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    (0) Diabetic people have the highest risk of getting affected by coronavirus.

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    (0) Common hormonal treatments linked to abnormal heart rhythms and sudden death in men being treated for prostate cancer

    Treatments for advanced prostate cancer that suppress testosterone, a hormone (also called an androgen) that drives the malignant cells to grow and spread, are collectively referred to as androgen deprivation therapies, or ADT. These therapies can significantly extend lifespans in men who have the disease, but they also have a range of challenging side effects.

    In 2004, Dr. Marc Garnick, Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org, reported that in some men, an ADT drug called aberelix lengthens the time it takes for cardiac cells to recharge electrically between beats. Known as the QT interval, this measure is determined with the use of an electrocardiogram. Prolonged QT intervals are worrying because in rare instances they induce potentially fatal heart rhythms. In fact, the FDA has withdrawn several approved medications from the market after they were associated with drug-induced lengthening of the QT interval, leading to documented cases of either fatal or nonfatal cardiac arrhythmias. The decision to withdraw a drug in these cases is based on the strength of the evidence linking to these sorts of cardiac outcomes.

    Now a French research team is reporting that many widely used forms of ADT are linked to these sorts of cardiac side effects and their potential consequences. The study was led by Dr. Joe-Elie Salem, a cardio-oncologist at Sorbonne University in Paris.

    One of testosterone’s normal effects in the body is to shorten QT intervals. Salem was aware from prior research that the intervals are longer — and the risk of potentially fatal heart attacks greater — in women than in men, possibly because women have lower testosterone levels than men do.

    Would ADT — because it suppresses testosterone — elevate risks for men in a similar way that naturally low levels of the hormone do in women? That’s what Dr. Salem and his team wanted to know.

    To find out, they combed through a global database of more than 17 million adverse drug reactions reported by doctors, patients, and pharmaceutical companies between 1967 and 2018.

    Their investigation showed that seven out of the 10 hormone therapies evaluated were disproportionately associated with prolonged QT intervals, abnormal heart rhythms, or sudden death. The link with sudden death was strongest with enzalutamide, a second-generation ADT drug used after weaker front-line testosterone-suppressing drugs fail.

    The frequency of prolonged QT, abnormal heart rhythms, or sudden death among men taking hormonal therapy in the general population is unknown. But in an email, Dr. Salem wrote that the combined incidence is “probably low — less than 1%.”

    Importantly, the tendency towards prolonged QT intervals has a range of causes, and some men are born with it — this is called congenital long QT. Dr. Salem and his colleagues are now planning a study that they hope will allow clinicians to predict in advance which men face the greatest risks of these heart problems when taking hormone-suppressing therapy.

    In the meantime, Dr. Salem recommends that men have a baseline electrocardiogram before starting testosterone-suppressing treatments. If abnormalities are noted before or after the treatments begin, he says, patients should be monitored further, and taken off any other drugs they might be taking that also have QT prolonging effects. The list of these drugs is quite extensive, and includes various antihistamines, antidepressants, antipsychotics, and antibiotics, among others.

    “This new research reflects ongoing efforts to assess cardiac risk factors among men taking ADT, and underscores the need to better understand how prolonged QT intervals cause irregular heart rhythms,” Dr. Garnick said. “This is important because men are not routinely screened with a baseline electrocardiogram before beginning ADT. Future research is needed to determine if a longer baseline QT interval when starting on ADT should be monitored during the course of treatment.”

    (304) Intensive blood sugar control doesn’t have lasting cardiovascular benefits for those with diabetes

    In 2009, the New England Journal of Medicine published results from the Veterans Affairs Diabetes Trial (VADT). The study found that intensive glucose (blood sugar) control in older men with longstanding type 2 diabetes did not significantly reduce their risk of major cardiovascular (CV) events, including heart attack, stroke, and death from CV causes, compared with standard blood sugar control.

    Researchers recently reported 15-year follow-up results from VADT. They found that intensive blood sugar control did not exert any “legacy effect”: the intensive blood sugar control group did not enjoy CV benefits 15 years after the start of the study.

    The Veterans Affairs Diabetes Trial

    The VADT study originally enrolled over 1,700 veterans with longstanding type 2 diabetes, who were at high risk of cardiovascular disease, and had poorly controlled blood sugar when they enrolled in the study. At the time of enrollment, study participants had been diagnosed with diabetes for an average of 12 years. Their average A1c level, a measure of average blood sugar levels over the previous two to three months, was 9.4%.

    The participants were randomly assigned to either intensive glucose-lowering therapy or usual care for about 5.6 years. At the completion of the study, there was a significant difference in blood sugar control: the average A1c in the intensive treatment group was 6.9%, while the average A1c in the usual care group was 8.4%.

    Despite the lower A1c levels, there were no benefits shown from intensive treatment on CV outcomes, which included nonfatal heart attack, nonfatal stroke, new or worsening congestive heart failure, amputation for diabetes-related tissue damage, or death from CV causes.

    No long-term cardiovascular benefit of intensive blood sugar control

    A follow-up observational study was then undertaken to assess whether intensive treatment during the 5.6-year study period had any long-lasting effects, after the interventions were completed. The 10-year VADT follow-up showed some benefits to intensive treatment with regard to CV events. At that time, participants in the intensive treatment group still had lower A1c levels compared to the usual care group, despite the gap of several years since the completion of the study.

    However, at the newly published 15-year follow-up, the benefits of intensive control on any of the CV outcomes were lost. By this time, both groups had similar A1c levels of about 8%.

