Jacob C Langer

University of Toronto, Toronto, Ontario, Canada

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Publications (292)663.77 Total impact

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    ABSTRACT: Pancreatitis-Panniculitis-Polyarthritis (PPP) syndrome is rare and its physiopathology unclear. A 6-year old boy suffered traumatic pancreatitis complicated by PPP syndrome. Extensive investigations demonstrated high levels of pancreatic lipase and fatty acids in the affected peripheral tissues. These findings support the sequence of peripheral lipolysis and fatty acid accumulation inducing tissue inflammation.
    04/2015; 33(5). DOI:10.1016/j.epsc.2015.03.014
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    ABSTRACT: The primary objective was to determine the diagnostic accuracy of a serial ultrasound (US) clinical diagnostic pathway to detect appendicitis in children presenting to the emergency department (ED). The secondary objective was to examine the diagnostic performance of the initial and interval US and to compare the accuracy of the pathway to that of the initial US. This was a prospective cohort study of 294 previously healthy children 4 to 17 years old with suspected appendicitis and baseline pediatric appendicitis scores of ≥2, who were managed with the serial US clinical diagnostic pathway. This pathway consisted of an initial US followed by a clinical reassessment in each patient and an interval US and surgical consultation in patients with equivocal initial US and persistent concern about appendicitis. The USs were interpreted by published criteria as positive, negative, or equivocal for appendicitis. Children in whom this pathway did not rule in or rule out appendicitis underwent computed tomography (CT). Cases with missed appendicitis, negative operations, and CTs after the pathway were considered inaccurate. The primary outcome was the diagnostic accuracy of the serial US clinical diagnostic pathway. The secondary outcomes included the test performance of the initial and interval US imaging studies. Of the 294 study children, 111 (38%) had appendicitis. Using the serial US clinical diagnostic pathway, 274 of 294 children (93%, 95% confidence interval [CI] = 90% to 96%) had diagnostically accurate results: 108 of the 111 (97%) appendicitis cases were successfully identified by the pathway without CT scans (two missed and one CT), and 166 of the 183 (91%) negative cases were ruled out without CT scans (14 negative operations and three CTs). The sensitivity of this pathway was 108 of 111 (97%, 95% CI = 94% to 100%), specificity 166 of 183 (91%, 95% CI = 87% to 95%), positive predictive value 108 of 125 (86%; 95% CI = 79% to 92%), and negative predictive value 166 of 169 (98%, 95% CI = 96% to 100%). The diagnostic accuracy of the pathway was higher than that of the initial US alone (274 of 294 vs. 160 of 294; p < 0.0001). Of 123 patients with equivocal initial US, concern about appendicitis subsided on clinical reassessment in 73 (no surgery and no missed appendicitis). Of 50 children with persistent symptoms, 40 underwent interval US and 10 had surgical consultation alone. The interval US confirmed or ruled out appendicitis in 22 of 40 children (55.0%) with equivocal initial US, with one false-positive interval US. The serial US clinical diagnostic pathway in suspected appendicitis has an acceptable diagnostic accuracy that is significantly higher than that of the initial US and results in few CT scans. This approach appears most useful in children with equivocal initial US, in whom the majority of negative cases were identified at clinical reassessment and appendicitis was diagnosed by interval US or surgical consultation in most study patients. © 2015 by the Society for Academic Emergency Medicine.
    Academic Emergency Medicine 03/2015; 22(4). DOI:10.1111/acem.12631 · 2.20 Impact Factor
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    ABSTRACT: Neonates with cholestasis may undergo many tests before biliary atresia (BA) or an alternative diagnosis is reached, and delayed intervention may worsen outcomes. An optimal diagnostic approach to reduce risk, cost, and delay has yet to be defined. The purpose of this study was to develop an algorithm that rapidly and accurately excludes BA for infants with cholestatic jaundice. A single-center retrospective comparison of diagnostic workup was made between cholestatic infants with BA, and those without BA who underwent hepatobiliary iminodiacetic acid (HIDA) scan during admission. Patients were born between 2000 and 2010 and those older than 100days at assessment were excluded. Sensitivity and specificity analysis of predictive variables was performed and an algorithm constructed. There were 45 BA and 167 non-BA patients. Some variables were 100% sensitive for the exclusion of BA: conjugated bilirubin <2.5mg/dL, gamma-glutamyl transpeptidase <150U/L, excretion on HIDA, or a normal percutaneous cholangiogram. Clinical variables and ultrasound were less useful as screening tests owing to low specificity and sensitivity, respectively. Liver biopsy was 98% sensitive and 84% specific in the diagnosis of BA. An algorithm was constructed that rules out BA with a negative laparotomy rate of 3-22%. We propose a screening algorithm for infants with conjugated hyperbilirubinemia that permits efficient exclusion of BA with minimal invasive testing and with a low risk of negative laparotomy. This algorithm now requires prospective evaluation to determine its diagnostic accuracy and its ability to reduce hospital costs, patient morbidity, and time to Kasai portoenterostomy in patients with BA. Copyright © 2015 Elsevier Inc. All rights reserved.
