The SAGES MASTERS program bariatric surgery pathway selects 10 seminal publications on revisional bariatrics.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program designated bariatric surgery as a clinical pathway. Among the tiers of the Masters Program, revisional bariatric surgery is the highest tier of "mastery" within the pathway. This article presents the top 10 seminal studies representing the current landscape of revisional bariatrics. METHODS: The literature was systematically searched and seminal articles designated by consensus agreement of the SAGES Metabolic and Bariatric Surgery committee using multiple criteria, including impact on the field, citation frequency, and expert opinion. Articles were reviewed by committee members and presented in summarized fashion. RESULTS: The top 10 papers are presented in grouped thematic categories covering the early evolution of revisional bariatrics, changing criteria for reoperative bariatric surgery, divergence of revision versus conversion bariatric surgery, and recent technologic innovations in revisional bariatric surgery. Each summary is presented with expert appraisal and commentary. CONCLUSION: These seminal papers represent a snapshot of the dynamic field of revisional bariatric surgery and emphasize the need to not only remain current with contemporary trends but also keep a patient-oriented perspective on patient and intervention selection for optimal success.

Longitudinal Fatigue Symptoms and Inflammatory Markers in African American Adults With Hypertension and Obstructive Sleep Apnea.

BACKGROUND: There is a dearth of research inclusive of African Americans living with obstructive sleep apnea (OSA) despite differences in symptom presentations compared to non-Hispanic White patient populations. Less is known regarding the potential effect of comorbidities, such as hypertension, on commonly reported symptoms, such as fatigue, and their association with inflammatory biomarkers. OBJECTIVE: This longitudinal pilot study aimed to characterize fatigue symptom presentations among African Americans newly diagnosed with OSA and discern peripheral blood analytes linked to symptoms while accounting for co-occurring hypertension. METHODS: Adult African Americans newly diagnosed with OSA with and without co-occurring hypertension were approached by study staff and recruited following their diagnostic visit with sleep medicine clinicians at two health systems and followed over 6 months after commencing continuous positive airway pressure treatment. Patient-Reported Outcomes Measurement Information System Fatigue surveys and plasma were collected every 3 months from 29 participants. Mixed effects models examined changes in fatigue symptom presentations over time while accounting for plasma-based analytes and hypertension status. RESULTS: Despite higher fatigue symptom severity upon diagnosis, participants with co-occurring hypertension reported greater improvements in fatigue scores after commencing continuous positive airway pressure treatment for up to 6 months than those without hypertension. Inverse correlations were observed between fatigue scores, C-reactive protein, matrix-metalloproteinase-8, and osteoprotegerin analyte levels among participants with/without hypertension. Across all participants, changes in interleukin-6 were associated with changes in fatigue scores in the first three months after diagnosis. DISCUSSION: Findings indicate that hypertension is linked to increased fatigue upon diagnosis of OSA in this sample of African Americans. Fatigue in persons with hypertension improved after treatment. These hypothesis-generating findings can inform future interventional studies aimed at improving fatigue among persons with OSA while leveraging markers linked to fatigue symptom severity as potential objective markers of improvements. Further research on the role of inflammatory markers, such as IL-6, on fatigue symptom presentations is warranted in those with OSA regardless of hypertension status.

Community-engaged Systems for Population Health Improvement: A Novel Approach to Improve Diabetes Outcomes in Rural Communities.

