Epidemiology and Economic Burden of Acute Infectious Gastroenteritis Among Adults Treated in Outpatient Settings in US Health Systems.

INTRODUCTION: Acute infectious gastroenteritis (AGE) is a common reason for outpatient visits and hospitalizations in the United States. This study aimed to understand the demographic and clinical characteristics, common pathogens detected, health care resource utilization (HRU), and cost among adult outpatients with AGE visiting US health systems. METHODS: A retrospective cohort study was conducted using one of the largest hospital discharge databases (PINC AI Healthcare Database) in the United States. Adult patients (aged ≥18 years) with a principal diagnosis of AGE during an outpatient visit between January 1, 2016, and June 30, 2021, were included. Pathogen detection analysis was performed in those with microbiology data available. RESULTS: Among 248,896 patients, the mean age was 44.3 years (range 18-89+ years), 62.9% were female, and 68.5% were White. More than half (62.0%) of the patients did not have any preexisting comorbidity, and only 18.3% underwent stool workup at the hospital. Most patients (84.7%) were seen in the emergency department, and most (96.4%) were discharged home. Within 30 days of discharge, 1.0% were hospitalized, and 2.8% had another outpatient visit due to AGE. The mean cost of the index visit plus 30-day AGE-related follow-up was $1,338 per patient, amounting to $333,060,182 for the total study population. Among patients with microbiology data available (n = 12,469), common pathogens detected were Clostridioides difficile (32.2%), norovirus (6.3%), and Campylobacter spp. (4.0%). DISCUSSION: AGE is a common and costly disease affecting adults of all ages and more females than males, including individuals with or without baseline conditions in a hospital-based outpatient setting. C. difficile was the most common pathogen detected.

Relationship between Diagnostic Method and Pathogen Detection, Healthcare Resource Use, and Cost in U.S. Adult Outpatients Treated for Acute Infectious Gastroenteritis.

A retrospective observational study was performed to assess the relationship between diagnostic method (traditional work-up [TW], multiplex PCR panel with < 12 target pathogens [PCR < 12], or multiplex PCR panel with ≥ 12 target pathogens [PCR12]), and diagnostic yield, health care resource use (HRU), and cost in adult outpatients visiting U.S. hospitals for acute infectious gastroenteritis (AGE). Using data from PINC AI Healthcare Database during January 1, 2016-June 30, 2021, we analyzed adult patients with an AGE diagnosis and stool testing performed during an outpatient visit. Detection rates for different pathogens were analyzed for those with microbiology data available. Among 36,787 patients, TW was most often performed (57.0%). PCR12 testing was more frequent in patients from large, urban, and teaching hospitals, compared to TW (all P < 0.01). PCR12 was associated with a higher mean index visit cost (by $97) but lower mean 30-day AGE-related follow-up cost (by $117) than TW. Patients with PCR12 had a lower 30-day AGE-related hospitalization risk than TW (1.7% versus 2.7% P < 0.01). Among the 8,451 patients with microbiology data, PCR12 was associated with fewer stool tests per patient (mean 1.61 versus 1.26), faster turnaround time (mean 6.3 versus 25.7 h) and lower likelihood of receiving in-hospital antibiotics (39.4% versus 47.1%, all P < 0.01) than TW. A higher percentage of patients with PCR12 had a target pathogen detected (73.1%) compared to PCR < 12 (63.6%) or TW (45.4%, P < 0.01). Thus, we found that large multiplex PCR panels were associated with lower 30-day AGE-related follow-up cost and risk of AGE-related hospitalization, and increased diagnostic yield compared to TW.

Is Coronavirus Disease 2019 (COVID-19) Less Deadly Now? Trends in In-Hospital Mortality Among Hospitalized COVID-19 Patients in the United States.

After an initial decline from April through June 2020 (from 22.2% to 11.9%), adjusted in-hospital mortality in coronavirus disease 2019 (COVID-19) inpatients peaked twice and was significantly higher than June 2020 for subsequent months except in July and October 2020. Adjusted mortality trends differed across age groups between November 2020 and February 2021.

