A recent investigation found that the HgbA1c test is a more reliable screening tool for diabetes risk than a fasting glucose. Persons enrolled in the study all had normal fasting glucose levels less than 100 mg/dl and Hgb A1c < 6.5 %, and therefore were considered low risk for diabetes.
The persons who had an HgbA1c between 5.9 and 6.5 were more than 8 times more likely to develop diabetes within 4 years than a person with a normal fasting glucose and a HgbA1c less than 5.7%
A study of 35 middle-aged adults conducted by UCLA researchers showed that those participants who spend more time sitting have the medial temporal lobe thickness, that is, an increase in brain atrophy compared with people who do spend much time seated.
Temporary medial atrophy detected by magnetic resonance is a finding which is found in cases of memory loss and Alzheimer's disease.
Siddarth P, Burggren AC, Eyre HA et al. Sedentary behavior associated with reduced medial temporal lobe thickness in middle-aged and older adults. PLoS ONE 13 (4): e0195549. https://doi.org/10.1371/journal.pone.0195549
Researchers at the University of California San Diego and Seoul National University report that person with 25-hydroxyvitamin D levels below 30 ng/ml have a 5 times greater risk for developing type 2 diabetes than people with levels above 50 ng/ml.
The prospective cohort study enrolled 904 healthy adults with a mean age of 74 years and followed them for 10 to 12 years. During that time 337 patients developed pre-diabetes and 47 patients developed diabetes.
Persons with 25-hydroxyvitamin D levels > 50 ng/ml had an HR = 0.19, CI = 0.06–0.56 when compared to individuals with 25 hydroxyvitamin D levels < 30 ng/ml. This means that individuals with higher 25-hydroxyvitamin D levels had an 81% decreased probability of developing prediabetes or diabetes.
Multiple recent research studies have found strong correlations between low levels of vitamin D and depression , dementia, schizophrenia, type 2 diabetes, and hypertension yet supplementation with pharmacologic vitamin D has not been proven to be as beneficial as outdoor activities to raise vitamin D levels.
There is a real possibility that sedentary behavior and lack of exercise is the confounding factor in this correlation between vitamin D and diabetes. After all lack of exercise leads to increased glucose, increased adiposity, hypertension, hyperglycemia and for many people decreased exposure to the sunshine which is necessary for vitamin D formation.
One of the recurrent nightmares faced by emergency medicine physicians is: What to do with a severely depressed and suicidal patient when there are no beds in a psychiatric facility?
Recent studies have indicated that one option may be ketamine. Previous studies of injected ketamine had indicated some benefits, but raised real concerns about the need for vital signs monitoring and prolonged observation prior to discharge.
This new study published in the American Journal of Psychiatry shows significant improvement in suicidal ideation and depression after administration of ketamine vía nasal aerosol.
In a double blind, multi-center prospective study, 68 people with severe depression or suicidal ideation were randomly assigned to receive 84 mg of intranasal ketamine or placebo twice weekly for 4 weeks. Significant improvement of depression was observed at 4 hours and at 24 hours in the group which received ketamine. Ketamine also improved suicidal ideation at 4 hours, although not at 24 hours.
Ketamine is not innocuous. Adolescents in particular may experience a adverse reaction where they become transiently agitated. Someone experienced with the use of ketamine should be present. While certainly this is far from definitive treatment, it possibly provides an additional treatment option for emergency situations.
Canuso CM, Singh JB. Fedgchin M, Alphs L et al. Efficacy and Safety of Intranasal Esketamine for the Rapid Reduction of Symptoms of Depression and Suicidality in Patients at Imminent Risk for Suicide: Results of a Double-Blind, Randomized, Placebo-Controlled Study. American Journal of Psychiatry 2018
Researchers have reported that increased consumption of juices and sweetened beverages is associated with cardiovascular disease and increased mortality among the overweight. The REGARDS study involved 17,930 participants age 45 years and older who were followed for an average of 6,9 years. There were 1465 deaths of whom 279 were associated with coronary artery disease. Those who drink more sweetened beverages and fruit juices doubled their risk of death from coronary vascular disease compared to those who consumed the least amount. This effect was strongest among obese patients. 
These results were reported in the American Heart Association's Epidemiology and Prevention Scientific Sessions 2018.
