Gray Zone Research Articles

Nucleos(t)ide analogs to treat patients with positive hepatitis B virus deoxyribonucleic acid and normal alanine transaminase: protocol for an open-label single-center randomized parallel controlled trial

BackgroundDirect high-quality evidence remains absent on the benefits of HBeAg-negative chronic hepatitis B patients (CHB) with normal alanine transaminase (ALT) and positive HBV DNA after nucleos(t)ide analogs (NAs) treatment.MethodsThis is a single-center, open-label, randomized parallel controlled trial with a follow-up duration of 96 weeks. An estimated 300 patients will be recruited at West China Hospital of Sichuan University, China. After stratified by serum HBV DNA (< 2000 vs. ≥ 2000 IU/ml), eligible patients will be randomized (allocation ratio 1:1) to receive either antiviral therapy (the treatment group) or regular examination alone (the control group). The primary outcomes are rates of virological response and changes in the levels of serum HBV pregenomic RNA (pgRNA) and scores of health-related qualities of life.DiscussionThis randomized controlled trial focuses on HBeAg-negative patients with normal ALT, including those of the inactive carrier phase and the grey zone, whose antiviral treatment remains controversial. Additionally, a health-related quality of life scale is introduced to comprehensively estimate the benefit of antiviral treatment apart from virological response and adverse liver events. Meaningfully, the study findings will provide high-quality and direct evidence for optimal clinical management in such populations.Trial registrationThis trial was registered with the Chinese Clinical Trial Registry (ChiCTR2300069391) on 15 March 2023.Graphical

Assessment of Y-90 Radioembolization Treatment Response for Hepatocellular Carcinoma Cases Using MRI Radiomics.

This study aimed to investigate the ability of radiomics features extracted from magnetic resonance imaging (MRI) images to differentiate between responders and non-responders for hepatocellular carcinoma (HCC) cases who received Y-90 transarterial radioembolization treatment. Thirty-six cases of HCC who underwent MRI scans after Y-90 radioembolization were included in this study. Tumors were segmented from MRI T2 images, and then 87 radiomic features were extracted through the LIFEx package software. Treatment response was determined 9 months after treatment through the modified response evaluation criteria in solid tumours (mRECIST). According to mRECIST, 28 cases were responders and 8 cases were non-responders. Two radiomics features, "Grey Level Size Zone Matrix (GLSZM)-Small Zone Emphasis" and "GLSZM-Normalized Zone Size Non-Uniformity", were the radiomics features that could predict treatment response with the area under curve (AUC)= 0.71, sensitivity= 0.93, and specificity= 0.62 for both features. Whereas the other 4 features (kurtosis, intensity histogram root mean square, neighbourhood gray-tone difference matrix strength, and GLSZM normalized grey level non-uniformity) have a relatively lower but acceptable discrimination ability range from AUC= 0.6 to 0.66. MRI radiomics analysis could be used to assess the treatment response for HCC cases treated with Y-90 radioembolization.

The value of adjusted PSAD in prostate cancer detection in the Chinese population.

To investigate the value of adjusted prostate-specific antigen density (PSADadj) in the diagnosis of prostate cancer (PCa). Data from 410 patients who underwent transrectal ultrasound-guided prostate biopsy were retrospectively analyzed in Beijing Tsinghua Changgung Hospital between November 2014 and March 2024. All patients were divided into PCa and benign prostatic hyperplasia (BPH) groups according to pathological results. Multivariate logistic regression analyses were performed to evaluate the odd ratios (ORs) of predictors for PCa occurrence. Receiver operating characteristic curves were plotted, and the area under the curve (AUC) values were used to assess and compare the diagnostic accuracies of total PSA (tPSA), free-to-total (f/t) PSA, free PSA (fPSA), PSAD, and PSADadj (PSAD×weight). There were 166 patients in the PCa group and 244 in the BPH group. Multivariate analyses demonstrated that PSAD was positively correlated with the presence of PCa, with the highest OR value among all PSA-related parameters (OR = 19.075, p<0.001). tPSA, fPSAD, PSAD, and PSADadj had high accuracy in predicting PCa, with AUC values of 0.633, 0.730, 0.778, and 0.780. Of note, PSADadj had the highest AUC with a sensitivity of 63.3% and specificity of 81.6%. Similarly, in patients with a PSA level in the gray zone, the diagnostic accuracy of PSADadj in predicting PCa (AUC, 0.709; 95% CI, 0.616-0.802) remained better than other PSA-related markers. PSADadj has an advantage over other PSA-related markers in detecting PCa and could be used for making biopsy decisions.