BACKGROUND: Approaches to prevent and manage diabetes at a community population level are hindered because current strategies are not aligned with the structure and function of a community system. We describe a community-driven process based on local data and rapid prototyping as an alternative approach to create diabetes prevention and care management solutions appropriate for each community. We report on the process and provide baseline data for a 3-year case study initiative to improve diabetes outcomes in two rural Nebraska communities. METHODS: We developed an iterative design process based on the assumption that decentralized decision-making using local data feedback and monitoring will lead to the innovation of local sustainable solutions. Coalitions act as community innovation hubs and meet monthly to work through a facilitated design process. Six core diabetes measures will be tracked over the course of the project using the electronic health record from community clinics as a proxy for the entire community. RESULTS: Baseline data indicate two-thirds of the population in both communities are at risk for prediabetes based on age and body mass index. However, only a fraction (35% and 12%) of those at risk have been screened. This information led both coalitions to focus on improving screening rates in their communities. DISCUSSION: In order to move a complex system towards an optimal state (e.g., improved diabetes outcomes), stakeholders must have access to continuous feedback of accurate, pertinent information in order to make informed decisions. Conventional approaches of implementing evidence-based interventions do not facilitate this process.

Investigate-Design-Practice-Reflect: An Iterative Community-Engaged Action Process to Improve Population Health.

BACKGROUND: Community-based coalitions are a common strategy for community engagement efforts targeting the improvement of a variety of population health outcomes. The typical processes that coalitions follow to organize efforts include steps that are sequential, slow, and time intensive. These processes also limit local decision-making to the selection of evidence-based policies or programs. METHODS: We present a process control theory-based Community Action Process, Investigate-Design-Practice-Reflect (IDPR), where community hubs (i.e., coalitions) organize agile efforts in a non-sequential, rapid, and efficient manner to harness local assets and data to make decisions regarding the provision and production of population health services. Using qualitative methods, we illustrate and analyze the use of IDPR in a one community case study as part of Wellscapes, a Type 3-hybrid implementation-effectiveness community randomized controlled trial to improve children's population health physical activity. RESULTS: We found community members followed the IDPR Community Action Process to rapidly design, organize, deliver, and receive feedback on a community-based, children's population physical activity prototype, an afterschool Play-in-the-Park opportunity for all children. DISCUSSION: Following IDPR afforded the community coalition timely learning through feedback within a process that coordinated decisions regarding what community services met community needs (provision decisions) and how to organize the production of the population health services (production decisions).

Preoperative Depression Status and 5 Year Metabolic and Bariatric Surgery Outcomes in the PCORnet Bariatric Study Cohort.

OBJECTIVE: To examine whether depression status before metabolic and bariatric surgery (MBS) influenced 5-year weight loss, diabetes, and safety/utilization outcomes in the PCORnet Bariatric Study. SUMMARY OF BACKGROUND DATA: Research on the impact of depression on MBS outcomes is inconsistent with few large, long-term studies. METHODS: Data were extracted from 23 health systems on 36,871 patients who underwent sleeve gastrectomy (SG; n=16,158) or gastric bypass (RYGB; n=20,713) from 2005-2015. Patients with and without a depression diagnosis in the year before MBS were evaluated for % total weight loss (%TWL), diabetes outcomes, and postsurgical safety/utilization (reoperations, revisions, endoscopy, hospitalizations, mortality) at 1, 3, and 5 years after MBS. RESULTS: 27.1% of SG and 33.0% of RYGB patients had preoperative depression, and they had more medical and psychiatric comorbidities than those without depression. At 5 years of follow-up, those with depression, versus those without depression, had slightly less %TWL after RYGB, but not after SG (between group difference = 0.42%TWL, P = 0.04). However, patients with depression had slightly larger HbA1c improvements after RYGB but not after SG (between group difference = - 0.19, P = 0.04). Baseline depression did not moderate diabetes remission or relapse, reoperations, revision, or mortality across operations; however, baseline depression did moderate the risk of endoscopy and repeat hospitalization across RYGB versus SG. CONCLUSIONS: Patients with depression undergoing RYGB and SG had similar weight loss, diabetes, and safety/utilization outcomes to those without depression. The effects of depression were clinically small compared to the choice of operation.

Sphinganine is associated with 24-h MAP in the non-sleepy with OSA.

