Intrafractional motion and dosimetric analysis in prostate stereotactic body radiation therapy with auto beam hold technique.

Objective: To summarize our institutional prostate stereotactic body radiation therapy (SBRT) experience using auto beam hold (ABH) technique for intrafractional prostate motion and assess ABH tolerance of 10-millimeter (mm) diameter.Approach: Thirty-two patients (160 fractions) treated using ABH technique between 01/2018 and 03/2021 were analyzed. During treatment, kV images were acquired every 20-degree gantry rotation to visualize 3-4 gold fiducials within prostate to track target motion. If the fiducial center fell outside the tolerance circle (diameter = 10 mm), beam was automatically turned off for reimaging and repositioning. Number of beam holds and couch translational movement magnitudes were recorded. Dosimetric differences from intrafractional motion were calculated by shifting planned isocenter.Main Results: Couch movement magnitude (mean ± SD) in vertical, longitudinal and lateral directions were -0.7 ± 2.5, 1.4 ± 2.9 and -0.1 ± 0.9 mm, respectively. For most fractions (77.5%), no correction was necessary. Number of fractions requiring one, two, or three corrections were 15.6%, 5.6% and 1.3%, respectively. Of the 49 corrections, couch shifts greater than 3 mm were seen primarily in the vertical (31%) and longitudinal (39%) directions; corresponding couch shifts greater than 5 mm occurred in 2% and 6% of cases. Dosimetrically, 100% coverage decreased less than 2% for clinical target volume (CTV) (-1 ± 2%) and less than 10% for PTV (-10 ± 6%). Dose to bladder, bowel and urethra tended to increase (Bladder: ΔD10%:184 ± 466 cGy, ΔD40%:139 ± 241 cGy, Bowel: ΔD1 cm3:54 ± 129 cGy; ΔD5 cm3:44 ± 116 cGy, Urethra: ΔD0.03 cm3:1 ± 1%). Doses to the rectum tended to decrease (Rectum: ΔD1 cm3:-206 ± 564 cGy, ΔD10%:-97 ± 426 cGy; ΔD20%:-50 ± 251 cGy).Significance: With the transition from conventionally fractionated intensity modulated radiation therapy to SBRT for localized prostate cancer treatment, it is imperative to ensure that dose delivery is spatially accurate for appropriate coverage to target volumes and limiting dose to surrounding organs. Intrafractional motion monitoring can be achieved using triggered imaging to image fiducial markers and ABH to allow for reimaging and repositioning for excessive motion.

The relationship between palliative radiotherapy and opioid prescribing patterns among patients with metastatic cancer.

BACKGROUND: While randomized trials have established that palliative radiotherapy, especially to bone, can improve qualitative measures of pain, its quantitative relationship to opioid prescribing patterns has remained underexplored. We aimed to identify the association of palliative radiotherapy on opioid prescriptions received among patients with metastatic cancer. METHODS: The Virginia Commonwealth University Institutional Review Board approved retrospective analysis extracted prescription data from all adult patients with metastatic cancer who underwent outpatient palliative external beam radiation therapy at Virginia Commonwealth University Health System from 2008-2018. Institutional prescribing data were used to calculate the average opioid oral morphine milligram equivalent (MME) dose 30, 60 and 90 days both before and after radiotherapy. Univariate and bivariate ordinary least squares (OLS) regression models were used to estimate the relationship of MME changes with clinical, radiation-related, and demographic patient factors. RESULTS: A total of 182 patients met inclusion criteria. Overall, patients required higher opioid doses after radiotherapy, with mean MME 30, 60, and 90 days prior to radiotherapy of 24.6, 20.2, and 16.8 mg, respectively; which increased to 62.9, 77.7 and 82.4 mg post-radiation therapy (P<0.01). Multivariate OLS models predicting the change of MME 60 days pre- and post-radiation treatment showed that younger age and comorbid depression predicted increased MME after radiotherapy. CONCLUSIONS: Patients with metastatic cancer face a relatively high opioid burden, which increases over time, even among those who receive palliative radiation therapy. Patients who are younger and have comorbid depression may have a higher risk of increased opioid burden after radiotherapy.