Healthcare Resource Utilization of Patients With COVID-19 Visiting US Hospitals.

OBJECTIVES: Severe cases of COVID-19 have overwhelmed hospital systems across the nation. This study aimed to describe the healthcare resource utilization of patients with COVID-19 from hospital visit to 30 days after discharge for inpatients and hospital-based outpatients in the United States. METHODS: A retrospective cohort study was conducted using Premier Healthcare Database COVID-19 Special Release, a large geographically diverse all-payer hospital administrative database. Adult patients (age ≥ 18 years) were identified by their first, or "index," visit between April 1, 2020, and February 28, 2021, with a principal or secondary discharge diagnosis of COVID-19. RESULTS: Of 1 454 780 adult patients with COVID-19, 33% (n = 481 216) were inpatients and 67% (n = 973 564) were outpatients. Among inpatients, mean age was 64.4 years and comorbidities were common. Most patients (80%) originated from home, 10% from another acute care facility, and 95% were admitted through the emergency department. Of these patients, 23% (n = 108 120) were admitted to intensive care unit and 14% (n = 66 706) died during index hospitalization; 44% were discharged home, 15% to nursing or rehabilitation facility, and 12% to home health. Among outpatients, mean age was 48.8 years, 44% were male, and 60% were emergency department outpatients (n = 586 537). During index outpatient visit, 79% were sent home but 10% had another outpatient visit and 4% were hospitalized within 30 days. CONCLUSIONS: COVID-19 is associated with high level of healthcare resource utilization and in-hospital mortality. More than one-third of inpatients required post hospital healthcare services. Such information may help healthcare providers better allocate resources for patients with COVID-19 during the pandemic.

To oversew or not to oversew in robotic sleeve gastrectomy: a case against oversewing the staple line.

BACKGROUND: The benefits of oversewing the staple lines during laparoscopic sleeve gastrectomy have been controversial. No study examined the benefit of oversewing the staple lines in robotic sleeve gastrectomy (RSG). This retrospective study aims to examine the difference in immediate postoperative complications, readmissions, reoperations, and emergency room visits between RSG patients with and without oversewn staple lines at a single, large-volume, bariatric center. METHODS: A retrospective chart review was conducted on 623 patients who underwent RSG between November 1, 2017, and November 1, 2019. Of these, 316 had their staple line oversewn between November 1, 2017, and November 12, 2018, and 307 did not have their staple line oversewn between November 13, 2018, and November 1, 2019. RESULTS: A total of 623 patients underwent RSG, of which 50.7% (n = 316) had their staple line oversewn. The mean length of hospital stay was similar between the two groups. However, the mean operative time was significantly longer in the "oversew" group than "no oversew" group by 7.4 minutes (p < 0.001). Readmission, reoperation, and intervention rates during the 30-day postoperative period were similar between the two groups. However, the percentage of patients requiring outpatient emergency room visits during the 30 days after RSG was significantly higher in the "oversew" group than that of the "no oversew" group. CONCLUSIONS: No significant difference in major complications was found between RSG patients with and without oversewn staple lines. Oversewing of the staple line may be associated with increased emergency room visits.

Late Adiposity Rebound and the Probability of Developing and Reversing Childhood Obesity.

OBJECTIVE: To evaluate the associations between late adiposity rebound (at or after 7.0 years of age) and the probability of developing and reversing obesity during elementary school years. STUDY DESIGN: Using nationally representative cohorts from Early Childhood Longitudinal Studies, Kindergarten Class of 1998-1999 and 2010-2011, weighted extended Cox hazard models were used to assess the probability of developing and reversing obesity (cut-offs for extended models were 6 and 12 months after kindergarten entry, respectively). Measurements used in the study were collected 6 times between kindergarten and fifth grade (Early Childhood Longitudinal Studies, Kindergarten Class of 1998-1999) and 8 times between kindergarten through fourth grade (Early Childhood Longitudinal Studies, Kindergarten Class of 2010-2011). RESULTS: Among children with obesity at kindergarten entry, within 6 months, the risk of developing obesity was 73% and 76% lower for boys with late adiposity rebound than their classmates without late adiposity rebound (hazard ratio 0.27 and 0.24). Six months after entering kindergarten, similar association was observed for both boys and girls. Among children without obesity at kindergarten entry, within 12 months, the probability of reversing obesity was 52% and 54% higher for boys with late adiposity rebound than their peers without late adiposity rebound (hazard ratio 1.52 and 1.54). Twelve months after entering kindergarten, the probability of reversing obesity among both sexes with late adiposity rebound was 6-8 times that among children without late adiposity rebound. CONCLUSIONS: Late adiposity rebound was significantly associated with a decreased risk of developing obesity and an increased probability of reversing obesity among kindergarteners.

