Optimal Antihypertensive Systolic Blood Pressure: A Systematic Review and Meta-Analysis.

BACKGROUND: Systolic blood pressure (SBP) lowering reduces major cardiovascular disease (CVD) and all-cause mortality. However, the optimal target for SBP lowering remains controversial. METHODS: We included trials with random allocation to an SBP <130 mm Hg treatment target and CVD as the primary outcome. Data were extracted from each study independently and in duplicate using a standardized protocol. Random-effects meta-analysis was used to obtain pooled hazard ratios (HRs) and 95% CIs for CVD and all-cause mortality comparing SBP <130 and ≥130 mm Hg treatment targets. A secondary analysis compared the same outcomes for randomization to an SBP target of <120 or <140 mm Hg. RESULTS: Seven trials, including 72 138 participants, met the eligibility criteria. Compared with an SBP target of ≥130 mm Hg, an SBP target of <130 mm Hg significantly reduced major CVD (HR, 0.78 [95% CI, 0.70-0.87]) and all-cause mortality (HR, 0.89 [95% CI, 0.79-0.99]). Compared with an SBP target of <140 mm Hg, an intensive SBP target of <120 mm Hg significantly reduced major CVD (HR, 0.82 [95% CI, 0.74-0.91]), but all-cause mortality was marginally insignificant (HR, 0.85 [95% CI, 0.71-1.01]). Adverse events were significantly more likely in the intensive SBP target groups, but the absolute risks were low. CONCLUSIONS: This study suggests targeting an SBP <130 mm Hg significantly reduces the risks of major CVD and all-cause mortality. The findings also support an SBP target of <120 mm Hg, based on a smaller number of trials. REGISTRATION: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42023490693.

Socioeconomic and Urban-Rural Disparities in Genome-Matched Treatment Receipt and Survival after Genomic Tumor Testing.

PURPOSE: Emerging cancer treatments are often most available to socially advantaged individuals. This study examines the relationship of patient educational attainment, income level, and rurality to the receipt of genome-matched treatment (GMT) and overall survival. METHODS: Survey and clinical data were collected from patients with cancer (n = 1258) enrolled in the Maine Cancer Genomics Initiative. Logistic regression models examined whether receipt of GMT differed by patient education, income, and rurality. Kaplan-Meier curves and Cox regression were conducted to evaluate 12-month mortality. We completed additional exploratory analyses using Kaplan-Meier curves and Cox models stratified by receipt of GMT. Both logistic and Cox regression models were adjusted for age and gender. RESULTS: Educational attainment, income level, and rurality were not associated with GMT receipt. Of 1258 patients, 462 (36.7%) died within 365 days of consent. Mortality risk was associated with lower educational attainment (hazard ratio (HR): 1.30; 95% CI: 1.06 to 1.59; p = .013). No statistically significant differences in mortality risk were observed for income level or rurality. Exploratory models suggest that patients who did not receive GMT with lower educational attainment had higher mortality risk (HR = 1.36, 95% CI: 1.09 to 1.69, p = .006). For patients who did receive GMT, there was no difference in mortality risk between the education groups (HR: 1.01, 95% CI: 0.56 to 1.81, p > .9). CONCLUSION: While there were no disparities in who received GMT, we found a disparity in mortality associated with education level, which was more pronounced for patients who did not receive GMT. Future research is warranted to investigate the intersectionality of social disadvantage with clinical outcomes to address survival disparities.

Point-of-Care Diagnostics (POCD) in Resource-Limited Settings.

Diagnostic testing is critical to provide adequate healthcare, and the emergence of various rapid point-of-care diagnostics (POCD) allows for greater access and broader implementation in resource-limited settings [...].

Occupational exposure and new-onset asthma in the population-based Telemark study: a 5-year follow-up.

