Gray Zone Research Articles

Transrectal versus transperineal prostate biopsy for cancer detection in patients with gray-zone prostate-specific antigen: a multicenter, real-world study.

Knowledge about the effect of different prostate biopsy approaches on the prostate cancer detection rate (CDR) in patients with gray-zone prostate-specific antigen (PSA) is limited. We performed this study to compare the CDR among patients who underwent different biopsy approaches and had rising PSA levels in the gray zone. Two hundred and twenty-two patients who underwent transrectal prostate biopsy (TRB) and 216 patients who underwent transperineal prostate biopsy (TPB) between June 2016 and September 2022 were reviewed in this study. In addition, 110 patients who received additional targeted biopsies following the systematic TPB were identified. Clinical parameters, including age, PSA derivative, prostate volume (PV), and needle core count, were recorded. The data were fitted via propensity score matching (PSM), adjusting for potential confounders. TPB outperformed TRB in terms of the CDR (49.6% vs 28.3%, P = 0.001). The clinically significant prostate cancer (csPCa) detection rate was not significantly different between TPB and TRB (78.6% vs 68.8%, P = 0.306). In stratified analysis, TPB outperformed TRB in CDR when the age of patients was 65-75 years (59.0% vs 22.0%, P < 0.001), when PV was 25.00-50.00 ml (63.2% vs 28.3%, P < 0.001), and when needle core count was no more than 12 (58.5% vs 31.5%, P = 0.005). The CDR (P = 0.712) and detection rate of csPCa (P = 0.993) did not significantly differ among the systematic, targeted, and combined biopsies. TPB outperformed TRB in CDR for patients with gray-zone PSA. Moreover, performing target biopsy after systematic TPB provided no additional benefits in CDR.

The comprehensive checklist of myxomycetes of Ukraine, based on extended occurrence and reference datasets

A significant body of valuable data about the myxomycetes of Ukraine lies in a “grey zone”. This encompasses undigitised historical books and articles published in languages such as Polish, French or German, as well as proceedings from local conferences, articles featured in local scientific journals and annual reports submitted to public authorities by employees of protected areas, published in Ukrainian or Russian. Yet, due to their exclusive existence in print and often the Cyrillic alphabet, these publications remain neither findable nor accessible to a wider audience. The datasets presented here aim to summarise over 150 years of myxomycetes research in Ukraine. The majority of the data has been extracted from published literature sources spanning the years 1842 to 2023, with a minor supplement from unpublished herbarium specimens. The datasets include 5036 georeferenced occurrences, 339 taxa and 91 literature sources. Seventy-one of the used literature sources, mostly published before 2010, were uploaded to Zenodo and are available in open access.

Changes in the cardiovascular profile in patients 3 and 12 months after COVID-19 pneumonia: parameters of arterial stiffness, global longitudinal strain, and diastolic function of the left ventricle

Aim. To study changes in the brachial – ankle pulse wave velocity (baPWV), ankle – brachial index (ABI), diastolic function, and global longitudinal strain of the left ventricle (LV) 3 and 12 months after COVID-19 pneumonia.Materials and methods. The dynamics of vascular age and LV global longitudinal strain was studied in 154 patients 3 and 12 months after COVID-19 pneumonia (51 ± 12 years, 48% were women). The control group consisted of 55 sexand age-matched individuals.Results. During the follow-up, the average baPWV decreased (13.2 [11.8; 15.1] cm / sec vs. 13.0 [11.8; 14.1] cm/ s; p &lt; 0.001), and the frequency of its elevated values declined (45.4 vs. 35.1%; p = 0.008). The average ABI increased (1.09 [1.04; 1.14] vs. 1.11 [1.06; 1.17]; p = 0.012), but remained within the normal range. LV global longitudinal strain (LV GLS) (–19.6 ± 2.2 and –19.7 ± 2.5%; p = 0.854) and the frequency of reduced LV GLS (21.4 and 26.6%; p = 0.268) did not change significantly and did not differ from values in the control group. Global longitudinal strain in the LV basal inferoseptal segment improved (–19.2 ± 3.6% vs. –20.1 ± 4.0%; p = 0.032). The early diastolic mitral annular velocity decreased (8.4 ± 3.0 cm / s vs. 8.0 ± 2.5 cm / s; p = 0.023). The LV isovolumic relaxation time was greater than in the control group (101.8 ± 22.3 ms at the 1st visit vs. 92.9 ± 21.5 ms; p = 0.012; 105.9 ± 21.9 ms vs. 92.9 ± 21.5 ms at the 2nd visit; p &lt; 0.001). A positive correlation was found between baPWV (r = 0.209; p = 0.009) and ABI (r = 0.190; p = 0.021) and strain parameters of the LV basal segments 12 months after discharge.Conclusion. Patients with optimal visualization on echocardiography at 12 months after COVID-19 pneumonia, compared to the results of the examination 3 months after the disease, had deteriorated parameters of LV diastolic function. LV GLS was within the grey zone and did not change significantly. An improvement in arterial stiffness was noted, associated with an improvement in the strain of basal LV segments.