Conversions of Roux-en-Y gastric bypass to duodenal switch (SADI-S and BPD-DS) for weight regain.

BACKGROUND: Duodenal switch is a choice of conversion when patients fail to lose or regain weight after Roux-en-Y gastric bypass (RYGB). This study aims to evaluate the effectiveness and safety of duodenal switch as a secondary operation for patients who presented with insufficient weight loss or weight regain after a RYGB. METHODS: A retrospective chart review was performed on 15 patients who underwent a conversion of RYGB to single anastomosis duodeno-ileal bypass with sleeve (SADI-S) or biliopancreatic diversion with duodenal switch (BPD-DS) due to weight regain between December 31, 2013 and October 31, 2018. For the body mass index (BMI) analysis, the multilevel model for change was used. RESULTS: Of 15 patients, 10 underwent a conversion to SADI-S, and 5 underwent a conversion to BPD-DS. Also, 7 patients underwent the conversion in two-stages, while 8 did as single-stage. One patient had a duodenal stump leak after SADI-S, and another patient had a sleeve leak after BPD-DS. One patient underwent a reoperation to increase the common channel 20 months after the conversion to BPD-DS due to malnutrition. There was no mortality. Mean percentage of total weight loss (TWL) was 18.4% at 6 months, 25.0% at 12 months, 26.4% at 18 months, and 25.7% at 24 months after the conversion. The rate of decrease in BMI was slower in SADI-S patients than in BPD-DS patients (p < 0.01), adjusting for preoperative BMI. CONCLUSION: Conversions of RYGB to SADI-S and BPD-DS can provide significant additional weight loss. However, complications and malnutrition can develop after the conversion, and further research is needed for evaluating safety.

Safety and short-term effectiveness of endoscopic sleeve gastroplasty using overstitch: preliminary report from a multicenter study.

BACKGROUND: Endoscopic sleeve gastroplasty (ESG) is an option for patients with Class I and II obesity or patients who refuse to undergo a laparoscopic bariatric surgery. The aims of this study are as follows: (1) to demonstrate a short-term outcome after primary ESG and (2) to compare the effectiveness of weight loss between Class I and Class II obesity patients. METHODS: Patients undergoing ESG at four bariatric centers in Brazil between April 1, 2017 and December 31, 2018 were prospectively enrolled in the study (BMI 30.0-39.9 kg/m2). ESG was performed using Overstitch (Apollo Endosurgery, Austin, TX). Descriptive analysis, t test, Chi-square test, and Mann-Whitney test were used to present the results. RESULTS: A total of 233 patients underwent primary ESG. The mean age and BMI of the patients were 41.1 years and 34.7 kg/m2, respectively. Following ESG, the mean percentage of total weight loss (TWL) was 17.1% at 6 months and 19.7% at 12 months. Percentage of excess BMI loss (EBMIL) was 47.3% at 6 months and 54.8% at 12 months after ESG. The mean EBMIL was significantly greater among patients with Class I obesity than those with Class II obesity at 6 (51.1% vs. 43.7%) and 12 months (60.2% vs. 49.2%). One patient experienced bleeding during the procedure that was managed with sclerotherapy. CONCLUSION: Short-term results suggest that ESG is a safe and effective option for patients with Class I and II obesity.