    This phenomenon may suggest that to achieve the CV benefits, blood sugar control needs to be maintained and that the short-term tight control, without lasting blood sugar control, may not have long-lasting effects.

    New evidence supports existing evidence

    The new VADT results add to existing evidence from previous large studies that have failed to show any long-lasting benefits of intensive blood sugar control during observational follow-up. One study, however, did show some beneficial legacy effect. The United Kingdom Prospective Diabetes Study (UKPDS) evaluated intensive treatment versus usual care in adults with newly diagnosed type 2 diabetes. When the UKPDS cohort was evaluated 10 years after the completion of the study, the participants from the intensive treatment arm showed benefits with regard to cardiovascular disease, compared to standard care.

    Taken together, the evidence suggests that older adults with longer duration of diabetes and/or multiple coexisting conditions may not benefit from intensive blood sugar control. On the other hand, intensive treatment might be beneficial in younger patients, with shorter duration of diabetes and fewer coexisting medical conditions.

    Individualize treatment and control other cardiovascular risk factors

    Personalization of goals and treatment regimens that can be maintained safely over the long term by the patient might be the best strategy to lower the risk of cardiovascular disease. As I discussed in a previous blog post, treatment of older adults should consider possible dangers of intensive treatment. For example, intensive blood sugar control can overshoot and lead to hypoglycemia, a potentially dangerous condition in which blood sugar falls too low. Hypoglycemic episodes in older adults are particularly harmful and may negate the possible benefits or tighter diabetes control. In older adults, rather than aiming for tight control, we aim for the best control that can be achieved without increasing the risk of hypoglycemia.

    For reducing CV risk, the authors of an editorial that accompanied the NEJM study recommend prioritizing interventions that address other CV risk factors. That includes quitting smoking, and managing blood pressure and cholesterol levels with medication, if needed. Newer classes of diabetes medications, such as sodium glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists appear to have CV benefits and low risk of hypoglycemia, and may be considered as well.

    (4) Is there a test for Alzheimer’s disease?

    After spending 30 minutes hunting for your car in a parking lot, or getting lost on a familiar route, have you ever considered asking your doctor for a blood test or brain scan to find out if you have Alzheimer’s disease?

    number of factors contribute to Alzheimer’s disease. By definition, this form of dementia involves the buildup of a protein in brain called beta-amyloid. Beta-amyloid forms plaques that disrupt communication between brain cells, and ultimately destroys them. For this reason, tests for Alzheimer’s disease focus on beta-amyloid.

    Blood tests for Alzheimer’s disease are being developed

    Recently, researchers at Washington University in St. Louis measured the levels of beta-amyloid in the blood of 158 mostly normal people (10 had cognitive impairment).

    When they compared their findings with those of amyloid brain PET (positron emission tomography) scans performed within 18 months of the blood draw, they found very similar results. Moreover, the few people in their study who had a positive blood test and negative brain scan were actually 21 times more likely to have a positive brain scan in the future. This means that the new blood test may be extremely sensitive at detecting Alzheimer’s disease — that is, it results in few false negatives.

    If you’re worried about your memory, should you ask your doctor for this test? Not yet — the blood test is still being evaluated and is not currently available for clinical use.

    What about amyloid brain PET scans?

    Maybe you’re thinking about having an FDA-approved amyloid brain PET scan. These tests involve the injection of a radioactive dye attached to a molecule that sticks to amyloid plaques in the brain. The radioactivity is then measured by special imaging technology, similar to a CT scan.

    Should you get one? You could, but there are two issues to consider. First, they are not paid for by insurance — and they cost about $5,000 — so you either have to pay out of pocket or join a research study at a National Institute on Aging Alzheimer’s Disease Research Center, where you might get one for free. Second, how would the information help you?

    No special amyloid brain scans are needed for the straightforward diagnosis and treatment of memory loss. If you are having significant symptoms of memory loss, such as those mentioned above, talk with your doctor about them. Your doctor will likely evaluate your overall health and the medications you take, then do some standard blood tests and brain scans as well as pencil and paper testing. Based on the results of those tests, your doctor may start you on a medication intended to boost your memory function.

    Perhaps you don’t have any symptoms of Alzheimer’s disease today, but one of your parents had it. Should you get an amyloid brain scan to find out if you are likely to develop Alzheimer’s in the future?

    Unfortunately, there are no medications that can prevent or slow down the development of Alzheimer’s disease. So if you get the scan and it is positive, again, what will you do with the information?

    Spinal fluid tests are available now — and paid for by insurance

    Perhaps I’ve convinced you that you don’t need to rush out and have an expensive amyloid brain scan. But there are situations when it is important to find out if you or a loved one has Alzheimer’s, versus another brain disease that would be treated differently. In these situations, we often use a spinal fluid test that is quite good at being able to distinguish Alzheimer’s from other brain diseases affecting thinking and memory.

    To obtain the spinal fluid, you need to undergo a lumbar puncture, more commonly known as a spinal tap. Although it may sound frightening, it is actually a perfectly safe test. You simply sit or lie down on your side with your back to the doctor and curl into a little ball by bringing your shoulders down and your knees up. The doctor finds the right spot, cleans the area well, gives you some numbing medicine, inserts a thin needle, and takes out a small amount of spinal fluid, which is sent to a lab for analysis.

    Exercise daily, eat right, stay social, keep active

    Lastly, don’t forget that you can work to prevent Alzheimer’s disease every day by performing aerobic exercise, eating a Mediterranean-style diet, staying socially engaged, and keeping your mind active. These activities are the only things that have been proven to reduce your chances of developing Alzheimer’s disease — regardless of the results of any special tests.

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