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Grant writing takes significant time and effort and often may be elusive, especially on a first attempt. After the rejection of a grant, many investigators face a dilemma regarding the best next steps. In this article, we discuss the options of revision versus resubmission and how to navigate these decisions. The literature was surveyed, including review articles, personal perspectives, and editorial pieces regarding the grant writing and funding processes. The National Institute of Health database was reviewed, and data were extrapolated from the past 10 years of funding percentages and rates of both R01 initial applications and resubmissions. Recommendations were then generated based on pertinent literature and experience from the authors. The grant writing process involves many checkpoints between conception and funding. Only approximately 15% of R01 and R01-equivalent grants are accepted for funding on the initial submission. However, this statistic increases to >30% if the appropriate steps are taken to revise and resubmit the grant. These steps include consulting co-investigators, modifying hypotheses, drafting a succinct "Introduction" document, and many more. Knowing the options after the rejection of an original submission plays a huge role in the ultimate success of the grant. Although receiving funding for an original grant can be difficult, with appropriate guidance, it may seem more feasible than initially expected. Adequately responding to the critiques of the grant and revising the grant appropriately can make or break the outcome of the grant. [ABSTRACT FROM AUTHOR]

Innovation is essential to the advancement of the field of pediatric surgery. The natural skepticism toward new technologies in pediatrics leads to frequent confusion of surgical innovation and research. Using fluorescence-guided surgery as an archetype for this ethical discussion, we apply existing conceptual frameworks of surgical innovation to understand the distinction between innovation and experimentation, acknowledging the spectrum and "grey zone" in between. In this review, we discuss the role of Institutional Review Boards in evaluating surgical practice innovations, and the aspects of certain surgical innovations that are distinct from experimentation, including a thorough understanding of the risk profile, preexisting use in humans, and adaptation from related fields. Examining fluorescence-guided surgery through these existing frameworks as well as the concept of equipoise, we conclude that new applications of indocyanine green do not constitute human subjects research. Most importantly, this example gives practitioners a lens through which they may appraise potential surgical innovations to allow for a sensible and efficient improvement of the field of pediatric surgery. V. [ABSTRACT FROM AUTHOR]

There is wide variability and considerable controversy regarding the classification of appendicitis and the need for postoperative antibiotics. This study aimed to assess interrater agreement with respect to the classification of appendicitis and its influence on the use of postoperative antibiotics amongst surgeons and surgical trainees. A survey comprising 15 intraoperative images captured during appendectomy was distributed to surgeons and surgical trainees. Participants were asked to classify severity of disease (normal, inflamed, purulent, gangrenous, perforated) and whether they would prescribe postoperative antibiotics. Statistical analysis included percent agreement, Krippendorff's alpha for interrater agreement, and logistic regression. In total, 562 respondents completed the survey: 206 surgical trainees, 217 adult surgeons, and 139 pediatric surgeons. For classification of appendicitis, the statistical interrater agreement was highest for categorization as gangrenous/perforated versus nongangrenous/nonperforated (Krippendorff's alpha = 0.73) and lowest for perforated versus nonperforated (Krippendorff's alpha = 0.45). Fourteen percent of survey respondents would administer postoperative antibiotics for an inflamed appendix, 44% for suppurative, 75% for gangrenous, and 97% for perforated appendicitis. Interrater agreement of postoperative antibiotic use was low (Krippendorff's alpha = 0.28). The only significant factor associated with postoperative antibiotic utilization was 16 or more years in practice. Surgeon agreement is poor with respect to both subjective appendicitis classification and objective utilization of postoperative antibiotics. This survey demonstrates that a large proportion (59%) of surgeons prescribe antibiotics after nongangrenous or nonperforated appendectomy, despite a lack of evidence basis for this practice. These findings highlight the need for further consensus to enable standardized research and avoid overtreatment with unnecessary antibiotics. [ABSTRACT FROM AUTHOR]

• Clarifies differences in the definition of NEC totalis. • Defines key ethical issues that arise during the care of patients with NEC totalis. • Provides ethical framework for addressing family and provider dilemmas. Necrotizing enterocolitis (NEC) totalis is a devastating disease of the newborn intestine. A precise clinical definition of the extent of gastrointestinal involvement is lacking in the existing literature, and the clinical outcomes are typically viewed as grim. Herein, we present a series of clinical case examples of patients with varying degrees of NEC totalis and other co-morbid conditions, with possible anticipated outcomes based on current data. We define the key ethical issues and provide a framework and discussion of the ethical issues involved in the care of patients with NEC totalis and recommendations of how to approach discussions with the family of these patients We discuss the ethical considerations for both the providers caring for these patients, and the patient's family members. The management of patients with NEC totalis is complex and ethically challenging. V [ABSTRACT FROM AUTHOR]