A Case-Control Study Examining the Association of Fiber, Fruit, and Vegetable Intake and the Risk of Colorectal Cancer in a Palestinian Population.

While there is an association between Western diets and the incidence of colorectal cancer (CRC), this dietary association has remained unexplored in Palestine. The aim of this study was to examine how fiber and fruit and vegetable (FV) intakes are associated with CRC risk among Palestinian adults. We recruited 528 Palestinians between 2014 and 2016. We identified 118 patients who received CRC treatment at Augusta Victoria Hospital, East Jerusalem. We additionally identified 410 controls who consisted of community-based Palestinians without cancer. All participants completed a survey on demographics and a validated dietary intake food screener. Multivariable logistic regression models tested associations between fiber and FV intakes (categorized into quartiles) with CRC risk. After adjusting for significant covariates (age, sex, education, physical activity, smoking status, BMI, IBD, and family history of CRC), as fibers increased across increasing quartiles, the CRC risk significantly decreased (OR = 0.36, 95% CI: 0.15-0.86, p-trend = 0.02). After adjusting for age and sex, as FV intake increased, the CRC risk significantly decreased (OR = 0.34, 95% CI: 0.15-0.75, p-trend = 0.009). Consumption of fiber-rich foods was inversely associated with CRC risk. Understanding this relationship among Palestinians is essential in order to develop targeted, culturally relevant strategies that may potentially alleviate the burden of CRC.

Risk of Disease Recurrence and Mortality Varies by Type of Fat Consumed before Cancer Treatment in a Longitudinal Cohort of Head and Neck Squamous Cell Carcinoma Patients.

BACKGROUND: The associations between specific types of fat and head and neck squamous cell carcinoma (HNSCC) recurrence and mortality rates have not yet been examined. OBJECTIVES: The purpose of this study was to determine how intakes of various fat subtypes before cancer treatment are associated with recurrence and mortality in adults diagnosed with HNSCC. METHODS: This was a secondary analysis longitudinal cohort study of data collected from 476 newly diagnosed patients with HNSCC. Patients completed baseline FFQs and epidemiologic health surveys. Recurrence and mortality events were collected annually. Fat intakes examined included long-chain fatty acids (LCFAs), unsaturated fatty acids (FAs), PUFAs, ω-3 (n-3) PUFAs, ω-6 (n-6) PUFAs, MUFAs, animal fats, vegetable fats, saturated FAs, and trans fats. Associations between fat intake (categorized into tertiles) and time to event were tested using multivariable Cox proportional hazards models, adjusting for age, sex, smoking status, human papillomavirus status, tumor site, cancer stage, and total caloric intake. Intake of fats was compared with the lowest tertile. RESULTS: During the study period, there were 115 recurrent and 211 death events. High LCFA intake was associated with a reduced all-cause mortality risk (HR: 0.55; 95% CI: 0.34, 0.91; P-trend = 0.02). High unsaturated FA intake was associated with a reduced all-cause mortality risk (HR: 0.62; 95% CI: 0.40, 0.97; P-trend = 0.04) and HNSCC-specific mortality risk (HR: 0.51; 95% CI: 0.29, 0.90; P-trend = 0.02). High intakes of ω-3 PUFAs (HR: 0.56; 95% CI: 0.35, 0.91; P-trend = 0.02) and ω-6 PUFAs (HR: 0.57; 95% CI: 0.34, 0.94; P-trend = 0.02) were significantly associated with a reduced all-cause mortality risk. There were no significant associations between other fat types and recurrence or mortality risk. CONCLUSIONS: In this prospective survival cohort of 476 newly diagnosed patients with HNSCC, our data suggest that HNSCC prognosis may vary depending on the fat types consumed before cancer treatment. Clinical intervention trials should test these associations.

Attitudes and Perceptions Towards Radiation Therapy in Breast Cancer Patients: The Role of a Multidisciplinary Care Team.

