R Lawrence Moss

Nationwide Children's Hospital, Columbus, Ohio, United States

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Publications (102)329.9 Total impact

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    ABSTRACT: Objectives: The purpose of this project was to implement a protocol facilitating discharge from the emergency department (ED) after successful radiologic ileocolic intussusception reduction in a pediatric referral center. Methods: A multidisciplinary team identified drivers for successful quality improvement including educational brochures, a standardized radiologic report, an observation period in the ER with oral hydration challenges, and follow-up phone calls the day after discharge. Patient outcomes were tracked, and quarterly feedback was provided. Results: Of 80 patients identified over a 24-month period, 34 (42.5%) did not qualify for discharge home due to need for surgical intervention (n = 9), specific radiologic findings (n = 11), need for additional intravenous hydration (n = 4), or other reasons (n = 7). Of 46 patients who qualified for discharge, 30 (65.2%) were successfully sent home from the ED. One patient returned with recurrent symptoms that required repeat enema reduction. Sixteen patients were observed and discharged within 23 hours. Adherence with discharge from the ED improved over time. Discharge from the ED was associated with cost savings and improved net margins at the hospital level for each encounter. Conclusions: A sustainable multidisciplinary quality improvement project to discharge intussusception patients from the ED after air-contrast enema reduction was successfully integrated in a high-volume referral center through education, standardized radiologic reporting, and protocoled follow-up.
    PEDIATRICS 10/2015; DOI:10.1542/peds.2014-3122 · 5.47 Impact Factor
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    ABSTRACT: Gastrostomy feeding tube placement in children is associated with a high frequency of adverse events. This study sought to preoperatively estimate postoperative adverse events in children undergoing gastrostomy feeding tube placement. This was an observational study of children who underwent gastrostomy with or without fundoplication at 1 of 50 participating hospitals, using 2011-2013 data from the American College of Surgeons' National Surgical Quality Improvement Program Pediatric. The outcome was the occurrence of any postoperative complications or mortality at 30 days after gastrostomy tube placement. The preoperative clinical characteristics significantly associated with occurrence of adverse events were included in a multivariate logistic model. The area under the receiver operating characteristic curve was computed to assess model performance and split-set validated. A total of 2817 children were identified as having undergone gastrostomy tube placement. The unadjusted rate of adverse events within 30 days after gastrostomy tube placement was 11%. Thirteen predictor variables were identified. Notable preoperative variables associated with a greater than 75% increase in adverse event rate were preoperative sepsis/septic shock (odds ratio [OR], 10.76, 95% confidence interval [CI], 3.84-30.17), central nervous system tumor (OR, 3.36; 95% CI, 1.42-7.95), the primary procedure as indicated by the current procedural terminology (CPT) linear risk variable (OR, 1.93; 95% CI, 1.50-2.49), severe cardiac risk factors (OR, 1.88; 95% CI, 1.17-3.03), and preoperative seizure history (OR, 1.90; 95% CI, 1.38-2.62). The area under the receiver operating characteristic curve was 0.71 with the derivation data set and 0.71 upon split-set validation. Preoperatively estimating postoperative adverse events in children undergoing gastrostomy tube placement is feasible. Copyright © 2015 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.
    Academic pediatrics 08/2015; DOI:10.1016/j.acap.2015.05.004 · 2.01 Impact Factor
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    ABSTRACT: Necrotizing enterocolitis (NEC) is the most common gastrointestinal (GI) medical/surgical emergency of the newborn and a leading cause of preterm neonate morbidity and mortality. NEC is a challenge to diagnose since it often shares similar clinical features with neonatal sepsis. In the present study, plasma protein profiling was compared among NEC, sepsis and control cohorts using gel electrophoresis, immunoblot and mass spectrometry. We observed significant impairment in the formation of fibrinogen-γ dimers (FGG-dimer) in the plasma of newborns with NEC that could efficiently differentiate NEC and sepsis with a high level of sensitivity and specificity. Interestingly, the impaired FGG-dimer formation could be restored in NEC plasma by the addition of exogenous active factor XIII (FXIII). Enzymatic activity of FXIII was determined to be significantly lower in NEC subject plasma for crosslinking FGG when compared to sepsis. These findings demonstrate a potential novel biomarker and related biologic mechanism for diagnosing NEC, as well as suggest a possible therapeutic strategy.
