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Importance: Although cases of neonatal opioid withdrawal syndrome (NOWS) increased 5-fold in recent years, no study has examined national hospital readmission rates for these infants., Objective: To examine hospital readmissions for infants with and without NOWS., Design, Setting, and Participants: This retrospective cohort study analyzed serial cross-sectional samples of US hospital discharge records from the Nationwide Readmissions Database for calendar years 2016 to 2020. Infants with NOWS were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. The data analysis was performed between January 5, 2023, and May 6, 2024., Exposure: Neonatal opioid withdrawal syndrome., Main Outcome and Measures: Survey-weighted logistic regression was used to examine 90-day all-cause and cause-specific hospital readmissions. Multivariable models adjusted for sex, low birth weight, gestational age, multiple gestation, type of insurance, and year of birth., Results: Of the 13 855 246 newborns identified in this weighted analysis, 89 018 (0.6%) were diagnosed with NOWS, of whom 53.8% were male and 81.1% born full-term (>36 weeks gestation). The 90-day all-cause readmission rate was 4.2% for infants with NOWS compared with 3.0% for those without NOWS (P < .001). After risk adjustment, the odds of all-cause readmission were higher among infants with NOWS (adjusted odds ratio [AOR], 1.18; 95% CI, 1.08-1.29). Infants with NOWS had significantly higher odds of readmissions for seizures (AOR, 1.58; 95% CI, 1.01-2.46), failure to thrive (AOR, 1.99; 95% CI, 1.36-2.93), traumatic brain injury (AOR, 2.95; 95% CI, 1.76-4.93), and skull fractures (AOR 3.72; 95% CI, 2.33-5.93). Infants with NOWS had higher odds of receiving a diagnosis of confirmed maltreatment (AOR, 4.26; 95% CI, 2.19-8.27), including for neglect (AOR, 14.18; 95% CI, 5.55-36.22) and physical abuse (AOR, 2.42; 95% CI, 0.93-6.29); however, the latter finding was not statistically significant., Conclusions and Relevance: In this nationally representative cohort study, infants with NOWS were at increased risk of readmission for any cause as well as for trauma and confirmed maltreatment. These findings may in part reflect the dual stressors that mothers with opioid use disorder face in caring for a newborn with NOWS in the context of a substance use disorder and underscore the need for family-based, in-home services that focus concurrently on substance use treatment and parenting support.

Objectives: To identify, chart and analyse the literature on recent initiatives to improve long-term care (LTC) coverage, financial protection and financial sustainability for persons aged 60 and older., Design: Rapid scoping review., Data Sources: Four databases and four sources of grey literature were searched for reports published between 2017 and 2022. After using a supervised machine learning tool to rank titles and abstracts, two reviewers independently screened sources against inclusion criteria., Eligibility Criteria: Studies published from 2017-2022 in any language that captured recent LTC initiatives for people aged 60 and older, involved evaluation and directly addressed financing were included., Data Extraction and Analysis: Data were extracted using a form designed to answer the review questions and analysed using descriptive qualitative content analysis, with data categorised according to a prespecified framework to capture the outcomes of interest., Results: Of 24 reports, 22 were published in peer-reviewed journals, and two were grey literature sources. Study designs included quasi-experimental study, policy analysis or comparison, qualitative description, comparative case study, cross-sectional study, systematic literature review, economic evaluation and survey. Studies addressed coverage based on the level of disability, income, rural/urban residence, employment and citizenship. Studies also addressed financial protection, including out-of-pocket (OOP) expenditures, copayments and risk of poverty related to costs of care. The reports addressed challenges to financial sustainability such as lack of service coordination and system integration, insufficient economic development and inadequate funding models., Conclusions: Initiatives where LTC insurance is mandatory and accompanied by commensurate funding are situated to facilitate ageing in place. Efforts to expand population coverage are common across the initiatives, with the potential for wider economic benefits. Initiatives that enable older people to access the services needed while avoiding OOP-induced poverty contribute to improved health and well-being. Preserving health in older people longer may alleviate downstream costs and contribute to financial sustainability., Competing Interests: Competing interests: LEW is the co-owner of an assisted living home., (© World Health Organization 2024. Licensee BMJ.)