Navigating the ‘grey zone’: academic collaboration and research on/in Russia during geopolitical crisis

Russia’s illegal annexation of Crimea in 2014 and attack on Ukraine in 2022 have led to widespread sanctions being placed on Russia by the European Union, including sanctions related to academic cooperation. National governments, supranational bodies, science academies and research institutions as well as publishers have likewise formed policies suspending and restricting collaboration regarding Russia-related research. These policies are, however, not straight forward and there are many practical and ethical questions that individual researchers must ask themselves. At Finnish Geography Days 2023 in Joensuu, a panel was dedicated to discussing some of these questions. This article summarizes main themes discussed during the panel and sheds light on the multiple ways researchers experience and navigate the ‘grey zone’ of academic collaboration and research on/in Russia in the current geopolitical context. The article emphasizes the necessity of further discussing the effectiveness and impact of the sanctions and restrictions: Are they reasonable? Who benefits from them, and who suffers?

Grey Zone Healers and the COVID-19 Pandemic in Chechnya, Russia.

The Chechen authorities' focus upon population health is enacted both through the principles of Islamic medicine and approved biomedical practices. Any healing practices beyond these domains are met with deep suspicion. Practitioners of unofficial complementary and alternative medicine healers may abruptly find themselves regarded as enemies of the state. In light of this precarious circumstance, it becomes pertinent to inquire: How do these healers employ their daily tactics to negotiate the intricate power dynamics between the formidable state apparatus and the established biomedical order? Drawing from our meticulous fieldwork conducted in the year 2021, we investigated the intricate tactics employed by unofficial healers in the Chechen medical landscape during COVID-19. Our research centred on discerning the nuanced tactics aimed at mitigating potential risks. We conclude that healers, having embodied tactics to creatively manoeuvre within the confines of the authoritarian state, perceived the challenges posed by COVID-19 as merely another, often inconsequential, obstacle in their enduring struggle.

On the Sensitivity of Large-Eddy Simulations of the Atmospheric Boundary Layer Coupled with Realistic Large-Scale Dynamics

Abstract We present a new ensemble of 36 numerical experiments aimed at comprehensively gauging the sensitivity of nested large-eddy simulations (LES) driven by large-scale dynamics. Specifically, we explore 36 multiscale configurations of the Weather Research and Forecasting (WRF) Model to simulate the boundary layer flow over the complex topography at the Perdigão field site, with five nested domains discretized at horizontal resolutions ranging from 11.25 km to 30 m. Each ensemble member has a unique combination of the following input factors: (i) large-scale initial and boundary conditions, (ii) subgrid turbulence modeling in the gray zone of turbulence, (iii) subgrid-scale (SGS) models in LES, and (iv) topography and land-cover datasets. We probe their relative importance for LES calculations of velocity, temperature, and moisture fields. Variance decomposition analysis unravels large sensitivities to topography and land-use datasets and very weak sensitivity to the LES SGS model. Discrepancies within ensemble members can be as large as 2.5 m s−1 for the time-averaged near-surface wind speed on the ridge and as large as 10 m s−1 without time averaging. At specific time points, a large fraction of this sensitivity can be explained by the different turbulence models in the gray zone domains. We implement a horizontal momentum and moisture budget routine in WRF to further elucidate the mechanisms behind the observed sensitivity, paving the way for an increased understanding of the tangible effects of the gray zone of turbulence problem. Significance Statement Several science and engineering applications, including wind turbine siting and operations, weather prediction, and downscaling of climate projections, call for high-resolution numerical simulations of the lowest part of the atmosphere. Recent studies have highlighted that such high-resolution simulations, coupled with large-scale models, are challenging and require several important assumptions. With a new set of numerical experiments, we evaluate and compare the significance of different assumptions and outstanding challenges in multiscale modeling (i.e., coupling large-scale models and high-resolution atmospheric simulations). The ultimate goal of this analysis is to put each individual assumption into the wider perspective of a realistic problem and quantify its relative importance compared to other important modeling choices.