The Significance and Innovation sections of a grant application are the cornerstones to a successful application. These sections emphasize the importance of the problem being studied, highlight what is novel about the proposal, and are an opportunity to get the reviewers excited about the application. To the novice grant writer, it may be difficult to know what "Significance" and "Innovation" are meant to describe. In this article we define the role of the Significance and Innovation sections and provide suggestions on what to include in each section and potential pitfalls to avoid. [ABSTRACT FROM AUTHOR]

The presence of pain may interrupt sleep and impede normal postoperative recovery; however, no prior studies have quantified sleep loss due to pain in children undergoing inpatient surgery. Wearable accelerometers objectively measure sleep patterns in children. We aimed to quantify sleep loss associated with patient reported pain scores after a Modified Nuss operation. Ten patients undergoing Modified Nuss operations were recruited during their inpatient stay. Children wore an Actigraph GT3X-BT accelerometer postoperatively during their hospital stay. Hourly sleep minutes were recorded using the Actigraph between 10 pm and 6 am. Patient reported pain scores were abstracted from patient charts. Mixed linear regression models, adjusting for within-subject random effects, were estimated to quantify the association between hourly sleep minutes and patient reported pain scores. Patients were 30% female, with an average age of 15.7 years (range 13–22). The majority (70%) of patients were white non-Hispanic. All patients received a patient controlled analgesic pump. Average postoperative length of stay was 4.8 days (range 4.0–6.0; SD = 0.8). A total of 240 sleep hours and associated pain scores were analyzed. Patients slept on average 48 min per hour. Mixed model analysis predicted that a 1-point increase in pain score was associated with 2.5 min per hour less sleep time. Increases in patient-reported pain scores are associated with sleep loss after a Modified Nuss operation. Objectively quantifying sleep loss associated with postoperative pain using accelerometer data may help clinicians better understand their patient's level of pain control. Our findings provide the basis for future studies aimed at more accurately titrating pain medication to optimize sleep and speed up recovery. Case Series Without Comparison Group, Level IV. [ABSTRACT FROM AUTHOR]

Objective preoperative assessment of pectus excavatum (PE) deformity in patients is limited to preoperative measurement of severity using computed tomography (CT) or magnetic resonance imaging (MRI). Postoperative assessment is currently subjective as postoperative CT scans are not recommended in light of radiation exposure and high cost to families. White Light Scanning (WLS) is a novel 3D imaging modality that offers an alternative that is a quick, nonionizing, inexpensive, and safe strategy for measurement both pre- and postsurgery. Our prior investigation demonstrated the feasibility of using WLS to measure PE deformity and showed very strong correlation of a new WLS-derived PE severity index, the Hebal–Malas Index (HMI), with CT-derived HI. The purpose of this study was to demonstrate use of WLS to assess extent of correction of PE deformities after the Nuss procedure. WLS scan data were gathered prospectively in pediatric patients with PE from 2015 to 2018. HMI was obtained from the preoperative and postoperative WLS scans. Analysis assessed the differences of preoperative and postoperative HMI. Preoperative CT-derived HI was collected from the medical record and estimated postoperative Haller Index was calculated from HMI and correlation of HMI and HI using historical data. A total of 71 patients received a preoperative CT scan and underwent surgery for PE. Of those, 63 (89%) received WLS preoperatively and 51 (72%) had complete preoperative and postoperative WLS data. The average postoperative decrease in the WLS-derived HMI was 0.35 (SD: 0.15) and 1.73 (SD: 1.03) in WLS-estimated HI. WLS is highly effective in objectively quantifying the extent of surgical correction in PE patients. IV Diagnostic Study [ABSTRACT FROM AUTHOR]