Objective: We examined weight loss patterns and feeding practices of infants hospitalized for neonatal opioid withdrawal syndrome (NOWS) managed by the eat, sleep, console approach, which emphasizes nonpharmacologic treatment. Although feeding practices during hospitalization vary widely, weight loss patterns for infants managed under this approach have not yet been described., Methods: Of 744 infants with NOWS born from 2014 to 2019 at our institution, 330 met inclusion criteria (≥35 weeks' gestation and no NICU transfer). We examined maximum weight loss and created weight loss percentile curves by delivery type using mixed effects quantile modeling with spline effect for hour of life; 95% confidence intervals (CI) were compared to published early weight loss nomograms., Results: In the cohort, the mean gestational age was 39.2 weeks, mean birth weight was 3.1 kg, and mean length of stay was 6.5 days; 94.6% did not require pharmacologic treatment. Median percent weight loss was significantly more compared to early weight loss nomograms for both vaginally-delivered infants at 48 hours (6.9% [95% CI: 5.8-8.5] vs 2.9%) and cesarean-delivered infants at 48 hours (6.5% [95% CI: 4.1-9.1] vs 3.7%) and 72 hours (7.2% [95%CI 4.7-9.9] vs 3.5%), all P < .001. Overall, 27.9% lost >10% birth weight., Conclusions: We demonstrate weight loss patterns of infants with NOWS managed by the eat, sleep, console approach at a single center. Infants with NOWS lose significantly more weight than nonopioid exposed infants and are at increased risk of morbidity and health care use. Studies to address optimal feeding methods in these infants are warranted., (Copyright © 2022 by the American Academy of Pediatrics.)

Objectives: The COVID-19 pandemic has stimulated growing research on treatment options. We aim to provide an overview of the characteristics of studies evaluating COVID-19 treatment., Design: Rapid scoping review DATA SOURCES: Medline, Embase and biorxiv/medrxiv from inception to 15 May 2021., Setting: Hospital and community care., Participants: COVID-19 patients of all ages., Interventions: COVID-19 treatment., Results: The literature search identified 616 relevant primary studies of which 188 were randomised controlled trials and 299 relevant evidence syntheses. The studies and evidence syntheses were conducted in 51 and 39 countries, respectively.Most studies enrolled patients admitted to acute care hospitals (84%), included on average 169 participants, with an average age of 60 years, study duration of 28 days, number of effect outcomes of four and number of harm outcomes of one. The most common primary outcome was death (32%).The included studies evaluated 214 treatment options. The most common treatments were tocilizumab (11%), hydroxychloroquine (9%) and convalescent plasma (7%). The most common therapeutic categories were non-steroidal immunosuppressants (18%), steroids (15%) and antivirals (14%). The most common therapeutic categories involving multiple drugs were antimalarials/antibiotics (16%), steroids/non-steroidal immunosuppressants (9%) and antimalarials/antivirals/antivirals (7%). The most common treatments evaluated in systematic reviews were hydroxychloroquine (11%), remdesivir (8%), tocilizumab (7%) and steroids (7%).The evaluated treatment was in favour 50% and 36% of the evaluations, according to the conclusion of the authors of primary studies and evidence syntheses, respectively., Conclusions: This rapid scoping review characterised a growing body of comparative-effectiveness primary studies and evidence syntheses. The results suggest future studies should focus on children, elderly ≥65 years of age, patients with mild symptoms, outpatient treatment, multimechanism therapies, harms and active comparators. The results also suggest that future living evidence synthesis and network meta-analysis would provide additional information for decision-makers on managing COVID-19., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study aims to evaluate the impact of hospital setting on outcomes for infants with neonatal abstinence syndrome., Study Design: We conducted a retrospective study in two hospitals and three different hospital units. The inpatient group (n = 60) was managed on general inpatient floors, the NICU group (n = 50) was managed primarily in an NICU, and the combination group (n = 49) was managed in both NICU and inpatient units. The primary outcome was length of stay. Secondary outcomes included breastfeeding rates, morphine usage rates, and hospital costs., Results: The length of stay in the inpatient group (8.5 days) was significantly lower than the combination group (18 days) and NICU group (23 days) (p < 0.01). The inpatient group had significantly lower rates of morphine treatment and hospital costs with no difference in breastfeeding rates., Conclusions: Infants with neonatal abstinence syndrome had a significantly shorter length of stay and less use of morphine when managed on inpatient units versus NICU.