B-345 The PSA and free PSA Concentrations in Serum of Apparently Healthy Subjects Using the Atellica IM hsPSA and fPSAII Assays

Abstract Background PSA assays are recommended in the screening for prostate cancer (PC) among males 50 years and older. Those with PSA results in the gray zone (between 4 ng/mL and 10 ng/mL) and a nonsuspicious digital rectal examination (DRE) may be further tested with the free PSA (fPSA) assays to improve detection of PC. PSA and fPSA are also detected in apparently healthy subjects. The goal of this study was to evaluate the distribution of high sensitivity PSA (hsPSA), fPSAII, and %fPSAII (fPSAII/hsPSA x 100) values generated on the Atellica® IM Analyzer among apparently healthy subjects by age decade. Methods Serum samples were prospectively collected from apparently healthy subjects at multiple sites across the United States: 673 males 50-70+ years presenting at primary care facilities for routine PSA testing (&amp;gt;120 samples in each age decade (50-59, 60-69, 70+ years) and 113 samples in each of two younger decades (30-39, 40-49 years). Distribution statistics include the mean, median, interquartile range, 2.5th, 95th, and 97.5th percentiles. Results In this study, using samples from healthy men 30-70+ years (N=786), it was observed that median hsPSA results increased with every decade from 0.682 ng/mL at 30-39 years to 2.183 ng/mL at age 70+ years. The 97.5th percentiles were below 4.0 ng/mL in men &amp;lt;50 years, and above 4.0 ng/mL in men &amp;gt;50 years. All men (100%) 30-49 years had an hsPSA result below 4.0, and 95.5% of men 50-59 years had an hsPSA result below 4.0. The percent of subjects with hsPSA values above the cut-off of 4.0 was 6.6% among men 60-69 years and 12.4% among men &amp;gt;70 years. Median hsPSA values for each age group were comparable to median PSA values reported for healthy men older than 50 years old without cancer undergoing routine health check-ups in the United States and other countries (median hsPSA value was 0.90 among men 50-59 years). For both hsPSA and fPSAII, it was observed that average values increased with each successive decade for subjects 30-70+ years. The range across decades was 0.904-2.183 ng/mL for hsPSA and 0.23-0.46 ng/mL for fPSAII. However, the average %fPSAII (fPSA/hsPSAx100) values did not consistently rise over time because hsPSA variances also increase, a pattern previously documented. Conclusions The distribution of Atellica® IM hsPSA and fPSAII assay values from apparently healthy males was determined. CAUTION: Investigational Device. Not available for sale. Future availability cannot be guaranteed. The results are preliminary and were achieved in unique setting with no expected timeline for completion.

B-218 Inconclusive results in the Fetal Sex Determination from maternal plasma assay may indicate miscarriage