Generalized eddy‐diffusivity mass‐flux formulation for the parametrization of atmospheric convection and turbulence

AbstractThe atmospheric convection is a phenomenon that has a length scale smaller than the resolution at which the state‐of‐the‐art general circulation numerical models are running, and thus the convection needs to be parametrized. In this work, a theoretical formulation for the parametrization of subgrid‐scale convection based on subgrid averaging that represents a generalized eddy‐diffusivity mass‐flux formulation is presented. The subgrid fluxes are derived by considering a decomposition of subgrid variables into convective and turbulent variables, and by assuming that the convection is modeled by round convective plumes with generic radial profiles. The main difference between our formulation and the mass‐flux formulations is that the condition of a very small fractional area occupied by the convection is replaced with the condition that the convective vertical velocity goes to the mean state far from the updraft region of the plume. The plume model can also be generalized by considering that the convective elements are energy‐consistent plumes, governed by the conservation of mass, momentum, kinetic energy, and buoyancy, which provides a physical‐based closure for the entrainment. Therefore, the closing problem of our formulation consists of the specification of the convective radial profiles and the boundary conditions at the initial vertical level. Furthermore, our formulation allows one to consider more realistic profiles for the convective variables, making the formulation suitable for the parametrization of atmospheric convection at the convective gray zone. This aspect is discussed in the last part of this work, where it is showed how the formulation can be implemented at any resolution. Moreover, in the present framework, no distinct assumptions are required for each convective type, thus facilitating the parametrization of convection in a unified way.

Modulation of Tropical Convection‐Circulation Interaction by Aerosol Indirect Effects in Convective Self‐Aggregation Simulations of a Gray Zone Global Model

AbstractDisentangling the response of tropical convective updrafts to enhanced aerosol concentrations has been challenging. Leading theories for explaining the influence of aerosol concentrations on tropical convection are based on the dynamical response of convection to changes in cloud microphysics, neglecting possible changes in the environment. In recent years, global convection‐permitting models (GCPM) have been developed to circumvent problems arising from imposing artificial scale separation on physical processes associated with deep convection. Here, we use a global model in the convective gray zone that partially simulates deep convection to investigate how enhanced concentrations of aerosols that act as cloud condensate nuclei (CCN) impact tropical convection features by modulating the convection‐circulation interaction. Results from a pair of idealized non‐rotating radiative‐convective equilibrium simulations show that the enhanced CCN concentration leads to weaker large‐scale circulation, the closeness of deep convective systems to the moist cluster edges, and more mid‐level cloud water at an equilibrium state in which convective self‐aggregation occurred. Correspondingly, the enhanced CCN concentration modulates how the physical processes that support or oppose convective aggregation maintain the aggregated state at equilibrium. Overall, the enhanced CCN concentration facilitates the development of deep convection in a drier environment but reduces mean precipitation. Our results emphasize the importance of allowing atmospheric phenomena to evolve continuously across spatial and temporal scales in simulations when investigating the response of tropical convection to changes in cloud microphysics.

Cyber Operations in Peace and War: A Framework for Persistent Engagement

During 1990s, the concept of information warfare (IW) and information operations (including cyber operations, psychological operations, and electronic warfare) could be conducted with varying intensity across all stages of peace and conflict. At that time, many of the concepts related to cyber operations were still hypothetical. Subsequently, conflicts and competition between states have demonstrated the capabilities and limitations of cyber operations. Research emerging in 2022 by multiple authors demonstrate the limitations and usage of offensive cyber operations and maintaining a sustainable military cyber capability, as well as proposing alternative models for conflict in cyberspace. Alongside this, there has been increased attention on the impact of ICTs on international security and the responsible behaviour of nation-states in cyberspace. There is still ambiguity and different perspectives on the application of international law in cyberspace. This uncertainty disrupts the original models of IW and warfare, which assumed clear distinctions amongst the conflict stages. Both the discourse of ICTs in international security and recent conflict necessitate a reconsideration of the decades-old view of IW in times of peace, war and the grey zone in between. This paper proposes a framework for the roles of cyber operations across the stages of conflict based on contemporary perspectives on the utility of cyber operations as well as practical examples. In rethinking the IW model, a multidisciplinary view is required, considering the technical, legal, social and international security perspectives.