Previous studies have shown that breast cancer patients' beliefs regarding radiation therapy (RT) are influenced by a multitude of factors encompassing demographic, socioeconomic, cultural, and healthcare-related domains. The association between consultation with a multidisciplinary care team and breast cancer patients' attitudes towards RT, however, remains understudied. Using survey and medical record data from 185 women with invasive, non-metastatic breast cancer who received breast conserving surgery, we aimed to characterize the relationship between the number and type of oncological specialties consulted and women's belief in RT's ability to decrease the likelihood of breast cancer recurrence. Using multivariable models, we found that compared to women who discussed RT with only one oncologist (medical, radiation, or surgical), women who discussed RT with all three oncologists were more likely to report increased agreement with RT's ability to reduce cancer recurrence. No single specialty of oncology, including radiation oncology, showed increased associations with women's beliefs regarding RT's efficacy. We conclude that women's beliefs in the ability of radiation therapy to reduce breast cancer recurrence are associated with an increased number of oncologic physicians consulted.

Cardiac MRI utilizing late gadolinium enhancement (LGE) and T1 mapping in the detection of radiation induced heart disease.

BACKGROUND AND PURPOSE: Radiotherapy has been associated with late dose-dependent cardiovascular toxicity. In this cross-sectional pilot study, radiation dose distributions were correlated with areas of localized and diffuse myocardial fibrosis as measured by novel cardiac MRI (CMR) sequences including late gadolinium enhancement (LGE) and T1 mapping with the goal to identify early markers of myocardial damage. MATERIALS AND METHODS: Twenty-eight patients with chest tumors including lung, breast, esophagus, and lymphoma underwent CMR per study protocol on average 46.4 months (range 1.7-344.5) after radiotherapy. Patients without pretreatment cardiac history were included if the volume of heart receiving 5 Gy or more was at least 10% (V5Gy ≥ 10%). The association of LGE with cardiac dosimetric factors, clinical factors (e.g., tumor type, smoking history, BMI), and T1 values was analyzed. RESULTS: Cardiac maximum (Dmax) and mean dose (Dmean) equivalent to doses delivered in 2 Gy fractions (EQD2) were on average 50.9 Gy (range 6.2-108.0) and 8.2 Gy (range 1.0-35.7), respectively, compared to 60.8 Gy (40.8-108.0) and 6.8 Gy (1.8-21.8) among the 9 patients with LGE. Doses were not different between patients with and without LGE (p = 0.16 and 0.56, respectively). The average T1 value of the left ventricle myocardium was 1009 ms (range 933-1117). No significant correlation was seen for heart Dmax and Dmean and T1 values (p = 0.14 and 0.58, respectively). In addition, no significant association between clinical factors and the development of LGE was identified. CONCLUSIONS: No relation between cardiac doses, the presence of LGE or T1 values was observed. Further study is needed to determine the benefit of CMR for detecting radiotherapy-related myocardial fibrosis.

Racial differences in the relationship between surgical choice and subsequent patient-reported satisfaction outcomes among women with early-stage hormone-positive breast cancer.

PURPOSE: The last fifteen years has seen a rising proportion of women who are eligible for breast conserving therapy (BCT) choosing mastectomy despite equivalent survival in early-stage breast cancer. We aim to explore potential racial differences in the association of surgical choice with subsequent patient-reported satisfaction outcomes. METHODS: Women who were within one year of diagnosis with hormone receptor (HR)-positive breast cancer were asked the Short Version of Patient Satisfaction Questionnaire (PSQ-18), which assesses their overall satisfaction with their medical care. We conducted bivariate analyses, including paired t-tests, to clarify differences in these patient-reported factors by surgical choice and race. Multivariable linear regression models were used to adjust for clinical and demographic control variables. RESULTS: For the sample of 279 women who underwent definitive surgery, women who received a mastectomy had lower levels of overall satisfaction, 71 vs. 75 (out of 90) (p = .001). In stratifying this relationship by race, the difference in total satisfaction score was largest among Black women (69 among mastectomy patients vs. 75 among BCT patients; p = 0.016). On multivariable linear regression, Black race and mastectomy status (together) exhibited a significantly large negative association with total satisfaction score, with negative associations across all domains of the PSQ-18. CONCLUSION: Despite the high prevalence of mastectomy among Black women with early-stage, HR-positive breast cancer, this population is more likely to report lower levels of patient satisfaction compared to patients receiving BCT. These findings suggest there may be potential racial differences in the psychosocial consequences of surgical choice.