The distance of the primary intimal tear from the left subclavian artery predicts aortic growth in uncomplicated type B aortic dissection.

OBJECTIVE: Controversy exists about the optimal treatment of acute uncomplicated type B aortic dissection (auTBAD). Optimal medical therapy (OMT) provides excellent short-term outcomes, but long-term results are poor. Ideally, auTBAD patients who will fail to respond to OMT in the chronic phase could be identified and undergo thoracic endovascular aortic repair. The purpose of this study was to identify radiographic predictors of auTBAD patients who will fail to respond to OMT. METHODS: A review of the Emory aortic database from 2000 to 2017 identified 320 auTBAD patients initially treated with OMT. From this cohort, 121 patients with two or more contrast-enhanced imaging scans were available for analysis. These patients were initially divided into groups based on growth of the thoracic aorta ≥10 mm or intervention due to aneurysmal growth: growth (n = 72) and no growth (n = 49). TeraRecon (Foster City, Calif) imaging software was used to analyze characteristics of the primary intimal tear (PIT), false lumen, and overall aortic size. Finally, Cox proportional hazards models were constructed to estimate hazard ratios and to identify predictors of OMT failure. RESULTS: The mean age of all patients was 54 ± 11 years, and 67% were male. Thirty-eight patients (53%) in the growth group underwent intervention. There were no differences between groups in age, hypertension, diabetes mellitus, tobacco abuse, or chronic obstructive pulmonary disease. The distance of the PIT from the left subclavian artery in patients with auTBAD was significantly shorter in the growth group (growth, 27 mm [9-66 mm]; no growth, 77 mm [26-142 mm]; P < .01). Multivariable Cox regression analysis identified the distance of the PIT from the left subclavian artery and a thoracic aortic diameter >45 mm as independent predictors of failure of OMT. Partial false lumen thrombosis was not a predictor of aortic growth. CONCLUSIONS: The distance of the PIT from the left subclavian artery is a predictor of aortic growth in auTBAD. Patients with a primary tear located in zone 3 of the proximal descending thoracic aorta should be monitored closely and may be considered for early thoracic endovascular aortic repair in the setting of auTBAD.

Pathologic findings of the removed stomach during sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the preferred surgical intervention to treat morbid obesity. Despite the rising popularity of LSG, little is known on the histopathologic findings of the resected partial stomach specimens. Our study aims to identify prevalent pathologic findings of the removed stomach and explore the association between patient characteristics and abnormal findings. METHODS: A retrospective analysis was conducted using a prospectively maintained database of 649 patients who underwent LSG between November 1, 2013 and December 31, 2015 at our institution. Patient characteristics included age, body mass index, gender, and preoperative comorbidities (diabetes, hyperlipidemia, depression, gastroesophageal reflux, hypertension, and sleep apnea). Statistical analysis was performed using descriptive analysis and logistic regression models. RESULTS: Abnormal pathologic findings were identified in approximately one-fifth (n = 142, 21.9%) of the patients. The most common find is non-specific chronic gastritis (9.7%), followed by Helicobacter pylori gastritis (4.9%). Approximately 15% of patients had significant histopathological alterations that might require further investigation, treatment, or follow-up, including non-specific chronic gastritis, H. pylori gastritis, autoimmune atrophic gastritis, and gastrointestinal stromal tumor. The odds of abnormal findings in patients without hyperlipidemia was 0.09 times the corresponding odds in those with hyperlipidemia (95% CI 0.03-0.29), controlling for factors including age, body mass index, gender, and other preoperative comorbidities. CONCLUSION: Patients with gastroesophageal reflux and hyperlipidemia might suggest higher incidence rate of gastric histopathologic abnormalities. Routine preoperative screening may not be beneficial for patients undergoing sleeve gastrectomy.

Endoscopic treatment of food intolerance after a banded gastric bypass: inducing band erosion for removal using a plastic stent.