OBJECTIVES: This study aimed to estimate the incidence of asthma and assess the association between job exposure matrix (N-JEM) assigned occupational exposure, self-reported occupational exposure to vapour, gas, dust and fumes (VGDF), mould, damages from moisture and cold, and new-onset asthma. We also aimed to assess the corresponding population attributable fraction (PAF) for ever exposure to VGDF. DESIGN: Longitudinal population-based respiratory health study. SETTING: Responders from the baseline Telemark Study in south-eastern Norway were followed up from 2013 to 2018. PARTICIPANTS: 7120 participants, aged 16-55, were followed during a 5-year period. MAIN OUTCOME MEASURES: New-onset asthma and its association with self-reported occupational exposure to VGDF, data from the N-JEM and self-reported workplace conditions were assessed using logistic regression adjusted for gender, age, smoking and body mass index. The PAF was calculated using the PUNAF command in STATA. RESULTS: There were 266 (3.7%) cases of new-onset asthma and an incidence density of 7.5 cases per 1000 person-years. A statistically significant association was found for ever exposed to VGDF with an OR of 1.49 (95% CI 1.15 to 1.94), weekly OR 2.00 (95% CI 1.29 to 3.11) and daily OR 2.46 (95% CI 1.39 to 4.35) exposure to VGDF. The corresponding PAF for ever exposed to VGDF was 17% (95% CI 5.4% to 27.8%) and the risk of asthma onset increased with frequent VGDF exposure, indicating a possible exposure-response relationship (p=0.002 for trend). The N-JEM exposure group, accidental peak exposure to irritants had an increased risk of new-onset asthma, OR 2.43 (95% CI 1.21 to 4.90). A significant association was also found for self-reported exposure to visible damages due to moisture 1.51 (95% CI 1.08 to 2.11), visible and smell of mould 1.88 (95% CI 1.32 to 2.68), 1.55 (95% CI 1.12 to 2.16) and cold environment 1.41 (95% CI 1.07 to 1.86). CONCLUSION: Participants had elevated ORs for asthma associated with self-reported and N-JEM-assigned exposures. A PAF of 17% indicates that work-related asthma is still common. The possible exposure-response relationship suggests that reducing occupational VGDF exposure frequency could prevent the onset of asthma.

Primary Care Providers' and Laypersons' Perceptions of Multi-Cancer Detection Clinical Trial Designs.

BACKGROUND: The National Cancer Institute Cancer Screening Research Network is launching a pilot study ("Vanguard") to determine feasibility of successful completion of a clinical trial of multi-cancer detection (MCD) tests. This focus group study reports perceptions of primary care physicians (PCP) and laypersons of different clinical trial designs, and willingness to participate in an MCD clinical trial. METHODS: We undertook 14 focus groups with 88 laypersons and six focus groups with 45 PCPs. Participants were shown graphics of clinical trial designs and asked for their reactions. Focus group recordings were transcribed verbatim and thematic analysis of the transcripts were conducted to identify emergent themes. RESULTS: PCP and laypersons participants recognized the importance of conducting clinical trials to determine the clinical utility of MCD tests. PCPs expressed reluctance to participate in trials due to workload burden and laypersons expressed hesitancy about enrolling in the control group. Both PCPs and laypersons expressed concern about a study design in which MCD test results would not be returned to the control group ("Intended Effect"), but they respectively indicated a willingness to refer patients to, or participate in, an MCD test clinical trial given transparent and clear communication on collection and use of biospecimens and data, particularly if an MCD test would eventually be run and results eventually returned. CONCLUSION: This study yielded important insights to guide trial design in planning prospective evaluation of MCD testing. Maintaining transparency and trust while possibly withholding MCD test results to maximize trial feasibility and efficiency, is of particular concern.

Study protocol for the Functional Communication Checklist for people living with primary progressive aphasia.

