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Visit-to-Visit HbA1c Variability Is Associated With Cardiovascular Disease and Microvascular Complications in Patients With Newly Diagnosed Type 2 Diabetes

OBJECTIVE

To investigate the association between visit-to-visit HbA1c variability and cardiovascular events and microvascular complications in patients with newly diagnosed type 2 diabetes.

RESEARCH DESIGN AND METHODS

This retrospective cohort study analyzed patients from Tayside and Fife in the Scottish Care Information–Diabetes Collaboration (SCI-DC) who were observable from the diagnosis of diabetes and had at least five HbA1c measurements before the outcomes were evaluated. We used the previously reported HbA1c variability score (HVS), calculated as the percentage of the number of changes in HbA1c >0.5% (5.5 mmol/mol) among all HbA1c measurements within an individual. The association between HVS and 10 outcomes was assessed using Cox proportional hazards models.

RESULTS

We included 13,111–19,883 patients in the analyses of each outcome. The patients with HVS >60% were associated with elevated risks of all outcomes compared with the lowest quintile (for example, HVS >80 to ≤100 vs. HVS ≥0 to ≤20, hazard ratio 2.38 [95% CI 1.61–3.53] for major adverse cardiovascular events, 2.4 [1.72–3.33] for all-cause mortality, 2.4 [1.13–5.11] for atherosclerotic cardiovascular death, 2.63 [1.81–3.84] for coronary artery disease, 2.04 [1.12–3.73] for ischemic stroke, 3.23 [1.76–5.93] for heart failure, 7.4 [3.84–14.27] for diabetic retinopathy, 3.07 [2.23–4.22] for diabetic peripheral neuropathy, 5.24 [2.61–10.49] for diabetic foot ulcer, and 3.49 [2.47–4.95] for new-onset chronic kidney disease). Four sensitivity analyses, including adjustment for time-weighted average HbA1c, confirmed the robustness of the results.

CONCLUSIONS

Our study shows that higher HbA1c variability is associated with increased risks of all-cause mortality, cardiovascular events, and microvascular complications of diabetes independently of high HbA1c.




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Impact of Glucose Level on Micro- and Macrovascular Disease in the General Population: A Mendelian Randomization Study

OBJECTIVE

To evaluate whether high glucose levels in the normoglycemic range and higher have a causal genetic effect on risk of retinopathy, neuropathy, nephropathy, chronic kidney disease (CKD), peripheral arterial disease (PAD), and myocardial infarction (MI; positive control) in the general population.

RESEARCH DESIGN AND METHODS

This study applied observational and one-sample Mendelian randomization (MR) analyses to individual-level data from 117,193 Danish individuals, and validation by two-sample MR analyses on summary-level data from 133,010 individuals from the Meta-Analyses of Glucose and Insulin-Related Traits Consortium (MAGIC), 117,165 from the CKDGen Consortium, and 452,264 from the UK Biobank.

RESULTS

Observationally, glucose levels in the normoglycemic range and higher were associated with high risks of retinopathy, neuropathy, diabetic nephropathy, PAD, and MI (all P for trend <0.001). In genetic causal analyses, the risk ratio for a 1 mmol/L higher glucose level was 2.01 (95% CI 1.18–3.41) for retinopathy, 2.15 (1.38–3.35) for neuropathy, 1.58 (1.04–2.40) for diabetic nephropathy, 0.97 (0.84–1.12) for estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, 1.19 (0.90–1.58) for PAD, and 1.49 (1.02–2.17) for MI. Summary-level data from the MAGIC, the CKDGen Consortium, and the UK Biobank gave a genetic risk ratio of 4.55 (95% CI 2.26–9.15) for retinopathy, 1.48 (0.83–2.66) for peripheral neuropathy, 0.98 (0.94–1.01) for eGFR <60 mL/min/1.73 m2, and 1.23 (0.57–2.67) for PAD per 1 mmol/L higher glucose level.

CONCLUSIONS

Glucose levels in the normoglycemic range and higher were prospectively associated with a high risk of retinopathy, neuropathy, diabetic nephropathy, eGFR <60 mL/min/1.73 m2, PAD, and MI. These associations were confirmed in genetic causal analyses for retinopathy, neuropathy, diabetic nephropathy, and MI, but they could not be confirmed for PAD and seemed to be refuted for eGFR <60 mL/min/1.73 m2.