Abstract Background/purpose Computed tomography (CT) derived Haller Index (HI) remains the standard for quantifying severity in patient with pectus excavatum (PE). Optical scanning described in literature reports optimistic results and new indices that correlate with HI. This study assessed the feasibility of a handheld White Light Scanner (WLS) to obtain 3D measurements and indices of PE deformity. Methods From April 2015–April 2017, WLS scanning was conducted by orthotists during clinical visits. Included were children with PE up to 18 years. Analysis assessed correlation of a WLS-derived severity index, Hebal-Malas Index (HMI), with physician measured PE Depth (PED), and CT-derived HI. Results Of 195 participants, 185(94%) patients with PE were scanned and 127(69%) had complete WLS data. For 88 patients undergoing monitoring, HMI correlated with PED (r = 0.42, p = 0.004). For 39 patients with pre-operative CT, HMI demonstrated strong correlation with HI (r = 0.87, p < 0.0001). Conclusions WLS demonstrated high feasibility of scanning PE. WLS-derived HMI best correlates with HI for patients with severe pectus deformity. Our current data is suggestive that WLS is best applied for severe deformities and yet to be established for milder deformities. Future yearly WLS will provide data on deformity progression and surgical therapy. Level of Evidence IV. Type of Study Diagnostic Study. [ABSTRACT FROM AUTHOR]

Abstract Background Evaluation of Pectus Carinatum (PC) deformity in patients undergoing bracing is limited to subjective assessment of the chest through physical exam and photography. White Light Scanning (WLS) is a novel 3D imaging modality and offers an objective alternative that is quick, inexpensive, and safe. We previously demonstrated the feasibility of using a WLS-derived proxy for Haller index, called the Hebal–Malas Index (HMI), in measuring the surgical correction of Pectus Excavatum. The purpose of this study was to demonstrate the use of WLS to measure the severity of pre- and postbracing intervention of PC deformities and assess corrected difference between the two scans. Methods We conducted a prospective review of preintervention WLS scans in pediatric patients with PC from 2015 to 2017. HMI was obtained from the preintervention and postintervention WLS scans. Analysis assessed the differences of pre- and postbracing intervention of measurements. Results Of 32 patients with both pre- and postbracing scans, 13 (34%) showed improvement of more than 10%, 21 (55%) showed slight improvement of 1%–10%, and 4 (11%) did not improve at follow-up. The average postbracing change in the WLS-derived HMI was 0.10 (SD:0.11). The average length of bracing days was 331.4 (SD: 127.3) with an average of 6.8 h worn per day. Compliance was defined as patient reported utilization of the brace. Patients who were compliant showed a significant improvement (p = 0.004) compared to those who were not compliant (Table 2). However, even patients with moderate compliance still improved in many instances. Change in height was a significant factor correlating with improvement. Children who grew more while wearing a brace showed greater improvement in their deformity. Conclusion Using this technique, we have the ability to objectively quantify the impact of bracing on the severity of PC deformity and measure change in deformity over time. Type of study Prospective study. Level of evidence Level IV. [ABSTRACT FROM AUTHOR]

Necrotizing enterocolitis (NEC) remains one of the highest causes of mortality and of acute and long-term morbidity in premature infants. Multiple factors are involved in the pathophysiology of NEC including the immaturity of the immune system and the complex changing composition of the intestinal microbiome. This is compounded by the fact that the premature infant should ideally still be a developing fetus and has an immature intestinal tract. Because these complexities are beyond the scope of studies in single-cell cultures, animal models are absolutely essential to understand the mechanisms involved in the pathophysiology of NEC and the effects of inflammation on the immature intestinal tract. To this end, investigators have utilized many different species (e.g., rats, mice, rabbits, quails, piglets, and non-human primates) and conditions to develop models of NEC. Each animal has distinct advantages and drawbacks related to its preterm viability, body size, genetic variability, and cost. The choice of animal model is strongly influenced by the scientific question being addressed. While no model perfectly mimics human NEC, each has greatly improved our understanding of disease. Examples of recent discoveries in NEC pathogenesis and prevention underscore the importance of continued animal research in NEC. [ABSTRACT FROM AUTHOR]

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease that affects premature neonates. It frequently results in significant morbidity and mortality for those affected. Years of research into the pathophysiology of NEC have revealed it to be a variable and multifactorial disease. However, there are risk factors associated with NEC including low birth weight, prematurity, intestinal immaturity, alterations in microbial colonization, and history of rapid or formula based enteral feeds (Fig. 1). 1–3 An accepted generalization of the pathogenesis of NEC includes a hyperresponsive immune reaction to insults such as ischemia, starting formula feeds, or alterations in the microbiome with pathologic bacterial colonization and translocation. This reaction causes a hyperinflammatory response disrupting the normal intestinal barrier, allowing abnormal bacterial translocation and ultimately sepsis. 1,2,4 This review will focus specifically on the interactions with the microbiome and intestinal barrier function in NEC. [ABSTRACT FROM AUTHOR]