Over the mean follow-up period of 6.9 years, there were a total of 1465 all-cause deaths and 279 coronary heart disease deaths among the 17,930 participants.
The risk of coronary vascular disease was highest among those who consumed a mean of 20 ounces of juices and sweetened beverages. (Hazard ratio [HR], 2.0; 95% CI, 1.12 - 3.54) compared with those who consumed a mean of 0.8 ounces. Persons with a BMI between 25 and 29,9 also had increased mortality associated with increased juice and sweetened beverage consumption (HR, 1.12; 95% CI, 1.02 - 1.22; P = .04),
There are many explanations for this phenomenon. Increased sweetened beverage and juice consumption leads to increased insulin stimulation (due to glucose), increased hepatic gluconeogenesis, advanced glycation end products, and increased triglyceride levels (due to fructose and glucose) all of which contribute to formation of oxidized LDL, atherosclerosis and heart failure. 
 Collin L, Safford M, Vaccarino V and Welsh J. Abstract P235: Sugar-Sweetened Beverage and Food Intake and Mortality Risk Among U.S. Adults Circulation, 2018;137:AP235, originally published March 21, 2018
 Basta G, Schmidt AM, De Caterina R; Advanced glycation end products and vascular inflammation: implications for accelerated atherosclerosis in diabetes, Cardiovascular Research, Volume 63, Issue 4, 1 September 2004, Pages 582–592
In a cross sectional study published in the Journal of the American Heart Association looking at 4,426 participants with a median age of 50 years in Sao Paolo Brazil, researchers found that consumption of > 3 cups of coffee per day by persons who have never smoked led to a 63% decrease in the odds of finding significant coronary artery calcifications by CT scan. (OR: 0.37 [95% confidence interval, 0.15–0.91])
Miranda AM, Steluti J, Goulart AC et al. Consumption and Coronary Artery Calcium Score: Cross‐Sectional Results of ELSA‐Brasil (Brazilian Longitudinal Study of Adult Health) Journal of the American Heart Association. 2018;7:e007155, originally published March 24, 2018
This diagram is a modification of an illustration by InfoCan at Turkish Wikipedia CC BY 2.5 via Wikimedia
Atherosclerosis begins with an increase in LDL-P levels, that is, an increase in the number of small and dense LDL particles primarily as a result of excess refined carbohydrates (sugar and flour) which stimulate insulin secretion and fructose (juices and sweetened beverages) induced lipogenesis. Smaller LDL particles and VLDL enter the subendothelial space in proportion to their serum level. Apoprotein B of LDL and VLDL interacts with proteoglycans and LDL undergoes oxidation that initiates an inflammatory response. Chronic periodontitis or chronic infections with Chlamydia pneumoniae or Helicobacter pylori activates IL-6 and C-reactive protein and contributes to the inflammatory process.
The activation of NF-KB as a signal transducer for atherosclerosis and the inactivation of eNOS (which is the endothelial nitric oxide synthetase that produces nitric oxide) is the result of:
-A sedentary lifestyle or hypertension resulting in stasis and decreased shear stress. Atheromatous plaques begin at the bifurcations of the arteries.
-The consumption of refined carbohydrates such as flour and the excesses of fructose from sweetened beverages resulting in an increase in the products of advanced glycation,
- Tobacco consumption
- The insufficient consumption of fruits and vegetables that results in hyperhomocysteinemia and a deficiency of nitrates and polyphenols in the diet.
Inactivation of eNOS results in vasospasm. Activated endothelial cells express monocyte adhesion molecules known as VCAM-1 and chemokine MCP-1. Monocytes bind to VCAM-1 and MCP-1 facilitates the transmigration of monocytes to the subendothelial space. Monocytes are converted into macrophages and express receptors that allow phagocytosis of oxidized LDL cholesterol, VLDL and ApoE residues. The macrophages overflow with lipids and become foam cells. As the space fills with foam cells, they produce chemotactic and proliferative factors that recruit smooth muscle cells that migrate to form a fibrous barrier. If the fibrous layer is firm, the atherosclerotic plaque is stable but at the same time there is less likelihood of regression. If it forms a necrotic center the fibrous layer is more fragile and plaque rupture is more likely ..
To see this process in greater detail here is a more extensive summary:
Linton MF, Yancy PG, Davies SS, et al. The role of lipids and lipoproteins in atherosclerosis. Endotext
Multiple recent medical research studies have shown that exercise, even just walking for several hours a week, can prolong life, decrease the risk of 13 types of cancer, and even prolong survival time in patients with advanced colon cancer.
