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In North America, more than 800,000 youth are registered in organized ice hockey leagues. Despite the many benefits of involvement, young players are at significant risk for injury. Body-checking and aggressive play are associated with high frequency of game-related injury including concussion. We conducted a qualitative study to understand why youth ice hockey players engage in aggressive, injury-prone behaviours on the ice. Semi-structured interviews were conducted with 61 minor ice hockey participants, including male and female players, parents, coaches, trainers, managers and a game official. Players were aged 13-15 playing on competitive body checking teams or on non-body checking teams. Interviews were manually transcribed, coded and analyzed for themes relating to aggressive play in minor ice hockey. Parents, coaches, teammates and the media exert a large influence on player behavior. Aggressive behavior is often reinforced by the player's social environment and justified by players to demonstrate loyalty to teammates and especially injured teammates by seeking revenge particularly in competitive, body-checking leagues. Among female and male players in non-body checking organizations, aggressive play is not reinforced by the social environment. These findings are discussed within the framework of social identity theory and social learning theory, in order to understand players' need to seek revenge and how the social environment reinforces aggressive behaviors. This study provides a better understanding of the players' motivations and environmental influences around aggressive and violent play which may be conducive to injury. The findings can be used to help design interventions aimed at reducing aggression and related injuries sustained during ice hockey and sports with similar cultures and rules.

An 86-year-old woman tripped and fell on the sidewalk, hitting the front of her head. She did not lose consciousness, but diplopia developed. She presented to the emergency department where a noncontrast computed tomography (CT) scan of the head was within normal limits, and she was referred to the ophthalmology service. During ophthalmologic consultation, the patient stated she had primary hypothyroidism and osteoporosis. Her only medication was levothyroxine. Her main concern was binocular vertical diplopia that increased on downgaze, along with mild periorbital pain. Perineural spread of malignant growth is the migration of tumour cells from a primary site along any of the three layers of a nerve (epineurium, perineurium, endoneurium). This unusual means of tumour extension is distinct from spread through vascular and lymphatic channels. The mechanisms underlying this phenomenon are poorly understood. It was initially postulated that neural sheaths provided planes of relatively low resistance for growth of tumour cells.

BackgroundThe reported prevalence and burden of coronary artery disease in young adults varies markedly in published studies from the 1950s through 2000s but has not been evaluated in a large contemporary multicentre cohort of young adults referred for clinically indicated coronary CT angiography (CCTA).MethodsRetrospective, international, multicentre, cross-sectional study of consecutive patients aged 18–49 in 29 healthcare systems who underwent clinically indicated CCTA with artificial intelligence-enabled coronary plaque analysis (AI-CPA) between January 2021 and May 2022. The prevalence of coronary atherosclerosis and coronary plaque volume and characteristics were evaluated.Results1621 patients with mean age 41.9±6.6 years and 712 (43.9%) women were included. Among young adults referred for clinically indicated CCTA, 62.8% had coronary plaque identified by AI-CPA, including 34.7% of patients aged 18–29, 50.6% aged 30–39 and 68.8% aged 40–49 (p=<0.0001). In patients with coronary plaque, all had non-calcified plaque, 54.7% had calcified plaque and 63.4% had low-attenuation plaque. Median (IQR) total plaque volume was 36 (11–153) mm3, which increased with age and was higher in men than women (59 (17–214) mm3 vs 22 (9–70) mm3 (p≤0.0001)). In the entire cohort, 44% had a nadir CT fractional flow reserve (FFR-CT) ≤0.80, and this proportion increased with age.ConclusionsOver 62% of young adults referred for clinically indicated CCTA have coronary artery plaque detected by AI-CPA, and plaque prevalence and burden increase with age. These findings suggest that coronary artery plaque is present in most individuals referred for CCTA by early adulthood, warranting the development of strategies for risk stratification and prevention of coronary events early in life.

Beneficial insects provide valuable services upon which we rely, including pollination. Pollinator conservation is a global priority, and a significant concern in Ireland, where over half of extant bee species have declined significantly in recent decades. As flower‐visiting insects rely on flowering plants, one way to conserve and promote pollinator populations is to protect high‐quality habitat. We analyzed the structure of insect–flower interactions from multiple habitat categories in a large database of interactions from Ireland. Our primary goals were to compare spatial and temporal variation in Irish network structures, compare Irish networks to published networks from other countries, and provide evidence‐based recommendations for pollinator conservation in Ireland by identifying well‐visited plant species that may promote high pollinator diversity, abundance, and functional complementarity. Habitat types within Ireland differed substantially: seminatural grasslands had the highest pollinator species richness and largest number of unique pollinator species, while intensively managed habitats exhibited negative asymmetry (more plant than pollinator species). This negative asymmetry is notable because most plant–pollinator networks exhibit a positive asymmetry. Within intensively managed habitats, agricultural and urban habitats differed. Urban habitats had the highest number of non‐native plant species while agricultural habitats had the lowest pollinator species richness. We also found Irish networks varied across the growing season, where July had the highest plant and insect species richness. When comparing Irish networks to published networks from other countries, we found Irish networks had a higher ratio of plant species to pollinator species, and that this difference was most evident in agricultural habitats. This ratio means the typical network asymmetry (more pollinator than plant species) was flipped (more plant than pollinator species) in the Irish network. We conclude that conserving seminatural grasslands in Ireland will be an essential component of pollinator conservation and identify thirty‐five plant species important for restoring seminatural habitats. We show that semi‐natural grasslands are critical to pollinator conservation in Ireland. We also show that intensive land management affects the structure of Irish networks, and that urban and agricultural land‐use affect these networks differently.