Necrotizing enterocolitis is a severe gastrointestinal disease of the infant. It most commonly targets those that are born prematurely. NEC has been associated with initiation of feeds and in most cases, it can be managed with antibiotics and bowel rest. However, in up to half of the cases, intestinal perforation, peritonitis, and failure of medical treatment will require surgical intervention. The following review will discuss the surgical approach to managing NEC, based on an updated review of practice patterns and recently published literature. [ABSTRACT FROM AUTHOR]

Background Blunt head trauma accounts for a majority of pediatric trauma admissions. There is a growing subset of these patients with isolated skull fractures, but little evidence guiding their management. We hypothesized that inpatient neurological observation for pediatric patients with isolated skull fractures and normal neurological examinations is unnecessary and costly. Methods We performed a single center 10 year retrospective review of all head traumas with isolated traumatic skull fractures and normal neurological examination. Exclusion criteria included: penetrating head trauma, depressed fractures, intracranial hemorrhage, skull base fracture, pneumocephalus, and poly-trauma. In each patient, we analyzed: age, fracture location, loss of consciousness, injury mechanism, Emergency Department (ED) disposition, need for repeat imaging, hospital costs, intracranial hemorrhage, and surgical intervention. Results Seventy-one patients presented to our ED with acute isolated skull fractures, 56% were male and 44% were female. Their ages ranged from 1 week to 12.4 years old. The minority (22.5%) of patients were discharged from the ED following evaluation, whereas 77.5% were admitted for neurological observation. None of the patients required neurosurgical intervention. Age was not associated with repeat imaging or inpatient observation (p = 0.7474, p = 0.9670). No patients underwent repeat head imaging during their index admission. Repeat imaging was obtained in three previously admitted patients who returned to the ED. Cost analysis revealed a significant difference in total hospital costs between the groups, with an average increase in charges of $4,291.50 for admitted patients (p < 0.0001). Conclusion Pediatric isolated skull fractures are low risk conditions with a low likelihood of complications. Further studies are necessary to change clinical practice, but our research indicates that these patients can be discharged safely from the ED without inpatient observation. This change in practice, additionally, would allow for huge health care dollar savings. [ABSTRACT FROM AUTHOR]

Abstract: Clear cell sarcoma of the kidney (CCSK) is a rare tumor. It has a wide histologic spectrum and often mimics other pediatric renal tumors, resulting in considerable diagnostic difficulty. We report the case of a two-year-old who presented with a large (14 cm) abdominal mass. Prior to neoadjuvant chemotherapy, a biopsy was performed, which revealed Wilms' tumor. The final pathology diagnosis at the time of resection revealed CCSK. [Copyright &y& Elsevier]

Ethical considerations surrounding clinical research have been a topic of intense debate and discussion for many years, however, issues specific to the surgeon-scientist are rarely discussed. This article summarizes ethical issues pertinent to the surgeon-scientist including conflicts of interest, use of human biospecimens, data integrity, manuscript authorship, and mentorship for trainees. The methods include a review of the current and past literature on each of these topics with a brief overview of how it relates to the surgeon-scientist. Case examples are provided throughout to provide further discussion points related to the topic. The purpose of this review is to promote awareness of the ethical challenges that the surgeon-scientist faces when engaging in basic science research in order to spark discussion and encourage integrity and ethical behavior. [ABSTRACT FROM AUTHOR]

Necrotizing enterocolitis (NEC) is the most common life-threatening gastrointestinal disease encountered in the premature infant. Although the inciting events leading to NEC remain elusive, various risk factors, including prematurity, hypoxemia, formula feeding, and intestinal ischemia, have been implicated in the pathogenesis of NEC. Data from our laboratory and others suggest that NEC evolves from disruption of the intestinal epithelial barrier, as a result of a combination of local and systemic insults. We postulate that nitric oxide (NO), an important second messenger and inflammatory mediator, plays a key role in intestinal barrier failure seen in NEC. Nitric oxide and its reactive nitrogen derivative, peroxynitrite, may affect gut barrier permeability by inducing enterocyte apoptosis (programmed cell death) and necrosis, or by altering tight junctions or gap junctions that normally play a key role in maintaining epithelial monolayer integrity. Intrinsic mechanisms that serve to restore monolayer integrity following epithelial injury include enterocyte proliferation, epithelial restitution via enterocyte migration, and re-establishment of cell contacts. This review focuses on the biology of NO and the mechanisms by which it promotes epithelial injury while concurrently disrupting the intrinsic repair mechanisms. [Copyright &y& Elsevier]

