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Biomaterial flow modeling beyond the nozzle: A rheological perspective

Achieving optimal printability is the key hurdle in extrusion-based 3D printing for medical use. Predicting printability before conducting costly and time-consuming physical experiments is necessary to save valuable biomaterial. This can be done with numerical models. An accurate viscosity model should be incorporated into numerical models to accurately represent biomaterial behavior under shear. Time-averaged and time-dependent viscosity models are available in the literature and can predict material behavior under shear. Here, the power-law and lambda-thixotropic viscosity model curves are obtained from experiments on the same biomaterial. Optimal model coefficients for the lambda-thixotropic viscosity model are obtained by computationally modeling the rheometer plate gap in 2D and solving the resulting equations using a Computational Fluid Dynamics (CFD) model. The performance of the power-law (time-averaged viscosity) and lambda-thixotropic viscosity models is qualitatively examined by incorporating them into the CFD model. To achieve a trade-off between accuracy and computational speed, a time-averaged viscosity model is used in a three-dimensional CFD model. A three-dimensional CFD model employs the Volume of Fluid method within the Finite Volume Method framework to investigate flow behavior outside a single nozzle. Simulations are carried out using a three-dimensional CFD model to assess the stackability of the biomaterial on the substrate. Additionally, the ability to print biomaterials one after another is evaluated.

The neutrophil-to-lymphocyte ratio independently predicts all-cause mortality in non-dialysis chronic kidney disease patients with preserved red cell distribution width: A retrospective cohort study

Background The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), inflammatory indices derived from routine complete blood counts, and red cell distribution width (RDW) have been proposed as prognostic markers in chronic kidney disease (CKD). However, whether the inflammatory ratios retain independent prognostic value once erythrocyte homeostasis is considered, and whether their performance varies across the spectrum of erythrocyte heterogeneity captured by RDW, remains uncertain. Methods This retrospective cohort study included 2,654 adults with non-dialysis CKD followed at a single tertiary center between 2015 and 2022. Optimal biomarker cut-off values were determined by receiver operating characteristic analysis based on 3-year all-cause mortality. Associations of RDW, NLR, and PLR with dialysis-free survival and overall survival were assessed using Kaplan–Meier analysis and multivariable Cox proportional hazards models adjusted for age, sex, kidney function, comorbidities, and nutritional and metabolic parameters. RDW-stratified analyses and formal interaction testing were performed to to determine whether NLR retains independent prognostic value within RDW-defined subgroups. Parallel analyses restricted to patients with eGFR < 60 mL/min/1.73 m 2 were performed as a sensitivity analysis and reported as supplementary material. Results During a median follow-up of 2,413 days, 451 patients (17.0%) initiated dialysis and 239 (9.0%) died. In multivariable Cox analyses of the whole cohort, NLR did not retain an independent association with either dialysis initiation (HR 1.03, 95% CI 0.84–1.26; p = 0.771) or all-cause mortality (HR 1.23, 95% CI 0.92–1.64; p = 0.162). However, a statistically significant RDW × NLR interaction was observed for overall survival (p for interaction = 0.006): NLR was independently associated with mortality in the low RDW subgroup (HR 2.07, 95% CI 1.25–3.45; p = 0.006) but not in the high RDW subgroup (HR 0.88, 95% CI 0.62–1.26; p = 0.494). PLR did not retain independent prognostic value in any analysis, whereas RDW remained the only marker independently associated with all-cause mortality in the overall multivariable model (HR 1.72, 95% CI 1.31–2.26; p < 0.001). Fine-Gray competing-risks models yielded virtually identical estimates, and findings were consistent in the eGFR < 60 mL/min/1.73 m 2 subgroup. Conclusions In patients with non-dialysis CKD, NLR independently predicts all-cause mortality specifically in patients with preserved RDW, but loses incremental prognostic information once RDW is already elevated. These findings argue against the uncritical use of NLR as a universal prognostic marker in CKD and support an RDW-stratified, outcome-specific framework for applying inflammatory ratios in routine risk stratification.