    Journal of Pediatric Surgery 03/2015; 50(3):363-70. DOI:10.1016/j.jpedsurg.2014.08.014 · 1.31 Impact Factor
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    Jacob C. Langer, Paul W. Wales
    Journal of Pediatric Surgery 03/2015; 50(5). DOI:10.1016/j.jpedsurg.2015.02.019 · 1.31 Impact Factor
  • Journal of Pediatric Surgery 03/2015; 50(3):497-8. DOI:10.1016/j.jpedsurg.2014.12.003 · 1.31 Impact Factor
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    ABSTRACT: The outcomes of children with congenital hemolytic anemia (CHA) undergoing total splenectomy (TS) or partial splenectomy (PS) remain unclear. In this study, we collected data from 100 children with CHA who underwent TS or PS from 2005-2013 at 16 sites in the Splenectomy in Congenital Hemolytic Anemia (SICHA) consortium using a patient registry. We analyzed demographics and baseline clinical status, operative details, and outcomes at 4, 24, and 52 weeks after surgery. Results were summarized as hematologic outcomes, short-term adverse events (AEs) (≤ 30 days after surgery), and long-term AEs (31-365 days after surgery). For children with hereditary spherocytosis, after surgery there was an increase in hemoglobin (baseline 10.1 ± 1.8 gm/dl, 52 week 12.8 ± 1.6 gm/dl; mean ± SD), decrease in reticulocyte and bilirubin as well as control of symptoms. Children with sickle cell disease had control of clinical symptoms after surgery, but had no change in hematologic parameters. There was an 11% rate of short-term AEs and 11% rate of long-term AEs. As we accumulate more subjects and longer follow-up, use of a patient registry should enhance our capacity for clinical trials and engage all stakeholders in the decision-making process.
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    ABSTRACT: Purpose: Children with perianal Crohn's disease (PCD) are a unique and diverse patient population. The purpose of this study was to describe the spectrum of disease and role of surgery. Methods: A retrospective chart review of all children having at least one surgical intervention for PCD over 10 years was performed. Results: Fifty-seven patients (63% male) aged 0.5-17 (median 13) years were identified. Perianal disease consisted of skin tags (49%), superficial fistulae (49%), deep fistulae (37%), superficial abscesses (68%), deep abscesses (9%), skin breakdown (19%), and anal strictures (7%). 84% received anti-TNF therapy, with 27% treated with a second anti-TNFmedication. Minor surgical procedures, commonly done during anti-TNF therapy, included abscess drainage (67%) and seton placement (33%). Major surgical procedures, done almost exclusively after anti-TNF failure, included defunctioning ileostomy (23%) and subtotal colectomy (9%). Follow-up ranged from 7 to 160 (median 54) months. Conclusions: Pediatric PCD has awide range of disease severity. Minor surgery provides adequate drainage before and during anti-TNF therapy, while major surgery plays a role in medically refractory disease. Appropriate surgical intervention remains an important part of the treatment paradigm.
