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Although grey zone and hybrid threats, such as cyberattacks, information campaigns, and sabotage against critical infrastructure, are becoming increasingly common in the contemporary world, relatively little attention has been directed to similar threats in the maritime environment. The recent global pandemic, Russian aggression against Ukraine, the Nord Stream sabotage in 2022, the sabotage of the Finnish-Baltic pipeline in 2023 in the Baltic Sea, as well as drone attacks on shipping in the Persian Gulf are but a few examples that illustrate the fragility of international maritime communications. The present article explores the topic of grey zone and hybrid threats within the maritime environment. Based on an analysis of recent security events, particularly hybrid threats in the maritime environment, the article proposes that it is essential to seek a broader role for naval forces in supporting national sovereignty and international law and order regarding the Open Seas. The article aims to conceptualize and explore the foundations of maritime grey zone threats and the new roles of naval forces operating within this new context, asking whether the UN, through the International Maritime Organization, NATO, and the European Union, suffer from "sea blindness" concerning how they are preparing for the new world order. [ABSTRACT FROM AUTHOR]

AbstractThis article examines the vulnerability of the law of the sea to grey-zone lawfare based on the maxim pacta sunt servanda, arguing that this rule can readily be employed as a means of lawfare. Through the broad lenses of (1) passage and operational rights in sovereign waters and (2) exclusive economic zone (EEZ) operational rights, the susceptibility to grey-zone lawfare stratagems and tactics based on both “different pacta” and “different servanda” claims are examined. To this end, the specific issues leveraged to illustrate these uses of the different available pacta strategies in grey-zone lawfare at sea are archipelagic sea lanes passage through neutral archipelagic waters, and due regard in respect of third state operational rights in the EEZ. The analysis of each of these contexts then facilitates assessment of the methodology and rule-source tactics that can be exploited when employing pacta sunt servanda as a means of lawfare in respect of grey-zone operations at sea. [ABSTRACT FROM AUTHOR]

This article highlights a comprehensive approach of modern threats to international security and also identifies how they adjust to new environments of action. Therefore, using the method of contextual analysis, I will answer the following research questions: What are the main challenges affecting the current security environment? Which of these represents the most widespread threat and involves possible prospects for the future? Thus, the aim of this approach is to provide, in the first part, an up-to-date examination of the transfiguration of the current security threats by observing the dominant trends, useful for future scientific research, and in the second part I will demonstrate, based on the views of some specialists in the field but also as a result of indirect observation on the developments of international conflicts, that hybrid war remains the defining concept for recent events in international security.

Hepatitis B virus (HBV) infection is a dynamic disease where patients progress through several stages defined by HBV e‐antigen (HBeAg) status, HBV‐DNA levels and transaminase elevations, with antiviral therapy indicated only in specific stages. However, some patients cannot be classified into one of the stages and are said to fall into an ‘indeterminate phase’ or ‘grey zone’. Exact definitions of the indeterminate phase vary from guideline to guideline as a result of different cut‐off values for biomarker measurements. Data suggest that as many as 50% of HBV patients may be in an indeterminate phase and may not rapidly transition out of this phase. Clinical data that suggest these patients are at increased risk of hepatocellular carcinoma (HCC) are complemented by molecular evidence of integrations of HBV‐DNA into the host genome, chromosomal translocations and immune activation despite liver enzymes that may suggest lack of inflammation. Antiviral therapy reduces these hepatocarcinogenic mechanisms and is reflected in a reduction of fibrosis and HCC risk. We review key data on patients in the indeterminate phase, with emphasis on HCC as an outcome. We take a holistic approach and link new biological data with clinical observations as well as examine the potential role of antiviral therapy in reducing HCC risk among patients in the indeterminate phase. With the availability of safe and effective oral antivirals, consideration must be given as to how much residual risk of HCC should be tolerated among patients in the indeterminate phase. [ABSTRACT FROM AUTHOR]

Objective 28–55% of chronic hepatitis B (CHB) patients belong to the grey zone (GZ). By analyzing the pathological characteristics of the liver of patients in the GZ, this study clarified whether the patients in the GZ need anti-hepatitis B virus treatment.Method We reviewed 324 cases of liver pathology that underwent liver biopsy between 2011 and 2022. According to the total score of inflammation G, 0–6 points are classified as mild, 7–12 points are classified as moderate, and 13–18 points are classified as severe. According to the total score of fibrosis F, 0–2 is mild, 3–4 is moderate, and 5–6 is severe. Significant histological diseases (SHD) are defined as the presence of inflammation G ≥ 6 and/or fibrosis F ≥ 2 in liver biopsy specimens.Result 324 GZ patients were scored using the Ishak method, with G7-18 accounting for 9%, F3-6 accounting for 19.2%, and SHD accounting for 37%. The inflammation, fibrosis, and SHD in the HBeAg (+) group were more pronounced than those in the HBeAg (-) group. Among the GZ-A ∼ GZ-D subgroups, the highest proportion of SHD in the GZ-B group was 58.35%.Conclusion More than 1/3 of the patients in GZ need anti-hepatitis B virus treatment. More than half of GZ-B patients need anti-hepatitis B virus treatment. It is very necessary to carry out rescue anti-hepatitis B virus treatment for patients in GZ as soon as possible.