New perspectives in the echocardiographic hemodynamics multiparametric assessment of patients with heart failure.

International Guidelines consider left ventricular ejection fraction (LVEF) as an important parameter to categorize patients with heart failure (HF) and to define recommended treatments in clinical practice. However, LVEF has some technical and clinical limitations, being derived from geometric assumptions and is unable to evaluate intrinsic myocardial function and LV filling pressure (LVFP). Moreover, it has been shown to fail to predict clinical outcome in patients with end-stage HF.The analysis of LV antegrade flow derived from pulsed-wave Doppler (stroke volume index, stroke distance, cardiac output, and cardiac index) and non-invasive evaluation of LVFP have demonstrated some advantages and prognostic implications in HF patients.Speckle tracking echocardiography (STE) is able to unmask intrinsic myocardial systolic dysfunction in HF patients, particularly in those with LV preserved EF, hence allowing analysis of LV, right ventricular and left atrial (LA) intrinsic myocardial function (global peak atrial LS, (PALS)). Global PALS has been proven a reliable index of LVFP which could fill the gaps "gray zone" in the previous Guidelines algorithm for the assessment of LV diastolic dysfunction and LVFP, being added to the latest European Association of Cardiovascular Imaging Consensus document for the use of multimodality imaging in evaluating HFpEF.The aim of this review is to highlight the importance of the hemodynamics multiparametric approach of assessing myocardial function (from LVFP to stroke volume) in patients with HF, thus overcoming the limitations of LVEF.

Availability and threshold of the vasoactive-inotropic score for predicting early extubation in adults after rheumatic heart valve surgery: a single-center retrospective cohort study.

Early extubation (EEx) is defined as the removal of the endotracheal tube within 8h postoperatively. The present study involved determining the availability and threshold of the vasoactive-inotropic score (VIS) for predicting EEx in adults after elective rheumatic heart valve surgery. The present study was designed as a single-center retrospective cohort study which was conducted with adults who underwent elective rheumatic heart valve surgery with CPB. The highest VIS in the immediate postoperative period was used in the present study. The primary outcome, the availability of VIS for EEx prediction and the optimal threshold value were determined using ROC curve analysis. The gray zone analysis of the VIS was performed by setting the false negative or positive rate R = 0.05, and the perioperative risk factors for prolonged EEx were identified by multivariate logistic analysis. The postoperative complications and outcomes were compared between different VIS groups. Among the 409 patients initially screened, 379 patients were ultimately included in the study. The incidence of EEx was determined to be 112/379 (29.6%). The VIS had a good predictive value for EEx (AUC = 0.864, 95% CI: [0.828, 0.900], P < 0.001). The optimal VIS threshold for EEx prediction was 16.5, with a sensitivity of 71.54% (65.85-76.61%) and a specificity of 88.39% (81.15-93.09%). The upper and lower limits of the gray zone for the VIS were determined as (12, 17.2). The multivariate logistic analysis identified age (OR, 1.060; 95% CI: 1.017-1.106; P = 0.006), EF% (OR, 0.798; 95% CI: 0.742-0.859; P < 0.001), GFR (OR, 0.933; 95% CI: 0.906-0.961; P < 0.001), multiple valves surgery (OR, 4.587; 95% CI: 1.398-15.056; P = 0.012), and VIS > 16.5 (OR, 12.331; 95% CI: 5.015-30.318; P < 0.001) as the independent risk factors for the prolongation of EEx. The VIS ≤ 16.5 group presented a greater success rate for EEx, a shorter invasive ventilation support duration, and a lower incidence of complications than did the VIS > 16.5 group, while the incidence of reintubation was similar between the two groups. In adults, after elective rheumatic heart valve surgery, the highest VIS in the immediate postoperative period was a good predictive value for EEx, with a threshold of 16.5.