    Journal of Pediatric Surgery 11/2014; 50(1). DOI:10.1016/j.jpedsurg.2014.10.034 · 1.31 Impact Factor
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    The Laryngoscope 09/2014; 124(9). DOI:10.1002/lary.24650 · 2.03 Impact Factor
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    ABSTRACT: Background: Despite randomized controlled trials and meta-analyses, it remains unclear whether laparoscopic pyloromyotomy (LP) carries a higher risk of incomplete pyloromyotomy and mucosal perforation compared with open pyloromyotomy (OP). Methods: Multicenter study of all pyloromyotomies (May 2007-December 2010) at nine high-volume institutions. The effect of laparoscopy on the procedure-related complications of incomplete pyloromyotomy and mucosal perforation was determined using binomial logistic regression adjusting for differences among centers. Results: Data relating to 2830 pyloromyotomies (1802 [64%] LP) were analyzed. There were 24 cases of incomplete pyloromyotomy; 3 in the open group (0.29%) and 21 in the laparoscopic group (1.16%). There were 18 cases of mucosal perforation; 3 in the open group (0.29%) and 15 in the laparoscopic group (0.83%). The regression model demonstrated that LP was a marginally significant predictor of incomplete pyloromyotomy (adjusted difference 0.87% [95% CI -0.006-4.083]; P = 0.046) but not of mucosal perforation (adjusted difference 0.56% [95% CI -0.096 to 3.365]; P = 0.153). Trainees performed a similar proportion of each procedure (laparoscopic 82.6% vs. open 80.3%; P = 0.2) and grade of primary operator did not affect the rate of either complication. Conclusions: This is one of the largest series of pyloromyotomy ever reported. Although laparoscopy is associated with a statistically significant increase in the risk of incomplete pyloromyotomy, the effect size is small and of questionable clinical relevance. Both OP and LP are associated with low rates of mucosal perforation and incomplete pyloromyotomy in specialist centers, whether trainee or consultant surgeons perform the procedure.
    Journal of Pediatric Surgery 07/2014; 49(7):1083-6. DOI:10.1016/j.jpedsurg.2013.10.014 · 1.31 Impact Factor
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    ABSTRACT: Large solid sacrococcygeal teratomas (SCT) can cause high output cardiac failure and fetal or neonatal death. We describe the outcomes of minimally invasive antenatal procedures for the treatment of fetal SCT. Material and methodsCase review of 5 fetuses with large SCT's treated antenatally using minimally invasive techniques and systematic literature review on fetal therapy for solid SCT's. Five women were referred between 17.7-26.6 weeks gestation for large fetal SCT's with evidence of fetal cardiac failure. Vascular flow to the tumors was interrupted by fetoscopic laser ablation (n = 1), radiofrequency ablation (RFA, n = 2) and interstitial laser ablation +/- vascular coiling(n = 2). There were 2 intra-uterine fetal deaths. The other 3 cases resulted in preterm labor within 10 days of surgery. One neonate died. Two survived without procedure related complications but had long-term morbidity related to prematurity. Systematic literature review revealed 15 SCT's treated minimally invasively for (early) hydrops. Including ours, 6 of 20 hydropic fetuses survived after minimally invasive therapy (30%). Survival after RFA or interstitial laser was 45% (n = 5/11). Of 12 fetuses treated for SCT without obvious hydrops, 67% (n = 8/12) survived. Mean gestational age at delivery after minimally invasive therapy was 29.7 ± 4.0 weeks. Survival after open fetal surgery in hydropic fetuses was 55% (n = 6/11) with a mean gestational age at delivery of 29.8 ± 2.9 weeks. Fetal therapy can potentially improve perinatal outcomes for hydropic fetuses with solid SCT's but is often complicated by intrauterine death and preterm birth.
    Ultrasound in Obstetrics and Gynecology 06/2014; 43(6). DOI:10.1002/uog.13315 · 3.14 Impact Factor
  • Annals of Surgery 05/2014; 261(1). DOI:10.1097/SLA.0000000000000748 · 7.19 Impact Factor
  • Nada Gawad, Dafydd A. Davies, Jacob C. Langer
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    ABSTRACT: Background Longer wait time for infant inguinal hernia (IH) repair is associated with higher complication rates. We wished to determine if socioeconomic and demographic factors influence wait times for IH repair. Methods Children < 2 yo with IH at a Canadian children’s hospital were retrospectively reviewed. Days from diagnosis to surgical consultation (W1) and from consultation to repair (W2) were collected along with demographic, medical ,and socioeconomic data. Linear regression analysis was performed. Results 131 patients were appropriate for analysis (82.4% male). Median distance to hospital was 27.5 km (IQR = 10.5-50.4) and median income was $34,477 (IQR = 30,127-41,986). Median W1, W2. and Wtotal (W1 + W2) were 24 (IQR = 8-48), 43 (IQR = 21-69) and 79 (IQR = 38-112) days, respectively. Wait times were shorter in infants who were male (p = 0.044), symptomatic (p < 0.001), diagnosed in the ED (p < 0.001), or had an incarcerated hernia (p = 0.006). They were longer for premature infants (p = 0.009) and those with significant comorbidities (p = 0.018). Neither income (p = 0.328) nor distance from hospital (p = 0.292) was associated with longer wait times. Conclusion Wait times for IH repair were appropriately influenced by medical risk factors. Income and distance to hospital did not appear to influence wait times. A population-based study is needed to determine if these findings reflect a general trend within the Canadian health care system.