Objective: To determine the relationship between the prostate volume and the serum values of prostate specific antigen among patients in the "grey zone", classified according to their age group. Gray zone represents serum prostate specific antigen values between 4.1 ng/ml to 10 ng/ml. Material and Methods: Prospective and retrospective 1420 patients classified in four age-groups with LUTS (Lower Urinary Tract Symptoms) were analyzed. Patients were treated for Benign Prostate Hyperplasia (BPH) in the urology clinical at the University Clinical Center of Kosovo during the period of January 2010-October 2020. Data were recorded from patients according to age, prostate size estimated by trans abdominal ultrasound using 3.5 MHz ultrasonography, according to the ellipsoid formula, V = D1 × D2 × D3/2.5, Volume of prostate (V)=T × AP × CC × Pi/6 where T=Transverse diameter, AP=Antero Posterior diameter, CC=Cranial Caudal diameter. Patients with confirmed prostate cancer were excluded from the study. Statistical analyses used t-test and ANOVA (Analysis of Variance) with 95% and 99% confidence intervals. Results: For the grey zone patients, these mean values were 44.6 cm3 and 5.9 ng/mL. Conclusions: The data provide evidence to support that prostate volume and serum Prostate Specific Antigen (PSA) concentration significantly correlate with aging and within the grey zone patients. [ABSTRACT FROM AUTHOR]

Guojian Yang,&ast; Le Li,&ast; Xi Peng, Guodong Tang, Naixin Zheng, Ying Zhao, Hui Li, Huiping Zhang, Fucheng Sun, Hu Ai Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Hu Ai, Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 DaHua Road, Dong Dan, Beijing, 100730, People’s Republic of China, Tel +86 18601025086, Email aihumd@aliyun.comPurpose: Coronary angiography-derived fractional flow reserve (caFFR) is a novel computational flow dynamics (CFD)-derived assessment of coronary vessel flow with good diagnostic performance. Herein, we performed a retrospective study to evaluate the reproducibility of caFFR findings between observers and investigate the diagnostic performance of caFFR for coronary stenosis defined as FFR ≤ 0.80, especially in the grey zone (0.75≤caFFR ≤ 0.80).Patients and Methods: A total of 150 patients (167 coronary vessels) underwent caFFR (with FlashAngio used for calculation of flow variables) and subsequent invasive fractional flow reserve (FFR) measurements. Outcomes, including reproducibility, were compared for vessels in and outside the grey zone.Results: The correlation of caFFR findings was good between the two laboratories (r = 0.723, p< 0.001). The AUC of ROC were both high for caFFR-CoreLab1 and caFFR-CoreLab2 (0.975 and 0.883). The diagnostic accuracy, sensitivity, specificity, and negative and positive predictive values were not significantly different between the two laboratories (p> 0.05). caFFR had a strong correlation with measures to FFR (r=0.911, p

Background & Aims: Risk scores have been designed to predict the development of hepatocellular carcinoma (HCC) in treatment-naive patients with chronic hepatitis B (CHB). However, little is known about their predictive accuracy in HBeAg-negative patients in the grey zone (GZ). We aimed to develop a HBcrAg-based HCC risk score and explore whether it outperforms other risk scores in GZ patients. Methods: Two retrospective cohorts of HBeAg-negative patients with American Association for the Study of Liver Diseases-defined GZ were established for derivation and validation (Taiwanese, N = 911; Japanese, N = 806). All of them were non-cirrhotic at baseline and remained treatment-naive during the follow-up. The primary endpoint was HCC development. Results: In a median follow-up period of 15.5 years, 85 patients developed HCC in the derivation cohort. We found that age, sex, alanine aminotransferase, platelet count, and HBcrAg, but not HBV DNA levels, were independent predictors and a 20-point GZ-HCC score was developed accordingly. The 10-year and 15-year area under the ROC curve (AUROC) ranged from 0.83 to 0.86, which outperformed the HBV DNA-based HCC risk scores, including REACH-B and GAG-HCC scores (AUROC ranging from 0.66 to 0.74). The better performance was also validated in EASL- and Asian Pacific Association for the Study of the Liver-defined GZ patients. These findings remained consistent in the validation cohort. Finally, the low-risk and high-risk GZ patients (stratified by a score of 8) had an HCC risk close to inactive CHB and immune-active CHB patients, respectively, in both cohorts. Conclusions: The HBcrAg-based GZ-HCC score predicts HCC better than other HBV DNA-based risk scores in GZ patients who are HBeAg-negative patients, which may help optimise their clinical management. Impact and implications: We have developed a risk score based on HBcrAg, which has shown better predictive ability for HCC compared with other risk scores based on HBV DNA. Using a score of 8, GZ patients can be classified into low- and high-risk groups, which can guide follow up and early treatment, respectively. This validated risk score is a valuable tool for optimising the management of GZ patients who are HBeAg-negative.

Background: On an initial urine screening test for illegal sub- sta nces, if the concentration of a su bstance is at or a bove the determined legislative threshold, it is reported as positive. Repeating testing with the same sample to verify it before reporting is a common practice in clinical laboratories. This study aimed to determine whether measurement uncertainty (MU) results can be used to detect a grey Tone to reduce repeat testing. Methods: A retrospective study was conducted using data from the laboratory information system between January 1, 2020, and July 1, 2022. Samples studied twice within one hour before reporting for the same urine sample were analyzed. The MU values for urinary amphetamine, cannabinoid, cocaine, and opioid parameters were calculated using ADVIA Chemistry reagents on a Siemens ADVIA 1800 chemical analyzer. The grey Tone was defined as the cut-off value ± MU. Results: Urine samples, 319 amphetamine, 198 cannabinoid, 112 cocaine, and 125 opiate tests were repeated from 31.839 patients (16-65 years). Ten amphetamine, 12 cannabinoid and 2 cocaine test results changed from positive to negative or negative to positive on retesting, all within the grey zone level defined by the MU value. Mean biases between the repeated test results were -7.64 (95% Cl: -13.71 to -1.57) ng/mL for the amphetamine and 1.16 (95% Cl: 0.31 to 2.01) ng/mL for the cannabinoid results. Conclusion: Repeating only values within the grey area for each illicit substance may be useful to reduce unnecessary duplicate measurements. [ABSTRACT FROM AUTHOR]