ANALISIS MODEL ALTMAN Z-SCORE TERHADAP INDIKASI FINANCIAL DISTRESS PADA PERUSAHAAN MANUFAKTUR SUB SEKTOR KOSMETIK DAN KEPERLUAN RUMAH TANGGA YANG TERDAFTAR DI BURSA EFEK INDONESIA

This study aims to determine the indication of financial distress using the calculation of the Altman Z-Score model  in manufacturing companies in the cosmetics and household utilities sub-sector listed on the Indonesia Stock Exchange for the 2018-2022 period. This study will use descriptive research methods with a qualitative approach using research objects, namely as many as 6 manufacturing companies in the cosmetics and household utilities sub-sector listed on the Indonesia Stock Exchange. The results showed that PT. Martina Berto Tbk with an average Z-Score obtained in 2018-2022 of 0.338 (Distress Zone), which means that the company is in a condition of financial distress. Companies with the category of being in standard financial condition (Grey Zone) with an average Z-Score value  , namely PT. Mustika Ratu Tbk amounted to (2,642), and PT. Kino Indonesia Tbk amounted to (1,898). While PT. Unilever Indonesia Tbk (3,259), PT. Akasha Wira International Tbk (3,981), and PT. Mandom Indonesia (4,896) shows the average Z-Score in a healthy financial condition (Safe Zone). The conclusion in this study is that  the Altman Z-Score model  can be used to calculate an indication of the level of financial distress in a company. The results of the calculation analysis of the Altman Z-Score model  of companies that are indicated to have financial difficulties are PT. Martina Berto Tbk. Policy carried out by PT. Martina Berto Tbk is business transformation, increasing marketing and promotion, expanding distribution cooperation, and divesting assets. The impact of this policy is that in 2021 the company recorded positive performance improvements

Neither housing nor hotel

One of the many impacts of the Covid pandemic on Canadian cities was the complete collapse of short-term rental (STR) markets, as long-distance travel nearly vanished for more than a year. Many dedicated STRs shifted back to the long-term rental market, but others remained on STR platforms such as Airbnb but with minimum stays of one month or more—a land use we describe as “medium-term rentals” (MTRs). This paper provides a planning analysis of online-platform-mediated MTRs in Canadian cities and their housing-market, land-use, and regulatory implications. First, we identify and explore the regulatory grey zone inhabited by MTRs, which appear to be neither standard residential tenancies nor short-term tourist accommodations. Second, the paper provides a brief empirical overview of the emergence of MTRs during and after the Covid pandemic in Toronto, Montreal, and Vancouver. Third, the paper uses a policy case study of situations in which Ontario’s Landlord and Tenant Board has been asked to adjudicate non-standard tenancies to establish whether there is a planning basis for distinguishing medium-term rentals from other tenancy types. The paper concludes by identifying a key planning principle which could allow Canadian municipalities to pull MTRs out of the regulatory grey zone: regulating type of stay instead of length of stay.

Differentiation of invasive ductal and lobular carcinoma of the breast using MRI radiomic features: a pilot study.

Breast cancer (BC) is one of the main causes of cancer-related mortality among women. For clinical management to help patients survive longer and spend less time on treatment, early and precise cancer identification and differentiation of breast lesions are crucial. To investigate the accuracy of radiomic features (RF) extracted from dynamic contrast-enhanced Magnetic Resonance Imaging (DCE MRI) for differentiating invasive ductal carcinoma (IDC) from invasive lobular carcinoma (ILC). This is a retrospective study. The IDC of 30 and ILC of 28 patients from Dukes breast cancer MRI data set of The Cancer Imaging Archive (TCIA), were included. The RF categories such as shape based, Gray level dependence matrix (GLDM), Gray level co-occurrence matrix (GLCM), First order, Gray level run length matrix (GLRLM), Gray level size zone matrix (GLSZM), NGTDM (Neighbouring gray tone difference matrix) were extracted from the DCE-MRI sequence using a 3D slicer. The maximum relevance and minimum redundancy (mRMR) was applied using Google Colab for identifying the top fifteen relevant radiomic features. The Mann-Whitney U test was performed to identify significant RF for differentiating IDC and ILC. Receiver Operating Characteristic (ROC) curve analysis was performed to ascertain the accuracy of RF in distinguishing between IDC and ILC. Ten DCE MRI-based RFs used in our study showed a significant difference (p <0.001) between IDC and ILC. We noticed that DCE RF, such as Gray level run length matrix (GLRLM) gray level variance (sensitivity (SN) 97.21%, specificity (SP) 96.2%, area under curve (AUC) 0.998), Gray level co-occurrence matrix (GLCM) difference average (SN 95.72%, SP 96.34%, AUC 0.983), GLCM interquartile range (SN 95.24%, SP 97.31%, AUC 0.968), had the strongest ability to differentiate IDC and ILC. MRI-based RF derived from DCE sequences can be used in clinical settings to differentiate malignant lesions of the breast, such as IDC and ILC, without requiring intrusive procedures.