    Journal of Pediatric Surgery 05/2014; DOI:10.1016/j.jpedsurg.2014.02.064 · 1.31 Impact Factor
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    ABSTRACT: Background Both the Swenson and the Soave procedures have been adapted to a transanal approach. The purpose of this study was to compare outcomes following the transanal Swenson and Soave procedures using a matched case control analysis. Methods A retrospective chart review was performed to identify all transanal Soave and Swenson pullthroughs done at 2 tertiary care children’s hospitals between 2000 and 2010. Patients were matched for gestational age, mean weight at time of the operation, level of aganglionosis, and presence of co-morbidities. Student’s t-test and chi-squared analysis were performed. Results Fifty-four patients (Soave 27, Swenson 27) had adequate data for matching and analysis. Mean follow-up was 4 ± 1.6 years and 3.2 ± 2.7 years for the Soave and Swenson groups, respectively. No significant differences in mean operating time (Soave:191 ± 55, Swenson:167 ± 61 mins, p = 0.6), overall hospital stay (6 ± 4vs7.8 ± 5 days, p = 0.7) , and number with intra-operative complications (3vs4, p = 1.0), post-operative obstructive symptoms (6vs9, p = 0.5), enterocolitis episodes (4vs4, p = 1.0),or fecal incontinence (0vs2, p = 0.4) were noted. Conclusion After controlling for potential confounders, there were no significant differences in the short and intermediate term outcome between transanal Soave and transanal Swenson pullthrough procedures.
    Journal of Pediatric Surgery 05/2014; DOI:10.1016/j.jpedsurg.2014.02.073 · 1.31 Impact Factor
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    ABSTRACT: Background There is significant lack of information regarding the Canadian pediatric surgery workforce. Methods An IRB-approved survey aimed at assessing workforce issues was administered to pediatric surgeons and pediatric surgery chiefs in Canada in 2012. Results The survey was completed by 98% of practising surgeons and 13 of the 18 division chiefs. Only 6% of surgeons are older than 60 years, and only a fifth anticipate retirement over the next decade. The workforce is stable, with 82% of surgeons unlikely to change current positions. Surgical volume showed essentially no growth during the 5-year period 2006–2010. The majority of surgeons felt they were performing the right number or too few cases and anticipated minimal or no future growth in their individual practices or that of their group. Based on anticipated vacancies, the best estimate is a need for 20 new pediatric surgeons over the next decade. This need is significantly surpassed by the current output from the Canadian training programs. Conclusions The Canadian pediatric surgery workforce is currently saturated. The mismatch between the number of graduating trainees and the available positions over the next decade has significant repercussions for current surgery and pediatric surgery residents wishing to practice in Canada.
    Journal of Pediatric Surgery 05/2014; DOI:10.1016/j.jpedsurg.2014.02.045 · 1.31 Impact Factor
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    ABSTRACT: In 2000, we described the variability of pediatric surgical information on the Internet. Since then, online videos have become an increasingly popular medium for education and personal expression. The purpose of this study was to examine the content and quality of videos related to pediatric surgical diagnoses on the Internet. YouTube™ was searched for videos on gastroschisis, congenital diaphragmatic hernia, pediatric inguinal hernia, and pectus excavatum. The first 40 English language videos for each diagnosis were reviewed for owner and audience characteristics, content and quality. A small majority of videos were made by medical professionals (50.63%, vs. 41.25% by lay persons and 8.13% by fundraising organizations). Eighty percent of videos were intended for a lay audience. Videos by medical professionals were more accurate and complete than those posted by lay persons. The YouTube™ videos varied significantly in content and quality. Videos by lay persons often focused on the emotional aspect of the diagnosis and clinical course. Videos by members of the medical profession tended to be more complete and accurate. These findings underscore the continued need for high quality pediatric surgical information on the Internet for patients and their families.