    Scientific Reports 08/2015; 5:13119. DOI:10.1038/srep13119 · 5.58 Impact Factor
  • Karl G Sylvester · R Lawrence Moss ·
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    ABSTRACT: Necrotizing enterocolitis (NEC) remains a significant cause of morbidity and mortality in premature neonates. Despite decades of investigation, treating clinicians are still not able to determine which premature infants are at greatest risk of developing NEC and which of the affected infants will develop severe NEC requiring operation. A biomarker is a specific molecular indicator that can be used to identify or measure the progress of a disease. Many potential biomarkers have been studied for their potential relevance to NEC. Those showing promise include C-reactive protein, intestinal fatty acid-binding protein, platelet-activating factor and many others. None to date have achieved sufficient predictive value to be clinically useful. Distinguishing between the specific changes in NEC and the non-specific inflammation of sepsis has proven challenging. Urine is a particularly attractive site for potential biomarkers. It can be collected readily and non-invasively, and it is a rich source of both proteins and peptides. Preliminary work has revealed some promising biomarkers of NEC in urine. Combined with clinical data, they have been shown to be highly predictive in small series of patients. Advances in high-throughput molecular analysis have opened the door to finding biomarkers that may meaningfully improve the outcome of infants at risk for NEC.
    Pediatric Surgery International 03/2015; 31(5). DOI:10.1007/s00383-015-3693-0 · 1.00 Impact Factor

  • 2014 American Academy of Pediatrics National Conference and Exhibition; 10/2014
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    ABSTRACT: This study sought to demonstrate the feasibility of a risk calculator for neonates undergoing major abdominal or thoracic surgery with good discriminative ability. The American College of Surgeons' National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-P) 2011-12 data were queried for neonates who underwent major abdominal or thoracic surgery. The outcome of interest was the occurrence of any adverse event, including mortality, within 30-days postoperatively. The preoperative clinical characteristics significantly associated with any adverse event were used to build a multivariate model. The model's discriminative ability was assessed with the area under the receiver operating characteristic curve (AUROC). The model was split-set validated with 2013 data. A total of 2967 neonates undergoing major abdominal or thoracic surgery were identified. The overall rate of adverse events was 23.3%. Sixteen variables were found to be associated with adverse events. Four variables increased the odds of adverse events at least two-fold: dirty or infected wound class [odds ratio (OR)=2.1] dialysis (OR=3.8), hepatobiliary disease (OR=2.1), and inotropic agent use (OR=2.6). The AUROC=0.79 for development data and 0.77 on split-set validation. Preoperatively estimating the probability of postoperative adverse events in neonates undergoing major abdominal or thoracic surgery with good discrimination is feasible. Copyright © 2015 Elsevier Inc. All rights reserved.
    2014 American Academy of Pediatrics National Conference and Exhibition; 10/2014

  • Journal of the American College of Surgeons 10/2014; 219(4):e27. DOI:10.1016/j.jamcollsurg.2014.07.457 · 5.12 Impact Factor
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    ABSTRACT: Background Urgent operation has been considered the only appropriate management of acute appendicitis in children for decades. The purpose of this study was to investigate the feasibility of non-operative management of uncomplicated acute appendicitis in children. Study Design A prospective non-randomized clinical trial of children with uncomplicated acute appendicitis comparing non-operative management to urgent appendectomy was performed. The primary outcome is the 30-day success rate of non-operative management. Secondary outcomes include comparisons of disability days, missed school days, hospital length of stay (LOS), and measures of quality of life and healthcare satisfaction. Results Seventy-seven patients were enrolled during October 2012-October 2013; 30 chose non-operative management and 47 chose surgery. There were no significant differences in demographic or clinical characteristics. The immediate and 30-day success rates of non-operative management were 93% (n=28/30) and 90% (n=27/30). There was no evidence of progression of appendicitis to rupture at the time of surgery in the three patients that failed non-operative management. Compared to the surgery group, the non-operative group had fewer disability days (3 vs. 17 days, p<0.0001), returned to school more quickly (3 vs. 5 days, p=0.008), and exhibited higher quality of life scores in both the child (93 vs. 88, p=0.01) and the parent (96 vs. 90, p=0.03), but incurred a longer LOS (38 vs. 20 hours, p<0.0001). Conclusions Non-operative management of uncomplicated acute appendicitis in children is feasible with a high 30-day success rate and short-term benefits including a quicker recovery and improved quality of life scores. Additional follow-up will allow for determination of a longer-term success rate, safety, and cost-effectiveness.