INTRODUCTION: Excessive daytime sleepiness is a debilitating symptom of obstructive sleep apnea (OSA) linked to cardiovascular disease, and metabolomic mechanisms underlying this relationship remain unknown. We examine whether metabolites from inflammatory and oxidative stress-related pathways that were identified in our prior work could be involved in connecting the two phenomena. METHODS: This study included 57 sleepy (Epworth Sleepiness Scale (ESS) ≥ 10) and 37 non-sleepy (ESS < 10) participants newly diagnosed and untreated for OSA that completed an overnight in-lab or at home sleep study who were recruited from the Emory Mechanisms of Sleepiness Symptoms Study (EMOSS). Differences in fasting blood samples of metabolites were explored in participants with sleepiness versus those without and multiple linear regression models were utilized to examine the association between metabolites and mean arterial pressure (MAP). RESULTS: The 24-h MAP was higher in sleepy 92.8 mmHg (8.4) as compared to non-sleepy 88.8 mmHg (8.1) individuals (P = 0.03). Although targeted metabolites were not significantly associated with MAP, when we stratified by sleepiness group, we found that sphinganine is significantly associated with MAP (Estimate = 8.7, SE = 3.7, P = 0.045) in non-sleepy patients when controlling for age, BMI, smoking status, and apnea-hypopnea index (AHI). CONCLUSION: This is the first study to evaluate the relationship of inflammation and oxidative stress related metabolites in sleepy versus non-sleepy participants with newly diagnosed OSA and their association with 24-h MAP. Our study suggests that Sphinganine is associated with 24 hour MAP in the non-sleepy participants with OSA.

Research priorities to reduce risks from work hours and fatigue in the healthcare and social assistance sector.

BACKGROUND: The services of Healthcare and Social Assistance (HCSA) workers are needed by society around the clock. As a result, these workers are exposed to shift work and long work hours. The combination of demanding work schedules and other hazards in the HCSA work environment increases the health and safety risks to these workers, as well as to their patients/clients and the public. METHODS: This paper has three aims: (1) provide an overview of the burden of shift work, long hours, and related sleep and fatigue problems in this sector; (2) suggest research priorities that would improve these; and (3) discuss potential positive impacts of addressing these research priorities for the health and safety of workers and the public. The authors used a modified Delphi approach to anonymously rank-order priorities for improving HCSA worker health and safety and public safety. Input was also obtained from attendees at the 2019 National Institute for Occupational Safety and Health (NIOSH) Work Hours, Sleep, and Fatigue Forum. RESULTS: The highest rated research priorities were developing better designs for work schedules, and improving the HCSA culture and leadership approaches to shift work and long work hours. Additional priorities are identified. CONCLUSION: Research in these priority areas has the potential to benefit HCSA workers as well as their patients/clients, employers, and society.

Interventional Radiology Obesity Therapeutics: Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel.

The Society of Interventional Radiology Foundation commissioned a Research Consensus Panel to establish a research agenda on "Obesity Therapeutics" in interventional radiology (IR). The meeting convened a multidisciplinary group of physicians and scientists with expertise in obesity therapeutics. The meeting was intended to review current evidence on obesity therapies, familiarize attendees with the regulatory evaluation process, and identify research deficiencies in IR bariatric interventions, with the goal of prioritizing future high-quality research that would move the field forward. The panelists agreed that a weight loss of >8%-10% from baseline at 6-12 months is a desirable therapeutic endpoint for future IR weight loss therapies. The final consensus on the highest priority research was to design a blinded randomized controlled trial of IR weight loss interventions versus sham control arms, with patients receiving behavioral therapy.

Laparoscopic sleeve gastrectomy in patients with complex abdominal wall hernias.

