Objective This study investigates the association between urinary phthalate metabolite levels and attention deficit disorder (ADD), learning disability (LD), and co-occurrence of ADD and LD in 6–15-year-old children. Methods We used cross-sectional data from the National Health and Nutrition Examination Survey (NHANES, 2001–2004). Phthalate metabolites with ≥ 75% detection in urine samples were examined. The study population comprised 1493 children with parent-reported information on ADD or LD diagnosis and phthalate concentrations in urine. Phthalate concentrations were creatinine-adjusted and log10-transformed for analysis. All models controlled for child sex, age, race, household income, blood lead, and maternal smoking during pregnancy. Results There were 112 ADD cases, 173 LD cases, and 56 ADD and LD cases in the sample. After adjusting for potential confounders, we found increased odds of ADD with increasing urinary concentration of di-2-ethylhexyl phthalates (OR: 2.1; 95% CI: 1.1, 3.9) and high molecular weight phthalates (OR: 2.7; 95% CI: 1.2, 6.1). In addition, dibutyl phthalates (OR: 3.3; 95% CI: 0.9, 12.7) and high molecular weight phthalates (OR: 3.7; 95% CI: 0.9, 14.8) were marginally associated with increased odds of co-occurring ADD and LD. We did not find associations for any phthalate and LD alone. We observed stronger associations between phthalates and ADD and both ADD and LD in girls than boys in some models. Conclusions We found cross-sectional evidence that certain phthalates are associated with increased odds of ADD and both ADD and LD. Further investigations with longitudinal data are needed to confirm these results.

Objective To examine women’s journeys with gynecologic cancer from before diagnosis through death and identify elements of their healthcare experience that warrant improvement. Methods This exploratory study used longitudinal progress notes data from a multispecialty practice in Northern California. The sample included women with stage IV gynecological cancer diagnosed after 2011 and who died before 2018. Available progress notes from prior to diagnosis to death were qualitatively analyzed. Results We identified 32 women, (median age 61 years) with mostly uterine (n=17) and ovarian (n=9) cancers and median survival of 9.2 months (min:2.9 and max:47.5). Sixteen (50%) received outpatient palliative care and 18 (56%) received hospice care. The analysis found wide variation in documentation about communication about diagnosis, prognosis, goals of care, stopping treatment, and starting hospice care. Challenges included escalating/severe symptoms, repeated urgent care/emergency department/hospital encounters, and lack of or late access to palliative and hospice care. Notes also illustrated how patient background and goals influenced care trajectory and communication. Documentation styles varied substantially, with palliative care notes more consistently documenting conversations about goals of care and psychosocial needs. Conclusion This analysis of longitudinal illness experience of women with advanced gynecological cancer suggests that clinicians may want to (1) prioritize earlier discussion about goals of care; (2) provide supplemental support to patients with higher needs, possibly through palliative care or navigation; and (3) write notes to enhance patient understanding now that patients may access all notes.

Background: The Group Lifestyle Balance™ (GLB) program is an adaption of the landmark Diabetes Prevention Program that has been recognized by the CDC as a model curriculum for diabetes prevention. The implementation of GLB at 8 predominantly autonomous and highly diverse clinics within a single, large multi-specialty healthcare organization provides a unique opportunity to evaluate the program in a real-world setting. Methods: We conducted structured interviews with GLB facilitators at Sutter Health, a Healthcare Delivery System in Northern California, using snowball sampling. Interview questions were based on the RE-AIM framework to explore the reach, effectiveness, adoption, implementation and maintenance of the program between sites. We focused this analysis on a single regional affiliate of Sutter, with 8 clinic sites offering GLB to examine potential within-region variation. Results: Ten GLB facilitators were interviewed, representing 8 clinical sites within the Sutter Health regional affiliate. All the facilitators were diabetes educators; 9 were registered dietitians and 1 was a registered nurse. Five sites began offering GLB in 2010, followed by two sites in 2013 and one in 2015. Eligibility criteria were the same across sites, and included all patients regardless of risk factors, except pregnant women. While all sites consistently offer 12 weekly “core” sessions over a 3-month period, the maintenance sessions are optional and are only offered at half of the sites. Almost all facilitators (n= 9) reported that they use a modified version of the curriculum developed by the University of Pittsburgh and all mentioned that they provide participants with additional information. Conclusion: These preliminary data suggest that the GLB program has been implemented within a regional affiliate of a healthcare system, consistently, yet with some variation in the use of the post-core maintenance curriculum. Future work will examine the effectiveness of GLB based on the type of curriculum and duration of the program. Disclosure K.M.J. Azar: Research Support; Self; Janssen Scientific Affairs, LLC., Regeneron Pharmaceuticals, Inc..C. Nasrallah: None. N. Szwerinski: None. V. Chopra: None. M. Halley: None. R. Romanelli: Research Support; Self; Janssen Scientific Affairs, LLC., Regeneron Pharmaceuticals, Inc., Pfizer Inc..

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