    Journal of the American College of Surgeons 08/2014; 219(2). DOI:10.1016/j.jamcollsurg.2014.02.031 · 5.12 Impact Factor
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    ABSTRACT: Background Anthropomorphic data is an important indicator of child health. This study sought to determine whether anthropomorphic data of extreme weight was a significant predictor of peri-operative morbidity in pediatric surgery. Study Design This was a cohort study of children 29 days up to 18 years of age undergoing surgical procedures at participating American College of Surgeons’ National Surgical Quality Improvement Program Pediatric (ACS-NSQIP Pediatric) hospitals in 2011 and 2012. The primary outcomes were composite morbidity and surgical site infection. The primary predictor of interest was weight percentile divided into three categories (less than or equal to 5th percentile, 6th to 94th, or greater than or equal to 95th percentile). A hierarchical multivariate logistic model, adjusting for procedure case-mix, demographic and clinical patient characteristic variables, was used to quantify the relationship between weight percentile category and outcomes. Results Children at or below the 5th weight percentile had 1.19-fold higher odds of developing overall postoperative morbidity than children in the non-extreme range (95% CI: 1.10-1.30) when controlling for clinical variables. Yet, these children did not have higher odds of developing surgical site infection. Children at or above the 95th weight percentile did not have a significant increase in overall postoperative morbidity. However, they were at 1.35-fold increased odds of surgical site infection compared to those in the middle range while controlling for clinical variables (95% CI: 1.16-1.57). Conclusions Both extremely high and extremely low weight percentile scores may be associated with increased postoperative complications after controlling for clinical variables.
    Journal of the American College of Surgeons 05/2014; 218(5). DOI:10.1016/j.jamcollsurg.2013.12.051 · 5.12 Impact Factor
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    ABSTRACT: Necrotizing enterocolitis (NEC) is a major source of neonatal morbidity and mortality. Since there is no specific diagnostic test or risk of progression model available for NEC, the diagnosis and outcome prediction of NEC is made on clinical grounds. The objective in this study was to develop and validate new NEC scoring systems for automated staging and prognostic forecasting. A six-center consortium of university based pediatric teaching hospitals prospectively collected data on infants under suspicion of having NEC over a 7-year period. A database comprised of 520 infants was utilized to develop the NEC diagnostic and prognostic models by dividing the entire dataset into training and testing cohorts of demographically matched subjects. Developed on the training cohort and validated on the blind testing cohort, our multivariate analyses led to NEC scoring metrics integrating clinical data. MACHINE LEARNING USING CLINICAL AND LABORATORY RESULTS AT THE TIME OF CLINICAL PRESENTATION LED TO TWO NEC MODELS: (1) an automated diagnostic classification scheme; (2) a dynamic prognostic method for risk-stratifying patients into low, intermediate and high NEC scores to determine the risk for disease progression. We submit that dynamic risk stratification of infants with NEC will assist clinicians in determining the need for additional diagnostic testing and guide potential therapies in a dynamic manner. http://translationalmedicine.stanford.edu/cgi-bin/NEC/index.pl and smartphone application upon request.
    PLoS ONE 02/2014; 9(2):e89860. DOI:10.1371/journal.pone.0089860 · 3.23 Impact Factor

  • Journal of Surgical Research 02/2014; 186(2):508. DOI:10.1016/j.jss.2013.11.255 · 1.94 Impact Factor
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    ABSTRACT: We implemented and validated a linkage algorithm for cases in both the National Surgical Quality Improvement Program-Pediatric (NSQIP-Peds) and the Pediatric Health Information System (PHIS) to investigate healthcare utilization during the first post-operative year. NSQIP-Peds and PHIS cases from our institution who were operated on between January 2010 and September 2011 were matched on gender and dates of birth, admission, and discharge. Rates of true matches were validated using medical records. We examined rates of emergency department (ED) visits, hospital readmissions, potentially preventable readmissions (PPR), and hospital charges within one year of the NSQIP-Peds encounter. Of the 2,409 NSQIP-Peds and 61,147 PHIS records, 93.6% met match criteria with 92.5% being true matches. Post-operative ED visit rates were 7.8% within 30days, 17.2% between 31-180days, and 18.1% between 181-365days. Readmission rates were 5.5% within 30days, 9.3% between 31-180days, and 8.4% between 181-365days. In patients undergoing inpatient procedures, 10.6% had readmissions within 30days, and 23.7% had readmissions within 365days that were potentially preventable. Using indirect identifiers, a linked NSQIP-Peds-PHIS dataset demonstrated high rates of ED visits, readmissions, and PPR in the first post-operative year. This dataset may provide a more comprehensive way to study health care utilization and clinical outcomes.
