Grey Area Research Articles

Rational Antibiotic Prescribing Is Underpinned by Dental Ethics Principles: Survey on Postgraduate and Undergraduate Dental Students' Perceptions.

Dentists bear the burden of responsibility for antimicrobial resistance since antibiotics are the drugs most prescribed by dentists. Often, "inappropriate" antibiotic use is considered as a "gray area" by dentists mainly due to ethical challenges associated with the clinical judgement depending on patients and/or prescribers. The study aimed to assess whether and in what way dental ethical principles underpin rational antibiotic use by investigating perceptions of postgraduate and undergraduate dental students without formal knowledge of dental ethics. A cross-sectional anonymous survey comprised nine close-ended questions and was conducted among dental students (n = 125). The investigated practice of appropriate antibiotic prescribing in the survey relied on the respect of three basic principles of ethics: autonomy, non-maleficence, and beneficence. Results show that dental students exhibit a lack of dental ethics knowledge that results in an inappropriate antibiotic-prescribing practice: prescribing an antibiotic when it is not necessary, without examination, or for indications that are not within the competence of the dentist. Multivariate regression analysis revealed that there was a significant difference between under- and postgraduates. Within the pharmacology course, a review of the clinical scenarios which cover both ethical and clinical complexities regarding the appropriate use of antibiotics should be introduced as an educational approach.

The gray area of RQ-PCR-based measurable residual disease: subdividing the “positive, below quantitative range” category

The gray area of RQ-PCR-based measurable residual disease: subdividing the “positive, below quantitative range” category

The marbling of carcases is determined more by the characteristics of the animals themselves than by farming practices

Improved marbling could be of great benefit to the beef industry, responding more effectively to consumer preferences and increasing the market value of the product. To identify the management elements that could determine the degree of marbling of carcases, 128 cows were collected on six different farms, each using different breeding and feeding practices. Multiple statistical tests were carried out to determine whether marbling was more influenced by animal characteristics than by management practices. As expected, within the same farm, the practices used to finish the cows were the same from one animal to the next. We confirm that there was indeed a general level of marbling per farm (highly marbled animals coming from farms ‘used’ to producing highly marbled animals), without being able to determine the weight of genetic choices or feeding and management practices in this determinism. However, we were able to establish that very high marbled carcases came from heavier slaughtered animals and were associated with (1) management that maximised finishing times and time spent on grass (during the animal’s life) and (2) finishing diets rich in maize (grain or silage) and containing flax. The practices and performances associated with low and medium marbling carcases were difficult to separate using the indicators available in this study but were opposite to those of high marbling carcases. This ‘overall level of marbling’ on the farm makes it possible to prioritise the practices that favour or do not favour the development of marbling on the carcase, and allows to formulate advice to breeders to increase the marbling of their carcases. However, there are still grey areas to be covered to effectively achieve a maximum success rate, which will require further work and a more detailed characterisation of the practices and genetic orientations of the animals.

Heterogeneity, Bayesian thinking, and phenotyping in critical care: A primer.

To familiarize clinicians with the emerging concepts in critical care research of Bayesian thinking and personalized medicine through phenotyping and explain their clinical relevance by highlighting how they address the issues of frequent negative trials and heterogeneity of treatment effect. The past decades have seen many negative (effect-neutral) critical care trials of promising interventions, culminating in calls to improve the field's research through adopting Bayesian thinking and increasing personalization of critical care medicine through phenotyping. Bayesian analyses add interpretive power for clinicians as they summarize treatment effects based on probabilities of benefit or harm, contrasting with conventional frequentist statistics that either affirm or reject a null hypothesis. Critical care trials are beginning to include prospective Bayesian analyses, and many trials have undergone reanalysis with Bayesian methods. Phenotyping seeks to identify treatable traits to target interventions to patients expected to derive benefit. Phenotyping and subphenotyping have gained prominence in the most syndromic and heterogenous critical care disease states, acute respiratory distress syndrome and sepsis. Grouping of patients has been informative across a spectrum of clinically observable physiological parameters, biomarkers, and genomic data. Bayesian thinking and phenotyping are emerging as elements of adaptive clinical trials and predictive enrichment, paving the way for a new era of high-quality evidence. These concepts share a common goal, sifting through the noise of heterogeneity in critical care to increase the value of existing and future research. The future of critical care medicine will inevitably involve modification of statistical methods through Bayesian analyses and targeted therapeutics via phenotyping. Clinicians must be familiar with these systems that support recommendations to improve decision-making in the gray areas of critical care practice.