Narrowing Racial Gaps in Breast Cancer: Factors Affecting Probability of Adjuvant Radiation Therapy.

PURPOSE: Adjuvant radiation therapy has historically been underused by black patients with breast cancer compared with white patients. We prospectively investigated factors, including sociocultural, psychosocial, and health care factors, that may be associated with the use or omission of adjuvant radiation therapy by both racial groups. METHODS AND MATERIALS: Women with primary invasive, nonmetastatic breast cancer were recruited from hospitals and through community outreach efforts in the Washington, DC, and Detroit, Michigan, areas between July 2006 and April 2011. Data were collected via telephone interviews regarding psychosocial (eg, self-efficacy) and health care factors (eg, communication) at the time they received a diagnosis. Clinical data were extracted from their medical charts after the completion of treatment. We examined the association among multiple demographic, socio-cultural, healthcare process factors and the use of radiotherapy. Logistic multivariable regression models identified associations with radiotherapy receipt. RESULTS: Among 395 eligible and consenting women, 315 had complete baseline data, and 217 were in the final analytical sample, having met criteria for adjuvant breast or chest wall radiation therapy after breast conservation surgery or mastectomy. Among women eligible for radiation, all were insured, 59% were black, the mean age was 55.4 years, and the majority had stage I or II disease. Overall, approximately 70% percent of women received adjuvant radiation therapy. On multivariable analyses, the likelihood of receiving adjuvant radiation therapy was higher for those who were black with any level of indication for radiation therapy (odds ratio 2.21; P < .01), those for whom comorbidities were present, and those who demonstrated positive sociocultural factors such as self-efficacy and high reported rates of provider communication about radiation therapy (odds ratio 1.20; P < .05). Among women with strong indications for radiation therapy, there was no significant association with race on multivariable analysis. CONCLUSIONS: Our findings suggest that among women with any indication for radiation therapy, black patients were more likely to receive radiation therapy compared with white patients. Furthermore, data suggest improved provider communication and self-efficacy are important predictors of receipt of radiation therapy. Further studies exploring the effects of provider communication and sociocultural factors to diverse patient populations may be warranted.

Long-term sleep disturbance and prescription sleep aid use among cancer survivors in the United States.

PURPOSE: Insomnia and related sleep disorders are common complaints among cancer patients, and use of prescription sleep aids can be high in the treatment setting. The prevalence of sleep disturbance and prescription sleep aid use in the community-dwelling cancer survivorship population, however, remains relatively unexplored. We aim to ascertain the extent to which a cancer diagnosis is associated with sleep disturbances and prescription sleep aid use as measured in several cross sections of individuals across multiple disease sites and time since cancer diagnosis. METHODS: We used data from five cross-sectional cycles of the National Health and Nutrition Evaluation Survey (NHANES) from 2005 to 2014. We identified a total of 2371 individuals who reported a diagnosis of cancer (averaging 61 years old) and 25,788 individuals who did not report a cancer diagnosis (averaging 45 years old). We considered several patient-reported sleep-related outcomes. Multivariate regression analyses, as well as propensity score matching, were used to clarify the relationship between sleep disturbances, prescription sleep aid use, and cancer diagnosis, stratified by time since diagnosis and primary disease site. RESULTS: Reported sleep disturbance was common in cancer survivors, with approximately 34% of patients with a history of cancer reporting having ever been told they had trouble sleeping, compared to 23% of non-cancer patients in the general population with no history of cancer (p < 0.001). Propensity score matching supported a significantly higher rate of trouble sleeping among cancer survivors compared to matched controls. Compared to the general adult population without cancer, cancer survivors 11 or more years past diagnosis were more likely to report being diagnosed with trouble sleeping or a sleep disorder. Further, patients with gynecological cancers were more likely to report prescription sleep aid use, sleep disorders, and trouble sleeping compared to adults without a history of cancer. CONCLUSIONS: Sleeping problems are common in the cancer survivorship population, especially in patients with a long survivorship history and a history of gynecological cancers. Consideration of symptoms of insomnia and sleep disturbance may be helpful in the follow-up care of these patients.