Chronic HBV infection patients who do not conform to any of the usual immune states are regarded as 'grey zone' patients. We aimed to investigate the proportion of chronic HBV infection patients in the grey zone, and evaluate the clinical characteristics and liver pathological changes in grey zone patients. Clinical data of 1391 treatment‐naive chronic HBV infection patients with liver biopsy were collected. Natural history of HBV infection was determined based on European Association for the Study of the Liver (EASL) 2017, American Association for the Study of Liver Diseases (AASLD) 2018 and Chinese 2019 guidelines for the prevention and treatment of chronic HBV infection. Significant liver histological changes and associated risk factors of normal ALT grey zone patients were analysed. According to EASL, AASLD and Chinese criteria, there were 50.0%, 28% and 37.4% chronic HBV infection patients in the grey zone. Among the 353 grey zone patients with normal ALT, 72.4% had significant liver histological changes. ALT (optimal cut‐off value 25 IU/L) and HBV DNA (optimal cut‐off value 18,000 IU/mL) were independent risk factors of significant liver histological abnormalities. In conclusion, a substantial proportion of grey zone patients with normal ALT have significant liver histological changes that can be predicted by levels of serum ALT and HBV DNA. These results provide guidance of antiviral treatment in grey zone patients. [ABSTRACT FROM AUTHOR]

This article examines the threat analysis across Africa that should be included in Force Design 2030 (FD2030) for the United States Marine Corps. FD2030 is a strategic guidance document with emphasis on Great Power Competition with China, Russia, Korea, Iran and violent extremist organisations. Africa is not mentioned. This is a notable omission, given that high-level interventions by the Marines in the past to Africa have not been overtly successful. Given geo-strategic significances and hot spots, it is inevitable that the Marines will be deployed again landward to Africa or seaward of the continent. Recommendations are made to be included in the document based upon lessons learned from failures in Somalia, Libya and Lebanon and successes in Syria and Iraq, and the experiences of others – France in Mali and Burkina Faso and United States Africa Command. Great Power Competition, violent extremist organisations and the grey-zone phenomenon across Africa are scrutinised, as are intelligence, counterintelligence and hybrid warfare. [ABSTRACT FROM AUTHOR]

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Tensions between Spain and Morocco rose throughout 2021. However, they stem from decades-long conflicts over territory. One of Rabat's main claims relates to the Spanish cities of Ceuta and Melilla, located on the north coast of Africa. The present article highlights the main clashes between the two countries and their respective positions. It then explores whether Morocco is operating a Grey Zone strategy to secure control over the two cities in the medium term and concludes that this is indeed the case. [ABSTRACT FROM AUTHOR]

There has been growing concern about the increase in gender-based violence (GBV) among young people. The aim of this study was to explore the grey zones in GBV alongside gender (masculinities and femininities) discourses in young adults. We used the concept of a "grey zone" as an analytical tool to identify possible contradictory discursive positions where the notions of victims and perpetrators of GBV converge and become ambiguous. We performed a qualitative study based on 20 semi-structured interviews and 4 focus groups (October 2019 to February 2020) in Spain with a sample of 49 cisgender women and men, aged between 18 and 24, some involved in feminist activism and some not. We conducted a sociological analysis of the discourse system. Study findings show how culturally constructed gender norms intervene in the ways in which young people understand and deal with GBV. When asked general questions about GBV, this concept was problematized along with gender assumptions and two discursive positions were identified: the discourse of "men as authors of GBV" and the discourse of "GBV as an individual genderless issue." When vignettes of everyday GBV situations were shown, grey zones became visible when discussing subtle forms of GBV influenced by the myths of romantic love, victim-blaming around sexual violence, digital GBV and bystander men intervention on GBV. In those grey zones, discourses on GBV were articulated around unequal notions of gender that, in turn, served as its justification, reproduction, and normalization. The grey zones identified represent contexts of oppression that illustrate how GBV is systematically reproduced, as well as the ways in which young people can be involved in it, perpetuating power and health inequalities. Our findings provide information as a guide to design GBV interventions and prevention actions that incorporate a focus on gender configurations. [ABSTRACT FROM AUTHOR]

We aim to investigate the impact of different clinical phases' definitions of chronic hepatitis B (CHB) infection on the profiles of grey zone, based on HBV guidelines set by the Chinese Society of Hepatology and Chinese Society of Infectious Diseases (CSH/CSID, 2022 version) and guidelines set by the American Association for the Study of Liver Diseases (AASLD, 2018 version). We retrospectively examined untreated CHB patients enrolled in the China Registry of Hepatitis B database. Patients' clinical phases were determined as per CSH/CSID and AASLD. Liver fibrosis was estimated by FIB-4 and/or APRI. Among 3462 CHB patients, 56.9% and 41.7% fell into the grey zone based on AASLD and CSH/CSID. Compared with grey zone patients as per AASLD, those under CSH/CSID guidelines showed lower levels of median ALT (26.0 vs. 37.0 U/L, p < 0.001), AST (25.0 vs. 29.4 U/L, p < 0.001) and APRI (0.3 vs. 0.4, p < 0.001), and lower rates of advanced fibrosis estimated by APRI (7.9% vs. 11.4% p = 0.001), but comparable rates by FIB-4 (13.0% vs. 14.1%, p = 0.389). With the stepwise lowering of ALT upper limits of normal (ULN) values from 50/40 U/L for males/females to 40/40 U/L, 35/25 U/L and 30/19 U/L, the proportions of grey zone patients as per CSH/CSID declined from 46.7% to 41.7%, 34.3% and 28.8%, respectively, whereas they remained stable (55.7%, 56.2%, 56.9% and 57.0%) as per AASLD. Compared with the AASLD guidelines, CSH/CSID guidelines leave fewer and less severe patients in the grey zone. Lowering ALT ULN values reduces the number of grey zone patients as per CSH/CSID, but not under AASLD guidelines. [ABSTRACT FROM AUTHOR]

The ILAE Task Force on Classification released a report in 2015 to clarify the classification of status epilepticus. Non-convulsive status epilepticus (NCSE) was defined as SE without prominent motor symptoms, with or without coma. This diverse entity’s electrophysiological diagnosis, which is more consistent in clinical recognition, may be challenging. Some classifications and revisions have been proposed recently, making NCSE diagnosis easier. There are, however, patients who remain in the ‘grey zone’. The increasing evidence in patients, who do not meet the Salzburg Consensus Criteria for NCSE diagnosis of ‘NCSE’ or ‘possible NCSE’, but whose clinical and electrophysiological features are still suspicious for NCSE, may pave the way for developing more comprehensive criteria. Therefore, we present here the ‘generalized non-reactive alpha activity’ in the electroencephalogram (EEG) of an elderly patient with no known epilepsy before, who presented with acute confusional state of unexplained cause, which we suspected as NCSE and managed a ccordingly with success. Considering that ‘time is brain’, early and correct NCSE diagnosis is critical and the NCSE EEG criteria should be more inclusive for the patients in the ‘grey zone like the one presented here with ‘generalized non-reactive alpha activity’.