A prospective cohort study published in October 2017 in the American Journal of Preventative Medicine followed 62,178 men (mean age 70.7 years) and 77,077 women (mean age 68.9 years) for 13 years. They found that walking between 2 and 7 hours per week decreased mortality by 20% (HR = 0.74 CI 0.72 to 0.76). 
A prospective cohort study published in BMJ in February 2018 followed 1181 men between 71 and 92 years of age without pre-existing cardiovascular disease for 5 years to determine their level of physical activity. This study showed that even mild physical activity such as gardening or walking the dog, decreased mortality by 17% (HR = 0.83 CI 0.77 to 0.90) and if it accumulates 150 minutes per week the mortality decreases by 41% (HR = 0.59 CI 0.43 to 0.81). 
In an investigation published in JAMA in June 2016 with 1.44 million participants and an average age of 59 years showed that exercise decreases the probability of contracting 13 of 26 types of cancer: adenocarcinoma of the esophagus (HR, 0.58, 95% CI, 0.37-0.89), liver (HR, 0.73, 95% CI, 0.55-0.98), lung (HR, 0.74, 95% CI, 0.71-0.77), kidney (HR, 0.77, 95% CI, 0.70-0.85 ), gastric (HR, 0.78, 95% CI, 0.64-0.95), endometrial (HR, 0.79, 95% CI, 0.68-0.92), myeloid leukemia (HR, 0.80, 95% CI, 0.70-0.92), myeloma ( HR, 0.83, 95% CI, 0.72-0.95), colon (HR, 0.84, 95% CI, 0.77-0.91), head and neck (HR, 0.85, 95% CI, 0.78-0.93), rectal (HR, 0.87 95% CI, 0.80-0.95), bladder (HR, 0.87, 95% CI, 0.82-0.92), and breast (HR, 0.90, 95% CI, 0.87-0.93). 
Surprisingly, even patients who already have colon cancer have benefited from walking. In a study conducted by Harvard University of 992 men with stage III colon cancer, it was shown that 30 minutes of exercise per day decrease mortality compared to similar patients, in 42%. 
How does exercise prolong life, even in cancer patients?
It is theorized that because exercise increases glucose metabolism, and therefore decreases the level of circulating glucose in the blood, this results in a decrease in insulin levels and eventually a decrease in obesity.
High levels of insulin result in a decrease in insulin-like growth factor binding proteins 1 and 2 (IGFBP1 and IGFBP2), resulting in high levels of insulin-like growth factor-1 (IGF-1.). High levels of IGF-1 increase the risk of cancer of the breast and prostate, but also accelerate cell proliferation. and therefore the growth of several types of tumors with IGF-1 receptors. An increase in exercise and decrease in carbohydrate consumption results in a decrease in insulin and IGF-1 and therefore decreases the proliferation of cancer cells. 
In summary, in patients with cancer it has been shown that the benefit may come from the decrease in circulating insulin levels, because insulin helps multiply the tumor cells. 
In addition to decreasing insulin levels, and therefore IGF-1, exercise decreases estrogen levels. 
1. Patel AV, Hildebrand JS, Leach CR, et al. Walking in relation to mortality in a large prospective cohort of older US adults. Am J Prev Med 2018 Jan;54(1):10-19.
2. Jefferis BJ, Parsons TJ, Sartini C, et al. Objectively measured physical activity, sedentary behaviour and all-cause mortality in older men: does volume of activity matter more than pattern of accumulation? Br J Sports Med Published Online 12 February 2018.
3. Moore SC, Lee I, Weiderpass E, et al. Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults. JAMA Intern Med. 2016;176(6):816–825.
4. Blarigan EV, Fuchs CS, Niedzwiecki D, et al. American Cancer Society Nutrition and Physical Activity Guidelines after colon cancer diagnosis and disease free, recurrence free, and overall survival in CALGB 89803 J Clin Oncol 35, 2017 (suppl/abstr 10006)
5.Manjinder S. Sandhu, David B. Dunger, Edward L. Giovannucci; Insulin, Insulin-Like Growth Factor-I (IGF-I), IGF Binding Proteins, Their Biologic Interactions, and Colorectal Cancer, JNCI: Journal of the National Cancer Institute, Volume 94, Issue 13, 3 July 2002, Pages 972–980,
6. Brown JC, Rickels MR, Troxel AB, et al. Dose response effects of exercise on insulin among cancer survivors. Endocr Relat Cancer. 2018 Jan;25(1):11-19.