Racial differences in the PSA bounce in predicting prostate cancer outcomes after brachytherapy: Evidence from the Department of Veterans Affairs.

PURPOSE: African American men have historically had poorer prostate cancer biochemical and survival outcomes than Caucasians. However, emerging data suggest nononcologic factors drive much of this disparity. Prior evidence has suggested an association between a transient prostate specific antigen (PSA) bounce and improved biochemical control. However, racial differences in this relationship have remained relatively unexplored. METHODS AND MATERIALS: We identified 4477 men treated for low- or intermediate-risk prostate cancer within the U.S. Department of Veterans Affairs (VA) from 2000 to 2010 with brachytherapy alone or in combination with external beam radiotherapy without androgen deprivation. Longitudinal PSA data were used to define to biochemical failure and PSA bounce. Cox proportional hazard models were used explore racial differences in the relationship between the PSA bounce and time to biochemical failure. RESULTS: Thirty-one percent of our sample experienced a PSA bounce, with African Americans more likely to experience a bounce (42%) compared with Caucasians (29%); p < 0.001. Despite this, African Americans had a higher likelihood of biochemical failure (hazard ratio [HR] 1.4; p = 0.006). However, African American men experiencing a PSA bounce were less likely to experience a biochemical failure (HR = 0.64; p = 0.046), whereas this relationship was not statistically significant for Caucasians (HR = 0.78; p = 0.092). On multivariate analysis, African Americans receiving brachytherapy alone were most sensitive to the protective benefit of the PSA bounce (HR = 0.64). CONCLUSIONS: A PSA bounce was associated with improved biochemical control among patients receiving brachytherapy as part of their treatment for low- or intermediate-risk prostate cancer at the VA. African American men treated with brachytherapy had a particularly pronounced biochemical control benefit of a PSA bounce.

The long-lasting relationship of distress on radiation oncology-specific clinical outcomes.

PURPOSE: The diagnosis and treatment of cancer can have significant mental health ramifications. The National Comprehensive Cancer Network currently recommends using a distress screening tool to screen patients for distress and facilitate referrals to social service resources. Its association with radiation oncology-specific clinical outcomes has remained relatively unexplored. METHODS AND MATERIALS: With institutional review board approval, National Comprehensive Cancer Network distress scores were collected for patients presenting to our institution for external beam radiation therapy during a 1-year period from 2015 to 2016. The association between distress scores (and associated problem list items and process-related outcomes) and radiation oncology-related outcomes, including inpatient admissions during treatment, missed treatment appointments, duration of time between consultation and treatment, and weight loss during treatment, was considered. RESULTS: A total of 61 patients who received either definitive (49 patients) or palliative (12 patients) treatment at our institution and completed a screening questionnaire were included in this analysis. There was a significant association between an elevated distress score (7+) and having an admission during treatment (36% vs 11%; P = .04). Among the patients treated with definitive intent, missing at least 1 appointment (71% vs 26%; P = .03) and having an admission during treatment (57% vs 10%; P = .009) were significantly associated with our institutional definition of elevated distress. We found no correlation between distress score and weight loss during treatment or a prolonged time between initial consult and treatment start. CONCLUSIONS: High rates of distress are common for patients preparing to receive radiation therapy. These levels may affect treatment compliance and increase rates of hospital admissions. There remains equipoise in the best method to address distress in the oncology patient population. These results may raise awareness of the consequences of distress among radiation oncology patients. Specific interventions to improve distress need further study, but we suggest a more proactive approach by radiation oncologists in addressing distress.

Prostate cancer and subsequent nutritional outcomes: the role of diagnosis and treatment.