BACKGROUND: Patients with severe obesity and complex abdominal wall hernias (CAWH) present a challenging clinical dilemma. Their body mass index (BMI) is often prohibitive of successful ventral hernia repair (VHR) and the CAWH presents technical challenges when pursuing bariatric surgery. Our hernia center policy is to refer patients with severe obesity for evaluation with the surgical weight loss program. This study describes outcomes of laparoscopic sleeve gastrectomy (LSG) in patients with both severe obesity and CAWH. METHODS: A retrospective analysis was performed on data prospectively collected between 2014 and 2020. CAWH patients referred for and undergoing LSG were included. Revisional bariatric surgery patients were excluded. The dataset was augmented with operative time, BMI changes, length of stay (LOS), hernia characteristics, postoperative complications, time from referral to weight loss surgery, and time from LSG to VHR. RESULTS: Twenty patients (10 males, mean age 54.3 years) met inclusion criteria. Mean BMI at LSG was 45.6 ± 6.1 kg/m2. Mean hernia area was 494.9 ± 221.2 cm2 and 90% had hernia extension into the subxiphoid and/or epigastric regions. Mean time from bariatric referral to LSG was 10.5 ± 5.4 months. Mean LSG operative time was 121.2 ± 50.3 min, and mean LOS was 1.6 ± 0.8 days. One patient had postoperative bleeding necessitating laparoscopic re-exploration. There were no readmissions. Sixteen patients subsequently underwent VHR on average13.5 ± 11.7 months later and on average 22.6 ± 12.5 months after initial hernia consultation. Two patients had a hernia-related complication between the period of initial hernia consultation and ultimate repair. Mean BMI was 37.5 ± 7.5 kg/m2 (mean 20.7 ± 12.3% decrease, p < 0.0001) at mean follow-up of 27.2 ± 17.2 months. CONCLUSIONS: LSG can be performed successfully even in patients with CAWH. Outcomes do not appear to differ significantly from typical patients undergoing LSG. Further study with larger cohorts is warranted to better delineate complication rates in this population as well as to determine long-term outcomes.

Concomitant laparoscopic cholecystectomy and antegrade wire, rendezvous cannulation of the biliary tree may reduce post-ERCP pancreatitis events.

INTRODUCTION: For patients with a gallbladder in situ, choledocholithiasis is a common presenting symptom. Both two-session endoscopic retrograde cholangiopancreatography (ERCP) and subsequent cholecystectomy (CCY) and single-stage (simultaneous CCY/ERCP) have been described. We utilize an antegrade wire, rendezvous cannulation (AWRC) technique to facilitate ERCP during CCY. We hypothesized that AWRC would eliminate episodes of post-ERCP pancreatitis (PEP). METHODS: An IRB approved, retrospective review of patients who underwent ERCP via AWRC for choledocholithiasis during CCY was performed. Patient characteristics, pre/postoperative laboratory values, complications, and readmissions were reviewed. AWRC was conducted during laparoscopic or open CCY for evidence of choledocholithiasis with or without preoperative biliary pancreatitis or cholangitis. Following confirmatory intraoperative cholangiogram, a flexible tip guidewire was inserted antegrade into the cystic ductotomy, through the bile duct across the ampulla and retrieved in the duodenum with a duodenoscope. Standard ERCP maneuvers to clear the bile duct are then performed over the wire. RESULTS: Thirty-seven patients (27 female, age 19-77, BMI 21-50 kg/m2) underwent intraoperative ERCP via AWRC technique during CCY. Seventeen underwent CCY for acute cholecystitis. Fifteen patients underwent transgastric ERCP in the setting of previous Roux-en-Y gastric bypass. Mean total operative time was 214 min. Mean ERCP time was 31 min. Thirty-three patients had biliary stents placed. There were no cannulations or injections of the pancreatic duct. There were no intraoperative complications associated with the ERCP and no patients developed PEP. Three patients developed a postoperative subhepatic abscess requiring drainage. CONCLUSION: AWRC is a useful technique for safe and efficient bile duct cannulation for therapeutic ERCP in the setting of choledocholithiasis at the time of CCY. Despite supine (rather than the traditional prone) positioning, total ERCP times were short and we eliminated any manipulation of the pancreatic duct. No patients in our series developed PEP or post-sphincterotomy bleeding.