    Journal of Pediatric Surgery 04/2014; 49(4):586-9. DOI:10.1016/j.jpedsurg.2013.08.004 · 1.31 Impact Factor
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    ABSTRACT: Canada faces a similar epidemic of obesity in their adolescent population as other Western countries. However, the development of programs to treat obesity and manage its sequelae has evolved in a unique way. This is in part due to differences in health care funding, population distribution, public demand, and availability of expertise and resources. In this article, we will describe the evolution of adolescent bariatric care in Canada and describe the current programs and future directions. The focus will be on the province of Ontario, the site of the first adolescent bariatric program in the country.
    Seminars in Pediatric Surgery 02/2014; 23(1):31-6. DOI:10.1053/j.sempedsurg.2013.10.014 · 1.94 Impact Factor
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    ABSTRACT: In hemodynamically normal children with blunt splenic injury (BSI), the standard of care is non-operative management. Several studies have reported that non-paediatric and non-trauma centres have higher operative rates in children with BSI compared to paediatric hospitals and trauma centres. We investigate the feasibility of using operative rate for BSI as a quality of care indicator. We performed a population-based retrospective cohort study of children (≤18 years) with BSI admitted to all acute-care hospitals in Canada from 2001 to 2010. The main outcome was rate of operative management for BSI. Hierarchical multivariable logistic regression models were constructed to evaluate the relationship between operative rate and different hospital types (paediatric or non-paediatric, trauma or non-trauma). These models also allowed for generation of hospital-level observed to expected (O/E) ratios for rate of operative management. We identified 3122 children with BSI. The majority (74%) were isolated splenic injuries and the grade of splenic injury was specified in 45% of cases (n=1391, 38% grade I or II; 62% grade III, IV, or V). The overall operative rate was 11% (n=315), of which 9% were total splenectomy and 2% were spleen-preserving operations. After adjusting for age, gender, mechanism of injury, splenic injury grade, ISS, and centre volume, admission to non-paediatric hospitals was associated with a higher probability of operative management (OR 7.6, 95% CI 2.4-24.4), whereas there was no significant difference in operative management between trauma and non-trauma centres (OR 1.6, 95% CI 0.8-3.2). Outlier status based on O/E ratio was determined to identify centres with higher or lower than expected operative rates. The operative rates for children with BSI are significantly higher in non-paediatric hospitals. In these hospitals that do not routinely care for children and have higher than expected operative rates, we have used operative rate for BSI as a quality of care indicator and identified opportunities for quality improvement initiatives. Level of evidence: III, Retrospective comparative study.
    Injury 12/2013; 45(5). DOI:10.1016/j.injury.2013.12.006 · 2.46 Impact Factor
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    ABSTRACT: There is considerable controversy regarding optimal mode and timing of delivery for fetuses with gastroschisis. Our objectives were to describe the variation in institutional approach regarding these factors, and to evaluate the effect of timing of delivery on outcomes in fetuses with gastroschesis. Members of the maternal-fetal medicine community across Canada were surveyed regarding their personal and institutional approach of delivery. Data from the Canadian Pediatric Surgery Network (CAPSnet) were analyzed. The survey showed significant variability in delivery approach between institutions, although no center routinely performs cesarean section. Infants delivered vaginally (VD) were categorized into three groups: Group 1, VD <36weeks (n=114); Group 2, VD 36-37weeks (n=218); and Group 3, VD ≥38weeks (n=75). Score of Neonatal Acute Physiology, complication rates, length of time on total parenteral nutrition (TPN), and length of hospital stay (LOS) were higher in Group 1; bowel matting was greater in Group 3. There were no differences between the groups regarding other complications. Our data suggest that preterm delivery was associated with more complications, longer time on TPN, and longer LOS; delivery ≥38weeks was associated with increased bowel matting. These outcomes should be considered when determining institutional protocol.