Abstract Background The purpose of this study was to evaluate the miscarriage rates from patients presenting inconclusive results in a cell-free DNA fetal sex determination test at Dasa, a Brazilian laboratory, between 2021 and 2023. Methods In validating the fetal sex determination test, a Ct value range was established to assign the presence of the Y chromosome on maternal plasma and a gray zone for determining an inconclusive result. In this case, our operational procedure is to repeat the analysis from the beginning, due to plasma volume limitation. When the result remains inconclusive upon repetition a new sample is requested.After the 2nd sample collection with inconclusive results, cases are forwarded to specialized medical contact, when patient is informed and potential explanations for the rare situation of a repeat-indeterminate sex determination result are discussed.At the end of 2022, the need to widen the sex-determining range and consequently the inconclusive zone was routinely perceived. The main reason for this change was to reduce unnecessary repetitions. Results The adjustments of range reduced unnecessary repetition, requests for new samples and medical contacts (Table). Between 2021 and 2023 the median gestational age at 1st collect of medical contact was 9 weeks, and in cases of miscarriages was 10 (2022) and 8 weeks (2023). Conclusions The widening of the Y chromosome Ct range proved to be efficient on a routine basis without changing the result error rates, which since 2021 have remained at 0.05%. In addition to providing more precision to the assay, the newly established gray zone increased the positive predictive value for miscarriage. Our results, show that what was thought to be a limitation of the technique in determining the fetal sex may in fact, in many cases, be associated to fetal loss

Postoperative irradiation in stage II thymomas: is it worth it?-shedding some light in the guidelines' gray zone.

Thymomas are rare, indolent tumors. Early stages (I-II) benefit from surgical treatment, while locally advanced diseases (stages III-IV) usually require a multidisciplinary approach. The role of postoperative radiotherapy (PORT) on anterior mediastinum for radically resected Masaoka-Koga stage II thymomas remains controversial. This study aims to determine the impact of PORT on the disease-free survival (DFS) of stage II thymomas. We retrospectively collected the clinical and oncologic data [age, sex, myasthenia gravis (MG) prevalence, Masaoka-Koga stage, World Health Organization (WHO) histologic subtype] of those patients who underwent radical exeresis in our Unit between January 2000 and December 2020. Kaplan-Meier estimates of DFS were then performed. Our study included 195 patients (M/F = 98/97). Almost all patients were affected by MG (90.7%) and most of them were operated by median sternotomy (93.3%). Thymoma stage was IIa in 87 cases (44.6%) and IIb in 108 cases (55.4%). The most represented histologic subtype was AB (27.7%), followed by B2 (24.6%), A (19%), B1 (14.9%) and B3 (13.8%). PORT was performed in 113 patients (58%, 39 stage IIa and 74 stage IIb). During the surveillance, 8 patients (4.1%) presented pleural recurrences and no local relapses. DFS was comparable in stage IIa and IIb patients, independently from PORT administration (p = .395 and p = .858, respectively). Moreover, PORT did not affect DFS considering the histologic subtypes (p = .304 for A and AB thymomas, p = .608 for B1, B2 and B3 thymomas). In our wide series, PORT administration didn't show any additional benefit on DFS. Therefore, based on our experience, patients with stage II thymoma who underwent radical surgery should not undergo any local adjuvant treatment.

Lower Limb Comprehensive Reconstructive Surgery: Experiences from an Orthopedic Teaching Unit

Abstract Introduction: The burden of open extremity fractures is well recognized in placing a burgeoning demand on an already exhausted medical facility in low- and middle-income countries. This study aims to evaluate the functional outcome following “orthoplastic management” by orthopedic surgeons trained in limb reconstruction surgery. Methodology: Adult patients with open lower limb injuries treated from January 1, 2022, to December 30, 2022, who underwent single or staged fixation and reconstruction procedures were identified. Patients with Gustilo–Anderson type IIIB fractures requiring skeletal stabilization with soft-tissue cover were included. Polytrauma patients requiring multidisciplinary surgical attention were excluded. A team of orthopedic surgeons trained in limb reconstruction was involved in the management. Inpatient and outpatient department follow-up by the treating team was done to document complications (infections, reoperations, and graft failures) and functional outcomes using the Lower Extremity Function Score. The duration of mean follow-up was 1 year since index surgery. Results: A total of 24 adult patients with open lower limb injuries with preoperative Ganga Hospital Score (GHS) were included. Decision toward fixation with primary closure or further reconstruction was made collectively. The gray zone (GHS score of 15–16) of patients was more aggressively managed with emphasis on salvage. Additional reconstructive procedures were carried out based on the assessment at consequent follow-up. Three patients had a suboptimal joint function (less than functional range of motion for the involved joint) due to the resultant loss of compartment(s) and joint contracture. Five patients were retaken to the theater for further supplementary or corrective procedures following the index, definitive surgical procedure (bone grafting, partial flap loss, and fixator readjustment). Conclusion: Good-to-excellent functional outcome was demonstrated with the “orthoplastic approach” where skeletal stabilization as well as soft-tissue reconstruction was performed by trained orthopedic surgeons. This study demonstrated that orthoplastic surgery is a safe and effective method of limb salvage.