Risk-Adapted Strategy Combining Magnetic Resonance Imaging and Prostate-Specific Antigen Density to Individualize Biopsy Decision in Patients With PI-RADS 3 ``Gray Zone'' Lesions

IntroductionRecent guidelines suggest that biopsy may be omitted in some groups of patients with PI-RADS 3 lesions on mpMRI. In this study, we aimed to evaluate biopsy strategies involving prostate-specific antigen density (PSAd) to avoid unnecessary biopsy versus the risk of missing clinically significant prostate cancer (csPCa) in patients with PI-RADS 3 lesions. Material and MethodsData of 616 consecutive patients who underwent PSAd and mpMRI before prostate biopsy between January 2017 and January 2022 at a single center were retrospectively assessed. All of these patients underwent combined cognitive or fusion targeted biopsy of suspicious lesions and transrectal ultrasonography guided systematic biopsy. PI-RADS 3 based strategies with PSAd and mpMRI combination were created. For each strategy, avoided unnecessary biopsy, reduced ISUP Grade 1, and missed ISUP Grade ≥ 2 ratios were determined. Decision curve analysis (DCA) was used to statistically compare the net benefit of each strategy. ResultsDCA revealed that patients who had PI-RADS 3 lesions with PSAd ≥ 0.2, and/or patients who had PI-RADS 4 and 5 lesions had the most benefit, under the threshold probability level between 10% and 50%, which avoided 48.2% unnecessary prostate biopsies and reduced 51% of ISUP grade 1 cases, while missed 17.5% of ISUP grade ≥ 2 cases. (22.1% for ISUP grade 2 and 8.8% for ISUP grade ≥ 3). Strategy 1 (PI-RADS 4-5 and/or PSAd ≥ 0.2), 3 (PI-RADS 4-5 and/or PI-RADS 3 if PSAd ≥ 0.15), and 7 (PI-RADS 4-5 and/or PI-RADS 3 if PSAd ≥ 0.15 and/or PI-RADS 2 if PSAd ≥ 0.2) were the next three best strategies. ConclusionmpMRI combined with PSAd strategies reduced biopsy attempts in PI-RADS 3 lesions. Using these strategies, the advantage of avoiding biopsy and the risk of missing the diagnosis of csPCa can be discussed with the patient, and the biopsy decision can be made afterwards.

A Cytohistologic Correlation Study of Thyroid Lesions: Evaluation of Diagnostic Accuracy and Pitfalls of Fine Needle Aspiration Cytology.

Background Only about 5% of palpable thyroid nodules are malignant; the rest are entirely benign. In order to reduce the number of unnecessary treatments and properly identify situations that need surgical intervention, it is essential to distinguish between benign and malignant lesions prior to surgery. There exists a "grey zone" in thyroid cytology characterized by a significant decrease in diagnostic accuracy, making it difficult to precisely classify the lesion and leading to discrepancies. Aims and objectives The study aims to accomplish the following objectives: (1) assess the prevalence of thyroid lesions according to age and sex; (2) evaluate the accuracy of the fine needle aspiration cytology (FNAC) in diagnosing thyroid conditions; and (3) investigate the causes of cytohistological discordance within the context of this study. Materials and methods In our five-year study of thyroid lesions, 125 cases were studied for cytohistological correlation. Discrepant and likened FNAs were classified according to the diagnostic findings. A review of the cytological smears and histological sections was conducted. Results The cytological diagnoses were correlated with histopathology in 109 cases (90.83%). A total of 11 cases (09.16%) were discrepant. There were no false positives (FPs). The causes of false negative (FN) diagnoses in our study can be attributed to geographic misses and failure to recognize dual pathologies. Conclusion FNA is a very precise and time-saving technique for the diagnosis and subsequent management of palpable thyroid nodules. Patients having thyroidectomies have a much higher malignant yield, and the frequency of procedures performed on the thyroid is decreased. When FNA interpretation based on strict specimen sufficiency standards is considered along with clinical and imaging findings, the occurrence of FN and FP diagnoses is expected to decrease.