BACKGROUND AND STUDY AIMS: Ring complications after a banded Roux-en-Y gastric bypass (RYGB) are usually managed surgically. The aim of this study was to analyze the safety and effectiveness of endoscopic removal of noneroded rings after banded-RYGB, by inducing intragastric erosion of the ring using a self-expandable plastic stent (SEPS). PATIENTS AND METHODS: A total of 41 patients with banded RYGB who had noneroded rings and food intolerance were prospectively enrolled. Patients were treated with endoscopic SEPS placement and ring removal. Data from time of stenting, resolution of symptoms, need for endoscopic dilation, and complications were recorded. RESULTS: Successful ring removal was possible in all patients. In 21 cases, the SEPS induced complete erosion, and in 17 cases the ring was removed a month later because of incomplete erosion at the time of SEPS removal. Nine patients (22.0 %) needed endoscopic dilation after stent removal in order to treat fibrotic strictures. Food tolerance was observed in 32 patients (78.0 %) after the procedure. No patient needed surgery and there were no deaths. CONCLUSIONS: Endoscopic removal of the ring using SEPS appeared to be safe and effective after a banded RYGB.

Causes of small bowel obstruction after Roux-en-Y gastric bypass: a review of 2,395 cases at a single institution.

BACKGROUND: Internal hernia is a relatively common postoperative complication after Roux-en-Y gastric bypass (RYGB) procedure. It has been reported that 1-9 % of laparoscopic RYGB patients develop internal herniation through Peterson's or mesenteric defect. However, a considerable number of patients presenting with possible small bowel obstruction (SBO) after laparoscopic RYGB do not always have internal herniation. PURPOSE: The aim of our study was to determine the causes of SBO for patients in which both potential internal hernia spaces were closed at the time of the original operation. SETTING: Academic Practice, USA. MATERIALS AND METHODS: Of 2,395 patients who underwent laparoscopic RYGB between January 2004 and October 2012, a total of 93 (3.9 %) patients were reoperated for possible SBO at our institution. A retrospective review of a prospectively collected database was performed for all patients. RESULTS: A total of 93 patients had 105 reoperations in the study period, resulting in a reoperation rate for possible SBO of 3.9 %. The mean time period between the laparoscopic RYGB and the first 93 reoperations was 20.9 ± 18.1 months (range 0-100). Eleven patients required secondary reoperations at a mean period of 20.1 ± 17.7 months (range 0-52) after the first reoperation. Of these 105 reoperations, 29 (27.6 %) showed internal herniation at the mesenteric defect (N = 23), Peterson's defect (N = 5), and both (N = 1). A total of 50 (47.6 %) reoperations revealed extensive adhesions causing SBO. Of these 50 cases, 12 revealed adhesions at the jejunojejunostomy, causing it to kink and obstruct. Ten (9.5 %) cases showed intussusception of the jejunojejunal anastomosis. Overall, reoperation rate due to internal herniation was 1.1 % in our patient population. CONCLUSIONS: Our findings indicate a 3.9 % reoperation rate for abdominal pain and SBO, and more than 45 % of these patients had symptoms secondary to adhesions. Only 1.1 % of our laparoscopic RYGB patients developed internal herniation after closure of both internal hernia spaces.

In-Hospital Mortality Among Hospitalized Coronavirus Disease 2019 Patients in the United States: How Did It Change in 2021?

In this retrospective observational study in a US national sample of 501 671 adults hospitalized with coronavirus disease 2019, adjusted in-hospital mortality decreased from 12% in February 2021 to 9% in April 2021. However, adjusted in-hospital mortality increased to 16% in September and October 2021. Adjusted intensive care unit admission fluctuated between 20% and 27% in 2021.

In-hospital mortality, length of stay, and hospitalization cost of COVID-19 patients with and without hyperkalemia.