Bisphenol F-induced precocious genesis of aggressive neurobehavioral response is associated with heightened monoamine oxidase activity and neurodegeneration in zebrafish brain

The production and use of plastics and plastics products has increased dramatically in recent decades. Moreover, their unprotected disposal into ambient life sustaining environment poses a significant health risk. Bisphenol F (BPF) an alternative to bisphenol A (BPA) has been extensively employed for making of plastics. Recent reports have documented the neurotoxic potential of BPF through induction of altered neurochemical profile, microglia-astrocyte-mediated neuroinflammation, oxidative stress, transformed neurobehavioral response, cognitive dysfunction, etc. In the present study, our approach was to understand the underlying mechanism of BPF-persuaded genesis of aggressive neurobehavioral response in zebrafish. The basic findings advocated a temporal transformation in native explorative behaviour and progressive induction of aggressive behavioural response in zebrafish following exposure to BPF. Our neurobehavioral findings supported the argument of oxidative stress-mediated neuromorphological transformation in the periventricular grey zone (PGZ) of the zebrafish brain. In line with earlier reports, our findings also showed that heightened monoamine oxidase (MAO) activity and downregulation in tyrosine hydroxylase expression in the zebrafish brain is associated with the precocious genesis of aggressive neurobehavioral response in zebrafish brain. Our findings also shed light on BPF-instigated apoptotic neuronal death as revealed by augmented chromatin condensation and cleaved caspase-3 expression. Further observation showed that the downregulation of NeuN (a marker of post-mitotic mature neuron) expression provided substantial neurotoxicity, leading to neurodegeneration in the PGZ region of the zebrafish brain. These basic findings grossly advocate that BPF acts as a potent neurotoxicant in transmuting native neurobehavioral response through the induction of oxidative stress, heightened MAO activity and neuromorphological transformation in the zebrafish brain.

Understanding species limits through the formation of phylogeographic lineages.

The outcomes of speciation across organismal dimensions (e.g., ecological, genetic, phenotypic) are often assessed using phylogeographic methods. At one extreme, reproductively isolated lineages represent easily delimitable species differing in many or all dimensions, and at the other, geographically distinct genetic segments introgress across broad environmental gradients with limited phenotypic disparity. In the ambiguous gray zone of speciation, where lineages are genetically delimitable but still interacting ecologically, it is expected that these lineages represent species in the context of ontology and the evolutionary species concept when they are maintained over time with geographically well-defined hybrid zones, particularly at the intersection of distinct environments. As a result, genetic structure is correlated with environmental differences and not space alone, and a subset of genes fail to introgress across these zones as underlying genomic differences accumulate. We present a set of tests that synthesize species delimitation with the speciation process. We can thereby assess historical demographics and diversification processes while understanding how lineages are maintained through space and time by exploring spatial and genome clines, genotype-environment interactions, and genome scans for selected loci. Employing these tests in eight lineage-pairs of snakes in North America, we show that six pairs represent 12 "good" species and that two pairs represent local adaptation and regional population structure. The distinct species pairs all have the signature of divergence before or near the mid-Pleistocene, often with low migration, stable hybrid zones of varying size, and a subset of loci showing selection on alleles at the hybrid zone corresponding to transitions between distinct ecoregions. Locally adapted populations are younger, exhibit higher migration, and less ecological differentiation. Our results demonstrate that interacting lineages can be delimited using phylogeographic and population genetic methods that properly integrate spatial, temporal, and environmental data.