Study on the Determination of the Nature of Trademark Dilution--Taking the "Lao Gan Ma Case" as an Example

China's current legislation does not make clear provisions for the dilution of well-known trademarks, resulting in difficulties in identifying dilution cases in practice. One such notable instance is the "Lao Gan Ma" dispute, which serves as a telling example of this legal gray area. Consequently, it becomes imperative to delve into typical cases like the "Lao Gan Ma Case" to gain clarity on the disputed actions' legal nature, and then demonstrate how the dilution theory can be applied in the determination of specific cases. Utilizing the case study method, this paper aims to examine a particular case of trademark dilution in detail. The initial focus is on clarifying the concept of trademark dilution and its constituent elements of determination. This theoretical foundation is essential for accurately analyzing the nature of the complained-of infringing act. The significance of this paper is to theoretically solve the problem of determining the nature of dilution under the system of China's Trademark Law, to provide a reference for the determination of the same type of cases in the future, and hopefully to provide ideas for the future legislation on trademark dilution in China.

Addressing hidden tensions and grey areas of general practice: a qualitative study of the experiences of newly qualified GPs attending a course on generalist medicine.

Generalist approaches can help address several challenges facing today's primary care. However, GPs report insufficient support to deliver advanced generalist medicine (AGM) in daily practice, struggling within a healthcare system that imposes strict adherence to single-disease focused guidelines. To examine the professional and educational experiences of newly qualified GPs attending a course on AGM to understand how to redesign primary care systems to support their generalist work. This was a qualitative study focusing on AGM in UK general practice (England), conducted in the context of the research evaluation of an online career development programme on AGM. We conducted 36 interviews and six focus groups with newly qualified GPs attending an online career development programme on AGM, and analysed data using framework analysis. Three tensions experienced by the participants were identified: tension between realistic and idealistic practice; tension between different decision-making paradigms; and tension in the formation of the GPs' professional identities. These were owing to grey areas of practice deeply rooted in primary care systems - namely areas of work not adequately addressed by current education and service design. Our findings have implications for tackling the general practice workforce crisis, highlighting that solutions targeting individual problems will not suffice by themselves. By making visible the grey areas of everyday general practice, we describe the changes needed to target tensions as described by the GPs in this study to ultimately enable, enhance and make visible the complex work of generalist medicine.

The grey side of influencer marketing: Content, contexts, and consequences

AbstractThe wall of differentiation between genuine recommendations by social media influencers and brand‐sponsored promotions has become thinner since brands are increasingly sponsoring influencers to promote their products and services. This study has followed a qualitative research method using the grounded theory approach to conduct in‐depth, one‐to‐one, semi‐structured interviews with 25 social media users to delve into influencers' brand paid promotions and sponsorship disclosure, which marks a grey area in influencer marketing. The results delineate the grey characteristics of influencers through three main themes: (1) Disclosure of paid promotions/ non‐promotions (i.e., content factors), (2) Consumer conviction conundrum (i.e., context factors), and (3) Social media users' avoidance behaviour (i.e., consequences). This study also defines ‘Sinfluencer’ (i.e., commercially motivated influencers who hide their paid partnerships) and elucidates ‘evaluation’ as a critical step, thereby extending the discussion on the social media engagement cycle.

Testing Indonesia’s decisiveness: Vietnam’s continuous presence in the North Natuna Seas

In December 2022, Indonesia and Vietnam concluded the EEZ boundary lines that have been under negotiations for 12 years. Through this, it is expected that intrusions made by Vietnamese maritime constabulary forces into Indonesia’s North Natuna Seas can end. On the contrary, intrusions have risen in the first 8 months of 2023, indicating Vietnam’s intent to continue its maritime-based operations in the gray-zone areas of Indonesian waters. In making sense of this developing crisis, this article adopts secondary data from the Indonesia Open Justice Initiative between January 2023 and August 2023. In tracking the instances of intrusions, it utilizes an Automatic Identification System obtained from Marine Traffic. The analysis is made by framing the crisis under the maritime diplomatic framework, which concludes that Vietnam is persistent with its maritime diplomatic strategy of “paragunboat diplomacy” in showcasing effective occupancy in gray zone areas.

Pattern Recognition of EFL University Students’ Online Behaviors through Data Science: Any Investment on English Language Components or Skills?