BACKGROUND: Hyperkalemia (HK) may be associated with poor clinical outcomes among COVID-19 patients. This study aimed to describe the prevalence of HK and evaluate the associations between HK and in-hospital mortality, intensive care unit (ICU) admission, length of hospital stay (LOS), and hospitalization cost among COVID-19 inpatients. METHODS: A retrospective cohort study was conducted using a large hospital discharge database (PINC AI Healthcare Database) for COVID-19 inpatients discharged between April 1 and August 31, 2020. HK was defined with discharge diagnosis and potassium binder use. RESULTS: Of 192,182 COVID-19 inpatients, 12% (n = 22,702) had HK. HK patients were more likely to be older (median age 67 vs 63 years), male (63% vs 50%), black (30% vs 22%), and have a history of chronic kidney disease (45% vs 16%) or diabetes mellitus (55% vs 35%) than non-HK patients (all p<.001). A significantly higher proportion of patients with HK had in-hospital mortality (42% vs 11%, p<.001) than those without HK; this was persistent after adjusting for confounders (adjusted odds ratio [aOR] 1.69, 95% confidence interval [CI]1.62-1.77). Patients with HK were also more likely to be admitted to ICU (aOR 1.05, 95% CI 1.01-1.09), incur higher cost of care (adjusted mean difference $5,389) and have longer LOS (adjusted mean difference 1.3 days) than non-HK patients. CONCLUSIONS: Presence of HK was independently associated with higher in-hospital mortality, LOS, and cost of care among COVID-19 inpatients. Detecting and closely monitoring HK are recommended to improve clinical outcomes and reduce LOS and healthcare cost among COVID-19 patients.

ANTI-REFLUX PROCEDURES AFTER ROUX-EN-Y GASTRIC BYPASS.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) has been the choice of bariatric procedure for patients with symptomatic reflux - and is known to be effective in reducing the need for anti-reflux medication postoperatively. However, a small number of RYGB patients can still develop severe reflux symptoms that require a surgical intervention. AIM: To examine and describe the patient population that requires an anti-reflux procedure after RYGB evaluating demographics, characteristics, symptoms and diagnosis. METHODS: A retrospective chart review was performed on 32 patients who underwent a hiatal hernia repair and/or Nissen fundoplication after RYGB Jul 1st, 2014 and Dec 31st, 2019. Patients were identified using the MBSAQIP database and their electronic medical records were reviewed. RESULTS: Most patients were female (n=29, 90.6%). The mean age was 52.8 years and the mean body mass index (BMI) was 34.1 kg/m2 at the time of anti-reflux procedure. Patients underwent the anti-reflux procedure at a mean of 7.9 years after the RYGB procedure. The mean percentage of excess BMI loss during the time between RYGB and anti-reflux procedure was 63.4%. CONCLUSIONS: Female patients with a significant weight loss may develop a severe reflux symptoms years after RYGB. Complaints of reflux after RYGB should not be overlooked. Careful follow-up and appropriate treatment (including surgical intervention) is needed for this population.

Treatment patterns, healthcare resource use, and costs associated with uncomplicated urinary tract infection among female patients in the United States.

BACKGROUND: We evaluated associations between antibiotic prescription and healthcare resource use and costs (Part A), and between antibiotic switching and healthcare resource use, costs, and uncomplicated urinary tract infection recurrence (Part B) in female patients with uncomplicated urinary tract infection in the United States. METHODS: This retrospective cohort study of linked Optum and Premier Healthcare Database data included female patients ≥12 years old with an uncomplicated urinary tract infection diagnosis (index date), who were prescribed antibiotics during an outpatient/emergency department visit between January 1, 2013 and December 31, 2018. In Part A, patients were stratified by antibiotic prescription appropriateness: appropriate and optimal (compliant with Infectious Diseases Society of America 2011 guidelines for drug class/treatment duration) versus inappropriate/suboptimal (inappropriate drug class/treatment duration per Infectious Diseases Society of America 2011 guidelines, and/or treatment failure). In Part B, patients were stratified by treatment pattern (antibiotic switch vs no antibiotic switch). Healthcare resource use and costs during index episode (within 28 days of index date) and 12-month follow-up were compared. RESULTS: Of 5870 patients (mean age 44.5 years), 2762 (47.1%) had inappropriate/suboptimal prescriptions and 567 (9.7%) switched antibiotic. Inappropriate/suboptimal prescriptions were associated with higher healthcare resource use (mean number of ambulatory care and pharmacy claims [both p < 0.001]), and higher total mean cost (inpatient, outpatient/emergency department, ambulatory visits, and pharmacy costs) per patient ($2616) than appropriate and optimal prescriptions ($649; p < 0.001) (Part A). Antibiotic switching was associated with more pharmacy claims and higher total mean costs (p ≤ 0.01), and a higher incidence of recurrent uncomplicated urinary tract infection (18.9%) than no antibiotic switching (14.2%; p < 0.001) (Part B). CONCLUSIONS: Inappropriate/suboptimal prescriptions and antibiotic switching were associated with high costs, ambulatory care, and pharmacy claims, suggesting a need for improved uncomplicated urinary tract infection prescribing practices in the United States.