Background: The objective of this review was to examine the current guidelines for infection prevention and control (IPAC) of coronavirus disease-19 (COVID-19) or other coronaviruses in adults 60 years or older living in long-term care facilities (LTCF)., Methods: EMBASE, MEDLINE, Cochrane library, pre-print servers, clinical trial registries, and relevant grey literature sources were searched until July 31, 2020, using database searching and an automated method called Continuous Active Learning® (CAL®). All search results were processed using CAL® to identify the most likely relevant citations that were then screened by a single human reviewer. Full-text screening, data abstraction, and quality appraisal were completed by a single reviewer and verified by a second., Results: Nine clinical practice guidelines (CPGs) were included. The most common recommendation in the CPGs was establishing surveillance and monitoring systems followed by mandating the use of PPE; physically distancing or cohorting residents; environmental cleaning and disinfection; promoting hand and respiratory hygiene among residents, staff, and visitors; and providing sick leave compensation for staff., Conclusions: Current evidence suggests robust surveillance and monitoring along with support for IPAC initiatives are key to preventing the spread of COVID-19 in LTCF. However, there are significant gaps in the current recommendations especially with regard to the movement of staff between LTCF and their role as possible transmission vectors., Systematic Review Registration: PROSPERO CRD42020181993.

Objectives: Generativity, or concern with contributing to others, is theorized to be an important goal of mid-to-late life. Greater self-perceptions of generativity are associated with better well-being over time. The aim of this study is to examine how generative self-perceptions and failure to meet generative expectations over time are linked to specific cognitive-affective states (feelings of connectedness, self-worth, and positive affect), and consequently, life satisfaction., Method: Analyses used data from Waves 2 and 3 of the National Survey of Midlife Development in the United States (MIDUS). Multiple mediation was utilized to assess whether these cognitive-affective states linked generative failure to decreased life satisfaction. A Johnson-Neyman moderation analysis determined whether these associations vary with age., Results: In demographically adjusted regressions, generative contributions and expectations were associated with greater perceived social connectedness, self-worth, and positive effect. Generative failure was associated with lower life satisfaction, a link that was strongest in the middle-aged and young-old and mediated by the cognitive-affective states., Discussion: Greater feelings of generativity, and more positive expectations for future contributions, are associated cross-sectionally and over time with better affective well-being. Positive affect, social connectedness, and self-worth may partially explain why generative failure over time is linked to decreased life satisfaction., (© The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.

Objectives: In previous years, otherwise healthy infants with neonatal abstinence syndrome (NAS) in our hospital were transferred to the NICU and frequently treated with medication. Currently, infants with NAS room-in with their mothers and rarely require medication. We sought to understand the lived experience of nurses on maternity and well-newborn units caring for infants with NAS., Methods: We conducted focus groups of registered nurses on postpartum units at 2 hospitals using qualitative methodology. Themes were identified through consensus, and the focus groups were stopped when no new themes were identified., Results: Seventeen postpartum nurses participated in 5 focus groups. The following major themes emerged: (1) managing the expectations of parents of newborns with NAS, (2) current NAS protocol (positive aspects of rooming-in and challenges with withdrawal scoring tool), (3) inconsistencies in care and communication, (4) perceived increase in nursing workload on the postpartum unit, and (5) nurses' emotional response to the care of infants with NAS., Conclusions: We highlight the perspectives of nursing staff on the well-newborn unit who were previously unaccustomed to caring for infants with NAS. With increasing numbers of infants with NAS and longer stays on the well-newborn unit, hospitals must prepare to better support staff and implement protocols that offer consistency in practice., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Infants with in-utero opioid exposure are most commonly assessed using the Finnegan Neonatal Abstinence Scoring System (FNASS) or a modified version of that tool. Traditionally, the purpose of these tools has been to characterize the extent of withdrawal signs to guide the pharmacologic treatment for infants with neonatal opioid withdrawal syndrome (NOWS). In the past decade however, in response to some of the limitations of the FNASS tool, there has been an increasing emphasis on developing novel assessment tools not based on the FNASS in addition to the promotion of non-pharmacologic treatment options as the first line treatment for infants with opioid exposure. Additionally, several prediction tools that may be useful in determining which patients are at high or low risk for receiving pharmacologic therapy have been developed. In this review, we will evaluate the clinical utility of these novel tools and will consider new avenues for future research., (© 2019 Published by Elsevier Ltd.)

Competing Interests: Conflict of Interest: The authors declare that they have no conflict of interest.