From Mechanism to Catalyst: Integrated Catalysts for Direct Electrosynthesis of Glycine Through an Oxime Pathway

ABSTRACT The electrocatalytic synthesis of glycine from oxalic acid (H 2 C 2 O 4 ) and hydroxylamine (NH 2 OH) involves a complex multi‐step pathway comprising C–N coupling and multi‐step selective protonation, making rational catalyst design a major challenge. In this work, by combining constant‐potential density functional theory (DFT), the reaction mechanisms for the formation of glyoxylic oxime (GAO) from H 2 C 2 O 4 and NH 2 OH on Pb surfaces, and its subsequent reduction to glycine on Cu surfaces are revealed. Guided by these mechanistic insights, we propose a set of criteria for designing integrated dual‐site catalysts capable of catalyzing both GAO formation and selective protonation to glycine. Among the theoretically screened out integrated Pt 1 (Ir 1 , Ru 1 )/Pb(100) single atom catalysts, Pt 1 /Pb catalyst is synthesized experimentally, demonstrating high activity for glycine production. This study bridges fundamental mechanistic understanding with practical catalyst development for complex multi‐step electrosynthesis.

A K-band kinetic-inductance parametric amplifier near the quantum limit

Advancing superconducting quantum devices to higher operating frequencies broadens their functionality and enables operation at elevated temperatures, but it also requires near-quantum-limited amplifiers beyond the few-gigahertz regime. Here, we present a junction-free, kinetic-inductance parametric amplifier based on thin-film niobium nitride (NbN) operating at 23 GHz in the microwave K-band, achieving a gain up to 40 dB, a 100 MHz gain–bandwidth product, a 1 dB saturation input power of −85 dBm with 23 dB gain, and added noise not greater than 1.4 quanta for phase-preserving amplification. Leveraging the large superconducting gap of NbN, this architecture can be extended to even higher frequencies, supporting applications such as high-fidelity readout of millimeter-wave superconducting qubits and axion searches over an expanded mass window.

Bone marrow CCR3 dictates eosinophil lineage commitment of CD34⁺ progenitors to orchestrate allergic rhinitis: A composite study

Background Allergic rhinitis (AR) is a common Th2-mediated inflammatory disease of the nasal mucosa, in which eosinophils serve as pivotal effector cells. The CCR3 receptor, specific for eotaxin, plays a critical role in allergic inflammation. However, the role of CCR3 in the differentiation of bone marrow CD34 ⁺ progenitor cells into eosinophils and its contribution to AR pathogenesis remains incompletely defined. Objective This study aimed to investigate whether bone marrow cell-specific CCR3 deletion is associated with altered CD34 ⁺ progenitor abundance, eosinophil-lineage–related responses, and allergic inflammation in a murine model of allergic rhinitis. Methods An integrative approach was employed. Bioinformatic analyses of transcriptomic data from CCR3-deficient mice, including differential expression screening, WGCNA, functional enrichment, and six machine learning algorithms, were used to identify candidate genes associated with CCR3 deletion. A bone marrow cell-specific CCR3 conditional knockout (CCR3-CKO) mouse model was generated and subjected to an ovalbumin-induced AR protocol. Nasal symptoms, body weight, nasal mucosal histopathology (H&E, PAS), serum cytokine/mediator levels (IL-5, eotaxin, ECP, EPO), and immune cell populations were assessed. Flow cytometry quantified CD34 ⁺ progenitors, CD34 ⁺ CCR3 ⁺ progenitors, and eosinophils in bone marrow, peripheral blood, and nasal lavage fluid. In vitro transwell migration and eosinophil colony-forming assays were performed to evaluate progenitor cell function. Results Bioinformatic and machine-learning analyses identified CD34 as a candidate hub gene associated with CCR3 deletion. In the AR model, CCR3-CKO mice showed reduced nasal symptom scores, less inflammatory-cell infiltration, and attenuated tissue injury, with a trend toward reduced allergy-associated weight loss. CCR3 deletion was associated with lower CD34 mRNA and protein levels in bone marrow and peripheral blood, as well as reduced proportions of CD34 ⁺ progenitors, CD34 ⁺ CCR3 ⁺ progenitors, and eosinophils across the analyzed compartments. Serum IL-5, ECP, and EPO levels were decreased, whereas eotaxin levels were increased. In vitro, CCR3 deficiency showed a modest reduction in the migratory response of CD34 ⁺ progenitors to eotaxin and partially reduced IL-5/eotaxin-associated eosinophil colony formation. Conclusion Bone marrow cell-specific CCR3 deletion was associated with reduced eosinophil-lineage–related progenitor abundance, decreased eosinophilic inflammation, and partial improvement of AR-associated phenotypes. These findings suggest that the eotaxin/CCR3 axis may contribute to hematopoietic and eosinophil-lineage regulation in allergic inflammation. However, the direct cell-intrinsic regulation of CD34 expression and the relative contribution of IL-5-dependent pathways require further investigation.