Artificial intelligence (AI) has played a crucial role in many fields of study, and its merits and demerits have been investigated by related scholars. However, it seems a somewhat gray area when implementing AI in teaching and learning. This could be mainly because AI developers know little about learning varied sciences and they also lack pedagogical knowledge for implementing AI in teaching (Luckin & Cukurova, 2019). Therefore, the current research aimed at gathering data regarding the online behaviors of 21 Iranian EFL university students through installing an application on their mobile phones for a period of eight days. Afterwards, the collected data were analyzed through Data Science methods and varied patterns of behavior were recognized. The results exhibited that messaging and social media applications are two great parts of the students’ life. Also, there existed some common patterns regarding the applications students owned and the amount of time they spent on them. As a small case in point, the results of the study cannot be generalized; however, the outcomes highlight the proof that in an EFL context, serious steps need to be adopted by course designers and stakeholders in order to cultivate a greater and purposeful use of online learning applications, websites etc. among EFL university students so as to enhance the teaching-learning process. This gains prominence because any AI-mediated learning approach is believed to enhance students’ second/foreign language motivation as well as self-regulation in learning. AI is actually promising a revolution in the realm of language education.

Understanding the configurational causes of traveler's moral ambiguity in the sharing economy: Evidence from PLS‐fsQCA

AbstractAlthough the sharing economy in tourism has garnered much positive attention, perennial ethical gray areas have been ignored. Drawing upon the ecological systems theory, we investigate the influence of different systemic factors, classified as individual differences and environmental context, on the ethical behavior of travelers (i.e., reporting malfunctions in a bike‐sharing context and saving water/electricity in a peer‐to‐peer accommodation context). PLS‐SEM and fsQCA are applied to analyze and examine proposed hypotheses. The results complement the factor configuration differences between the two behaviors. Moreover, this study provides new insights into the regulatory guidelines for shared service operators in the tourism industry.

External dacryocystorhinostomy: A critical overview of the current evidence.

External dacryocystorhinostomy (ext-DCR) is still considered the gold standard in the treatment of distal lacrimal duct obstruction. Despite an overall high success rate, some patients do relapse after surgery and the ideal perioperative management has not been identified yet. The purpose of this study is to critically discuss the published evidence in the last five years on the medical and surgical management of external dacryocystorhinostomy. Furthermore, the drawbacks of the available literature and the perspectives in this field will be also highlighted. Systematic review of the literature in the last 5 years by using PubMed and Google Scholar. A total of 64 articles were included. Many technical modifications and surgical refinements have been proposed but a formal comparison among the various techniques is hampered by methodological heterogeneity. The use of local anesthesia, and the perioperative adjunctive techniques to reduce the risk of restenosis are also gaining popularity but the level of evidence remains weak. Ext-DCR offers satisfactory clinical outcomes even though there are many gray areas that need to be addressed in future high-quality studies.

Current Evidence in the Management of Central Skull Base Osteomyelitis: A Systematic Review

Objectives Based on current evidence, this systematic review focuses on various gray areas related to these patients' diagnosis, management, and follow-up in central skull base osteomyelitis (CSBO). Study Design A systematic review of all case reports and observational studies. Methods We systematically searched PubMed, Scopus database, Cochrane database, U.K. clinicaltrails.gov registry, and World Health Organization International Clinical Trials Registry Platform and included all reports as per our inclusion criteria. Data was analyzed systematically, and we made essential observations. Results Out of 179 articles, 25 were selected according to inclusion criteria and quality assessment. Among the 44 patients, refractory headache (95%) was the most common presentation, followed by cranial nerve paralysis (82%) and Pseudomonas (32%) as the most common bacteria. Contrary to the available literature the disease cure was worse in those who underwent targeted biopsy (64% vs. 36%, p = 0.023) and surgical debridement (61% vs. 39%, p = 0.013) in the late stages of the disease. Conclusion Otogenic osteomyelitis can spread to central skull bones in the absence of obvious ear symptoms. Early diagnosis and intervention of CSBO before progression to late stages can help decrease significant morbidity and mortality.

The health risks of generative AI-based wellness apps.

Artificial intelligence (AI)-enabled chatbots are increasingly being used to help people manage their mental health. Chatbots for mental health and particularly 'wellness' applications currently exist in a regulatory 'gray area'. Indeed, most generative AI-powered wellness apps will not be reviewed by health regulators. However, recent findings suggest that users of these apps sometimes use them to share mental health problems and even to seek support during crises, and that the apps sometimes respond in a manner that increases the risk of harm to the user, a challenge that the current US regulatory structure is not well equipped to address. In this Perspective, we discuss the regulatory landscape and potential health risks of AI-enabled wellness apps. Although we focus on the United States, there are similar challenges for regulators across the globe. We discuss the problems that arise when AI-based wellness apps cross into medical territory and the implications for app developers and regulatory bodies, and we outline outstanding priorities for the field.