Validation of Baveno VII criteria and other non-invasive diagnostic algorithms for clinically significant portal hypertension in hepatitis delta

Non-invasive tests (NIT) for clinically significant portal hypertension (CSPH) in compensated advanced chronic liver disease (cACLD) lack validation in patients infected with hepatitis D virus (HDV). HDV-cACLD patients (LSM ≥10kPa or histological METAVIR F3/F4 fibrosis) who underwent paired HVPG and NIT assessment at Medical University of Vienna or Hannover Medical School between 2013 and 2023 were retrospectively included. Liver stiffness measurement (LSM), von Willebrand factor to platelet count ratio (VITRO), and spleen stiffness measurement (SSM) were assessed. Individual CSPH risk was calculated according to previously published models (ANTICIPATE, 3P/5P). The diagnostic performance of Baveno-VII criteria and refined algorithms (Baveno-VII-VITRO, Baveno-VII-SSM) was evaluated. The prognostic utility of NIT was investigated in the main and an independent, multicenter validation cohort. Fifty-one patients (HVPG ≥10mmHg/CSPH prevalence: 62.7%, varices: 42.2%) were included. LSM (25.8 [17.2-31.0] vs. 14.0 [10.5-19.8] kPa; p<0.001), VITRO (n=31, 3.5 [2.7-4.5] vs. 1.3 [0.6-2.0] %/[G/L]; p<0.001), and SSM (n=20, 53.8 [41.7-75.5] vs. 24.0 [17.0-33.9] kPa; p<0.001) were significantly higher in CSPH patients. Composite CSPH risk models yielded excellent AUROC (ANTICIPATE: 0.885, 3P: 0.903, 5P: 0.912). Baveno-VII criteria ruled out CSPH with 100% sensitivity and ruled in CSPH with 84.2% specificity. The Baveno-VII 'grey zone' (41.1%) was significantly reduced by Baveno-VII-VITRO or Baveno-VII-SSM, while maintaining diagnostic accuracy. Hepatic decompensation within two years occurred only in patients who had CSPH or met Baveno-VII rule-in criteria. The prognostic value of NIT was confirmed in the validation cohort comprising 92 patients. Standalone and composite NIT/ diagnostic algorithms are useful for CSPH diagnosis in HDV-cACLD patients. Thus, NIT may be applied to identify and prioritize patients with CSPH for novel antiviral treatments against CHD. Non-invasive tests (NIT) for clinically significant portal hypertension (CSPH) have been developed to identify compensated advanced chronic liver disease (cACLD) patients at risk for decompensation, but conflicting data has been published regarding the accuracy of liver stiffness measurement (LSM) for the staging of fibrosis in patients infected with hepatitis D virus (HDV). In our study including 51 HDV-cACLD patients, NIT, i.e., most importantly, the ANTICIPATE model based on LSM and platelet count, but also lab-based approaches, i.e., 3P/5P model and the von Willebrand factor to platelet count ratio (VITRO), and spleen stiffness measurement (SSM) yielded high AUROC for CSPH. Moreover, only patients with CSPH or high non-invasively assessed CSPH-risk were at risk for decompensation within two years, and the prognostic value of NIT was confirmed in a validation cohort. Thus, NIT should be applied and updated in yearly intervals in clinical routine to identify HDV-cACLD patients at short-term risk and may guide prioritization for novel antiviral treatment options.

Univariate Flux Partition Functions for Planetary Boundary Layer Schemes at Gray Zone Resolutions

Abstract When the horizontal grid spacing of a numerical weather prediction model approaches kilometer scale, the so-called gray zone range, turbulent fluxes in the convective boundary layer (CBL) are partially resolved and partially subgrid scale (SGS). Knowledge of the partition between resolved and SGS turbulent fluxes is key to building scale-adaptive planetary boundary layer (PBL) schemes that are capable of regulating the SGS fluxes with varying grid spacing. However, flux partition depends not only on horizontal grid spacing, but also on local height, bulk stability of the boundary layer, and the particular turbulent flux. Such multivariate functions are difficult to construct analytically, so their implementations in scale-adaptive PBL schemes always involve certain levels of approximation that can lead to inaccuracies. This study introduces a physically based perspective for the flux partition functions that greatly simplifies their implementation with high accuracy. By introducing an appropriate scaling length λ that accounts for both height and bulk stability dependencies, the dimensionality of the partition functions is reduced to a single dimensionless group. Based on the analysis of a comprehensive large-eddy simulation dataset of the CBL, it is further shown that λ’s height and bulk stability dependencies can be separately represented by a similarity length scale and a stability coefficient. The resulting univariate partition functions are incorporated into a traditional first-order PBL scheme as a proof of concept. Our results show that the augmented scheme well-reproduces the SGS fluxes at gray zone resolutions. Significance Statement Flux partition functions are a key component in most scale-adaptive planetary boundary layer (PBL) schemes developed for kilometer- and subkilometer-resolution numerical weather prediction models. They regulate the parameterized turbulent fluxes as a function of horizontal grid spacing, while they also depend on height and atmospheric stability. Such multivariate dependencies forbid simple analytical expressions, and as a result, partition functions implemented in scale-adaptive PBL schemes are generally simplified at the cost of accuracy in previous works. This study investigates the possibility of constructing partition functions that are both accurate and easy to parameterize. Utilizing a physically based length scale, univariate partition functions are built, evaluated, and put into a conventional PBL scheme to improve the gray zone turbulence parameterization.