Brazilian Consensus on Endoscopic Sleeve Gastroplasty.

PURPOSE: Bariatric endoscopy is a less invasive approach for obesity management, with better efficacy than pharmacological treatment and low morbidity. Endoscopic sleeve gastroplasty (ESG) is the remodeling of the stomach using a suturing device showing technical feasibility, safety, and sustained weight loss. With growing numbers of procedures worldwide, there is a need to standardize the procedure. MATERIALS AND METHODS: A consensus meeting was held in São Caetano do Sul-SP, Brazil, in June 2019, bringing together 47 Brazilian endoscopists with experience in ESG from all regions of the country. Topics on indications and contraindications of the procedure, pre-procedure evaluation and multidisciplinary follow-up, technique and post-procedure follow-up, and training requirements were discussed. An electronic voting was carried, and a consensus was defined as ≥ 70% agreement. RESULTS: The panel's experience consisted of 1828 procedures, with a mean percentage total body weight loss (TBWL) of 18.2% in 1 year. Adverse events happened in 0.8% of the cases, the most common being hematemesis. The selected experts discussed and reached a consensus on several questions concerning patient selection, contraindications for the procedure, technical details such as patient preparation, procedure technique, and patient follow-up. CONCLUSIONS: This consensus establishes practical guidelines for performance of ESG. The experience of 1828 procedures shows the expertise of the selected specialists participating in this consensus statement. The group's experience has a satisfactory weight loss with low adverse events rate. The main points discussed in this paper may serve as a guide for endoscopists performing ESG. Practical recommendations and technique standardization are described.

The Associations between Childhood Obesity, Academic Performance, and Perception of Teachers: From Kindergarten to Fifth Grade.

Background: Obesity is weakly associated with negative academic achievement among school-aged children. The purpose of this study is to demonstrate the relationships between reading/mathematics scores (objective) and teachers' perception of learning ability (subjective) and childhood obesity-from kindergarten to fifth grade. Methods: This study examined a longitudinal study of a nationally representative sample of 18,174 children who were enrolled in kindergarten in 2010 in the United States (ECLS-K:2011). Weighted multiple logistic regression models were used to examine the associations between objective scores, subjective scores, and obesity (vs. healthy-weight children). Results: In the crude analyses, obesity was negatively associated with achieving above-median reading and mathematics scores. After adjusting for sex, race/ethnicity, age, and socioeconomic status (SES), the association weakened but was still present. Children with obesity were less likely to achieve above-median reading and mathematics scores than their healthy-weight peers (odds ratio [OR] 0.77 and 0.86 for reading; OR 0.85, 0.67, 0.79, 0.82, and 0.75 for mathematics). Similarly, teachers reported that children with obesity did not have Approaches to Learning and Attentional Focusing as good as their healthy-weight peers regardless of their objective test scores and SES (OR 0.82, 0.80, 0.78, 0.69, and 0.77 for Approaches to Learning; OR 0.80, 0.81, 0.83, 0.82, 0.80, and 0.74 for Attentional Focusing). Conclusions: Obesity during elementary school years is negatively associated with both objective and subjective measures of academic performance. Further studies are needed to understand if the connection is stemming from behavioral issues of children, weight-based bias of teachers, or both.