Management of the axilla in breast cancer patients: critical review, regional modified Delphi consensus and implementation in the Tuscan breast network.

Data from recently trials have provided practice-changing recommendations in management of the axilla in early breast cancer (eBC). However, further controversies have been raised, resulting in heterogeneous diffusion of these recommendations. Our purpose was to obtain a better homogeneity. In 2021, the Tuscan Breast Network (TBN) established a consensus with the aim to update recommendations in this area. We performed a literature review on axillary management in eBC patients which led to an expert Delphi consensus aiming to explore the gray areas, build consensus and propose evidence-based suggestions for an appropriate management. Thereafter, we investigate their implementation in clinical practice. (1) DCIS patients should have SLN biopsy only in case of mastectomy or in conservative surgery if tumor is in a location that would preclude future nodal sampling or in case of a mass; (2) ALND may be omitted for 1-2 positive SLN patients undergoing BCS in T1-2 tumors with 1-2 SLN positive, eligible for whole-breast irradiation and adjuvant systemic therapies; (3) consider the option of RNI in patients with 1-3 positive lymph nodes and one or more high-risk characteristics; (4) the population identified in 2) should NOT undergo lymph node irradiation as an alternative to axillary surgery and (5) patients with clinically (pre-operatively) positive axilla, or undergoing primary systemic therapy, or outside the criteria reported in 2) must receive additional ALND and/or RT as per local policy. This consensus provided a practical tool to stimulate local and national breast surgical and radiotherapy protocols.

Is Life Binary or Gradual?

The binary nature of life is deeply ingrained in daily experiences, evident in the stark distinctions between life and death and the living and the inert. While this binary perspective aligns with disciplines like medicine and much of biology, uncertainties emerge in fields such as microbiology, virology, synthetic biology, and systems chemistry, where intermediate entities challenge straightforward classification as living or non-living. This contribution explores the motivations behind both binary and non-binary conceptualizations of life. Despite the perceived necessity to unequivocally define life, especially in the context of origin of life research and astrobiology, mounting evidence indicates a gray area between what is intuitively clearly alive and what is distinctly not alive. This prompts consideration of a gradualist perspective, depicting life as a spectrum with varying degrees of "lifeness". Given the current state of science, the existence or not of a definite threshold remains open. Nevertheless, shifts in epistemic granularity and epistemic perspective influence the framing of the question, and scientific advancements narrow down possible answers: if a threshold exists, it can only be at a finer level than what is intuitively taken as living or non-living. This underscores the need for a more refined distinction between the inanimate and the living.

Clinical and Brain Morphometry Predictors of Deep Brain Stimulation Outcome in Parkinson’s Disease

Subthalamic deep brain stimulation (STN-DBS) is known to improve motor function in advanced Parkinson’s disease (PD) and to enable a reduction of anti-parkinsonian medication. While the levodopa challenge test and disease duration are considered good predictors of STN-DBS outcome, other clinical and neuroanatomical predictors are less established. This study aimed to evaluate, in addition to clinical predictors, the effect of patients’ individual brain topography on DBS outcome. The medical records of 35 PD patients were used to analyze DBS outcomes measured with the following scales: Part III of the Unified Parkinson’s Disease Rating Scale (UPDRS-III) off medication at baseline, and at 6-months during medication off and stimulation on, use of anti-parkinsonian medication (LED), Abnormal Involuntary Movement Scale (AIMS) and Non-Motor Symptoms Questionnaire (NMS-Quest). Furthermore, preoperative brain MRI images were utilized to analyze the brain morphology in relation to STN-DBS outcome. With STN-DBS, a 44% reduction in the UPDRS-III score and a 43% decrease in the LED were observed (p<0.001). Dyskinesia and non-motor symptoms decreased significantly [median reductions of 78,6% (IQR 45,5%) and 18,4% (IQR 32,2%) respectively, p=0.001 – 0.047]. Along with the levodopa challenge test, patients’ age correlated with the observed DBS outcome measured as UPDRS-III improvement (ρ= -0.466 – -0.521, p<0.005). Patients with greater LED decline had lower grey matter volumes in left superior medial frontal gyrus, in supplementary motor area and cingulum bilaterally. Additionally, patients with greater UPDRS-III score improvement had lower grey matter volume in similar grey matter areas. These findings remained significant when adjusted for sex, age, baseline LED and UPDRS scores respectively and for total intracranial volume (p=0.0041- 0.001). However, only the LED decrease finding remained significant when the analyses were further controlled for stimulation amplitude. It appears that along with the clinical predictors of STN-DBS outcome, individual patient topographic differences may influence DBS outcome. Clinical Trial Registration Number: NCT06095245, registration date October 23, 2023, retrospectively registered

Facial expression recognition ability and its neuropsychological mechanisms in children with attention deficit and hyperactive disorder.