This study protocol describes the development of the first instrument of functional communication for people living with primary progressive aphasia (PPA), with future applications to other progressive conditions, with expert validation, item-level reliability analyses, input from partners in research, and outcomes. Progressive conditions like PPA require monitoring, and as such, re-assessment. Re-assessment poses the high risk of being burdensome, destructive, and of little use to the patient. As such, there is a significant need to establish a validated and reliable measure that (1) poses minimal patient burden and (2) captures communication ability in a strengths-based manner for both clinical and research purposes. A strengths-based approach to assessment is widely recognized as the optimal way to promote patient autonomy, minimize harm, and implement functional treatment protocols and strategies. To date, there are no strengths-based assessment tools that were developed for people living with PPA nor ways to efficiently document functional communication performance. This study protocol outlines our work to address this gap in clinical practice and research.

Associations between perceived interpersonal support and aggressiveness of care in the last month of life among patients with advanced cancer.

PURPOSE: To determine quality of life (QoL) domains in the months leading up to death associated with the receipt of aggressive care in the last month of life among patients with advanced cancer. METHODS: A multisite, prospective cohort study conducted from January 2010 to May 2015 of 59 patients with advanced cancer (distant metastases and/or progression of disease following at least first-line chemotherapy) and poor prognosis (≤ 6 months) followed through death. At baseline, a median of 4 months from death, the McGill Quality of Life Questionnaire measured overall QoL and four QoL domains (i.e., interpersonal support, physical well-being, psychological, and existential). Postmortem data were collected via medical chart review and nurse/caregiver report and combined to capture the aggressiveness of end-of-life (EoL) care in patients' last month of life. Aggressive EoL care was defined as any receipt of care in an intensive care unit, being on a ventilator, or chemotherapy in the last month of life. RESULTS: Patients with higher interpersonal support domain scores (i.e., rating the world as more "caring and responsive" to their needs and their felt support as more complete) received significantly less aggressive care in their last month of life (odds ratio = 0.39, 95% confidence interval 0.20 to 0.75, p = 0.004). CONCLUSION: Perceived interpersonal support is the only QoL domain assessed that was associated with aggressiveness of care in the last month of life for patients with advanced cancer. Prioritizing caring and responsive relationships for patients may decrease receipt of aggressive EoL care.

Use and Cost Patterns of Antihypertensive Medications in the United States From 1996 to 2021.

BACKGROUND: Antihypertensive medication use patterns have likely been influenced by changing costs and accessibility over the past 3 decades. This study examines the relationships between patent exclusivity loss, medication costs, and national health policies on antihypertensive medication use. METHODS: Using 1996 to 2021 Medical Expenditure Panel Survey data of US adults with hypertension taking at least 1 antihypertensive medication, we conducted a cross-sectional analysis. We explored the associations between patent exclusivity loss, per-pill costs, and Medicare Part D enactment on medication use over time, focusing on the most commonly used medications (lisinopril, amlodipine, losartan, hydrochlorothiazide, and metoprolol). RESULTS: The unweighted sample comprised 50 095 US adults (mean age, 62 years; 53% female). The survey-weighted number of adults taking antihypertensive medications increased from 22 million (95% CIs, 20-23 million) to 55 million (95% CI, 51-60 million) between 1996 and 2021. Loss of patent exclusivity led to increased medication fills, notably for lisinopril, amlodipine, and losartan, which all exhibited within-class dominance. However, per-pill cost decreases coinciding with Medicare Part D did not increase the number of individuals treated or the use of specific antihypertensive medications or classes. CONCLUSIONS: The increase in antihypertensive medication use over the past decades highlights the significant impact of loss of patent exclusivity on the uptake in the use of specific medications. These findings underscore the complexity of factors influencing medication use, beyond cost reductions alone, and suggest that policies need to consider multiple facets to effectively improve antihypertensive medication accessibility and utilization.

Adsorptive Shield Derived Cathode Electrolyte Interphase Formation with Impregnation on LiNi0.8Mn0.1Co0.1O2 Cathode: A Mechanism-Guiding-Experiment Study.

