Necrotizing enterocolitis (NEC) is the most common cause of gastrointestinal-related morbidity and mortality in the neonatal intensive care unit (NICU). Its onset is sudden and the smallest, most premature infants are the most vulnerable. Necrotizing enterocolitis is a costly disease, accounting for nearly 20% of NICU costs annually. Necrotizing enterocolitis survivors requiring surgery often stay in the NICU more than 90 days and are among those most likely to stay more than 6 months. Significant variations exist in the incidence across regions and units. Although the only consistent independent predictors for NEC remain prematurity and formula feeding, others exist that could increase risk when combined. Awareness of NEC risk factors and adopting practices to reduce NEC risk, including human milk feeding, the use of feeding guidelines, and probiotics, have been shown to reduce the incidence of NEC. The purpose of this review is to examine the state of the science on NEC risk factors and make recommendations for practice and research.

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Background Despite international efforts moving toward integrated care using health information technologies and the potential of electronic PHRs to help us better coordinate patient-centered care, PHR adoption in the United States remains low among patients who have been offered free access to them from private-sector companies. If older adult stand to benefit from the use of PHRs for its usefulness in self-managing chronic illness, why have they not been more readily adopted? Since the chronically ill older adult has unique circumstances that impact their decision to participate in self-directed care, a theoretical framework to help understand factors that influence the adoption of PHRs is important. Here we describe the results of an exploratory study that provided an initial test of such a framework. Methods The study used a descriptive survey methodology with 38 older adults. The survey questionnaire asked about the personal barriers and facilitators associated with personal health record adoption and included items measuring each of the PHRAM's four interacting factors (environmental factors, personal factors, technology factors, and

Background Better measures are needed to identify infants at risk for developing necrotizing enterocolitis (NEC) and facilitate communication about risk across transitions. Although NEC is multi-factorial, quantification of composite risk for NEC in an individual infant is not clearly defined. Objective This study’s objective was to describe the derivation, validation and calibration testing of a novel clinical NEC risk index, GutCheckNEC. Individual risk factors were weighted to assess composite odds of developing NEC. GutCheckNEC is designed to improve communication about NEC risk and coordination of care among clinicians across an infant’s clinical course. Methods Based on a synthesis of research evidence about NEC risk and an e-Delphi study including 35 neonatal experts, we identified NEC risk factors believed by the experts to be most relevant for a NEC risk index then applied a logistic model building process to derive and validate GutCheckNEC. De-identified data from the Pediatrix BabySteps Clinical Data Warehouse (discharge date 2007-2011) were split into three samples for derivation, validation and calibration. By comparing infants with medical NEC, surgical NEC, and those who died to infants without NEC, we derived the logistic model using the un-matched derivation set. Discrimination was then tested in a case-control matched validation set and an un-matched calibration set using ROC curves. Results Sampled from a cohort of 58 820 infants, the randomly selected derivation set (n= 35 013) revealed 9 independent risk factors (gestational age, history of packed red blood cell transfusion, unit NEC rate, late onset sepsis, multiple infections, hypotension treated with inotropic medications, Black or Hispanic race, outborn status, and metabolic acidosis) and 2 risk reducers (human milk feeding on both days 7 and 14 of life, and probiotics). Unit NEC rate carried the most weight in the summed score. Validation using a 2: 1 matched case-control sample (n=360) demonstrated fair to good discrimination. In the calibration set (n= 23 447), GutCheckNEC scores (range 0-58) discriminated those infants who developed surgical NEC (AUC=0.84, 95% CI 0.82-0.84) and NEC leading to death (AUC=0.83, 95% CI 0.81-0.85), more accurately than medical NEC (AUC= 0.72, 95% CI 0.70-0.74). Conclusion GutCheckNEC represents weighted composite risk for NEC and discriminated infants who developed NEC from those who did not with very good accuracy. We speculate that targeting modifiable NEC risk factors could reduce national NEC prevalence.

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