Attention deficit and hyperactive disorder (ADHD) is a chronic neurodevelopmental disorder characterized by inattention, hyperactivity-impulsivity, and working memory deficits. Social dysfunction is one of the major challenges faced by children with ADHD. It has been found that children with ADHD can't perform as well as typically developing children on facial expression recognition (FER) tasks. Generally, children with ADHD have some difficulties in FER, while some studies suggest that they have no significant differences in accuracy of specific emotion recognition compared with typically developing children. The neuropsychological mechanisms underlying these difficulties are as follows. First, neuroanatomically. Compared to typically developing children, children with ADHD show smaller gray matter volume and surface area in the amygdala and medial prefrontal cortex regions, as well as reduced density and volume of axons/cells in certain frontal white matter fiber tracts. Second, neurophysiologically. Children with ADHD exhibit increased slow-wave activity in their electroencephalogram, and event-related potential studies reveal abnormalities in emotional regulation and responses to angry faces when facing facial stimuli. Third, psychologically. Psychosocial stressors may influence FER abilities in children with ADHD, and sleep deprivation in ADHD children may significantly increase their recognition threshold for negative expressions such as sadness and anger. This article reviews research progress over the past three years on FER abilities of children with ADHD, analyzing the FER deficit in children with ADHD from three dimensions: neuroanatomy, neurophysiology and psychology, aiming to provide new perspectives for further research and clinical treatment of ADHD.

Morphological and Clinical Patterns of Paederus Dermatitis.

Background The objective of the present study was to describe the morphological and clinical patterns of paederus dermatitis (PD). Methodology This retrospective case series was conducted in the outpatient department of the Department of Dermatology, Srinivasan Medical College and Hospital, Trichy, Tamil Nadu, between June 2023 and August 2023 among patients with a clinical diagnosis of PD. Results This study included a total of 10 patients. The mean (SD) age of the patients was 19.4 (1.9) years. More than half of the patients (60.0%) were males. Of the 10 patients included, four (40.0%) were from rural areas, three (30.0%) were from urban areas, and three (30.0%) were from semi-urban areas. The maximum number of cases was reported between June and September. The most common presenting complaint was a burning sensation in 80.0% of the patients, followed by pain in 80.0% and blisters in 20.0% of the patients. The mean (SD) duration of the lesion was 4.2 (1.3) days. Regarding the clinical pattern of lesions, linear lesions were the most common (40.0%), followed by erythematous lesions with central gray area in 30.0%, kissing lesions in 20.0%, and burnt appearance in 10.0% of the lesions. Nearly half of the patients presented with lesions in the face (40.0%), the most common site in the present study, followed by lesions in the leg (20.0%), and lesions in the axilla, chest, arm, and back (10.0% each). Conclusions Understanding the epidemiology and clinical manifestations of this condition is crucial for accurate diagnosis, timely management, and public health interventions aimed at preventing Paederus beetle-related dermatitis.

85 Navigating the Gray Area: Borderline Hemophagocytic Lymphohistiocytosis Criteria and Dilemmas in Diagnosis and Treatment – A Case Report

85 Navigating the Gray Area: Borderline Hemophagocytic Lymphohistiocytosis Criteria and Dilemmas in Diagnosis and Treatment – A Case Report

Entrepreneurship and organised crime: a systematic review and research agenda based on three decades of scholarship

PurposeScholarly interest in the business effects of organised crime (OC) has recently increased. This study aims to conduct a systematic literature review (SLR) on the conditions under which OC could pose a threat to or take control of firms within a particular context.Design/methodology/approachWe use narrative synthesis and thematic analysis, with a sample of 46 theoretical and empirical studies published over the past 30 years on the relationship between OC and firms within the disciplines of Business, Management and Accounting (BMA).FindingsSLR and thematic analysis show that scholarly interest has focused on four key domains: OC as a firm, the impact of OC on firms, firms’ efforts to counter OC’s influence and governmental interventions. Using medical metaphors, we also develop a diagram depicting the interplay between OC and firms within the BMA literature.Originality/valueThis study contributes to the literature shaping an agenda to steer future research towards these four key themes. The effectiveness of anti-OC tools and measures depends on a thorough understanding of local norms, behaviours and business practices. In addition to measurement and methodological challenges, several grey areas remain, including the distinction between criminal enterprises and legitimate businesses. Ambiguities also surround the circumstances under which the OC preys upon firms or employs them to establish dominance over a territory.