    Journal of Pediatric Surgery 01/2014; 49(1):207-12. DOI:10.1016/j.jpedsurg.2013.09.058 · 1.39 Impact Factor
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    ABSTRACT: To test the hypothesis that an exploratory proteomics analysis of urine proteins with subsequent development of validated urine biomarker panels would produce molecular classifiers for both the diagnosis and prognosis of infants with necrotizing enterocolitis (NEC). Urine samples were collected from 119 premature infants (85 NEC, 17 sepsis, 17 control) at the time of initial clinical concern for disease. The urine from 59 infants was used for candidate biomarker discovery by liquid chromatography/mass spectrometry. The remaining 60 samples were subject to enzyme-linked immunosorbent assay for quantitative biomarker validation. A panel of 7 biomarkers (alpha-2-macroglobulin-like protein 1, cluster of differentiation protein 14, cystatin 3, fibrinogen alpha chain, pigment epithelium-derived factor, retinol binding protein 4, and vasolin) was identified by liquid chromatography/mass spectrometry and subsequently validated by enzyme-linked immunosorbent assay. These proteins were consistently found to be either up- or down-regulated depending on the presence, absence, or severity of disease. Biomarker panel validation resulted in a receiver-operator characteristic area under the curve of 98.2% for NEC vs sepsis and an area under the curve of 98.4% for medical NEC vs surgical NEC. We identified 7 urine proteins capable of providing highly accurate diagnostic and prognostic information for infants with suspected NEC. This work represents a novel approach to improving the efficiency with which we diagnose early NEC and identify those at risk for developing severe, or surgical, disease.
    The Journal of pediatrics 01/2014; 164(3). DOI:10.1016/j.jpeds.2013.10.091 · 3.79 Impact Factor
  • Mehul V Raval · R Lawrence Moss ·
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    ABSTRACT: Necrotizing enterocolitis (NEC) is the most common surgical emergency occurring in neonatal intensive care unit (NICU) patients. Among patients with NEC, those that require surgery experience the poorest outcomes and highest mortality. Surgical intervention, while attempting to address the intestinal injury and ongoing mulitfactorial physiologic insults in NEC is associated with its own stresses that may compound the ongoing physiologic derangement. Surgery is thus reserved for those patients with clear indication for intervention such as pneumoperitoneum, confirmed stool or pus in the peritoneal cavity, or worsening clinical status. The purpose of this review is to briefly describe the physiologic stress induced by surgical intervention in the preterm, low birth weight patient with NEC and to provide a contemporary overview of available surgical management options for NEC. The optimal surgical plan employed is strongly influenced by clinical judgment and theoretical benefits in terms of minimizing physiologic stressors while providing temporary and/or definitive treatment in a timely fashion. While the choice of operation has not been shown to have a significant effect on any clinically important outcomes, ongoing investigations continue to study both short and long-term outcomes in patients with NEC.
    Pathophysiology 12/2013; 21(1). DOI:10.1016/j.pathophys.2013.11.017
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    ABSTRACT: A multicenter study of pectus excavatum was described previously. This report presents our final results. Patients treated surgically at 11 centers were followed prospectively. Each underwent a preoperative evaluation with CT scan, pulmonary function tests, and body image survey. Data were collected about associated conditions, complications, and perioperative pain. One year after treatment, patients underwent repeat chest CT scan, pulmonary function tests, and body image survey. A subset of 50 underwent exercise pulmonary function testing. Of 327 patients, 284 underwent Nuss procedure and 43 underwent open procedure without mortality. Of 182 patients with complete follow-up (56%), 18% had late complications, similarly distributed, including substernal bar displacement in 7% and wound infection in 2%. Mean initial CT scan index of 4.4 improved to 3.0 post operation (severe >3.2, normal = 2.5). Computed tomography index improved at the deepest point (xiphoid) and also upper and middle sternum. Pulmonary function tests improved (forced vital capacity from 88% to 93%, forced expiratory volume in 1 second from 87% to 90%, and total lung capacity from 94% to 100% of predicted (p < 0.001 for each). VO2 max during peak exercise increased by 10.1% (p = 0.015) and O2 pulse by 19% (p = 0.007) in 20 subjects who completed both pre- and postoperative exercise tests. There is significant improvement in lung function at rest and in VO2 max and O2 pulse after surgical correction of pectus excavatum, with CT index >3.2. Operative correction significantly reduces CT index and markedly improves the shape of the entire chest, and can be performed safely in a variety of centers.