PURPOSE: To comprehensively explore the role of a prostate cancer diagnosis and its treatment to several outcomes including diet, Hemoglobin A1c, and weight status, in a large, nationally representative, cross-sectional study. METHODS: This analysis used five cross sections from the publicly available National Health and Nutrition Evaluation Survey (NHANES) from 2001 to 2010. A sample of 289 men with a history of prostate cancer was matched to a comparison group of 655 men with elevated prostate-specific antigen (> 4 ng/mL) but no reported diagnosis of prostate cancer. Analyses were stratified by diabetic or pre-diabetes status and treatment including surgery, radiotherapy, or both. Outcomes of interest included several broad macronutrient categories, HbA1c, body mass index, and obesity status. Multivariate regression analyses were conducted to clarify the associations of a prostate cancer diagnosis with these outcomes. Demographic and socioeconomic factors, including age, education, race, income, and marital status, were controlled for in all models. RESULTS: The clinical and demographic characteristics were relatively well balanced between the "at risk" comparison group and the group of men diagnosed with prostate cancer. Diabetic or pre-diabetic men diagnosed with prostate cancer were more likely to be obese (p < 0.05) and have a higher BMI (p < 0.10). On multivariate analysis, compared to controls, men with prostate cancer treated with surgery and radiation therapy were predicted to have a higher BMI (p < 0.01) and were more likely to be obese (p < 0.05). These findings were largely driven by the diabetic and pre-diabetic sample. Further diabetics and pre-diabetics with prostate cancer treated with both radiation and surgery were predicted to consume an average of 72 and 59 more daily grams of carbohydrates and sugar, respectively, compared to controls (p < 0.05). CONCLUSION: Men with prostate cancer report fewer behaviors and outcomes consistent with optimal glycemic management including a higher BMI, and in diabetics and pre-diabetics, increased carbohydrate sugar consumption. Men with more intense treatment including surgery and radiotherapy appeared to be more likely to be obese and make poorer dietary carbohydrate and sugar choices compared to men without prostate cancer. IMPLICATIONS FOR CANCER SURVIVORS: Men treated for prostate cancer have, on average, very long survivorship periods and are susceptible to diabetes and its complications. Interventions designed to improve diabetes awareness and self-management, especially weight and dietary sugar control, may be useful in this population.

The impact of RTOG 0614 and RTOG 0933 trials in routine clinical practice: The US Survey of Utilization of Memantine and IMRT planning for hippocampus sparing in patients receiving whole brain radiotherapy for brain metastases.

INTRODUCTION: Two recent clinical trials, phase III RTOG 0614 and phase II RTOG 0933, showed some effectiveness of Memantine and IMRT planning for hippocampus sparing, among patients receiving whole brain radiotherapy (WBRT) for brain metastases; however, their use in routine clinical practice is unknown. METHODS: A survey was sent to 1933 radiation oncologists in the US. Data collected included utilization of Memantine and hippocampus sparing, reasons for adoption and non-adoption, and demographic variables. RESULTS: A total of 196 radiation oncologists responded to the survey, with 64% reporting using Memantine in almost none of the patients receiving WBRT for brain metastases, and only 11% considering Memantine for <10% of their patients. The most common reason for not using Memantine was a poor patient performance status, and limited life expectancy. Likewise, 56% of radiation oncologists would not change their clinical practice to include hippocampus sparing IMRT in patients receiving WBRT based on the results of RTOG 0933. Further validation of hippocampus sparing in a phase III trial was supported by 71% of radiation oncologists, whereas further exploration of Memantine for this purpose in a phase III trial was supported by 42%. CONCLUSIONS: At this time, the majority of surveyed radiation oncologists in the US do not use Memantine, or IMRT planning for hippocampus sparing in patients receiving WBRT. Further validation of the hippocampus sparing concept in a phase III trial was supported, before adopting it in routine clinical practice.

Managing excessive saliva with salivary gland irradiation in patients with amyotrophic lateral sclerosis.