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Effects of Bariatric Surgery in Early- and Adult-Onset Obesity in the Prospective Controlled Swedish Obese Subjects Study

OBJECTIVE

Bariatric surgery is an effective treatment for obesity, but it is unknown if outcomes differ between adults with early- versus adult-onset obesity. We investigated how obesity status at 20 years of age affects outcomes after bariatric surgery later in life.

RESEARCH DESIGN AND METHODS

The Swedish Obese Subjects study is a prospective matched study performed at 25 surgical departments and 480 primary health care centers. Participants aged 37–60 years with BMI ≥34 kg/m2 (men) or ≥38 kg/m2 (women) were recruited between 1987 and 2001; 2,007 participants received bariatric surgery and 2,040 usual care. Self-reported body weight at 20 years of age was used to stratify patients into subgroups with normal BMI (<25 kg/m2), overweight (BMI 25–29.9 kg/m2), or obesity (BMI ≥30 kg/m2). Body weight, energy intake, and type 2 diabetes status were examined over 10 years, and incidence of cardiovascular and microvascular disease was determined over up to 26 years using data from health registers.

RESULTS

There were small but statistically significant differences in reduction of body weight among the subgroups after bariatric surgery (interaction P = 0.032), with the largest reductions among those with obesity aged 20 years. Bariatric surgery increased type 2 diabetes remission (odds ratios 4.51, 4.90, and 5.58 in subgroups with normal BMI, overweight, or obesity at 20 years of age, respectively; interaction P = 0.951), reduced type 2 diabetes incidence (odds ratios 0.15, 0.13, and 0.15, respectively; interaction P = 0.972), and reduced microvascular complications independent of obesity status at 20 years of age (interaction P = 0.650). The association between bariatric surgery and cardiovascular disease was similar in the subgroups (interaction P = 0.674). Surgical complications were similar in the subgroups.

CONCLUSIONS

The treatment benefits of bariatric surgery in adults are similar regardless of obesity status at 20 years of age.




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Coronary Artery Disease and Type 2 Diabetes: A Proteomic Study

OBJECTIVE

Coronary artery disease (CAD) is a major challenge in patients with type 2 diabetes (T2D). Coronary computed tomography angiography (CCTA) provides a detailed anatomic map of the coronary circulation. Proteomics are increasingly used to improve diagnostic and therapeutic algorithms. We hypothesized that the protein panel is differentially associated with T2D and CAD.

RESEARCH DESIGN AND METHODS

In CAPIRE (Coronary Atherosclerosis in Outlier Subjects: Protective and Novel Individual Risk Factors Evaluation—a cohort of 528 individuals with no previous cardiovascular event undergoing CCTA), participants were grouped into CAD (clean coronaries) and CAD+ (diffuse lumen narrowing or plaques). Plasma proteins were screened by aptamer analysis. Two-way partial least squares was used to simultaneously rank proteins by diabetes status and CAD.

RESULTS

Though CAD+ was more prevalent among participants with T2D (HbA1c 6.7 ± 1.1%) than those without diabetes (56 vs. 30%, P < 0.0001), CCTA-based atherosclerosis burden did not differ. Of the 20 top-ranking proteins, 15 were associated with both T2D and CAD, and 3 (osteomodulin, cartilage intermediate-layer protein 15, and HTRA1) were selectively associated with T2D only and 2 (epidermal growth factor receptor and contactin-1) with CAD only. Elevated renin and GDF15, and lower adiponectin, were independently associated with both T2D and CAD. In multivariate analysis adjusting for the Framingham risk panel, patients with T2D were "protected" from CAD if female (P = 0.007), younger (P = 0.021), and with lower renin levels (P = 0.02).

CONCLUSIONS

We concluded that 1) CAD severity and quality do not differ between participants with T2D and without diabetes; 2) renin, GDF15, and adiponectin are shared markers by T2D and CAD; 3) several proteins are specifically associated with T2D or CAD; and 4) in T2D, lower renin levels may protect against CAD.