    Journal of the American College of Surgeons 12/2013; 217(6):1080-9. DOI:10.1016/j.jamcollsurg.2013.06.019 · 5.12 Impact Factor
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    ABSTRACT: Background: Appendectomy is one of the highest volume procedures in children performed across a variety of hospital types in the U.S. potentially making it the ideal procedure to target when assessing hospital and surgeon quality. Though appendiceal perforation rate has been identified as a potential quality target reflecting primary care access, perforation rates have little association with hospital or surgeon quality. The utility and reliability of appendectomy as a target procedure to judge hospital quality based on outcomes beyond perforation rates are unknown. Methods: Using the 2008 Nationwide Inpatient Sample, hospital pediatric appendectomy volumes were determined. Based on literature review, a variety of complication rate thresholds to identify hospital outlier status were determined using sample size calculations. The percent of U.S. hospitals that could exceed volume thresholds in order to be reliably compared was determined. Results: Several complication rates of interest were identified ranging from mortality at 0.19% to a composite overall morbidity at 6.44%. Minimum hospital caseloads required to detect a doubling of complication rates included 127 cases for a composite overall morbidity, 276 cases for wound infection, 285 cases for negative appendectomy, 335 cases for intra-abdominal abscess, 438 cases for postoperative ileus, and 4,729 cases for mortality. Based on annual volumes, only 22% of hospitals met the minimum volume thresholds for a composite overall morbidity. In order to use other outcomes to assess quality, multiple year aggregate data are needed in order to generate volumes sufficient for comparison. Even with 5 year aggregate data less than 2% of hospitals could be compared based on mortality. Conclusions: For the vast majority of complications very few hospitals accrue enough procedure specific volume with appendectomy to judge quality even with multiple years of data collection. In order to best assess hospital quality in children's surgery alternate targets beyond procedure specific traditional outcomes warrant exploration.
    Journal of Pediatric Surgery 11/2013; 48(11):2313-9. DOI:10.1016/j.jpedsurg.2013.03.057 · 1.39 Impact Factor
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    ABSTRACT: Necrotising enterocolitis (NEC) is a major source of neonatal morbidity and mortality. The management of infants with NEC is currently complicated by our inability to accurately identify those at risk for progression of disease prior to the development of irreversible intestinal necrosis. We hypothesised that integrated analysis of clinical parameters in combination with urine peptide biomarkers would lead to improved prognostic accuracy in the NEC population. Infants under suspicion of having NEC (n=550) were prospectively enrolled from a consortium consisting of eight university-based paediatric teaching hospitals. Twenty-seven clinical parameters were used to construct a multivariate predictor of NEC progression. Liquid chromatography/mass spectrometry was used to profile the urine peptidomes from a subset of this population (n=65) to discover novel biomarkers of NEC progression. An ensemble model for the prediction of disease progression was then created using clinical and biomarker data. The use of clinical parameters alone resulted in a receiver-operator characteristic curve with an area under the curve of 0.817 and left 40.1% of all patients in an 'indeterminate' risk group. Three validated urine peptide biomarkers (fibrinogen peptides: FGA1826, FGA1883 and FGA2659) produced a receiver-operator characteristic area under the curve of 0.856. The integration of clinical parameters with urine biomarkers in an ensemble model resulted in the correct prediction of NEC outcomes in all cases tested. Ensemble modelling combining clinical parameters with biomarker analysis dramatically improves our ability to identify the population at risk for developing progressive NEC.