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Background: Informal caregivers of older adults provide critical support for their loved ones but are subject to negative health outcomes because of burden and stress. Interventions to provide information and resources as well as social and emotional support reduce burden. Mobile apps featuring access to information, assistance with scheduling, and other features can automate support functions inexpensively and conveniently and reach a greater proportion of caregivers than otherwise possible., Objective: The aim of this study was to identify mobile apps geared towards caregivers of older adults, catalog features, and suggest best practices for adoption based on empirical findings of beneficial interventions in the caregiving literature., Methods: Search for apps focused on ones catered for caregivers of older adults in Google Play and iTunes, compiling their features, and identifying features reflecting categories of support identified in successful intervention studies to negative caregiver outcomes. Intervention research indicates that provision of information and resources, assistance in practical problem solving, coordinating care among multiple caregivers, and emotional support reduce caregiver burden., Results: Despite approximately over 200,000 mobile health-related apps, the availability of mobile apps for caregivers is relatively sparse (n=44 apps) as of October 2017. Apps generally addressed specific categories of support, including information and resources, family communication, and caregiver-recipient interactions. Few apps were comprehensive. Only 8 out of 44 (18%) had features that addressed three or more categories. Few apps provided specific stress reduction exercises for caregivers, which is important for reducing burden., Conclusions: Mobile apps have the potential to provide resources, just--in--time information for problem-solving, and stress reduction strategies for caregivers. Many apps offer functions that have been shown to reduce burden and improve health outcomes in caregivers, but few provide emotional support. Using an evidence--based practice approach, mobile apps for caregivers can provide multiple beneficial support functions. Apps can serve a much larger proportion of this highly underserved population in their mobile form than more traditional means, improving their health and quality of life., (©Molli R Grossman, Deanah Kim Zak, Elizabeth M Zelinski. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 30.07.2018.)

Objectives: Neonatal abstinence syndrome (NAS) is a growing problem and poses a significant burden on the health care system. The traditional Finnegan Neonatal Abstinence Scoring System (FNASS) assessment approach may lead to unnecessary opioid treatment of infants with NAS. We developed a novel assessment approach and describe its effect on the management of infants with NAS., Methods: We retrospectively compared treatment decisions of 50 consecutive opioid-exposed infants managed on the inpatient unit at the Yale New Haven Children's Hospital. All infants had FNASS scores recorded every 2 to 6 hours but were managed by using the Eat, Sleep, Console (ESC) assessment approach. Actual treatment decisions made by using the ESC approach were compared with predicted treatment decisions based on recorded FNASS scores. The primary outcome was postnatal treatment with morphine., Results: By using the ESC approach, 6 infants (12%) were treated with morphine compared with 31 infants (62%) predicted to be treated with morphine by using the FNASS approach ( P < .001). The ESC approach started or increased morphine on 8 days (2.7%) compared with 76 days (25.7%) predicted by using the FNASS approach ( P < .001). There were no readmissions or adverse events reported., Conclusions: Infants managed by using the ESC approach were treated with morphine significantly less frequently than they would have been by using the FNASS approach. The ESC approach is an effective method for the management of infants with NAS that limits pharmacologic treatment and may lead to substantial reductions in length of stay., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Objectives: Although a sizable body of research supports negative psychological consequences of caregiving, less is known about potential psychological benefits. This study aimed to examine whether caregiving was associated with enhanced generativity, or feeling like one makes important contributions to others. An additional aim was to examine the buffering potential of perceived generativity on adverse health outcomes associated with caregiving., Methods: Analyses utilized a subsample of participants (n = 3,815, ages 30-84 years) from the second wave of the National Survey of Midlife Development in the United States (MIDUS)., Results: Regression analyses adjusting for sociodemographic factors indicated greater negative affect and depression (p < .001) and lower levels of positive affect (p < .01), but higher self-perceptions of generativity (p < .001), in caregivers compared with non-caregivers. This association remained after adjusting for varying caregiving intensities and negative psychological outcomes. Additionally, generativity interacted with depression and negative affect (p values < .05) to lessen the likelihood of health-related cutbacks in work/household productivity among caregivers., Conclusions: Results suggest that greater feelings of generativity may be a positive aspect of caregiving that might help mitigate some of the adverse health and well-being consequences of care., Clinical Implications: Self-perceptions of generativity may help alleviate caregiver burden and explain why some caregivers fare better than others.