    Journal of Pediatric Surgery 11/2013; 48(11):2251-5. DOI:10.1016/j.jpedsurg.2013.07.004 · 1.31 Impact Factor
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    ABSTRACT: The differential diagnosis of an axillary mass during childhood is extensive and malignant processes such as lymphoma or metastatic disease must be excluded. We describe an unusual case of a fibroadenoma growing within ectopic breast tissue located in the axilla in a 10 year old girl. The mass grew rapidly and was removed during an excisional biopsy. Histological evaluation revealed a diagnosis of fibroadenoma. Fibroadenoma of ectopic breast tissue has not previously been reported in the pediatric age group, and must be considered as part of the differential diagnosis for pediatric axillary masses.
    10/2013; 1(10):359–361. DOI:10.1016/j.epsc.2013.09.009
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    ABSTRACT: Objective To report three different antenatal therapeutic approaches for fetal lung masses associated with hydrops. Methods Three prospectively followed cases are described, and all 30 previously published minimally invasive cases of fetal therapy for hydropic lung masses are reviewed. ResultsThree hydropic fetuses with large intrathoracic lung masses presented at 17, 25 and 21 weeks of gestation, respectively. An aortic feeding vessel was identified in each case and thus a bronchopulmonary sequestration (BPS) was suspected. Under ultrasound guidance, the feeding vessel was successfully occluded with interstitial laser (Case 1), radiofrequency ablation (RFA) (Case 2) and thrombogenic coil embolization (Case 3). Complete (Cases 1 and 2) or partial (Case 3) resolution of the lung mass and hydrops was observed. A healthy infant was born at term after laser therapy (Case 1), and the involved lung lobe was resected on day 2 of postnatal life. In Case 2, hydrops resolved completely following RFA, but an iatrogenic congenital diaphragmatic hernia and abdominal wall defect became apparent 4 weeks later. The neonate died from sepsis following spontaneous preterm labor at 33 weeks. In Case 3, despite technical success in complete vascular occlusion with coils, a stillbirth ensued 2 days after embolization. Conclusions The prognosis of large microcystic or echogenic fetal chest masses associated with hydrops is dismal. This has prompted attempts at treatment by open fetal surgery, with mixed results, high risk of premature labor and consequences for future pregnancies. We have demonstrated the possibility of improved outcome following ultrasound-guided laser ablation of the systemic arterial supply. Despite technical success, RFA and coil embolization led to procedure-related complications and need further evaluation. Copyright (c) 2013 ISUOG. Published by John Wiley & Sons Ltd.
    Ultrasound in Obstetrics and Gynecology 09/2013; 42(4). DOI:10.1002/uog.12515 · 3.14 Impact Factor

Publication Stats

6k Citations
663.77 Total Impact Points

Institutions

  • 1990–2015
    • University of Toronto
      • • Department of Surgery
      • • Hospital for Sick Children
      • • Department of Obstetrics and Gynaecology
      • • Division of Urology
      • • Division of General Surgery
      Toronto, Ontario, Canada
  • 1987–2015
    • SickKids
      • • Department of Surgery
      • • Division of General Surgery
      Toronto, Ontario, Canada
  • 2011
    • Institute for Clinical Evaluative Sciences
      Toronto, Ontario, Canada
    • University of Texas Southwestern Medical Center
      • Department of Pediatrics
      Dallas, Texas, United States
  • 2009
    • Child & Family Research Institute
      Vancouver, British Columbia, Canada
  • 1992–2009
    • McMaster University
      • Department of Surgery
      Hamilton, Ontario, Canada
  • 2008
    • Cincinnati Children's Hospital Medical Center
      • Division of Pediatric General and Thoracic Surgery
      Cincinnati, OH, United States
  • 2004
    • Childrens Hospital of Pittsburgh
      Pittsburgh, Pennsylvania, United States
  • 1995–2001
    • Washington University in St. Louis
      • Department of Surgery
      San Luis, Missouri, United States
  • 1999
    • Saint Louis Zoo
      San Luis, Missouri, United States
  • 1996–1998
    • St. Luke's Hospital (MO, USA)
      Saint Louis, Michigan, United States
  • 1993
    • University of Missouri - St. Louis
      Saint Louis, Michigan, United States
  • 1989
    • The University of Manchester
      Manchester, England, United Kingdom
  • 1987–1989
    • University of California, San Francisco
      • • Department of Surgery
      • • Division of Pediatric Surgery
      San Francisco, CA, United States