Ta2NiS5/GaSe van der Waals heterojunctions for self-driven photodetection

Two-dimensional (2D) van der Waals (vdW) heterojunctions provide an effective platform for realizing high-performance optoelectronic devices due to their tunable band alignments and unique layered structure. In this work, well-crystallized Ta2NiS5 single crystals were successfully synthesized using the chemical vapor transport method. Based on the complementary electronic structures, Ta2NiS5/GaSe vdW heterojunction photodetectors with type-II band alignment were designed and fabricated. The optoelectronic performance of the devices was systematically investigated, revealing a self-driven photodetection behavior without external bias. The photodetector exhibits a responsivity of 53.6 mA/W, a specific detectivity of 6.4 × 1010 Jones, and time-resolved response with rise/decay times of 60/50 ms, respectively. The efficient self-driven photoresponse is attributed to the built-in electric field, which facilitates effective separation and transport of photogenerated carriers. These results demonstrate the potential of Ta2NiS5-based vdW heterostructures for photodetection and provide valuable insights for the development of next-generation 2D optoelectronic devices.

Effectiveness of CoronaVac in a pioneer risk-based allocation clinical trial during the COVID-19 pandemic

CoronaVac, an inactivated SARS-CoV-2 vaccine, was one of the first deployed during the COVID-19 pandemic. Given the limited vaccine availability and the urgent need to assess effectiveness in target populations, a risk-based allocation clinical trial was designed to generate evidence under the ethical and logistical constraints at the beginning of the COVID-19 vaccination. In Manaus, Brazil, participants working in public service (education and public safety) aged 18–49 years were assessed regarding the risk of severe COVID-19 disease. Participants with one or more comorbidities, who were considered at higher risk of severe COVID-19 outcomes if infected, were allocated to early vaccination, while participants without comorbidities were enrolled as an unvaccinated comparison group. Blood samples were collected before each vaccine dose (D0 and D28) and during in-person follow-up visits (D90 and D180). Additional information was obtained through phone calls. Clinical cases of COVID-19, hospitalizations, deaths, and antibody titrations were the evaluated endpoints, considered after the second week following the second dose of the vaccine. A total of 6,226 participants were included: 1,139 in the low-risk group, and 5,087 in the high-risk vaccinated group. COVID-19 incidence was statistically significantly lower ( p  < 0.001) in the vaccinated group at D28 (5.2% vs. 40.9%) and D90 (10.3% vs 31.6%). Hospitalization and death rates were low, with no difference observed between the groups. There was a decline in highly reactive titers at D180 in the vaccinated group. This pioneer risk-based allocation clinical trial provided evidence that CoronaVac reduced the risk of severe COVID-19 outcomes among individuals with comorbidities, effectively aligning their risk with that of lower-risk, unvaccinated individuals. Beyond its clinical implications, the study underscores the importance of adaptive, real-world research designs in rapidly generating actionable evidence in response to emerging public health threats. ClinicalTrials.gov Registration: NCT04789356

Experimental synthesis of orbital angular momentum flux density-preserving random structured vortex beams

Optical coherence plays a crucial role in controlling the orbital angular momentum (OAM) characteristics of random structured beams. However, due to low spatial coherence, the OAM flux density distribution in traditional low-coherence vortex beams often fails to remain stable during propagation, leading to significant degradation with distance. In this work, we propose and experimentally demonstrate an OAM-preserving random structured vortex beam based on spatially varying correlation modulation. Both theoretical and experimental results show that, under the influence of spatially varying correlation, the beam maintains its hollow zero-intensity characteristic caused by phase singularity throughout propagation, while preserving the spatial distribution of OAM flux density without degradation. This approach provides an effective method for constructing robust random structured vortex beams with OAM preservation, offering significant potential for applications in free-space optical communication.

