rodenticides. Due to the scarcity of weasel and stoat captures, we were unable to make density estimates based on identification of individuals; however, we identified potential features that could be used for identification and density estimates with more captures.

Offshore wind energy development (OWED), while a key strategy for reducing carbon emissions, has potential negative effects to wildlife that should be examined to inform decision making and adaptive management as the industry expands. We present a conceptual framework to guide the long-term study of potential effects to birds and bats from OWED. This framework includes a focus on exposure and vulnerability as key determinants of risk. For birds and bats that are exposed to OWED, there are three main effects of interest that may impact survival and productivity: 1) collision mortality, 2) behavioral responses, including avoidance, displacement, and attraction, and 3) habitat-mediated effects to prey populations. If these OWED effects cause changes in survival and/or breeding success (e.g., fitness), they have the potential for population-level consequences, including changes in population size and structure. Understanding the influence of ecological drivers on exposure and effect parameters can help to disentangle the potential impacts of OWED from other stressors. We use this theoretical framework to summarize existing relevant knowledge and identify current priority research questions (n=22) for the eastern United States, where large-scale development of OWED is primarily in the planning and early construction phase. We also identify recommendations for study design and further prioritization of research topics.

IntroductionElite breath-hold divers (BHD) enduring apneas of more than 5 min are characterized by tolerance to arterial blood oxygen levels of 4.3 kPa and low oxygen-consumption in their hearts and skeletal muscles, similar to adult seals. Adult seals possess an adaptive higher hemoglobin-concentration and Bohr effect than pups, and when sedated, adult seals demonstrate a blood shift from the spleen towards the brain, lungs, and heart during apnea. We hypothesized these observations to be similar in human BHD. Therefore, we measured hemoglobin- and 2,3-biphosphoglycerate-concentrations in BHD (n = 11) and matched controls (n = 11) at rest, while myocardial mass, spleen and lower extremity volumes were assessed at rest and during apnea in BHD.Methods and resultsAfter 4 min of apnea, left ventricular myocardial mass (LVMM) determined by 15O-H2O-PET/CT (n = 6) and cardiac MRI (n = 6), was unaltered compared to rest. During maximum apnea (∼6 min), lower extremity volume assessed by DXA-scan revealed a ∼268 mL decrease, and spleen volume, assessed by ultrasonography, decreased ∼102 mL. Compared to age, BMI and VO2max matched controls (n = 11), BHD had similar spleen sizes and 2,3- biphosphoglycerate-concentrations, but higher total hemoglobin-concentrations.ConclusionOur results indicate: 1) Apnea training in BHD may increase hemoglobin concentration as an oxygen conserving adaptation similar to adult diving mammals. 2) The blood shift during dry apnea in BHD is 162% more from the lower extremities than from the spleen. 3) In contrast to the previous theory of the blood shift demonstrated in sedated adult seals, blood shift is not towards the heart during dry apnea in humans.

Background & Aims: Infections are frequent in patients with cirrhosis and worsen prognosis. We evaluated the incidence of infections and their impact on decompensation and death in patients with early alcohol-related liver disease (ALD) during long-term follow-up. Methods: We performed a prospective cohort study of patients in secondary care with a history of excess alcohol intake, no prior decompensation, and with liver biopsies along with clinical investigations conducted at baseline. During follow-up, we reviewed the patients’ electronic healthcare records for cases of infections, hospitalizations, transient elastography measurements, decompensations, all-cause mortality, and alcohol intake. Results: We included 461 patients with a mean age of 56±10 years (76% males; fibrosis stage F0-1/F2/F3-4 = 259/107/93 [56%/23%/20%]). During a median follow-up of 4.5 years (IQR 2.9-6.3), 134 patients (29%) developed a total of 312 infections, most frequently pneumonia (106/312, 34%) and urinary tract infections (57/312, 18%). Excessive alcohol intake during follow-up, smoking ≥30 pack years, MELD score and elevated liver stiffness during follow-up were independent predictors of infections. Patients who developed at least one infection had a significantly increased risk of subsequent decompensation (hazard ratio 4.98, 95% CI 2.47-10.03) and death (hazard ratio 8.24, 95% CI 4.65-14.59). Infections increased the risk of decompensation and death independently of baseline fibrosis stage, age, gender, and MELD score. Conclusions: Almost one-third of patients with early ALD develop an infection, which worsens their prognosis by increasing the risk of decompensation and death. The risk of infections increases with liver disease severity and ongoing harmful use of alcohol. Impact and implications: This study reveals that infections significantly worsen the prognosis of patients with early alcohol-related liver disease (ALD), increasing the likelihood of decompensation and death by up to eight times. These findings, pertinent to healthcare providers, researchers, and policymakers, emphasize the importance of early prevention and management of infections in patients with ALD, even those in early stages who may be asymptomatic. It was observed that nearly one-third of patients with early-stage ALD developed infections over 4.5 years, with risk factors including alcohol overuse, smoking, and higher MELD scores. The research underscores the critical need to incorporate these insights into clinical practice and public health policies to improve patient outcomes and mitigate the impact of infections in patients with ALD.