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Diabetes and Back Pain: Markers of Diabetes Disease Progression Are Associated With Chronic Back Pain

Lorenzo Rinaldo
Jul 1, 2017; 35:126-131
Feature Articles




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Interdisciplinary Team Care for Diabetic Patients by Primary Care Physicians, Advanced Practice Nurses, and Clinical Pharmacists

David Willens
Apr 1, 2011; 29:60-68
Feature Articles




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Diabetes Management Issues for Patients With Chronic Kidney Disease

Kerri L. Cavanaugh
Jul 1, 2007; 25:90-97
Feature Articles




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The Disparate Impact of Diabetes on Racial/Ethnic Minority Populations

Edward A. Chow
Jul 1, 2012; 30:130-133
Diabetes Advocacy




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No-Failure Design and Disaster Recovery: Lessons from Fukushima

One of the striking aspects of the early stages of the nuclear accident at Fukushima-Daiichi last March was the nearly total absence of disaster recovery capability. For instance, while Japan is a super-power of robotic technology, the nuclear authorities had to import robots from France for probing the damaged nuclear plants. Fukushima can teach us an important lesson about technology.

The failure of critical technologies can be disastrous. The crash of a civilian airliner can cause hundreds of deaths. The meltdown of a nuclear reactor can release highly toxic isotopes. Failure of flood protection systems can result in vast death and damage. Society therefore insists that critical technologies be designed, operated and maintained to extremely high levels of reliability. We benefit from technology, but we also insist that the designers and operators "do their best" to protect us from their dangers.

Industries and government agencies who provide critical technologies almost invariably act in good faith for a range of reasons. Morality dictates responsible behavior, liability legislation establishes sanctions for irresponsible behavior, and economic or political self-interest makes continuous safe operation desirable.

The language of performance-optimization  not only doing our best, but also achieving the best  may tend to undermine the successful management of technological danger. A probability of severe failure of one in a million per device per year is exceedingly  and very reassuringly  small. When we honestly believe that we have designed and implemented a technology to have vanishingly small probability of catastrophe, we can honestly ignore the need for disaster recovery.

Or can we?

Let's contrast this with an ethos that is consistent with a thorough awareness of the potential for adverse surprise. We now acknowledge that our predictions are uncertain, perhaps highly uncertain on some specific points. We attempt to achieve very demanding outcomes  for instance vanishingly small probabilities of catastrophe  but we recognize that our ability to reliably calculate such small probabilities is compromised by the deficiency of our knowledge and understanding. We robustify ourselves against those deficiencies by choosing a design which would be acceptable over a wide range of deviations from our current best understanding. (This is called "robust-satisficing".) Not only does "vanishingly small probability of failure" still entail the possibility of failure, but our predictions of that probability may err.

Acknowledging the need for disaster recovery capability (DRC) is awkward and uncomfortable for designers and advocates of a technology. We would much rather believe that DRC is not needed, that we have in fact made catastrophe negligible. But let's not conflate good-faith attempts to deal with complex uncertainties, with guaranteed outcomes based on full knowledge. Our best models are in part wrong, so we robustify against the designer's bounded rationality. But robustness cannot guarantee success. The design and implementation of DRC is a necessary part of the design of any critical technology, and is consistent with the strategy of robust satisficing.

One final point: moral hazard and its dilemma. The design of any critical technology entails two distinct and essential elements: failure prevention and disaster recovery. What economists call a `moral hazard' exists since the failure prevention team might rely on the disaster-recovery team, and vice versa. Each team might, at least implicitly, depend on the capabilities of the other team, and thereby relinquish some of its own responsibility. Institutional provisions are needed to manage this conflict.

The alleviation of this moral hazard entails a dilemma. Considerations of failure prevention and disaster recovery must be combined in the design process. The design teams must be aware of each other, and even collaborate, because a single coherent system must emerge. But we don't want either team to relinquish any responsibility. On the one hand we want the failure prevention team to work as though there is no disaster recovery, and the disaster recovery team should presume that failures will occur. On the other hand, we want these teams to collaborate on the design.

This moral hazard and its dilemma do not obviate the need for both elements of the design. Fukushima has taught us an important lesson by highlighting the special challenge of high-risk critical technologies: design so failure cannot occur, and prepare to respond to the unanticipated.