Retraction: Biogenic green synthesis of MgO nanoparticles using Saussurea costus biomasses for a comprehensive detection of their antimicrobial, cytotoxicity against MCF-7 breast cancer cells and photocatalysis potentials

Eutectic‐Based Polymer Electrolyte With High Ionic Conductivity by Regulating Solvation for Solid‐State Lithium Metal Batteries

ABSTRACT Polymer electrolytes are promising for high‐energy‐density lithium metal batteries (LMBs), yet their widespread use is hindered by low room‐temperature ionic conductivity, narrow electrochemical stability, and poor interfacial compatibility. A novel eutectic polymer electrolyte (I‐EPE0.15) has been developed by incorporating a succinonitrile‐based eutectic electrolyte into a poly(diacetone acrylamide) matrix. Such structure enhances continuous ion transport pathways by amplifying the eutectic network and decreases the likelihood of Li + capture by the polymer's polar groups through a coordination competition mechanism. As‐prepared I‐EPE0.15 exhibits an ionic conductivity of 2.3 mS cm −1 at 30°C and a 5.1 V electrochemical stability window. The corresponding Li/Li symmetric batteries achieve stable cycling over 1000 h at 0.1 mA cm −2 , and Li/NCM811 batteries retain 70.8% of their capacity after 500 cycles at 1 C. Moreover, pouch batteries further demonstrate robust cycling and safety. This work provides a viable strategy toward stable polymer electrolytes for practical LMBs.

Shape-optimized model-based reconstruction algorithm for radiacoustic imaging

We present a shape-optimized model-based reconstruction framework that addresses the limited-view problem in radiacoustic imaging arising from restricted detector placement, which creates severely ill-posed inverse problems that manifest as characteristic artifacts in reconstructed images. We first reconstruct an approximate dose-region boundary using a parametric level set–based shape optimization. Pointwise model-based dose reconstruction is then performed only within this shape-constrained region. By restricting reconstruction from the full imaging domain to only the pixels within the identified region, the number of unknowns is significantly reduced, transforming a severely ill-posed inverse problem into a much better-constrained one. We validate this methodology through computational studies and experiments using clinical x-ray and proton radiation sources under limited angular coverage data acquisition settings. Results demonstrate substantial artifact reduction and improved accuracy compared to standard model-based reconstructions, with a 3%–25% improvement in correlation coefficients across different imaging settings, with the more pronounced improvements occurring under stronger limited-view conditions. This shape-optimized approach provides a viable pathway for accurate radiation therapy monitoring under clinically realistic detector configurations.

Assessment of the implementation of SDG 4 goal by EU countries in the light of the 2030 Agenda using a hybrid approach in linear ordering

The goal of the following study was to rank EU countries on their progress in achieving SDG 4 “Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all” in 2023 and to determine their distance from the target values set for 2030. Eurostat monitors and evaluates progress towards SDG 4 using six indicators. Based on these indicators, an aggregate measure was constructed according to the assumptions of a hybrid approach combining multidimensional scaling with linear ordering. The proposed method involves a non-compensatory approach and target-based data adjustment, which prevents high values of some indicators from offsetting shortfalls in others, thereby providing a more reliable assessment of progress towards policy targets. The results show that Nordic countries, along with the Netherlands and Estonia, rank highest, while Romania, Bulgaria, Cyprus and Greece remain the furthest from the 2030 targets. It is worth noting that no EU country has yet reached the aggregate SDG 4 target level, which highlights a substantial implementation gap at the EU level. The hybrid approach additionally makes it possible to visualise the multidimensional phenomenon in a two-dimensional space, enhancing interpretability of cross-country differences.

Electrothermal Coupling Enables Defect‐Targeted Topological Repair for Rapid Graphite Upcycling

ABSTRACT Spent graphite (SG) from end‐of‐life lithium‐ion batteries suffers from persistent structural disorder, yet the defect chemistry governing its regeneration remains poorly understood. Here, we identify carbon vacancies and quasi‐sp 3 topological defects as the dominant degradation motifs and leverage this insight to devise a defect‐targeted regeneration strategy. Under electrothermal coupling enabled by flash Joule heating in a CoCl 2 molten‐salt medium, cobalt species are selectively directed to defect sites, where strong Co‐defect interactions reduce the energy barrier for topological reconstruction. The resulting Co‐induced charge redistribution activates quasi‐sp 3 ‐carbon via population of π * antibonding states, while thermally assisted and field‐directed carbon migration promotes its conversion into a more ordered sp 2 ‐rich lattice. Concurrently, residual interphases and impurities are eliminated, lattice stress is relieved, and the cobalt catalyst is efficiently recovered. The regenerated graphite (RG) delivers a capacity of 257 mAh g −1 after 1000 cycles at 1 A g −1 , corresponding to 83% retention relative to the post‐activation capacity, and outperforms commercial graphite under identical conditions. This work establishes a chemically informed route for the rapid upcycling of SG through defect‐selective topological repair.