OBJECTIVE: A significant fraction of patients with amyotrophic lateral sclerosis (ALS) are unable to swallow saliva, which may result in the spillage of saliva outside of the oral cavity. Although anticholinergic agents and botulin toxin injections are considered the first line of treatment, they have not been effective for all patients. We performed a literature search on therapeutic salivary gland irradiation in patients with ALS. METHODS: We searched the PubMed for English language publications up to December 2014 on therapeutic salivary gland irradiation in patients with ALS. The search was performed using the following key words: amyotrophic lateral sclerosis, excessive salivation, sialorrhea, and radiation therapy. RESULTS: The majority of ALS patients with excessive salivation respond well to salivary gland irradiation. The whole bilateral submandibular, and whole or partial bilateral parotid glands have been the target tissue for radiation therapy in most of the published studies. Various radiation therapy regimens have been utilized. The response to radiation therapy lasts for several months. CONCLUSIONS: The majority of ALS patients with excessive salivation respond well to salivary gland irradiation. Neurologists should consider this treatment option for select patients with ALS and excessive salivation.

The relationship between academic performance and recreation use among first-year medical students.

INTRODUCTION: Self-care activities, including exercise, may be neglected by medical students in response to increasing academic demands. Low levels of exercise among medical students may have ripple effects on patient care and counseling. This study investigates the reciprocal role of recreation use and academic performance among first-year medical students. METHODS: We combined retrospective administrative data from four cohorts of first-year medical students at the University of Illinois at Urbana-Champaign from 2006 to 2010 (n=408). We estimated regression models to clarify the role of changes in recreation use before examinations on changes in academic performance, and vice versa. RESULTS: The use of recreation facilities by first-year medical students was highly skewed. We found that changes in recreation use before an exam were positively associated with changes in exam performance, and vice versa. Students who make large decreases in their recreation use are likely to decrease their exam scores, rather than increase them. DISCUSSION: Students who make decreases in their recreation, on average, are likely to decrease their exam scores. These findings suggest that medical students may be able to boost their achievement through wellness interventions, even if they are struggling with exams. We find no evidence that decreasing wellness activities will help improve exam performance.

Dietary responses to a hypertension diagnosis: evidence from the National Health and Nutrition Examination Survey (NHANES) 2007-2010.

Dietary modification has been shown to substantially reduce blood pressure among people with hypertension. This article uses data from the 2007-2008 and 2009-2010 cross-sections of the National Health and Nutrition Examination Survey (NHANES) to examine the extent to which a hypertension diagnosis can influence individuals' dietary choices. Several models were estimated to clarify the association of a hypertension diagnosis with dietary factors related to hypertension management. A comparison group of individuals at risk for developing hypertension was used. Results suggest that individuals who received a recent diagnosis of hypertension are more likely to have lower intakes of some dietary factors important in blood pressure management, including sodium. The results also highlight a discrepancy between added salt use and dietary sodium intake. While more recent hypertensive patients tended to consume lower levels of dietary sodium, patients diagnosed longer ago tended to use less added salt. Given that those diagnosed were more likely to have lower blood pressure profiles and improved diets, especially close to the time of diagnosis, the results of this study underscore the need for a prompt and accurate diagnosis of hypertension.

Health investment decisions in response to diabetes information in older Americans.

Diabetes is a very common and serious chronic disease, and one of the fastest growing disease burdens in the United States. Further, health behaviors, such as exercise, smoking, drinking, as well as weight status, are instrumental to diabetes management and the reduction of its medical consequences. Nine waves of the Health and Retirement Study are used to model the role of a recent diabetes diagnosis and medication on present and subsequent weight status, exercise, drinking and smoking activity. Several non-linear dynamic population average probit models are estimated. Results suggest that compared to non-diagnosed individuals at risk for high blood sugar, diagnosed diabetics respond initially in terms of increasing exercise, losing weight, and curbing smoking and drinking behavior, but the effect diminishes after diagnosis. Evidence of recidivism is also found in these outcomes, especially weight status and physical activity, suggesting that some behavioral responses to diabetes may be short-lived.