Towards a Decolonial and Anti‐Racist Analysis of the Nation‐State and Nationalism

ABSTRACTThis paper addresses two calls emerging out of Sociological theory—against methodological nationalism and methodological whiteness—in relation to the study of nations, nation‐states and nationalisms. Building on Meghji's synergy of decolonial and race critical theory, I propose a historicized and globalized analysis of nationalisms and the nation‐state which can respond to these calls whilst also being attentive to the nation‐state and nationalism as sites of violence. I insist upon the importance of understanding ‘race’ and coloniality as foundational aspects to the emergence and functioning of nationalisms and nation‐states. I do so based on the empirical case of the nation‐state Romania and Romanian nationalism, what I call a ‘colonial gray zone’. I argue: (1) that modern colonialism and imperialism shaped the emergence of nation‐states and that, as a result, coloniality shapes the functioning of nation‐states and nationalisms; (2) that modern/colonial ‘race’ is central to the emergence and operation of nation‐states and nationalisms. Ultimately, I urge those concerned with the study of nations, nation‐states and nationalisms to shift their analytical tools towards coloniality and racism, and the scholarship and struggles against them.

Two Decades of High-Resolution Peripheral Quantitative Computed Tomography: Present and Future Clinical Perspectives.

Twenty years have passed since the introduction of high-resolution peripheral quantitative computed tomography (HR-pQCT) to assess human bone microarchitecture. During that time, the technique has emerged as an important research tool used by clinicians and scientists to learn about the pathophysiology of bone adaptation in the context of osteoporosis and many other bone-affected conditions. Its rich three-dimensional data is well suited for precise longitudinal monitoring of bone microarchitecture and associated patient-specific estimated bone strength.However, uptake of HR-pQCT as a clinical diagnostic tool has been limited, in part due to challenges such as availability, regulatory approvals, and demonstrated cost effectiveness. New research suggests fracture risk assessment using HR-pQCT is comparable with current standards based on traditional bone densitometry, but its contribution to clinical care is best suited to two areas: (1) leveraging microarchitectural information to assist in treatment decisions for the large subset of patients who lie in the so-called gray zone by current fracture risk assessment, and (2) longitudinal monitoring that establishes highly refined trajectories of bone adaptation and can inform decisions to initiate treatment, monitor treatment effects, and inform cessation.

In the gray zone: How representational deficit moderates the effect of openness on protest participation

This article investigates how the governmental status quo alters the effect of individuals’ openness as a predisposition for protest participation. We define the governmental status quo as individuals’ standing or position within the political system, contingent upon their party’s current status in government. Based on this, we clasify voters into three groups: Opposition voters, junior coalition partners’ voters (JCPV), and senior coalition partners’ voters (SCPV) or single-party government voters (SPGV). SCPV and SPGV are expected to have lower protest motivation due to their substantial governmental representation, whereas opposition voters, with lacking any governmental representation, are more likely to be motivated to protest. Nevertheless, given their fuzzy position that alleviates the effect of the representational deficit on their protest behavior, we argue that the protest participation of JCPV is more likely to be driven by their basic values belonging to the openness dimension. Statistical analyses based on data from the European Social Survey support our hypothesis, highlighting the stronger effect of stimulation, one of the components of the openness dimensions in Schwart's basic human values, for the JCPV compared to other voter categories.