Granulomatosis with polyangiitis (GPA), formerly Wegener's granulomatosis, is a small- and medium-vessel vasculitis with characteristic cutaneous morphologic presentation and systemic involvement. Most patients have palpable purpura at some point in their disease course, but this is not always the presenting manifestation. This autoimmune disorder can affect a range of organs, with the upper and lower respiratory tract, kidneys, and nervous system being commonly implicated, while gastrointestinal and cardiac involvement is less frequent. This is a 44-year-old female presenting to the emergency department (ED) with polyarthralgia and palpable purpura. Palpable purpura was distributed on the oral palate, elbow, and lower back, and a punch biopsy revealed leukocytoclastic vasculitis (LCV). While this was an atypical distribution for leukocytoclastic vasculitis, the skin biopsy provided the necessary evidence to diagnose GPA. This case characterizes non-specific and atypical signs and symptoms of GPA that all providers should be aware of in order to diagnose the condition early in its disease course.

Essential cellular processes of microtubule disassembly and protein degradation, which span lengths from tens of μm to nm, are mediated by specialized molecular machines with similar hexameric structure and function. Our molecular simulations at atomistic and coarse-grained scales show that both the microtubule-severing protein spastin and the caseinolytic protease ClpY, accomplish spectacular unfolding of their diverse substrates, a microtubule lattice and dihydrofolate reductase (DHFR), by taking advantage of mechanical anisotropy in these proteins. Unfolding of wild-type DHFR requires disruption of mechanically strong β-sheet interfaces near each terminal, which yields branched pathways associated with unzipping along soft directions and shearing along strong directions. By contrast, unfolding of circular permutant DHFR variants involves single pathways due to softer mechanical interfaces near terminals, but translocation hindrance can arise from mechanical resistance of partially unfolded intermediates stabilized by β-sheets. For spastin, optimal severing action initiated by pulling on a tubulin subunit is achieved through specific orientation of the machine versus the substrate (microtubule lattice). Moreover, changes in the strength of the interactions between spastin and a microtubule filament, which can be driven by the tubulin code, lead to drastically different outcomes for the integrity of the hexameric structure of the machine.

Coronary artery disease (CAD) is a major cause of ill health and death worldwide. Coronary computed tomographic angiography (CCTA) is the first-line investigation to detect CAD in symptomatic patients. This diagnostic approach risks greater second-line heart tests and treatments at a cost to the patient and health system. The National Health Service funded use of an artificial intelligence (AI) diagnostic tool, computed tomography (CT)-derived fractional flow reserve (FFR-CT), in patients with chest pain to improve physician decision-making and reduce downstream tests. This observational cohort study assessed the impact of FFR-CT on cardiovascular outcomes by including all patients investigated with CCTA during the national AI implementation program at 27 hospitals (CCTA n = 90,553 and FFR-CT n = 7,863). FFR-CT was safe, with no difference in all-cause ( n = 1,134 (3.2%) versus 1,612 (2.9%), adjusted-hazard ratio (aHR) 1.00 (0.93–1.08), P = 0.97) or cardiovascular mortality ( n = 465 (1.3%) versus 617 (1.1%), aHR 0.96 (0.85–1.08), P = 0.48), while reducing invasive coronary angiograms ( n = 5,720 (16%) versus 8,183 (14.9%), aHR 0.93 (0.90–0.97), P < 0.001) and noninvasive cardiac tests (189/1,000 patients versus 167/1,000), P < 0.001). Implementation of an AI-diagnostic tool as part of a health intervention program was safe and beneficial to the patient pathway and health system with fewer cardiac tests at 2 years. National implementation of a computed tomographic angiography and AI-diagnostic tool, CT-derived fractional flow reserve (FFR-CT), did not provide significant benefits in reducing mortality but led to fewer invasive coronary angiograms and downstream cardiac tests.