Changes in Alcohol Use after Metabolic and Bariatric Surgery: Predictors and Mechanisms.

PURPOSE OF REVIEW: This review synthesized the literature on predictors and mechanisms of post-bariatric alcohol problems, in order to guide future research on prevention and treatment targets. RECENT FINDINGS: Consistent evidence suggests an elevated risk of developing problems with alcohol following bariatric surgery. While there is a paucity of empirical data on predictors of problematic alcohol use after bariatric surgery, being male, a younger age, smoking, regular alcohol consumption, pre-surgical alcohol use disorder, and a lower sense of belonging have predicted alcohol misuse post-operatively. This review synthesizes potential mechanisms including specific bariatric surgical procedures, peptides and reinforcement/reward pathways, pharmacokinetics, and genetic influences. Finally, potential misperceptions regarding mechanisms are explored. Certain bariatric procedures elevate the risk of alcohol misuse post-operatively. Future research should serve to elucidate the complexities of reward signaling, genetically mediated mechanisms, and pharmacokinetics in relation to alcohol use across gender and developmental period by surgery type.

Sleep disorders, depression and anxiety are associated with adverse safety outcomes in healthcare workers: A prospective cohort study.

The objective of the study was to determine if sleep disorder, depression or anxiety screening status was associated with safety outcomes in a diverse population of hospital workers. A sample of shift workers at four hospitals participated in a prospective cohort study. Participants were screened for five sleep disorders, depression and anxiety at baseline, then completed prospective monthly surveys for the next 6 months to capture motor vehicle crashes, near-miss crashes, occupational exposures and medical errors. We tested the associations between sleep disorders, depression and anxiety and adverse safety outcomes using incidence rate ratios adjusted for potentially confounding factors in a multivariable negative binomial regression model. Of the 416 hospital workers who participated, two in five (40.9%) screened positive for a sleep disorder and 21.6% screened positive for depression or anxiety. After multivariable adjustment, screening positive for a sleep disorder was associated with 83% increased incidence of adverse safety outcomes. Screening positive for depression or anxiety increased the risk by 63%. Sleep disorders and mood disorders were independently associated with adverse outcomes and contributed additively to risk. Our findings suggest that screening for sleep disorders and mental health screening can help identify individuals who are vulnerable to adverse safety outcomes. Future research should evaluate sleep and mental health screening, evaluation and treatment programmes that may improve safety.

Gastric Bypass and Influence on Improvement of NAFLD.

PURPOSE OF REVIEW: Obesity is recognized as a chronic and recurring disease, often accompanied by other weight-related comorbid conditions such as obstructive sleep apnea, hypertension, type 2 diabetes, and non-alcoholic fatty liver disease (NAFLD). This chapter will seek to focus on the effect of weight loss surgery (WLS), in particular Roux-en-Y gastric bypass (RYGB), on NAFLD. RECENT FINDINGS: Among several modalities available to treat NAFLD, the one most likely to achieve rapid, significant, and sustained improvement of liver disease is WLS. The most commonly studied WLS procedure at this time is RYGB, and there is significant evidence that this is a safe and effective procedure both for weight loss and to bring about improvement of multiple associated comorbid conditions, including NAFLD. Further research focusing on non-surgical approaches that might mimic the effect of WLS on liver pathology is needed.

Visceral to subcutaneous fat ratio predicts acuity of diverticulitis.