Navigating the gray zone: Machine learning can differentiate malignancy in PI-RADS 3 lesions

IntroductionThe objective of this study is to predict the probability of prostate cancer in PI-RADS 3 lesions using machine learning methods that incorporate clinical and mpMRI parameters. MethodsThe study included patients who had PI-RADS 3 lesions detected on mpMRI and underwent fusion biopsy between January 2020 and January 2024. Radiological parameters (Apparent diffusion coefficient (ADC), tumour ADC/contralateral ADC ratio, Ktrans value, periprostatic adipose tissue thickness, lesion size, prostate volume) and clinical parameters (age, body mass index, total prostate specific antigen, free PSA, PSA density, systemic inflammatory index, neutrophil-lymphocyte ratio [NLR], platelet lymphocyte ratio, lymphocyte monocyte ratio) were documented. The probability of prostate cancer prediction in PI-RADS 3 lesions was calculated using 6 different machine-learning models, with the input parameters being the aforementioned variables. ResultsOf the 235 participants in the trial, 61 had malignant fusion biopsy pathology and 174 had benign pathology. Among 6 different machine learning algorithms, the random forest model had the highest accuracy (0.86±0.04; 95% CI 0.85–0.87), F1 score (0.91±0.03; 95% CI 0.91–0.92) and AUC value (0.92±0.06; 95% CI 0.88–0.90). In SHAP analysis based on random forest model, tumour ADC, tumour ADC/contralateral ADC ratio and PSA density were the 3 most successful parameters in predicting malignancy. On the other hand, systemic inflammatory index and neutrophil lymphocyte ratio showed higher accuracy in predicting malignancy than total PSA, age, free PSA/total PSA and lesion size in SHAP analysis. ConclusionAmong the machine learning models we developed, especially the random forest model can predict malignancy in PI-RADS 3 lesions and prevent unnecessary biopsy. This model can be used in clinical practice with multicentre studies including more patients.

Multiplex Determination of Glycan Profiles on Urinary Prostate-Specific Antigen by Quartz-Crystal Microbalance Combined with Surface-Enhanced Raman Scattering.

Prostate cancer remains a major health concern, with prostate-specific antigen (PSA) being a key biomarker for its detection and monitoring. However, PSA levels often fall into a "gray zone", where PSA levels are not clearly indicative of cancer, thus complicating early diagnosis and treatment decisions. Glycosylation profiles, which often differ between healthy and diseased cells, have emerged as potential biomarkers to enhance the specificity and sensitivity of cancer diagnosis in these ambiguous cases. We propose the integration of two complementary techniques, namely quartz-crystal microbalance with dissipation (QCM-D) and surface-enhanced Raman scattering (SERS) to study PSA glycan profiles. QCM-D offers real-time operation, PSA mass quantification, and label-free detection with high sensitivity, as well as enhanced specificity and reduced cross-reactivity when using nucleic acid aptamers as capture ligands. Complementary SERS sensing enables the determination of the glycosylation pattern on PSA, at low concentrations and without the drawbacks of photobleaching, thereby facilitating multiplexed glycosylation pattern analysis. This integrated setup could retrieve a data set comprising analyte concentrations and associated glycan profiles in relevant biological samples, which may eventually improve early disease detection and monitoring. Prostate-specific antigen (PSA), a glycoprotein secreted by prostate epithelial cells, serves as our proof-of-concept analyte. Our platform allows multiplex targeting of PSA multiplex glycosylation profiles of PSA at "gray zone" concentrations for prostate cancer diagnosis. We additionally show the use of SERS for glycan analysis in PSA secreted from prostate cancer cell lines after androgen-based treatment. Differences in PSA glycan profiles from resistant cell lines after androgen-based treatment may eventually improve cancer treatment.

MRI textural plasticity in limbic gray matter associated with clinical response to electroconvulsive therapy for psychosis.