Low-excess-noise quinary AlGaInAsSb avalanche photodiodes on InP

Quinary AlGaInAsSb avalanche photodiodes (APDs), lattice-matched to InP, were demonstrated as low-noise multiplication layers. A 995 nm thick p-i-n Al0.85Ga0.07In0.08As0.63Sb0.37 structure was grown on InP as a random alloy by molecular beam epitaxy. The devices exhibited breakdown at approximately −58 V, corresponding to a peak electric field of 628.8 kV/cm. Under 450 nm illumination, a maximum gain of 842 was achieved near breakdown with pure electron injection. Excess-noise measurements across multiple devices showed F(M) values that were reproducibly low and deviated from the McIntyre local-field prediction, remaining below those of comparable Al0.85Ga0.15As0.56Sb0.44 and Al0.79In0.21As0.74Sb0.26 APDs at moderate and high gain. At M ≈ 70, the effective k of AlGaInAsSb is approximately 0.01, compared with approximately ∼0.022 and ∼0.037 for AlGaAsSb and AlInAsSb, respectively. These results identify AlGaInAsSb as a promising quinary multiplication material for next-generation low-noise InP-based APDs and for potential application toward linear-mode single-photon detectors.

Gendered patterns in the associations between in-school physical activity, classroom peer ecology, and academic achievement among primary school students

School is an important setting for increasing students’ engagement in physical activity (PA) and reducing sedentary time (ST), both of which are linked to health and academic achievement. Peer interactions within the classroom can influence students’ engagement in PA and sedentary behaviors during the school day, yet research on how classroom peer ecology relates to objectively measured in-school PA and ST is limited. Even less is known about gender differences in these associations. The objective of this study was to examine how students’ perceived classroom peer ecology is associated with in-school PA and ST and how these factors relate to academic achievement. Gendered patterns in these dynamics were also explored. A sample of 517 Finnish primary school students (53% girls, 47% boys, M age  = 11.6 years, SD age  = 0.9 years) participated in this cross-sectional study in 2013. Students’ perceptions of classroom peer ecology were investigated through a survey. Moderate-to-vigorous PA (MVPA) and ST during school hours were measured by hip-worn accelerometers. Grade point averages (GPA) were calculated based on subject grades. Associations were investigated through multigroup structural equation modeling analyses. In girls, positive classroom peer relations were associated with lower in-school MVPA, while greater in-school ST was linked to higher GPA. Among boys, higher in-school MVPA was related to higher GPA. Although the MVPA-related associations differed in statistical significance across groups, subsequent formal tests did not indicate statistically significant gender differences, and hence further studies are needed on the subgroup-specific patterns to confirm or invalidate the findings. Efforts to promote a physically active school day could benefit from considering how activity opportunities are experienced within peer dynamics and in relation to gender, including the need for socially inclusive approaches.

Polar antivortex in ferroelastic nanodots

Nontrivial topological textures are significant for both scientific research and practical applications. Molecular dynamics simulations with a two-dimensional Landau potential reveal that surface relaxations generate isolated polar antivortices in mono-domain ferroelastic nanodots whose surfaces exhibit twin-boundary-like crystallographic orientation. These antivortices stem from the flexoelectric coupling between polarization and shear strain gradient induced by surface relaxations. As the nanodot size decreases, the average polarization of the antivortex first increases and then decreases, reaching a maximum value of 0.245 C/m2 at the size of 5 × 5 unit cells. Although thermal fluctuations perturb the instantaneous antivortices far below Ttr, where Ttr is the ferroelastic transition temperature of the nanodot, time-averaged dipole configurations reveal stable antivortices even near Ttr. Due to the polarization–strain-gradient coupling, bidirectional switching of the antivortex orientation can be achieved via ferroelastic domain switching, paving the way for applications in topological-based and electromechanical devices. Our findings may guide the discovery and manipulation of polar topological structures in ferroelastics, thereby broadening the range of material candidates for polar topologies.