Proposal of a new score system (Cervical Surgical Score) for management of degenerative cervical myelopathy.

To date, no shared algorithms with the aim of guiding surgical strategy in complex cases of degenerative cervical myelopathy (DCM) exist. Our purpose is to present the Cervical Surgical Score (CSS) which could help in identifying complex DCM cases, suggesting a surgical strategy. We created the CSS based on multidisciplinary and literature-focused discussions, based on eight parameters including number of levels of cervical pathology and myelopathy, type and predominance of compression and grade of clinical myelopathy. We prospectively enrolled surgical DCM patients in a 15-months period, collecting clinical and radiological data. During outpatient clinic a specific surgical indication was offered to DCM patients. To validate the score, each outpatient clinic surgical indication was compared a posteriori to the one that resulted from multidisciplinary CSS scoring, focusing on patients for which both an anterior and posterior approach were considered suitable. A total of 100 patients operated on for DCM at our Institution between December 2021 and February 2023 were prospectively enrolled. In 53% of patients the pathology was present at more than two levels. According to CSS calculation, 14% of patients resulted in the "grey zone", where both an anterior and posterior approach were deemed feasible. Among them, in 42.8% of cases the CSS allowed a modification of the originally planned surgery. Looking at outcome, an improvement of m-JOA score in 62% of patients was disclosed. This preliminary study showed the reliability and usefulness of CSS in detecting complex DCM cases, requiring further analysis by expert spine surgeons, suggesting a surgical strategy.

Diagnostic Performance of Angiography-Derived Quantitative Flow Ratio in Complex Coronary Lesions.

Quantitative flow ratio derived from computed tomography angiography (CT-QFR) and invasive coronary angiography (Murray law-based quantitative flow ratio [μQFR]) are novel approaches enabling rapid computation of fractional flow reserve without the use of pressure guidewires and vasodilators. However, the feasibility and diagnostic performance of both CT-QFR and μQFR in evaluating complex coronary lesions remain unclear. Between September 2014 and September 2021, 240 patients with 30% to 90% coronary diameter stenosis who underwent both coronary computed tomography angiography and invasive coronary angiography with fractional flow reserve within 60 days were retrospectively enrolled. The diagnostic performance of CT-QFR and μQFR in detecting functional ischemia among all lesions, especially complex coronary lesions, was analyzed using fractional flow reserve as the reference standard. CT-QFR and μQFR analyses were performed on 309 and 289 vessels, respectively. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for CT-QFR in all lesions at the per-vessel level were 91% (with a 95% CI of 84%-96%), 92% (95% CI, 88%-95%), 83% (95% CI, 75%-90%), 96% (95% CI, 93%-98%), and 92% (95% CI, 88%-95%), with values for μQFR of 90% (95% CI, 81%-95%), 97% (95% CI, 93%-99%), 92% (95% CI, 84%-97%), 96% (95% CI, 92%-98%), and 94% (95% CI, 91%-97%), respectively. Among bifurcation, tandem, and moderate-to-severe calcified lesions, the diagnostic values of CT-QFR and μQFR showed great correlation and agreement with those of invasive fractional flow reserve, achieving an area under the receiver operating characteristic curve exceeding 0.9 for each complex lesion at the vessel level. Furthermore, the accuracies of CT-QFR and μQFR in the gray zone were 85% and 84%, respectively. Angiography-derived quantitative flow ratio (CT-QFR and μQFR) demonstrated remarkable diagnostic performance in complex coronary lesions, indicating its pivotal role in the management of patients with coronary artery disease.