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Sex and Psychology Podcast: Maintaining a Healthy Intimate Life During Lockdown and Social Distancing

These are unprecedented times. Much of the world is currently living under lockdown conditions and practicing social distancing in order to curb the spread of the COVID-19 coronavirus. So how is this affecting people’s intimate lives? How are our sex lives and relationships holding up, and is there anything we can do to more effectively navigate this complex and challenging situation? For the answers to these questions, I spoke to Dr. Lori Brotto, a Professor at the University of British Columbia, a practicing psychologist, and author of the book Better Sex Through Mindfulness. I asked Dr. Brotto what she has been seeing in her clinical practice since the pandemic began and how it’s different from usual.




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An evolutionary perspective on human health and disease | Lara Durgavich

How does your genetic inheritance, culture and history influence your health? Biological anthropologist Lara Durgavich discusses the field of evolutionary medicine as a gateway to understanding the quirks of human biology -- including why a genetic mutation can sometimes have beneficial effects -- and emphasizes how unraveling your own evolutionary past could glean insights into your current and future health.




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How we're using AI to discover new antibiotics | Jim Collins

Before the coronavirus pandemic, bioengineer Jim Collins and his team combined the power of AI with synthetic biology in an effort to combat a different looming crisis: antibiotic-resistant superbugs. Collins explains how they pivoted their efforts to begin developing a series of tools and antiviral compounds to help fight COVID-19 -- and shares their plan to discover seven new classes of antibiotics over the next seven years. (This ambitious plan is a part of The Audacious Project, TED's initiative to inspire and fund global change.)




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Annual Interdisciplinary Symposium on Decision Neuroscience (ISDN), Philadelphia, June 5-6, 2020

DEADLINE FOR ORAL PRESENTATIONS: FEB 15, 2020 On June 5-6 2020, Temple University will host the 10th Annual Interdisciplinary Symposium on Decision Neuroscience (ISDN) in Philadelphia, PA. This symposium is unique in that it brings together a range of constituencies involved in the use of neuroscience techniques to understand consumer decision making – world renowned […]

The post Annual Interdisciplinary Symposium on Decision Neuroscience (ISDN), Philadelphia, June 5-6, 2020 appeared first on Decision Science News.




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Staff Email Addresses Removed From District Websites to Improve Cybersecurity

Some district technology leaders say having staff email addresses publicly available opens the door for phishing scams and potential hacks.




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Ohio Sues Cyber Charter Founder, Pursuing Millions in Disputed Funds

Ohio is seeking to recoup millions of dollars in funds from now-defunct online charter school, the Electronic Classroom of Tomorrow.




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Lion's Share of Ohio Districts Rank No Teachers as 'Ineffective'

About 94 percent of Ohio school districts did not rate a single teacher as "ineffective," the lowest rating on the state's four-rung teacher-evaluation scale, according to the 2016-17 state report card.




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Ohio Sues Cyber Charter Founder, Seeking Millions in Disputed Funds

Ohio's attorney general last week filed suit against the founder of the Electronic Classroom of Tomorrow, aiming to recover millions of dollars in public funding that the state claims wrongfully went to the cyber charter school.




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Ohio District's Armed-Employee Program Struck Down Over Training Requirement

An Ohio appellate court struck down a district's policy allowing staff members to carry concealed weapons in school with 24 hours of "active shooter/killer training."




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Oklahoma Orders Tulsa District to Review All Students' Special Education Plans

The decision comes after a state investigation of one Tulsa school found that the individualized education programs for students there frequently used generic educational goals.




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Will Child-Care Services Help Recruit Teachers? Oklahoma District Aims to Find Out

A small school district in Oklahoma plans to offer low-cost daycare services to its employees next year in an effort to better compete with larger districts when it comes to recruiting and retaining teachers.




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Washoe County School District names new superintendent




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District Hard-Hit by COVID-19 Begins 'Tough Work' of Getting On

No place in Georgia has suffered a higher rate of coronavirus cases than Dougherty County. And the school system, largely rural and poor, is in the middle of it.