Electroconvulsive therapy (ECT) is effective against treatment-resistant psychosis, but its mechanisms remain unclear. Conventional volumetry studies have revealed plasticity in limbic structures following ECT but with inconsistent clinical relevance, as they potentially overlook subtle histological alterations. Our study analyzed microstructural changes in limbic structures after ECT using MRI texture analysis and demonstrated a correlation with clinical response. 36 schizophrenia or schizoaffective patients treated with ECT and medication, 27 patients treated with medication only, and 70 healthy controls (HCs) were included in this study. Structural MRI data were acquired before and after ECT for the ECT group and at equivalent intervals for the medication-only group. The gray matter volume and MRI texture, calculated from the gray level size zone matrix (GLSZM), were extracted from limbic structures. After normalizing texture features to HC data, group-time interactions were estimated with repeated-measures mixed models. Repeated-measures correlations between clinical variables and texture were analyzed. Volumetric group-time interactions were observed in seven of fourteen limbic structures. Group-time interactions of the normalized GLSZM large area emphasis of the left hippocampus and the right amygdala reached statistical significance. Changes in these texture features were correlated with changes in psychotic symptoms in the ECT group but not in the medication-only group. These findings provide in vivo evidence that microstructural changes in key limbic structures, hypothetically reflected by MRI texture, are associated with clinical response to ECT for psychosis. These findings support the neuroplasticity hypothesis of ECT and highlight the hippocampus and amygdala as potential targets for neuromodulation in psychosis.

Population-based FMR1 carrier screening among reproductive women.

Fragile X syndrome (FXS) is a neurodevelopmental disorder, caused by an CGG repeat expansion (FM, > 200 CGG) in the fragile X messenger ribonucleoprotein 1 (FMR1) gene. Female carriers of a premutation (PM; 55-200 CGG) can transmit the PM allele, which, depending on the CGG allele size, can expand to an allele in the FM range in the offspring. Carrier screening for FMR1 PM is not available in Thailand. This study aimed to investigate the prevalence of PM carriers among Thai reproductive women at the tertiary hospital. A total of 1250 females participated in this study; ages ranged from 20 to 45years, mean of 30years (S.D. = 6.27). Two carriers of a premutation allele, with 32,62 and 32,69 CGG repeats respectively, were identified. This corresponds to 1 in 600 women or 0.17% of the population. Further, three women carrying a gray zone allele (45-54 CGG repeats) were identified (29,51; 29,49; and 30,47 CGG repeats) which equals to 1:400 women or 0.25% of the population. No FM case was detected. This study heightens the importance of PM carrier screening of women of reproductive age, particularly for the higher risk of developing fragile X-associated primary ovarian insufficiency (FXPOI). Early identification of PM carrier status enhances family planning and fecundity alternatives and improves reproductive health outcomes leading to a better life.

Quantitative real time PCR for distinction between Pneumocystis jirovecii infection/colonization in hospitalized patients.

Identification of the opportunistic fungus Pneumocystis jirovecii in respiratory specimens presents challenges, particularly in differentiating between colonization and active infection. The present study assessed a probe-based real time PCR (qPCR) diagnostic effectiveness in patients with diverse underlying conditions, particularly those with COVID-19 and pulmonary insufficiency. To set up the qPCR, clinical samples from 281 patients with respiratory ailments were tested. Subsequently, a descriptive study was conducted on 112 patients with pulmonary insufficiency with and without COVID-19 suspected of P. jirovecii infection. All specimens were subjected to DNA extraction followed by nested PCR and qPCR targeting the mitochondrial large subunit (mtLSU)-rRNA gene. Based on nested PCR and qPCR, P. jirovecii was identified in 40 out of 281 patients, with slight variations in positive samples observed across dilutions. Three patients who tested positive in nested PCR yielded negative results in probe-based qPCR. Conversely, three patients who tested positive in probe-based qPCR yielded negative results in nested PCR. Considering nested PCR as the golden standard, probe-based qPCR demonstrated good diagnostic performance, with 92.5% sensitivity and 98.7% specificity. Based on cycle threshold (Ct) values, the positive cases were categorized: ≤32 as infection, >35 as colonization, and a grey zone between these values (32 < X ≤ 35). The analysis of 112 PCP-suspected patients revealed a prevalence ranging from 6.25% (nested PCR) to 7% (probe-based qPCR). This study suggested Ct values to differentiate Pneumocystis pneumonia/colonization in immunocompromised patients. To further augment the diagnostic sensitivity, it is recommended to integrate qPCR results with clinical parameters and biomarkers to offer a more precise understanding of Pneumocystis-related conditions.