Though thematically diverse, the novels by German-British writer Rachel Seiffert share an interest in exploring the various ways in which ordinary people become entangled with structures of violence. Ranging from children to elderly people, the characters in The Dark Room (2001) and A Boy in Winter (2017) find themselves enmeshed in the politics of the Third Reich, whereas those in Afterwards (2007) and The Walk Home (2014) contribute to maintaining British colonialism in Kenya and Ireland. This paper proposes a narratological analysis, informed by theories within memory, trauma, and perpetrator studies, of the situated and multiperspectival narratives employed in the novels to reveal how Seiffert negotiates the ethical challenges implicit in the shades of grey existing between victims and perpetrators. It also intends to demonstrate that the tensions between the collective and the personal are deeply revealing in terms of exposing covert memory gaps and fostering new forms of solidarity. [ABSTRACT FROM AUTHOR]

Legally qualified as self-employed, home educational childcare providers (HECPs) in Quebec operate in a hybrid zone between wage employment and selfemployment. While the majority of the elements of their work organisation is determined from the outside, they are one of the few groups of self-employed workers with access to social protection. This exists under a special sectorbased regime of collective bargaining between trade unions and the State. To grasp the complexities of their work and employment conditions, the paper evaluates HECPs through the lens of social labour relation. SLR is defined as the relation between workers and any entity likely to control their conditions of work and employment. The article analyses the socio-historical construction of successive patterns of SLR for HECPs, showing that they operate not only in a hybrid zone between wage employment and self-employment, but also in a «grey» zone of recomposition of norms, under the pressure of multiple interacting actors The first aspect concerns the blurring of the identity of employer through the multiplicity of entities whose action controls and structures various dimensions of the SLR. The second aspect derives from the hybrid nature of the legal framework of collective bargaining, which offers real potential for improving HECPs’ conditions of work and employment, along with important limitations and ambiguities. [ABSTRACT FROM AUTHOR]

The dynamics of marine systems at decadal scales are notoriously hard to predict—hence references to this timescale as the "grey zone" for ocean prediction. Nevertheless, decadal-scale prediction is a rapidly developing field with an increasing number of applications to help guide ocean stewardship and sustainable use of marine environments. Such predictions can provide industry and managers with information more suited to support planning and management over strategic timeframes, as compared to seasonal forecasts or long-term (century-scale) predictions. The most significant advances in capability for decadal-scale prediction over recent years have been for ocean physics and biogeochemistry, with some notable advances in ecological prediction skill. In this paper, we argue that the process of "lighting the grey zone" by providing improved predictions at decadal scales should also focus on including human dimensions in prediction systems to better meet the needs and priorities of end users. Our paper reviews information needs for decision-making at decadal scales and assesses current capabilities for meeting these needs. We identify key gaps in current capabilities, including the particular challenge of integrating human elements into decadal prediction systems. We then suggest approaches for overcoming these challenges and gaps, highlighting the important role of co-production of tools and scenarios, to build trust and ensure uptake with end users of decadal prediction systems. We also highlight opportunities for combining narratives and quantitative predictions to better incorporate the human dimension in future efforts to light the grey zone of decadal-scale prediction. [ABSTRACT FROM AUTHOR]

This study examines the dynamics of gray zone warfare by analyzing its conceptualization in the literature and through its practice in several recent examples. Ever-increasing changes in the characteristics of contemporary warfare have complicated the security environment of the 21st century. Modern warfare inclines toward non-kinetic dimensions based on the principles of hybridity, soft power, and ambiguity. This changing nature of warfare has been defined and categorized in diverse ways, leading to numerous perspectives revealing more confusion than clarity. The terms "hybrid warfare," "gray zone warfare," "unrestricted warfare," and "ambiguous warfare" have received unprecedented attention in recent years. A key contemporary challenge is to differentiate between war and peace because gray zone warfare occupies the space in between both these situations. Many contemporary conflicts are neither black nor white; instead, they fall in the middle of the two: the gray zone. These factors underscore the significance of evaluating and understanding the concept of gray zone warfare. The United States considers Russia, China, and Iran as revisionist states that employ gray zone warfare in various domains to challenge the United States-led world order. South Asia is also a manifested playground of gray zone warfare. The research further distinguishes between gray zone warfare and hybrid warfare and proposes strategies for countering this threat. [ABSTRACT FROM AUTHOR]