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Vermont school district eliminates 36 teaching assistants




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No race balance, but desegregation ends for Georgia district




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How to Teach Math to Students With Disabilities, English Language Learners

Experts recommend emphasizing language skills, avoiding assumptions about ability based on broad student labels, and focusing on students’ strengths rather than their weaknesses.




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Ex-Florida sheriff's removal lawsuit dismissed




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Texas District Apologizes for Comments on Hijabs

A Houston-area school district is apologizing after an administrator told Muslim students they need to obtain permission from an imam to wear hijabs in school.




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Texas Republicans Eye Cash Rewards for Districts

Legislative leaders are preparing a proposal to set aside $800 million a year for school districts that demonstrate strong outcomes. Skeptics call it unfair and say it wouldn’t work.




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Measuring the Impact of Common-Core Test Disruptions in Three States

A Smarter Balanced testing vendor has released completion rates in three states that had serious challenges giving the common-core aligned exam.




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North Dakota Districts to Switch to Four-Day Week

Two rural North Dakota school districts will switch to a four-day school week to save costs and improve student and teacher morale.




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Clark County School District postpones graduation ceremonies




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Kentucky Districts Close Amid Wave of Teacher Absences

At least four Kentucky school districts were forced to close last Thursday as hundreds of teachers called in sick to continue protesting what they believe to be anti-public education proposals in the state legislature.




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Did a Misunderstanding Put One State's Aid for Disadvantaged Students At Risk?

U.S. Secretary of Education Betsy DeVos is not famous for pressuring states into desired outcomes, but did put at least two states' Title I funding on "high-risk" status last year.




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Rapid Deployment of Remote Learning: Lessons From 4 Districts

Chief technology officers are facing an unprecedented test of digital preparedness due to the coronavirus pandemic, struggling with shortfalls of available learning devices and huge Wi-Fi access challenges.




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Yonkers, N.Y., District Commits to More Inclusion of Students with Disabilities

The U.S. Department of Education's office for civil rights said that some students were placed in self-contained special education settings without an individualized justification for doing so.




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New York Denied ESSA Waiver to Test Students With Disabilities Off Grade Level

The state will be required to test all students using grade level tests, except for those with significant cognitive disabilities.




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Tennessee School District Prohibits Crowdfunding for Class Supplies

A school district in Tennessee says it no longer wants teachers to use crowdfunding websites to get extra school supplies.




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Virus Outbreaks Lead to Closure of Two Colorado School Districts

All 46 schools in the Mesa County Valley School District closed last Thursday and Friday after students and staff at more than a dozen schools experienced norovirus-like symptoms.




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Washoe County School District names new superintendent




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District Hard-Hit by COVID-19 Begins 'Tough Work' of Getting On

No place in Georgia has suffered a higher rate of coronavirus cases than Dougherty County. And the school system, largely rural and poor, is in the middle of it.




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Vermont school district eliminates 36 teaching assistants




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No race balance, but desegregation ends for Georgia district




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How to Teach Math to Students With Disabilities, English Language Learners

Experts recommend emphasizing language skills, avoiding assumptions about ability based on broad student labels, and focusing on students’ strengths rather than their weaknesses.




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Ex-Florida sheriff's removal lawsuit dismissed




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How Principals and District Leaders Are Trying to Boost Lagging Teacher Morale During COVID-19

Knowing the shift to remote learning would be tough for teachers, school and district administrators have scrambled to assemble as many kinds of supports as they can.




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A School District in Fiscal Free-Fall Scrambles to Avoid Crash Landing

Emotions remain raw as educators and residents in a rural Wisconsin district dig for solutions after being denied the option of dissolving.




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Open Enrollment Has Drained One District. It's Looking to Dissolve

Wisconsin’s Palmyra-Eagle district has lost more than half its students in the last decade, sparking a fiscal crisis. A special board is deciding whether the district should be allowed to dissolve.




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Most Wisconsin schools, districts meet expectations




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Verdict Looms on Whether Insolvent Wisconsin District Can Dissolve

Palmyra-Eagle, a mostly rural school district in Southeast Wisconsin, lost more than half its students to surrounding districts and then taxpayers voted to dissolve the district.




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Why Don't Struggling K-12 Districts Just Dissolve?

Emotions remain raw as educators and residents in a rural Wisconsin district dig for solutions after being denied the option of dissolving.