INTRODUCTION: There is an association between obesity and more complicated diverticular disease. We hypothesize that this link may be due to an increased level of visceral fat rather than an elevated body mass index alone. Adipose tissue secretes inflammatory cytokines, and chronic inflammation may account for the link between obesity and a more severe presentation of diverticular disease. We have applied a quantitative measure of visceral fat content in a series of patients admitted with diverticulitis, comparing those who required emergent versus elective surgical procedures for diverticulitis. METHODS: We performed a retrospective review of all adult patients who underwent emergent or elective surgery at our institution for diverticulitis from 2010 to 2014. Data were collected on demographics, comorbidities, operative findings, complications, and length of stay. Radiologic measurements of adiposity were obtained from preoperative CT scans. Visceral fat areas and subcutaneous fat areas were measured, and the V/S ratio was calculated. RESULTS: Thirty-four patients underwent emergent and 32 patients underwent elective surgery. The mean age was 66.3 years for the emergent and 57.11 for the elective group (p = 0.04178). The perinephric, visceral, subcutaneous fat, and V/S ratio for the emergent group were 1.71, 185.22, 338.22, and 0.56 and were 1.11, 127.18, 295.28, and 0.46 for the elective group. The difference between the V/S ratio for each group was significant (p = 0.0238). The emergent group had an average LOS of 16.11 days compared to 5.15 for the elective group (p = <0.00001). The complication rate was significantly higher (p = 0.024) in the emergent group (n = 12, 35.2 %) compared to the elective group (n = 4, 12.5 %). CONCLUSION: Our study demonstrates a clinically significant link between visceral fat and severity of presentation of diverticulitis. Patients with higher V/S fat ratios were more likely to require emergency surgery and have more complications and a longer LOS.

Insomnia Symptoms Are Associated With Abnormal Endothelial Function.

BACKGROUND: Insomnia is a prevalent sleep disorder, and it has been increasingly associated with cardiovascular morbidity and mortality. The reasons for this relationship are not completely understood but may involve endothelial dysfunction. In this study, we hypothesized that insomnia symptoms would be associated with reduced endothelial function. METHODS: Working adults (n = 496, 67.5% female, 78.6% white, mean age 48.7 [SD, 10.8] years, body mass index 28.2 [SD, 6.7] kg/m, diabetes 5.8%, hypertension 20.0%, hyperlipidemia 17.9%, heart disease 2.6%) enrolled in the Emory-Georgia Tech Predictive Health Institute study completed baseline demographic, clinical, depression (Beck Depression Inventory II), anxiety (General Anxiety Disorder 7), sleep (Pittsburg Sleep Quality Index), and noninvasive endothelial function (brachial artery flow-mediated dilation [FMD]) measures. Insomnia symptoms were defined as subjective sleep latency of 30 minutes or longer, nighttime or early morning awakenings, and/or sleep medication use occurring 3 times or more per week in the past month. RESULTS: Insomnia symptoms were reported by 39.5% of participants. Multivariable regression models showed that insomnia symptoms, age, baseline artery diameter, and dyslipidemia were inversely related to FMD. After adjusting for age, baseline artery diameter, and dyslipidemia, participants reporting insomnia symptoms had lower FMD than did participants reporting better sleep (adjusted FMD mean, 6.13% [SD, 0.28%] vs 6.83% [SD, 0.26%], P = .035). CONCLUSION: In this study, insomnia symptoms were associated with reduced FMD. Research examining the therapeutic benefits of treating insomnia on endothelial function and future cardiovascular risk is warranted.

A pilot functional MRI study in Roux-en-Y gastric bypass patients to study alteration in taste functions after surgery.