Introduction: The role of immune mediated injury in pathogenesis of Ankylosing Spondylitis (AS) is well established. HLA B27, a Major Histocompatibility Complex (MHC) class I molecule is one of the major genetic risk factors associated with the disease. Various techniques are used for testing HLA-B27 which includes Polymerase Chain Reaction (PCR) based tests, Enzyme Linked Immunosorbent Assay (ELISA) and flowcytometry. Flowcytometry has gained popularity due to ease of procedure, shortened turnaround time and cost-effectiveness. Aim: The aim of the present study was to assess the sensitivity and specificity of flowcytometry for HLA-B27 detection, taking PCR assay as the gold standard along with its association with demographic, clinicopathological and radiological parameters. Materials and Methods: This was a prospective study conducted in Department at Pathology of Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, India, for a period of 18 months from January 2020 to June 2021. The study included 51 patients for which HLA-B27 typing was done cases by flowcytometry and Sequence Specific Allele (SSA) PCR/Real time PCR on peripheral blood samples. The association of HLA-B27 with clinical features {Inflammatory Back Pain (IBP), arthritis, psoriasis, uveitis, dactylitis, Inflammatory Bowel Disease (IBD), cervicitis, urethritis, diarrhoea) along with MRI findings (sacroiliitis)}, laboratory findings {C-reactive protein and Erythrocyte Sedimentation Rate (ESR)} was evaluated. The performance analysis parameters of flowcytometry were evaluated both by excluding and including the cases in grey zone taking PCR as gold standard. Statistical testing was conducted with SPSS 20.0. Chi-square test or Fisher’s-exact test were used and a p-value of less than 0.05 was taken as significant. Results: A significant association of HLA-B27 was seen only with IBP (p-value= 0.001) and sacroiliitis (p-value= 0.03). Of the 22 (43.1%) patients positive for HLA-B27 by PCR, 18(81.8%) patients were positive while the remaining 4(18.1%) were in grey zone by flowcytometry. Of the 29(56.9%) patients testing negative by PCR, 27(93.1%) patients were negative, one (3.4%) was in grey zone and one (3.4%- false positive) tested positive for HLA-B27 by flowcytometry. Sensitivity and specificity of flowcytometry for detection of HLA-B27 was found to be 100% and 96.4% respectively when grey zone cases were excluded. Conclusion: The study brings to light that flowcytometry is a fairly specific and sensitive method for HLA-B27 detection with a high Negative Predictive Value (NPV) (100%) and Positive Predictive Value (PPV) (94.7%). In the COVID-19 era, it reiterates the importance of flowcytometry for HLA-B27 especially when PCR is overburdened.

The information age has transformed society by allowing people to interact digitally, yet it enables motivated actors to use mass influence to further their political objectives. The struggle against disinformation requires an appreciation of how a disinformation effect can be achieved in order to counter it. We consider the nature of disinformation and its use in the hybrid warfare domain, before examining the problem through frames of planning approach, truth theory, systems thinking, and military strategy. These approaches are informative in developing counter-strategies and we specifically identify the concept of kill chains as a useful framework to assist in the disinformation challenge. [ABSTRACT FROM AUTHOR]

The changing global environment has become an opportunity for Russia and Pakistan to redefine their relationship. Both countries believe in strong multilateralism as the way to go in foreign relations. They are quite conscious of peace and stability in the Eurasian region. Given the mutual benefits of fostering ties, Moscow and Islamabad are trying to move forward in three key broad areas where the convergence of interests is evident. They are emerging geopolitical and security milieus, geo-economic outlook and regional connectivity. Pakistan-Russia relations are set to exploit these realms and take them on an upward trajectory in years to come. In this paper, qualitative data has been dealt with analytically to identify how both countries could benefit from the changing strategic landscape to achieve these objectives. It pertains to the evolving geopolitical environment, interregional economic prospects, and emerging threats to regional stability (especially Afghanistan), which hold much in store for both in opting for a mutual course of action on regional and international fronts. The study explicitly examines the factors that may shape the commonality of interests in their foreign policy options. [ABSTRACT FROM AUTHOR]

In Bosnia and Herzegovina, memories of the 1990s war remain hugely divided on political and institutional levels, constituting what we may think of as a mnemonic war. Interview-based qualitative research shows that people in Bosnia on the individual level tend to follow the dominant narrative of their own group, yet, when challenged on these viewpoints, may also admit that other narratives and different truths may exist. Indeed, this research seems to propose the existence of a memorial grey zone where more open understanding and recognition of other positions is possible. Thus, while memory politics and memory institutionalization are rigidly opposed, other types of memory mediation may challenge the ethnic divisions of the memory landscape, opening up a memorial grey zone. In this article, we study the individual reception of literary works written by Bosnian émigré writers, asking how readers interact with established yet fluid memory discourses in Bosnia. Using focus groups as an interviewing method, we explore how the texts are perceived and discussed by lay readers in the two political entities, the Bosniak–Croat Federation and Republika Srpska. We are particularly interested in how readers make sense of the memory accounts in the texts, and how this relates to personal experiences and official memory narratives within each of the two entities. We argue that the reading and discussions of literary war memories allow for complex negotiations between personal and official 'group' narratives, opening a memorial grey zone that transcends the sharp divisions dominating memory politics in Bosnia and creates space for alternative memory positions. [ABSTRACT FROM AUTHOR]

The COURAGE Registry is a digital research tool that allows exploring the legacy of cultural opposition in former Eastern European socialist countries by cataloging and describing relevant collections on dissident culture across Eastern Europe and worldwide. The linked database reveals a great variety of nonconformist cultural practices that were formerly largely unknown and promotes comparative research of similar phenomena in Eastern European societies and cultures. The researchers on the project tended to treat visual sources as traces of the past equally as important as written documents. Images were not only illustrations of the given narratives but, in some cases, visual documents were the only sources that preserved the memory of the alternative or underground activity, while in other cases, it was the act of taking pictures that resulted in the confrontation with official cultural policy. This article aims to provide insight into the basic dilemmas and issues that the project faced dealing with images for the database through three examples. Firstly, we focus on the photo documentation of an exhibition of the Hungarian art group Inconnu that was made by the secret police following the destruction of the artworks. Secondly, we show how photos were also taken by official photographers who operated in the so-called “grey zone.” Finally, our third example refers to Fortepan, a unique public initiative that focuses on the digital preservation of private photographs created between 1900 and 1990.