Biomarkers of Hemodynamic Congestion in Heart Failure.

The purpose of this review is to describe the evidence behind various blood and imaging-based biomarkers that can improve the identification of congestion when not clearly evident on routine examination. The natriuretic peptides (NPs) BNP and NT-proBNP have been shown to closely correlate with intra-cardiac filling pressures, both at baseline and when trended following improvement in congestion. Additionally, NPs rise well before clinical congestion is apparent so can be used as a tool to help identify subclinical HF decompensation. Additional serum-based biomarkers including MR-proANP and CA-125 can be helpful in assisting with diagnostic certainty when BNP or NT-proBNP are in the "grey zone" or when factors are present which may confound NP levels. Additionally, the emerging use of ultrasound techniques may enhance our ability to fine-tune the assessment and treatment of congestion. Biomarkers, including the blood-based natriuretic peptides and markers on bedside point of care ultrasound, can be used as non-invasive indices of hemodynamic congestion. These biomarkers are particularly valuable to incorporate when the degree of a patient's congestion is not apparent on clinical exam, and they can provide important prognostic information and help guide clinical management.

Cyber intelligence and international security. Breaking the legal and diplomatic silence?

ABSTRACT In cyberspace intelligence agencies, rather than militaries, are the most prominent security actors. However, many cyber operations conducted by intelligence agencies are not ‘classic’ espionage activities, but may be best described as digital covert action (sabotage, subversion, information operations). Given the fact that international law and diplomacy traditionally do not address espionage, cyber operations conducted by intelligence agencies have developed in a legal grey zone that gets stretched by the behaviour of the intelligence agencies of the most brazen cyber powers. The digital age has significantly transformed the capabilities and the role of intelligence agencies, which raises the question if the traditional international consensus that ‘intelligence is not discussed’ is still useful in state-to-state relations. The theoretically underdefined role and activities of intelligence agencies are affected by four big changes in the digital age: increase in scale of their activities and effects, heightened ambiguity, massive expansion of the attack surface and trickle-down insecurity, which point to a need to rethink how cyber intelligence agencies should operate. Some states will continue to push the boundaries of what is possible in cyberspace, unless other states break with the legal and diplomatic silence to discuss ‘guardrails’ to cyber intelligence activities.

Analisis Penggunaan Model Zmijewski (X-Score) dan Altman (Z-Score) untuk Memprediksi Potensi Kebangkrutan pada PT Waskita Karya Persero Tbk

This study aims to predict the potential bankruptcy of PT Waskita Karya Persero Tbk. Quantitative descriptive research type. The population used is the financial statements of PT Waskita Karya Persero Tbk with a sample of financial position reports and income statements from 2018-2023. Research data collection was carried out using documentation and literature studies. The analysis technique is the Zmijewski model (X-Score) with the three ratios, namely return on assets, debt ratio, current ratio and Altman model (Z-Score) with four ratios, namely the ratio of working capital to total assets, retained earnings to total assets, earning before interest and taxes to taotal assets, book value of equity to book value of debt. The research results of the Zmijewski model (X-Score) show that PT Waskita Karya Persero Tbk in 2018 is predicted to be a healthy company because the X-Score value is below the value of 0, in 2019-2023 it is predicted that the company has the potential fo bankruptcy because the X-Score value is above the value of 0. Meanwhile the Altman (X-Score) model shows that PT Waskita Karya Persero Tbk in 2018 is in gray zone because the Z-Score value is between 1.1 and 2.60, in 2019-2023 it is ini the danger zone because the Z-Score value is below the value of 1.1.