7. Brown JC, Kontos D, Schnall MD, Wu S, Schmitz KH. The Dose–Response Effects of Aerobic Exercise on Body Composition and Breast Tissue among Women at High Risk for Breast Cancer: A Randomized Trial. Cancer prevention research (Philadelphia, Pa). 2016;9(7):581-588. doi:10.1158/1940-6207.CAPR-15-0408.
Tinnitus is caused by damage to the sensory hair cells in the cochlea of the inner ear. In the absence of stimuli at a particular frequency it is theorized that there is an imbalance between excitatory and inhibitory neural pathways resulting in neural hyperactivity. There are measures which can help to prevent tinnitus but unfortunately in the vast majority of cases there is no effective treatment. Once it is confirmed that the tympanic membrane is normal and there is no cerumen in the ear canal, no effusion, no infection, and if the tinnitus is persistent and bothersome, the best thing is an audiological examination. Audiograms help to determine the pattern of hearing loss, and to indicate if there is significant risk of tumor, which is an unlikely cause. If there is hearing loss associated with bothersome tinnitus the use of hearing aids is sometimes helpful.
Tinnitus prevention includes:
1- Use NSAIDs infrequently or not at all.
2- Increase routine consumption of dietary fresh fruits, berries, unsalted nuts, fish, herbs and spices in order to obtain sufficient zinc, magnesium, flavonoids and other polyphenols.
3- Do not listen to loud music with headphones or ear buds.
4- Eliminate artificial flavorings and sweeteners, especially aspartame.
At a later date we will publish a complete article about the genetics of age related hearing loss and the rationale and details behind specific preventive dietary measures.
The New England Journal of Medicine mentions psychotherapy in this review article. The issue of psychotherapy mentioned in this article merits clarification. Tinnitus represents a malfunction of the central nervous system which is exacerbated by the absence of normal auditory stimulation, and may be the first symptom of hearing loss. While hearing loss can be measured there is still no way to measure tinnitus with instruments. People who have very loud and persistent tinnitus may suffer from depression and panic when they realize that it is not improving. Initial management may include sound machines with white noise, rain, waves or other sounds to mask the tinnitus until it becomes less distressing. Eventually after about five years patients may reach a state where the tinnitus is present, but they do not feel emotional distress with it. Until they reach acceptance psychotherapy can be beneficial in some cases. A review article can be found at the following link
Rothaus C. What nonpharmacologic approaches presently exist for the management of tinnitus? NEJM Resident 360
Noone has definitively proven the cause of Alzheimer's disease yet, however there are certain things that everyone agrees on. There is a genetic predisposition in some types. The biomarker is the deposition of beta amyloid protein in plaques found on autopsy, and more recently by PET scan, and this deposition is detectable a decade before symptoms begin. However attempts to cure the disease by eliminating beta amyloid protein have been less than successful.
What has been shown over the years is that there is a diffuse inflammatory process, perhaps a single common pathway with many causes, which leads to the deposition of beta-amyloid. The heartening finding on epidemiological and retrospective case control studies was the effect of Ibuprofen on disease initiation and progression. These results have not been born out by clinical trials, and many have suggested the failure of clinical trials is due to the need to initiate treatment before symptoms begin. The enthusiasm by researchers for this idea is understandable, even as geriatricians around the world shake their heads. What about the side effects of ibuprofen in the elderly which include gastrointestinal bleeding and renal insufficiency? How do we figure out who these people are that need treatment?
This study is a first step in solving the answer to the first question: How to figure out who needs treatment? These researchers report developing an ELISA test on saliva for beta amyloid protein which can detect Alzheimer's disease prior to clinical manifestations. Once that is solved the next question will be what delivery system (perhaps a nasal aerosol?) do we need to bypass the kidneys and GI tract.
McGeer PL, Guo JP, Lee M et al. Alzheimer's Disease Can Be Spared by Nonsteroidal Anti-Inflammatory Drugs. J Alzheimer's Dis (2018) 62 (3): 1219-1222