The influence of Primo Levi’s writing on the ‘grey zone’ has only sharpened over the last decade, not only in terms of its broader application to human rights contexts beyond the Holocaust, but also through a greater focus on the question of how to understand the behaviour of so-called ‘privileged’ prisoners in the Nazi camps and ghettos. History has shown a court of law to be an inadequate setting for negotiating the complexities of the ethical dilemmas forced on victims in extremis, and substantial problems of judgement and representation have plagued efforts to understand these liminal figures elsewhere. This article examines the tensions within Levi’s writings and maps these onto attempts to represent the ‘grey zone’ in Holocaust films. Engaging in particular with Margarethe von Trotta’s critically acclaimed feature film Hannah Arendt (2012) and Tor Ben-Mayor’s lesser known documentary Kapo (1999), I highlight how these distinct approaches to depicting ‘privileged’ Jews expose the fraught nature of portraying victim complicity on screen. [ABSTRACT FROM AUTHOR]

Background: Passive leg raising-induced changes in cardiac index can be used to predict fluid responsiveness. We investigated whether passive leg raising-induced changes in pulse pressure variation (ΔPPVPLR) can also predict fluid responsiveness in mechanically ventilated patients.Methods: In this multicentre prospective observational study, we included 270 critically ill patients on mechanical ventilation in whom volume expansion was indicated because of acute circulatory failure. We did not include patients with cardiac arrythmias. Cardiac index and PPV were measured before/during a passive leg raising test and before/after volume expansion. A volume expansion-induced increase in cardiac index of >15% defined fluid responsiveness. To investigate whether ΔPPVPLR can predict fluid responsiveness, we determined areas under the receiver operating characteristic curves (AUROCs) and grey zones for relative and absolute ΔPPVPLR.Results: Of the 270 patients, 238 (88%) were on controlled mechanical ventilation with no spontaneous breathing activity and 32 (12%) were on pressure support ventilation. The median tidal volume was 7.1 (inter-quartile range [IQR], 6.6-7.6) ml kg-1 ideal body weight. One hundred sixty-four patients (61%) were fluid responders. Relative and absolute ΔPPVPLR predicted fluid responsiveness with an AUROC of 0.92 (95% confidence interval [95% CI], 0.88-0.95; P<0.001) each. The grey zone for relative and absolute ΔPPVPLR included 4.8% and 22.6% of patients, respectively. These results were not affected by ventilatory mode and baseline characteristics (type of shock, centre, vasoactive treatment).Conclusions: Passive leg raising-induced changes in pulse pressure variation accurately predict fluid responsiveness with a small grey zone in critically ill patients on mechanical ventilation.Clinical Trial Registration: NCT03225378. [ABSTRACT FROM AUTHOR]

A total of 15,267 pregnancies were tested by NIPT in this study. Grey zone (z score: 2.58 ∼ 4 and −4∼−2.58) was set for screening out aneuploidy 21, 18 and 13. Cases with z score located in the grey zone were retested starting from DNA extraction. The chi-squared test and/or the Fisher's exact test were used to compare variables. One hundred and eight screening-positive samples in the first run of NIPT were common trisomies 21 (N = 83), trisomies18 (N = 13) or trisomies 13 (N = 12), with PPVs of 87.18%, 76.92%, and 30% respectively. For the cases in the grey zone, most of them (67.15%, 184/274) were reported with Z score of Chromosome 21 in the grey zone and 176 were reclassified as negative by the second run of NIPT; while 3 cases reclassified as trisomy 21 and 1 case reclassified as trisomy 13 were finally confirmed by karyotyping analysis, with PPV 25% and 20% respectively. The grey zone and the second run of NIPT in this study showed that the grey zone and second run NIPT approach was able to accurately help categorise cases as negative and positive. Invasive diagnosis is recommended to prevent false negative aneuploidies for samples located in the special z score scope of 2.58–3 for two runs of NIPT. What is already known on this subject? Grey zone was widely used in NIPT. The performance of grey zone of clinical samples on Illumina HiSeq 2000 instrument has been reported, and the performance of grey zone on some mainstream sequencers with simulated samples has also been summarised. Reported treatments for samples located in the grey zone in NIPT usually included being classified into 'unclassified' or 'no call' followed by following up and/or karyotyping analysis. What do the results of this study add? This study investigated the performance of the grey zone on Ion Proton DA8600 with clinical samples; and it present an alternative treatment for samples in grey zone that reclassified them as negative or positive by the second run of sequencing. What are the implications of these findings for clinical practice and/or further research? Our own data for the performance of the grey zone in the cfDNA assay on the semiconductor sequencing platform might provide raw materials for other researchers' meta-analysis, cohort study, or other studies. Details of Z score distributions of chromosomes in grey zone, results of the second run of NIPT for samples in the grey zone, and false negative samples in the grey zone would help lab technicians better analyse the NIPT results and help doctors to improve genetic counselling. [ABSTRACT FROM AUTHOR]

We aim to investigate the impact of different clinical phases’ definitions of chronic hepatitis B (CHB) infection on the profiles of grey zone, based on HBV guidelines set by the Chinese Society of Hepatology and Chinese Society of Infectious Diseases (CSH/CSID, 2022 version) and guidelines set by the American Association for the Study of Liver Diseases (AASLD, 2018 version). We retrospectively examined untreated CHB patients enrolled in the China Registry of Hepatitis B database. Patients’ clinical phases were determined as per CSH/CSID and AASLD. Liver fibrosis was estimated by FIB-4 and/or APRI. Among 3462 CHB patients, 56.9% and 41.7% fell into the grey zone based on AASLD and CSH/CSID. Compared with grey zone patients as per AASLD, those under CSH/CSID guidelines showed lower levels of median ALT (26.0 vs. 37.0 U/L, p < 0.001), AST (25.0 vs. 29.4 U/L, p < 0.001) and APRI (0.3 vs. 0.4, p < 0.001), and lower rates of advanced fibrosis estimated by APRI (7.9% vs. 11.4% p = 0.001), but comparable rates by FIB-4 (13.0% vs. 14.1%, p = 0.389). With the stepwise lowering of ALT upper limits of normal (ULN) values from 50/40 U/L for males/females to 40/40 U/L, 35/25 U/L and 30/19 U/L, the proportions of grey zone patients as per CSH/CSID declined from 46.7% to 41.7%, 34.3% and 28.8%, respectively, whereas they remained stable (55.7%, 56.2%, 56.9% and 57.0%) as per AASLD. Compared with the AASLD guidelines, CSH/CSID guidelines leave fewer and less severe patients in the grey zone. Lowering ALT ULN values reduces the number of grey zone patients as per CSH/CSID, but not under AASLD guidelines.