Lithium difluoro(oxalate) borate (LiDFOB) contributes actively to cathode-electrolyte interface (CEI) formation, particularly safeguarding high-voltage cathode materials. However, LiNixCozMnyO2-based batteries benefit from the LiDFOB and its derived CEI only with appropriate electrolyte design while a comprehensive understanding of the underlying interfacial mechanisms remains limited, which makes the rational design challenging. By performing ab initio calculations, the CEI evolution on the LiNi0.8Co0.1Mn0.1O2 has been investigated. The findings demonstrate that LiDFOB readily adheres to the cathode via semidissociative configuration, which elevates the Li deintercalation voltage and remains stable in solvent. Electrochemical processes are responsible for the subsequent cleavage of B-F and B-O bonds, while the B-F bond cleavage leading to LiF formation is dominant in the presence of adequate Li+ with a substantial Li intercalation energy. Thus, impregnation is established as an effective method to regulate the conversion channel for efficient CEI formation, which not only safeguards the cathode's structure but also counters electrolyte decomposition. Consequently, in comparison to utilizing LiDFOB as an electrolyte additive, employing LiDFOB impregnation in the NCM811/Li cell yields significantly improved cycling stability for over 2000 h.

Trace metals in coastal marine sediments: Natural and anthropogenic sources, correlation matrices, and proxy potentials.

Rapidly spreading industrialization since the 19th century has led to a drastic increase in trace metal deposition in coastal sediments. Provided that these trace metals have remained relatively immobile after deposition, their sedimentary enrichments can serve as records of local-regional pollution histories. Factors controlling this proxy potential include trace metal geochemistry (carrier-, and host phase affinity), and depositional environmental factors (redox variability, particulate shuttling, organic matter loading, bathymetry). Yet, the relative importance and interactions between these controls are still poorly understood, hampering the reliable use of trace metal-based environmental proxies. By summarizing nine site-specific correlation matrices of 16 metal (loid) s (Pb, Cd, Cu, Zn, Sb, Sn, Ni, As, Tl, V, Mo, U, Re, Fe, Mn, Al), total organic C, and S contents in short sediment cores into a single meta-matrix, we test a novel approach for quickly detecting common and contrasting trace metal enrichment patterns across different study locations. Our meta-matrix shows two trace metal groups, within which positive correlations of e.g., Pb, Cd, Zn, Cu, Sb suggest a primary "anthropogenically sourced" (group I) control, whereas known "redox-sensitive" (group II) trace metals (Mo, U, Re) are characterized by fewer positive correlations. However, some group I metals (Cd, Zn, Cu, Sb) also covary with group II metals, inferring that redox variability may obscure primary anthropogenic signals; Sb even shows advantages over Mo and U under oxic conditions. As a more robust pollution indicator we identified Pb; yet for reconstructing historical Pb atmospheric pollution signals (1970s Pb peak), it is crucial to consider the distance from shore. In near-shore environments, local (fluvial) pollution signals may overprint large-scale (atmospheric) signals. Our findings demonstrate that combining site-specific sedimentary correlation and distribution patterns with a meta-matrix considerably aids the understanding of trace metal sequestration in different coastal sedimentary environments, which thereby improves trace metal proxy reliability.

Online MR-guided proton and ion beam radiotherapy: investigation of image quality.

Objective.Magnetic resonance (MR) images free of artefacts are of pivotal importance for MR-guided ion radiotherapy. This study investigates MR image quality for simultaneous irradiation in an experimental setup using phantom imaging as well asin-vivoimaging. Observed artefacts are described within the study and their cause is investigated with the goal to find conclusions and solutions for potential future hybrid devices.Approach.An open MR scanner with a field strength of 0.25 T has been installed in front of an ion beamline. Simultaneous magnetic resonance imaging and irradiation using raster scanning were performed to analyze image quality in dedicated phantoms. Magnetic field measurements were performed to assist the explanation of observed artifacts. In addition,in-vivoimages were acquired by operating the magnets for beam scanning without transporting a beam.Main Results.The additional frequency component within the isocenter caused by the fringe field of the horizontal beam scanning magnet correlates with the amplitude and frequency of the scanning magnet steering and can cause ghosting artifacts in the images. These are amplified with high currents and fast operating of the scanning magnet. Applying a real-time capable pulse sequencein-vivorevealed no ghosting artifacts despite a continuously changing current pattern and a clinical treatment plan activation scheme, suggesting that the use of fast imaging is beneficial for the aim of creating high quality in-beam MR images. This result suggests, that the influence of the scanning magnets on the MR acquisition might be of negligible importance and does not need further measures like extensive magnetic shielding of the scanning magnets.Significance.Our study delimited artefacts observed in MR images acquired during simultaneous raster scanning ion beam irradiation. The application of a fast pulse sequence showed no image artefacts and holds the potential that online MR imaging in future hybrid devices might be feasible.