    Gut 09/2013; 63(8). DOI:10.1136/gutjnl-2013-305130 · 14.66 Impact Factor
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    ABSTRACT: BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program-Pediatric was initiated in 2008 to drive quality improvement in children's surgery. Low mortality and morbidity in previous analyses limited differentiation of hospital performance.METHODS:Participating institutions included children's units within general hospitals and free-standing children's hospitals. Cases selected by Current Procedural Terminology codes encompassed procedures within pediatric general, otolaryngologic, orthopedic, urologic, plastic, neurologic, thoracic, and gynecologic surgery. Trained personnel abstracted demographic, surgical profile, preoperative, intraoperative, and postoperative variables. Incorporating procedure-specific risk, hierarchical models for 30-day mortality and morbidities were developed with significant predictors identified by stepwise logistic regression. Reliability was estimated to assess the balance of information versus error within models.RESULTS:In 2011, 46 281 patients from 43 hospitals were accrued; 1467 codes were aggregated into 226 groupings. Overall mortality was 0.3%, composite morbidity 5.8%, and surgical site infection (SSI) 1.8%. Hierarchical models revealed outlier hospitals with above or below expected performance for composite morbidity in the entire cohort, pediatric abdominal subgroup, and spine subgroup; SSI in the entire cohort and pediatric abdominal subgroup; and urinary tract infection in the entire cohort. Based on reliability estimates, mortality discriminates performance poorly due to very low event rate; however, reliable model construction for composite morbidity and SSI that differentiate institutions is feasible.CONCLUSIONS:The National Surgical Quality Improvement Program-Pediatric expansion has yielded risk-adjusted models to differentiate hospital performance in composite and specific morbidities. However, mortality has low utility as a children's surgery performance indicator. Programmatic improvements have resulted in actionable data.
    PEDIATRICS 08/2013; 132(3). DOI:10.1542/peds.2013-0867 · 5.47 Impact Factor
  • M. V. Raval · R. Lawrence Moss ·
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    ABSTRACT: Necrotizing enterocolitis (NEC) is the most common surgical emergency among NICU patients. Patients with NEC requiring surgical intervention have the highest morbidity and mortality and accrue the highest costs. The objective of this review is to provide the neonatologist with an overview of options available for the surgical management of this complex and potentially devastating disease. When evaluating patients with NEC, surgical intervention is reserved for those patients with pneumoperitoneum, confirmed stool or pus in the peritoneal cavity, or worsening clinical status. Options range from peritoneal drain placement to laparotomy with enterostomy creation, anastomoses, or temporizing measures with planned second-look operations. The choice of operation has not been shown to have a significant effect on any clinically important outcomes. The mortality rate for surgically managed NEC remains dependent upon the severity of disease and is directly correlated to gestational age.
    NeoReviews 08/2013; 14(8):e393-e401. DOI:10.1542/neo.14-8-e393
  • Mehul V Raval · Nigel J Hall · Agostino Pierro · R Lawrence Moss ·
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    ABSTRACT: Necrotizing enterocolitis remains a common cause of morbidity and mortality in the neonatal period. Despite many advances in the management of the critically ill neonate, the exact etiology, attempts at prevention and determining best treatment for NEC have been elusive. Unfortunately, the overall survival for this poorly understood and complex condition has not improved. NEC is a condition that can and should be studied with randomized prospective trials (RCTs). This chapter reviews the current evidence-based trials for this condition thus far performed.
    Seminars in Pediatric Surgery 05/2013; 22(2):117-21. DOI:10.1053/j.sempedsurg.2013.01.009 · 2.22 Impact Factor

Publication Stats

3k Citations
329.90 Total Impact Points


  • 2012-2015
    • Nationwide Children's Hospital
      • Department of Surgery
      Columbus, Ohio, United States
  • 2010-2014
    • The Ohio State University
      • Department of Surgery
      Columbus, Ohio, United States
  • 2004-2011
    • Yale-New Haven Hospital
      • Pediatric Surgery Program
      New Haven, Connecticut, United States
  • 2002-2011
    • Yale University
      • • Department of Surgery
      • • School of Medicine
      New Haven, Connecticut, United States
  • 2000-2003
    • Lucile Packard Children’s Hospital at Stanford
      Palo Alto, California, United States
  • 1998-2003
    • Stanford University
      • • Division of Pediatric General Surgery
      • • Division of Biostatistics
      • • Department of Surgery
      Stanford, California, United States
  • 1996
    • University of New Mexico
      • Department of Surgery
      Albuquerque, New Mexico, United States
  • 1993
    • Children's Memorial Hospital
      Chicago, Illinois, United States
  • 1991
    • Seattle Children's Hospital
      • Department of Surgery
      Seattle, Washington, United States