This article explores the nature and dynamics of criminal violence in central Mexico through the lived experience of internally displaced persons (IDPs) over the past ten years. First, the issue of internal displacement and the context of violence and drug‐trafficking in Mexico is addressed, then reflections are made on the methodological, security and ethical challenges of doing fieldwork in contexts of violence. Three case studies are drawn upon to illustrate the complexities of violence, organised crime and state (in)action leading to forced displacement. Findings are analysed and framed as grey zones, uncertain and at times indecipherable and terrifying. [ABSTRACT FROM AUTHOR]

All appears quiet on Australia's southern front – Antarctica. The continent remains a beacon of cooperation, home to a continued system of international governance and scientific engagement, lauded as a political win from the depths of the Cold War. Beneath the surface, however, this article argues that strategic competition is now building. In Antarctica, this competition takes the form of gray zone activities. This article argues that the proliferation of gray zone challenges could jeopardize the future of the Antarctic Treaty System (ATS). This article analyses gray zone activity in Antarctica and highlights the growing complexity Australia faces, as Canberra pursues the dual objectives of protecting Australia's territorial claim to the Australian Antarctic Territory (AAT) and bolstering the ATS. [ABSTRACT FROM AUTHOR]

In Il serpente, Luigi Malerba's first novel, the writer moves from the objectifying perspective, working-class protagonists, and themes of neorealism to a subjective realism that sets aside the direct dialogue of his first book (La scoperta dell'alfabeto, a collection of brief narratives) in favor of the exterior monologue. The narrating voice of Il serpente feels compelled to relive the guilt, shame, and humiliation of his youth. He prevaricates habitually because he is anxious as to how he appears, primarily to himself: he is caught between the need to express himself and the fear of being punished for having done so. The changes in narrative strategy, along with the psychological plausibility of the narrative and Malerba's analysis of Italy's 'grey zone', populated by those who did not actively participate in the civil war following the fall of Fascism, make Il serpente worthy of our close attention. [ABSTRACT FROM AUTHOR]

In recent years, the concept of grey zone has been popularised to analyse the activities a State can use to influence the decisions and to limit the strategic choices of another State below the threshold of war. This article presents a case study, aimed at verifying if the Russian activities in the Czech Republic may constitute a grey zone. The paper commences by introducing the concept of the grey zone and developing the appropriate theoretical framework to identify its main characteristics. It continues by examining the Russian influence in the Czech Republic by using open sources, local sources and documents from the Czech intelligence services. It concludes by asserting that the analysed case meets most of the requirements to classify it as a ‘limited grey zone’. This new theoretical development may help to assess similar situations that may occur in this or other nations.

This article discusses ambiguous tactics of German Communist resisters in the Third Reich. The official historiography of the German Democratic Republic (GDR) portrayed Communist resisters as unfaltering heroes. By contrast, revisionist studies published after 1990 presented Communists as traitors and renegades. This study transcends these approaches that revolve around legitimation or de-legitimation of the dictatorship, and examines the dubious manoeuvring of three German Communists who strategically collaborated with the Nazis, namely Theodor Bottländer, Friedrich Schlotterbeck and Wilhelm Knöchel. While Knöchel's attempts to outwit the Gestapo failed and could not prevent his execution, Schlotterbeck and Bottländer found ways to survive - largely without betraying their comrades. Even so, the Kommunistische Partei Deutschlands (KPD), as well as its successor in the GDR, the Sozialistische Einheitspartei Deutschlands (SED), reprimanded venturesome, inventive and obstinate Communists, excluded them from the party and brought them to court. The harsh reactions are indicative of the inability of Communist historiography to acknowledge 'Eigen-Sinn', and highlight a central shortcoming of the antifascist doctrine. Likewise, more recent revisionist approaches have failed to recognise various attempts of Communists to minimise harm and survive in the grey zone between betrayal and loyalty. [ABSTRACT FROM AUTHOR]

Objectives: To compare the accuracy of several volume and diameters modified prostate health index (mPHI) models with PHI density (PHID), PHI, and other prostate-specific antigen (PSA) derivatives in detecting PSA grey zone prostate cancer (PCa). Materials and methods: Between August 2020 and September 2021, a consecutive cohort of 214 suspected PCa patients with elevated total PSA values ranged from 4.0 to 10.0 ng/mL were prospectively recruited and received PHI detections and transrectal ultrasonography (TRUS) measurements, followed by systematic prostate biopsies confirmation. Results: Among the 214 patients enrolled in the project, a total of 80 were diagnosed with PCa. In univariate analysis for the training cohort, the area under curve (AUC) of mPHI-2 LD TRD × APD × TPV × PHI was 0.8310, which outperformed PHID in identifying PSA grey zone PCa (P ≤ 0.0001) and showed the best net benefit in decision curve analysis (DCA). By a threshold of 0.2835, the sensitivity and specificity in the prediction of PCa were 78.9% and 90.3%, while the positive predictive value (PPV) and negative predictive value (NPV) were 78.3% and 78.6%, respectively. Conclusions: According to our present single-center experience, the mPHI-2 risk predictor outperformed PHID or other classical parameters alone in the PCa detection with a grey zone PSA level in Asian males. [ABSTRACT FROM AUTHOR]