Background and Objectives: The incidence of neonatal abstinence syndrome (NAS), a constellation of neurologic, gastrointestinal, and musculoskeletal disturbances associated with opioid withdrawal, has increased dramatically and is associated with long hospital stays. At our institution, the average length of stay (ALOS) for infants exposed to methadone in utero was 22.4 days before the start of our project. We aimed to reduce ALOS for infants with NAS by 50%., Methods: In 2010, a multidisciplinary team began several plan-do-study-act cycles at Yale New Haven Children's Hospital. Key interventions included standardization of nonpharmacologic care coupled with an empowering message to parents, development of a novel approach to assessment, administration of morphine on an as-needed basis, and transfer of infants directly to the inpatient unit, bypassing the NICU. The outcome measures included ALOS, morphine use, and hospital costs using statistical process control charts., Results: There were 287 infants in our project, including 55 from the baseline period (January 2008 to February 2010) and 44 from the postimplementation period (May 2015 to June 2016). ALOS decreased from 22.4 to 5.9 days. Proportions of methadone-exposed infants treated with morphine decreased from 98% to 14%; costs decreased from $44 824 to $10 289. No infants were readmitted for treatment of NAS and no adverse events were reported., Conclusions: Interventions focused on nonpharmacologic therapies and a simplified approach to assessment for infants exposed to methadone in utero led to both substantial and sustained decreases in ALOS, the proportion of infants treated with morphine, and hospital costs with no adverse events., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Background and Objectives: The present study examined the psychometric characteristics of the Neonatal Abstinence Scoring System (NASS; "Finnegan Scale") and the MOTHER NAS Scale (MNS)., Methods: Secondary analysis of data from 131 neonates from the Maternal Opioid Treatment: Human Experimental Research (MOTHER) study, a randomized trial in opioid-dependent pregnant women administered buprenorphine or methadone., Results: Both the NASS and MNS demonstrated poor psychometric properties, with internal consistency (Cronbach's αs) failing to exceed .62 at first administration, peak NAS score, and NAS treatment initiation., Conclusions: Findings support the need for development of a NAS measure based on sound psychometric principles., Scientific Significance: This study found that two frequently used measures of neonatal abstinence syndrome suffer inadequacies in regard to their basic measurement characteristics. (Am J Addict 2016;25:370-373)., (© 2016 American Academy of Addiction Psychiatry.)

Male zebra finches display two song behaviors: directed and undirected singing. The two differ little in the vocalizations produced but greatly in how song is delivered. "Directed" song is usually accompanied by a courtship dance and is addressed almost exclusively to females. "Undirected" song is not accompanied by the dance and is produced when the male is in the presence of other males, alone, or outside a nest occupied by its mate. Here, we show that the anterior forebrain vocal pathway contains medial and lateral "cortical-basal ganglia" subdivisions that have differential ZENK gene activation depending on whether the bird sings female-directed or undirected song. Differences also occur in the vocal output nucleus, RA. Thus, although these two vocal behaviors are very similar, their brain activation patterns are dramatically different.

Aim: To measure 24-h ambulatory oesophageal pH data in patients with gastro-oesophageal reflux disease prior to, during and after acute treatment with comparable doses of omeprazole and ranitidine., Methods: The subjects were 20 adults with at least 8% acid contact time. Ten subjects were treated for 1 week with omeprazole 20 mg q.d.s. and 10 subjects with ranitidine 300 mg t.d.s. All subjects were examined at the end of 1 week of therapy and subsequent to cessation of treatment (1 day for ranitidine and 3 days for omeprazole)., Results: Both drugs produced a statistically significant (P < 0.05) decrease in acid contact time with acute treatment. Omeprazole produced a significantly greater decrease in acid contact time when compared to ranitidine. Subsequent to treatment cessation, the total acid contact time for omeprazole remained significantly less than the baseline level, while ranitidine returned to levels which were not significantly different from the baseline., Conclusion: These data provide no evidence for a 'reflux rebound' subsequent to the cessation of acute acid secretory suppression.

Veterinary medicine is a profession based on contract. Many aspects of veterinary practice involve legally enforceable contract obligations. Legal rules established by statutes or court cases govern contract formation, interpretation, and enforcement. This article explains several legal principles governing contract law and applies some of these principles to common contractual settings in veterinary medicine.

A neurilemoma presenting in the foot is uncommon. The tumor is a solitary benign type that does not require transection of the involved nerve. A clinical review with an uncommon presentation and brief history of a benign neurilemoma is presented, followed by a discussion using magnetic resonance imaging, ultrasonification, double contrast doppler, arteriograms and venograms to aid in a differential diagnosis.