Large-scale genomic investigation of pediatric cholestasis reveals a novel hepatorenal ciliopathy caused by PSKH1 mutations.

PURPOSE: Pediatric cholestasis is the phenotypic expression of clinically and genetically heterogeneous disorders of bile acid synthesis and flow. Although a growing number of monogenic causes of pediatric cholestasis have been identified, the majority of cases remain undiagnosed molecularly. METHODS: In a cohort of 299 pediatric participants (279 families) with intrahepatic cholestasis, we performed exome sequencing as a first-tier diagnostic test. RESULTS: A likely causal variant was identified in 135 families (48.56%). These comprise 135 families that harbor variants spanning 37 genes with established or tentative links to cholestasis. In addition, we propose a novel candidate gene (PSKH1) (HGNC:9529) in 4 families. PSKH1 was particularly compelling because of strong linkage in 3 consanguineous families who shared a novel hepatorenal ciliopathy phenotype. Two of the 4 families shared a founder homozygous variant, whereas the third and fourth had different homozygous variants in PSKH1. PSKH1 encodes a putative protein serine kinase of unknown function. Patient fibroblasts displayed abnormal cilia that are long and show abnormal transport. A homozygous Pskh1 mutant mouse faithfully recapitulated the human phenotype and displayed abnormally long cilia. The phenotype could be rationalized by the loss of catalytic activity observed for each recombinant PSKH1 variant using in vitro kinase assays. CONCLUSION: Our results support the use of genomics in the workup of pediatric cholestasis and reveal PSKH1-related hepatorenal ciliopathy as a novel candidate monogenic form.

Comparative Safety and Effectiveness of Ustekinumab and Anti-TNF in Elderly Crohn's Disease Patients.

BACKGROUND: Biologic therapies are associated with increased infection risk among elderly patients with inflammatory bowel disease (IBD). However, there are few data on the safety and effectiveness of ustekinumab compared with anti-tumor necrosis factor (anti-TNF) agents in the elderly. METHODS: The study sought to compare the safety and effectiveness of ustekinumab and anti-TNF agents in elderly Crohn's disease (CD) patients. Patients ≥60 years of age who commenced ustekinumab or an anti-TNF agent for CD were included in this retrospective multicenter cohort. The primary outcome was incidence of serious infections requiring hospitalization. Effectiveness was assessed by clinical remission, clinical response, and treatment persistence rates at 6 months. We adjusted for confounders using inverse probability of treatment weighting (IPTW) and performed a logistic regression analysis to assess factors associated with serious infections, clinical remission, and treatment persistence. RESULTS: Eighty-three patients commencing ustekinumab and 124 commencing anti-TNF therapy were included. There was no difference in serious infection rates between anti-TNF agents (2.8%) and ustekinumab (3.1%) (P = .924) after propensity adjustment. Clinical remission rates were comparable at 6 months for ustekinumab (55.9%) and anti-TNF agents (52.4%) (P = .762). There was a significant reduction in HBI at 6 months in both groups. Treatment persistence was comparable between ustekinumab (90.6%) and anti-TNF agents (90.0%) at 6 months. Cox regression analysis did not show differences in treatment persistence (hazard ratio, 1.23; 95% confidence interval, 0.57-2.61; P = .594) and serious infection incidence (hazard ratio, 1.38; 95% confidence interval, 0.25-7.57; P = .709) by 6 months. CONCLUSIONS: We observed comparable safety and effectiveness for ustekinumab and anti-TNF agents in treating elderly CD patients.