Contemporary hostile actors are increasingly attempting to destabilize targeted states' civilian domains via malign influence activities. With this civilian focus, societal destabilization is at least partly psychological. However, empirical evidence of a psychological dimension to societal destabilization is lacking. We assess the potential of five pertinent psychological factors to indicate societal destabilization using data captured about citizens living in the Ukrainian regions of Donetsk, Luhansk, and Crimea, prior to the outbreak of conflict in 2014. Analysts state that Russian influence activities contributed to societal destabilization in these regions. Using preregistered analyses, we contrast the self-reported levels of our selected psychological factors in these citizens against the self-reported levels of citizens from contextually and culturally similar societies. We confirmed that levels of political and social trust were significantly lower, and the perception of economic instability was significantly higher in citizens of Donetsk, Luhansk, and Crimea. Although observational, the results point to the relevance of these psychological factors for understanding societal destabilization provoked by influence activities. [ABSTRACT FROM AUTHOR]

Objective: 28-55% of chronic hepatitis B (CHB) patients belong to the grey zone (GZ). By analyzing the pathological characteristics of the liver of patients in the GZ, this study clarified whether the patients in the GZ need anti-hepatitis B virus treatment., Method: We reviewed 324 cases of liver pathology that underwent liver biopsy between 2011 and 2022. According to the total score of inflammation G, 0-6 points are classified as mild, 7-12 points are classified as moderate, and 13-18 points are classified as severe. According to the total score of fibrosis F, 0-2 is mild, 3-4 is moderate, and 5-6 is severe. Significant histological diseases (SHD) are defined as the presence of inflammation G  ≥ 6 and/or fibrosis F  ≥ 2 in liver biopsy specimens., Result: 324 GZ patients were scored using the Ishak method, with G7-18 accounting for 9%, F3-6 accounting for 19.2%, and SHD accounting for 37%. The inflammation, fibrosis, and SHD in the HBeAg (+) group were more pronounced than those in the HBeAg (-) group. Among the GZ-A ∼ GZ-D subgroups, the highest proportion of SHD in the GZ-B group was 58.35%., Conclusion: More than 1/3 of the patients in GZ need anti-hepatitis B virus treatment. More than half of GZ-B patients need anti-hepatitis B virus treatment. It is very necessary to carry out rescue anti-hepatitis B virus treatment for patients in GZ as soon as possible.

The ILAE Task Force on Classification released a report in 2015 to clarify the classification of status epilepticus. Non-convulsive status epilepticus (NCSE) was defined as SE without prominent motor symptoms, with or without coma. This diverse entity's electrophysiological diagnosis, which is more consistent in clinical recognition, may be challenging. Some classifications and revisions have been proposed recently, making NCSE diagnosis easier. There are, however, patients who remain in the 'grey zone'. The increasing evidence in patients, who do not meet the Salzburg Consensus Criteria for NCSE diagnosis of 'NCSE' or 'possible NCSE', but whose clinical and electrophysiological features are still suspicious for NCSE, may pave the way for developing more comprehensive criteria. Therefore, we present here the 'generalized non-reactive alpha activity' in the electroencephalogram (EEG) of an elderly patient with no known epilepsy before, who presented with acute confusional state of unexplained cause, which we suspected as NCSE and managed a ccordingly with success. Considering that 'time is brain', early and correct NCSE diagnosis is critical and the NCSE EEG criteria should be more inclusive for the patients in the 'grey zone like the one presented here with 'generalized non-reactive alpha activity'. [ABSTRACT FROM AUTHOR]

Land surface heterogeneity exerts a strong control on atmospheric boundary‐layer (ABL) evolution by spatially varying the distribution and partitioning of surface energy fluxes and triggering secondary circulations. The representation of this physical process in numerical weather prediction (NWP) models is especially affected in the terra incognita as the model grid resolution approaches the length‐scale of the largest eddies in the boundary layer. We explore these effects for a mesoscale strip‐like land surface inhomogeneity in land cover, soil moisture or a superposition of both embedded in an elsewhere homogeneous landscape. The study is conducted with the numerical weather prediction model ICON (ICOsahedral Nonhydrostatic), using the default operational level 2.5 Mellor–Yamada turbulence closure (MY) and a large‐eddy simulation (LES) configuration as a benchmark. While simulations with the default ABL scheme approach the LES reference when refining the spatial grid towards finer resolution, the model generates artificial circulations leading to ABL height oscillations when the horizontal grid resolution (∆x) approaches the ABL height zi. The effect of these model‐induced circulations on the state of the boundary layer is even present with weak thermal heterogeneity (∆H) under low background wind speed (vx) but diminishes with increasing background wind speed. The tuning of the asymptotic turbulent mixing length‐scale l∞ in the operational ABL scheme helps in reducing the amplitude of the oscillations, thereby reducing the artificially induced circulations due to thermal heterogeneity which might act as unintentional trigger for clouds and precipitation. Based on the tuned synthetic model data from sensitivity runs, we propose a new parametrization for a 2‐D l∞ as a function of ∆H, zi/∆x and vx, which is otherwise held as a constant in the ABL scheme. [ABSTRACT FROM AUTHOR]

The most common cause of hepatocellular carcinoma (HCC) worldwide is chronic hepatitis B virus (HBV) infection (CHB). Long-term suppression of HBV replication by antiviral treatment reduces the risk of HCC and mortality. Nonetheless, only 2.2% of CHB patients globally received the treatment in 2019. Current international CHB guidelines recommend antiviral treatment only in subsets of patients with clear evidence of liver damage as evidenced by elevation of alanine aminotransferase (ALT). This review aims to provide existing evidence that the risk of HCC is significantly associated with serum levels of HBV DNA, and the association is non-linear parabolic, in both untreated and treated CHB patients, regardless of HBeAg status or ALT levels. Therefore, the decision for the antiviral treatment should be based on serum HBV DNA levels and age, rather than ALT levels or liver biopsy, to reduce or prevent the risk of HCC in CHB patients. The potential impact and cost-effectiveness data on early antiviral treatment initiation were also collated., (© 2024 John Wiley & Sons Ltd.)