Association between phthalates and attention deficit disorder and learning disability in U.S. children, 6-15 years.

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.

Lifestyle change program engagement in real-world clinical practice: a mixed-methods analysis.

Participant engagement in structured lifestyle change programs (LCPs) is essential for adopting behaviors that promote weight loss; however, the challenges to, and facilitators that promote, engagement with such programs are not well understood. We conducted a mixed-methods study among real-world LCP participants to assess factors associated with program engagement and to examine the reasons for withdrawal. Using electronic health records (EHR), we identified LCP eligible participants between 2010 and 2017. Multivariable logistic regression was used to assess associations between program engagement and baseline characteristics. Semi-structured interviews with LCP participants were conducted and thematically analyzed to examine reasons for withdrawal. A total of 1,813 LCP participants were included. The median number of sessions attended was 10 of 21-25 sessions. Highest LCP engagement was associated with factors potentially related to self-efficacy/motivation, such as older age, higher baseline weight, prior healthcare utilization and an absence of a history of smoking or depression. Engagement was also negatively associated with being Non-Hispanic Black versus White. The qualitative analysis of the interviews revealed four general themes pertaining to participants' withdrawal: competing priorities, perceived program effectiveness, characteristics of the program, and facilitator-related factors. Taken together, results from this mixed-methods study suggest that motivation and self-efficacy are important for program engagement; future LCP enhancements should incorporate flexible formats that may help participants manage competing priorities and maximize personal and cultural relevance for all racial/ethnic groups, especially those who have not benefitted fully. Furthermore, participants should be encouraged to set realistic goals to manage expectations.

Engaging in a structured lifestyle change program (LCP) is essential to learn healthy behaviors, however, it is not well understood. This study examined factors associated with program engagement and reasons for program withdrawal at a large healthcare system. Highest LCP engagement was found to be associated to factors potentially related to self-efficacy/motivation including older age, higher initial weight, and prior healthcare utilization. Non-Hispanic Black, history of smoking, and prior diagnosis of depression were found to be negatively associated with LCP engagement. Program withdrawal was related to four themes: competing priorities, perceived program effectiveness, characteristics of the program, and facilitator-related factors. These findings suggest that motivation and self-efficacy are important for behavior change program engagement.

The Healthcare Journey of Women With Advanced Gynecological Cancer From Diagnosis Through Terminal Illness: Qualitative Analysis of Progress Note Data.

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.

Longitudinal Weight Outcomes From a Behavioral Lifestyle Intervention in Clinical Practice.

PURPOSE: The purpose of this electronic health record (EHR)-based retrospective cohort study was to characterize a population of patients participating in a 12-month, lifestyle change program in a community-based health system and to examine longitudinal weight outcomes. METHODS: Program participants were identified in the EHRs of a health care delivery system across 18 sites between 2010 and 2017. Outcomes were mean weight change and proportion of patients with ≥5% weight loss through 24 months from program initiation. RESULTS: Among 4463 program participants, 3156 met study eligibility criteria, with a mean ± SD age of 53.5 ± 13.1 years; 77.7% were women. Mean baseline weight ± SD was 101.3 ± 23.8 kg. Three main cardiometabolic risk groups were identified: prediabetes/high risk for diabetes (47.3%), overweight/obese in the absence of elevated diabetes risk (27.2%), and existing diabetes (23.9%). Maximal mean weight loss was 3.9% at 6 months from baseline. At 12 and 24 months from baseline, mean weight loss was 3.2% and 2.3%, respectively, with 31% and 29% of participants attaining ≥5% weight loss. Long-term weight outcomes were similar across risk groups. CONCLUSIONS: A lifestyle change program in a clinical practice setting is associated with modest weight loss, sustained through 24 months, among participants with a range of cardiometabolic risk factors. More than one-quarter of participants achieve ≥5% weight loss, regardless of cardiometabolic risk.