In this retrospective multicenter cohort study, we report equal safety and effectiveness for ustekinumab and anti-tumor necrosis factor agents in treating older adults with Crohn's disease over a 6-month period.

Deep generative model of the distal tibial classic metaphyseal lesion in infants: assessment of synthetic images.

Background: The classic metaphyseal lesion (CML) is a distinctive fracture highly specific to infant abuse. To increase the size and diversity of the training CML database for automated deep-learning detection of this fracture, we developed a mask conditional diffusion model (MaC-DM) to generate synthetic images with and without CMLs. Purpose: To objectively and subjectively assess the synthetic radiographic images with and without CMLs generated by MaC-DM. Materials and Methods: For retrospective testing, we randomly chose 100 real images (50 normals and 50 with CMLs; 39 infants, male = 22, female = 17; mean age = 4.1 months; SD = 3.1 months) from an existing distal tibia dataset (177 normal, 73 with CMLs), and generated 100 synthetic distal tibia images via MaC-DM (50 normals and 50 with CMLs). These test images were shown to 3 blinded radiologists. In the first session, radiologists determined if the images were normal or had CMLs. In the second session, they determined if the images were real or synthetic. We analyzed the radiologists' interpretations and employed t-distributed stochastic neighbor embedding technique to analyze the data distribution of the test images. Results: When presented with the 200 images (100 synthetic, 100 with CMLs), radiologists reliably and accurately diagnosed CMLs (kappa = 0.90, 95% CI = [0.88-0.92]; accuracy = 92%, 95% CI = [89-97]). However, they were inaccurate in differentiating between real and synthetic images (kappa = 0.05, 95% CI = [0.03-0.07]; accuracy = 53%, 95% CI = [49-59]). The t-distributed stochastic neighbor embedding analysis showed substantial differences in the data distribution between normal images and those with CMLs (area under the curve = 0.996, 95% CI = [0.992-1.000], P < .01), but minor differences between real and synthetic images (area under the curve = 0.566, 95% CI = [0.486-0.647], P = .11). Conclusion: Radiologists accurately diagnosed images with distal tibial CMLs but were unable to distinguish real from synthetically generated ones, indicating that our generative model could synthesize realistic images. Thus, MaC-DM holds promise as an effective strategy for data augmentation in training machine-learning models for diagnosis of distal tibial CMLs.

Understanding resilience: Lifestyle-based behavioral predictors of mental health and well-being in community-dwelling older adults during the COVID-19 pandemic.

BACKGROUND: Changes in sleep, physical activity and mental health were observed in older adults during early stages of the COVID-19 pandemic. Here we describe effects of the COVID-19 pandemic on older adult mental health, wellbeing, and lifestyle behaviors and explore predictors of better mid-pandemic mental health and wellbeing. METHODS: Participants in the Adult Changes in Thought study completed measures of lifestyle behaviors (e.g., sleep, physical activity) and mental health and wellbeing both pre-pandemic during regular study visits and mid-pandemic via a one-time survey. We used paired t-tests to compare differences in these measures pre- vs. mid-pandemic. Using multivariate linear regression, we further explored demographic, health, and lifestyle predictors of pandemic depressive symptoms, social support, and fatigue. We additionally qualitatively coded free text data from the mid-pandemic survey for related comments. RESULTS: Participants (N = 896) reported significant changes in mental health and lifestyle behaviors at pre-pandemic vs. mid-pandemic measurements (p < 0.0001). Qualitative findings supported these behavioral and wellbeing changes. Being male, never smoking, and lower pre-pandemic computer time and sleep disturbance were significantly associated with lower pandemic depressive symptoms. Being partnered, female, never smoking, and lower pre-pandemic sleep disturbance were associated with higher pandemic social support. Pre-pandemic employment, more walking, less computer time, and less sleep disturbance were associated with less pandemic fatigue. Participant comments supported these quantitative findings, highlighting gender differences in pandemic mental health, changes in computer usage and physical activity during the pandemic, the value of spousal social support, and links between sleep disturbance and mental health and wellbeing. Qualitative findings also revealed additional factors, such as stresses from personal and family health situations and the country's concurrent political environment, that impacted mental health and wellbeing. CONCLUSIONS: Several demographic, health, and lifestyle behaviors appeared to buffer the effects of the COVID-19 pandemic and may be key sources of resilience. Interventions and public health measures targeting men and unpartnered individuals could promote social support resilience, and intervening on modifiable behaviors like sleep quality, physical activity and sedentary activities like computer time may promote resilience to fatigue and depressive symptoms during future community stressor events. Further research into these relationships is warranted.