Introduction Hair tourniquet syndrome (HTS) is a rare disorder characterized by a hair becoming tightly wound around an appendage. There is little known about the epidemiology, optimal treatment, or indications for surgical intervention in HTS. We hypothesized that HTS could be readily diagnosed and treated in the pediatric emergency department and we sought out factors predictive of surgical intervention. Methods We performed a single center retrospective review of all patients who presented with a hair tourniquet from May 2004 till March 2014. Results Eighty-one patients were diagnosed with HTS, ranging in age from 2 weeks to 22 years. Of these patients, 69 were located on the toes, 5 on fingers, and 7 on genitalia. The average ages for each location were statistically different ( p < 0.0001). Ninety-four percent of patients were successfully treated by nonoperative means. Cellulitis was found in two patients. Tissue necrosis occurred in one patient. Conclusion HTS is an uncommon disorder and location differs with age. Chemical depilatory agents should be a first line treatment for this condition in most patients. If chemical tourniquet release fails, then the patient should undergo mechanical tourniquet release. If edema, erythema and pain fail to resolve after tourniquet release, then persistent hair tourniquet should be investigated. [ABSTRACT FROM AUTHOR]

Abstract: Background: Prenatal closure of the umbilical ring in gastroschisis may result in an amorphous, nonviable appearing extracorporeal tissue that is resected during the repair. However, it is unclear whether such remnant intestine is truly nonviable. Methods and Results: We examined the outcomes of patients when this tissue is preserved. We identified 8 patients who presented with a closing gastroschisis and a mass of tissue connected by a vascular pedicle. Four patients underwent abdominal exploration with resection of the mass and gastroschisis closure. Histologic examination revealed normal intestinal wall architecture. All patients in this group developed short bowel syndrome, requiring long-term parenteral nutrition. Conversely, 4 patients underwent abdominal exploration with internalization of the remnant tissue, a maneuver referred to as “parking,” along with either silo placement, or primary closure of the gastroschisis. At re-exploration, 3 of 4 patients were found to have viable intestine, and bowel continuity was reestablished. The mean parenteral nutrition requirement for this group was significantly shorter than the resected group. Conclusion: In this series, we show that this amorphous tissue, when preserved, may exhibit normal intestinal architecture and absorptive function. Therefore, such remnant tissue should be preserved as it may significantly increase bowel length and minimize parenteral nutrition requirement. [Copyright &y& Elsevier]

Abstract: Foreign body ingestion occurs most commonly in the pediatric population. Small bowel obstruction is a rare complication that can occur, and surgical intervention is required. We present the first report of a case of an 18-month-old child with a jejunal obstruction caused by ingestion of water-storing gel beads used for botanical arrangements. The child presented with obstipation and nonbloody, nonbilious emesis. Symptoms resolved after a large bead 3 cm in diameter was retrieved via laparoscopic-assisted excision. This case suggests that water-storing gel beads are particularly dangerous foreign bodies and should be kept out of the reach of children. [Copyright &y& Elsevier]

Abstract: Pneumatosis intestinalis (PI) is the presence of intraluminal gas within the wall of the intestine. As a marker for bowel injury owing to mucosal injury, PI may herald a severe underlying disease process in patients without a significant medical history. In other cases, PI is a benign process, and expectant management is appropriate. Here, we present the first reported case of pneumatosis associated with postoperative abscess after appendectomy and its successful management. Then, we describe the pathophysiology of pneumatosis and review the literature regarding its origin and management. [Copyright &y& Elsevier]

Abstract: Neuroblastoma is the most commonly occurring solid tumor in children. Most of these neoplasms are diagnosed within the first few years of life. The diagnosis of neuroblastoma may be difficult because of its ability to arise in different locations, its propensity to metastasize, and variable clinical signs and symptoms. Therefore, accurate and timely pathologic diagnosis is imperative. Herein, we present the rare description of an angiomatoid neuroblastoma. Only 1 other case has been previously reported. [Copyright &y& Elsevier]

A case of intraoperative cyanosis in a patient with a common atrioventricular canal palliated with a pulmonary artery (PA) band is presented. The patient's physiology was consistent with cyanosis due to inadequate pulmonary blood flow, and responded quickly to typical interventions used for a hypercyanotic episode in a patient with unrepaired Tetralogy of Fallot. Differences and similarities in the physiology of PA banding compared with Tetralogy of Fallot are presented, including a rationale for treatment options for hemodynamic decompensation occurring in the setting of anesthesia and surgery. [ABSTRACT FROM AUTHOR]