ObjectivesTo obtain more powerful assessment of the prognostic value of fractional flow reserveCT testing we performed a systematic literature review and collaborative meta-analysis of studies that assessed clinical outcomes of CT-derived calculation of FFR (FFRCT) (HeartFlow) analysis in patients with stable coronary artery disease (CAD).MethodsWe searched PubMed and Web of Science electronic databases for published studies that evaluated clinical outcomes following fractional flow reserveCT testing between 1 January 2010 and 31 December 2020. The primary endpoint was defined as ‘all-cause mortality (ACM) or myocardial infarction (MI)’ at 12-month follow-up. Exploratory analyses were performed using major adverse cardiovascular events (MACEs, ACM+MI+unplanned revascularisation), ACM, MI, spontaneous MI or unplanned (>3 months) revascularisation as the endpoint.ResultsFive studies were identified including a total of 5460 patients eligible for meta-analyses. The primary endpoint occurred in 60 (1.1%) patients, 0.6% (13/2126) with FFRCT>0.80% and 1.4% (47/3334) with FFRCT ≤0.80 (relative risk (RR) 2.31 (95% CI 1.29 to 4.13), p=0.005). Likewise, MACE, MI, spontaneous MI or unplanned revascularisation occurred more frequently in patients with FFRCT ≤0.80 versus patients with FFRCT >0.80. Each 0.10-unit FFRCT reduction was associated with a greater risk of the primary endpoint (RR 1.67 (95% CI 1.47 to 1.87), p<0.001).ConclusionsThe 12-month outcomes in patients with stable CAD show low rates of events in those with a negative FFRCT result, and lower risk of an unfavourable outcome in patients with a negative test result compared with patients with a positive test result. Moreover, the FFRCT numerical value was inversely associated with outcomes.

This study aimed to determine if an integrated structured reporting (SR) tool incorporating results from artificial intelligence (AI) enabled coronary stenosis quantification (AI-CSQ), AI-enabled coronary plaque analysis (AI-CPA), and fractional flow reserve CT (FFR ) can increase reader efficiency for coronary computed tomography angiography (CCTA), while reducing cognitive load. Eighty CCTAs from patients with stable chest pain or symptoms suggestive of coronary artery disease (CAD) were analyzed by five independent readers from two clinical sites. CCTA datasets were used to generate combined reports for AI-CSQ, AI-CPA, and FFR . Each reader randomly interpreted 40 cases with the SR tool (which provided a prepopulated fully editable template) and 40 cases without the SR tool using site-specific clinical workflows (400 total cases). Reporting times from initiation of case interpretation through report signing were measured with and without the SR tool and stratified by CAD-Reporting and Data System (CAD-RADS) 2.0 category. Reader confidence was recorded using a 5-point Likert Scale, and cognitive load (e.g., working memory load) was determined using a 9-point scale, with comparison by SR tool use. Inter-reader agreement associated with CCTA interpretation with versus without the SR tool also was compared. Reporting time per case was 40.2% shorter with versus without the SR tool (6.0 ± 2.0 vs. 10.0 ± 3.3 min; p < 0.001), independent of CAD-RADS 2.0 category. Readers were more likely to report very confident reads with the SR tool than without (48% vs. 29%; p < 0.001). Cognitive load also was significantly lower with the SR tool than without (3.8 ± 1.2 vs. 6.1 ± 1.5; p < 0.001). Report agreement was significantly higher with versus without the SR tool (94.6%±2.3% vs. 45.3%±9.2%; p < 0.001). The SR tool significantly improved reader efficiency and decreased work effort when interpreting comprehensive CCTA exams.

Clinicians vary widely in their preferred diagnostic approach to patients with non-acute chest pain. Such variation exposes patients to potentially avoidable risks, as well as inefficient care with increased costs and unresolved patient concerns. The Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization (PRECISE) trial (NCT03702244) compares an investigational “precision” diagnostic strategy to a usual care diagnostic strategy in participants with stable chest pain and suspected coronary artery disease (CAD). PRECISE randomized 2103 participants with stable chest pain and a clinical recommendation for testing for suspected CAD at 68 outpatient international sites. The investigational precision evaluation strategy started with a pre-test risk assessment using the PROMISE Minimal Risk Tool. Those at lowest risk were assigned to deferred testing (no immediate testing), and the remainder received coronary computed tomographic angiography (cCTA) with selective fractional flow reserve (FFRCT) for any stenosis meeting a threshold of ≥30% and <90%. For participants randomized to usual care, the clinical care team selected the initial noninvasive or invasive test (diagnostic angiography) according to customary practice. The use of cCTA as the initial diagnostic strategy was proscribed by protocol for the usual care strategy. The primary endpoint is time to a composite of major adverse cardiac events (MACE: all-cause death or non-fatal myocardial infarction) or invasive cardiac catheterization without obstructive CAD at 1 year. Secondary endpoints include health care costs and quality of life. PRECISE will determine whether a precision approach comprising a strategically deployed combination of risk-based deferred testing and cCTA with selective FFRCT improves the clinical outcomes and efficiency of the diagnostic evaluation of stable chest pain over usual care.