Evidence-Based Reading Instruction for Secondary Students With Reading Difficulties Within Multitiered Systems of Support.

Christian Scott recently returned home from college and was set to begin his first year as a middle school special education teacher. During his first meeting with his new principal, he learned about his teaching schedule. His principal, Mrs. Walker, explained their district was making a push for using multitiered systems of support (MTSS) as a framework for instruction. Her school would identify students with reading difficulties based on their performance on prior state reading tests and use this information to develop student schedules that allow students to receive additional reading interventions (i.e., Tier 2, Tier 3). Christian would teach reading to students with disabilities on his caseload across instructional tiers (Tiers 1-3). He would be tasked with providing co-teaching support for students with disabilities as they participate in general education classes (i.e., Tier 1). He would also provide additional Tier 2 supports to students with and without disabilities that did not pass the state achievement test in reading. Finally, he would provide intensive interventions to students with disabilities who required small group instruction (Tier 3). Having just received his special education teaching credential, Christian was familiar with the co-teaching service delivery model and the elements of effective instruction for middle school students with reading difficulties. However, he wondered, "What will this actually look like? How will I support the general education teacher providing Tier 1 supports? It sounds like I will also provide Tier 2-type instruction to students via a reading intervention class. What should this look like? How will this differ from the small group, Tier 3 instruction I need to provide?" Christian's mind raced with questions he was too nervous to ask in his first meeting with his new supervisor. The special education lead teacher noticed Christian seemed unsure how to respond. She jumped in, "Don't worry, Christian. School doesn't start for a few weeks. I'll help you with the details so you can hit the ground running." Christian felt excited about the challenge but also overwhelmed. Planning lessons for students with varying needs across instructional tiers was a tall order, and he felt unsure about how to get started.

Advanced 3D-Printed Potassium Ammonium Vanadate/rGO Aerogel Cathodes for Durable and High-Capacity Potassium-Ion Batteries.

A 3D-printed oxygen-vacancy-rich potassium ammonium vanadate/reduced graphene oxide (KNVOv/rGO) microlattice aerogel is designed for the cathode in high-performance K-ion batteries (KIBs). The 3D-printed KNVOv/rGO electrode with periodic submillimeter microchannels and interconnected printed filaments is composed of highly dispersed KNVOv nanobelts, wrinkled graphene nanoflakes, and abundant micropores. The well-defined 3D porous microlattice structure of the rGO backbone not only provides the interconnected conductive 3D network and the required mechanical robustness but also facilitates the penetration of the liquid electrolyte into inner active sites, consequently ensuring a stable electrochemical environment for K-ion intercalation/deintercalation within the KNVOv nanobelts. The 3D-printed KNVOv/rGO microlattice aerogel electrode has a high discharge capacity of 109.3 mAh g-1 with a capacity retention rate of 92.6% after 200 cycles at 50 mA g-1 and maintains a discharge capacity of 75.8 mAh g-1 after 2000 cycles at 500 mA g-1. The flexible pouch-type KIB battery consisting of the 3D-printed KNVOv/rGO has good mechanical durability and retains a high specific capacity under different forms of deformation such as bending and folding. The results provide valuable insights into the integration of advanced 3D-printed electrode materials into K-ion batteries and the design of flexible and wearable energy storage devices.