BACKGROUND: Gastric bypass restricts food intake, with a limited component of malabsorption. Gut and brain hormone changes also facilitate improvements in weight and comorbidities. Patients' perception of taste and smell also change, along with reduced appetite for savory meals. Data on how changes in gastrointestinal physiology affect brain centers of perception and reward are sparse. METHODS: With IRB approval, we recruited 13 patients to undergo pre- and postoperative taste testing and functional MRI (fMRI) in response to sweet and salty solutions. A delivery system to the tongue was used, and patients rated intensity and pleasantness. They then underwent fMRI scanning. Sensory and reward areas of the brain were evaluated for activation. Subjects were then compared to non-obese non-surgical controls with the same taste paradigm and scanning twice, at 1 month apart. RESULTS: All subjects experienced significant weight loss at 1 month and at 1 year after surgery. As expected, after surgery brain activation in the reward center of the brain was significantly decreased in response to sweet solutions, but this effect was also seen in non-surgical controls, making this result inconclusive. In contrast, surgical patients had significantly increased activation in the reward center to salty taste compared both to their preoperative scans and to healthy controls. CONCLUSIONS: After GBS, brain activation in the reward system of obese patients responding to palatable tastes may be significantly changed, and such changes can be detected using fMRI. They do not always correlate with subjective reports of intensity and pleasantness. To verify that such taste-related activation changes are caused specifically by the GBS, taste function of a control group of obese patients should be studied during the same period of time without GBS intervention but with similar weight loss.

Time-related increase in urinary testosterone levels and stable semen analysis parameters after bariatric surgery in men.

The aim of this prospective cohort study was to determine the time-course in androgen and semen parameters in men after weight loss associated with bariatric surgery. Six men aged 18-40 years, meeting National Institutes of Health bariatric surgery guidelines, were followed between 2005 and 2008. Study visits took place at baseline, then 1, 3, 6 and 12 months after surgery. All men underwent Roux-en-y gastric bypass (RYGB). At each visit, biometric, questionnaire, serum, and urinary specimens and seman analysis were collected. Urinary integrated total testosterone levels increased significantly (P < 0.0001) by 3 months after surgery, and remained elevated throughout the study. Circulating testosterone levels were also higher at 1 and 6 months after surgery, compared with baseline. Serum sex hormone-binding globulin levels were significantly elevated at all time points after surgery (P < 0.01 to P = 0.02). After RYGB surgery, no significant changes occurred in urinary oestrogen metabolites (oestrone 3-glucuronide), serum oestradiol levels, serial semen parameters or male sexual function by questionnaire. A threshold of weight loss is necessary to improve male reproductive function by reversing male hypogonadism, manifested as increased testosterone levels. Further serial semen analyses showed normal ranges for most parameters despite massive weight loss.

Inequality in Children's Physical Activity Across Time-Segmented Youth Sport Practice.

Purpose: Youth sport (YS) is a community system for promoting children's physical activity (PA). Studies have examined mean PA during YS practices, but few have examined inequalities in the distribution of PA among children during practice time. This study examined PA inequality in time-segmented YS practices and differences in inequality by time segment characteristics. Methods: Children's PA and YS practices were examined using accelerometer and video observation data from a sample of YS teams (n = 36 teams, n = 101 practices) for third- through sixth-grade children (n = 392), approximately eight to 12 years old, in two rural U.S. communities. Practices were time-segmented into smaller units (episodes; n = 991). Episodes were assigned codes for purpose (e.g. warm-up), member arrangement (e.g. whole group), and setting demand (i.e. fosters participation, creates exclusion). Group accelerometer data were paired with episodes, and the Gini coefficient quantified inequality in activity counts and minutes of moderate-to-vigorous PA (MVPA). Beta generalized estimating equations examined the influence of episode structure on PA inequality. Results: Warm-up (Gini = 0.22), fitness (Gini = 0.24), and sport skill (Gini = 0.24) episodes had significantly lower inequality (p < .05) in activity counts than other purpose types. Management (Gini = 0.32) and strategy (Gini = 0.40) episodes had significantly greater inequality (p < .05) in MVPA minutes than other purpose types. Episodes fostering participation (Gini = 0.32) had significantly lower activity count inequality (p < .05) than episodes creating exclusion (Gini = 0.35). Conclusion: PA inequality among children during YS varied by practice structure. Metrics such as the Gini coefficient can illuminate inequalities in PA and may be useful for guiding efforts to improve population PA in children. Trial Registration: This study is registered at www.clinicaltrials.gov (Identifier: NCT03380143).