Integrated assessment of growth performance, carcass characteristics, and economic efficiency of three broiler strains raised under humid-tropical conditions

This study evaluated the growth performance, carcass characteristics, economic efficiency, health status, and growth patterns of three commercial broiler strains (Hubbard, Cobb 500, and Ross 308) reared under humid tropical conditions in Ghana. A total of 300 day-old chicks were allocated to a completely randomized design with five replicate pens per strain and reared for six weeks under uniform management conditions. Performance traits, carcass and internal organ characteristics, mortality, and morbidity were assessed, and growth patterns were modeled using the Gompertz function. Although initial body weights differed among strains, no significant differences were observed in final body weight, weight gain, feed intake, feed conversion ratio, or feed cost per kg weight gain. Carcass characteristics were also comparable across strains. Cobb 500 exhibited numerically higher growth rate and asymptotic weight based on the Gompertz model, whereas Ross 308 showed slower growth but lower mortality and greater development of digestive organs, suggesting improved adaptability to tropical conditions. Overall, the findings indicate that while the three broiler strains demonstrate similar production performance under tropical conditions, differences in growth dynamics and survivability may influence strain suitability. These results highlight the importance of balancing growth efficiency with environmental adaptability when selecting broiler genotypes for humid tropical production systems.

Band edge states dominated by interface atoms and strong interlayer coupling work together to drive the direct generation of interlayer excitons in vdW heterostructures

Previous generation of interlayer excitons has been limited to heterojunctions of transition-metal dichalcogenides, where excitons form via a two-step process of intralayer excitation followed by interlayer transfer. Herein, we find a series of materials that exhibit efficient one-step generation of interlayer excitons. In type-II systems where band edge states originate from interface atoms, the interlayer coupling maximizes orbital overlap, this distinct feature dramatically enhances the interlayer transition probability. By investigating 57 composite heterostructures composed of polar X2Y3 (X = Al, Ga, and In; Y = S, Se, and Te) and group-VA (As, Sb, and Bi) monolayers, we successfully screened 20 ideal configurations. These configurations exhibit an exceptionally high interlayer transition probability to one-step generate interlayer excitons. This finding deepens the understanding of interlayer exciton formation mechanisms in 2D van der Waals heterostructures.

Structurally Encoded Mixed Proton–Electron Transport in Tetrathiafulvalene-Based Lanthanide MOFs

The association between patient preferred language and end-of-life outcomes of home care patients who died from a cancer in Ontario, Canada – A retrospective cohort study

Background Language is an often-forgotten determinant of health. The impact of patient preferred language on health outcomes of patients with cancer remains under-investigated. Aim To explore the association between patient preferred language and end-of-life outcomes of patients who died of cancer. Design/setting/participants We conducted a population-based, retrospective cohort study of home care recipients who died of cancer between 2013 and 2018 in Ontario, Canada. We identified patient preferred language from standardized home care assessments. The primary outcomes included place of death, emergency department (ED) visits and hospital admissions within the last 30 days of life. Secondary outcomes included aggressive interventions. We used descriptive statistics and multivariable logistic regression models to characterize the association between patient language and end-of-life outcomes in this population. Results 33,958 home care recipients were included, with 28,322 (83.4%) anglophones, 786 (2.3%) francophones, and 4,850 (14.3%) allophones. Allophones were older, more likely to reside in lower-income neighborhoods and more likely to have immigrated to Canada within 5 years. Allophones had significantly higher odds of death in hospital (OR 1.35, 95% CI 1.25–1.45), hospital admissions (OR 1.16, 95% CI 1.07–1.24), ED visits (OR 1.16, 95% CI 1.08–1.24), and increased odds of aggressive interventions in the last 30 days of life compared to anglophones. Francophones also had increased odds of death in hospital (OR 1.23, 95% CI 1.04–1.46) compared to anglophones. Conclusion Our study showed that in patients with terminal cancer, allophone home care recipients had more hospital deaths and aggressive interventions compared to anglophones. Additional research is needed to identify root causes and strategies to improve care.