David Carter

New global survey shows an increasing cancer burden.

Data show a 20% increase in breast cancer from 2008 to 2012.

Comprehensive sex education for teens is more effective than abstinence.

The United States has the highest rates of teenage pregnancy and sexually transmitted diseases (STDs) among developed countries— but the appropriate response has been contested because of debate over how sex education should be taught. Some federal laws promote an abstinence-only approach. Such legislation provides funds for abstinence-based programs and prohibits most programs from providing information about contraception or safer-sex practices. A recent study, however, has found that not only does that approach to sex education fail to prevent teenage pregnancies, it’s positively correlated with increases in teenage pregnancies and births. The sex education laws and policies in each of the 48 states studied were analyzed to determine the extent to which the state emphasized abstinence in its sex education program. (North Dakota and Wyoming were excluded, as they had no state law or policy regarding sex or STD and HIV education as of 2005.) States were assigned ordinal values from 0 to 3 in four categories of emphasis: no provision (0), abstinence covered (1), abstinence promoted (2), and abstinence stressed (3). The most recent data available from national reports on teenage pregnancy, teenage births, and abortion rates among teens 15 to 19 years of age were from 2005. Data analysis showed that the more abstinence was stressed, the higher were the rates of teen pregnancy and births. Of the four approaches, the most effective was level 1, which included comprehensive sex or HIV education (or both) and covered contraception, condom use, and abstinence. Anne Teitelman, assistant professor of nursing at the University of Pennsylvania, responded to the study by saying that with this additional evidence, NPs in family planning, adolescent health, and school nursing can be confident that providing comprehensive sexual health information to youths is appropriate and effective. “Practicing nurses can also reassure parents,” she added, “that talking with their teenagers about sex and contraception will not encourage sexual activity and will result in lessening the chance that young people will experience unintended pregnancy or sexually transmitted infections.” Barbara Huberman, a nurse and director of education and outreach for Advocates for Youth, noted that a major initiative, the Future of Sex Education, created new National Sexuality Education Standards, which were released in January (to read the standards, go to http://bit.ly/ zbbN8R). “Among developed countries, we’re the last to create national standards for minimum, essential core content and skills in sex education,” Huberman says. “School nurses are the most trusted by parents to deliver sex education,” she adds, and should be trained as sexuality educators and in providing “leadership in their school to adopt comprehensive sex education.”—David Carter

A 'hospital at home' program shows good outcomes.

Acute care in the home setting lowered costs and improved patient satisfaction.

CDC Advisory Warns of Possible Nationwide Increase in Fentanyl Deaths.

Improved detection and expanded use of naloxone are recommended.

Controversy over Cardiovascular Risks of Testosterone Therapy

In 2013 and 2014, several studies got widespread attention for their findings that men receiving testosterone therapy were at increased risk for cardiovascular complications, including myocardial infarction, stroke, and death. Because of the media coverage generated by these studies, some physicians stopped prescribing testosterone, and the U.S. Food and Drug Administration (FDA) announced plans to review the cardiovascular safety issues. In March of this year, the FDA issued an alert saying, in part, that health care professionals should make patients aware of the possible elevated cardiovascular risk associated with starting or continuing testosterone therapy. The FDA also required manufacturers to clarify the approved uses of testosterone therapy in their labeling. In February, however, a team of researchers published a review in Mayo Clinic Proceedings of the available literature on the cardiovascular risk associated with testosterone therapy and specifically singled out the 2013 and 2014 studies (by Vigen and colleagues and Finkle and colleagues, respectively) that had sparked the media storm and changes in prescribing practices, noting serious flaws in data collection and analysis, as well as two others, which they believe do not prove an elevated risk. Morgentaler and colleagues, who had submitted their data to the FDA for review during the agency’s public commentary period, note (as does an accompanying editorial) that there has been a widespread international call for the retraction of the study by Vigen and colleagues, who used unvalidated methodology to interpret the study’s findings and misrepresented the study population, among other mistakes. When that study’s data are appropriately interpreted, the authors write, they in fact demonstrate a lower percentage of adverse cardiovascular events in the men who received testosterone therapy than in the group that was untreated. Morgentaler and colleagues point out that testosterone deficiency has significant negative health effects in men, including increased risks of death, atherosclerosis, and incident coronary artery disease, as well as the worsening of cardiovascular risk factors such as obesity, increased fat mass, and insulin resistance. In fact, two decades of evidence suggest that testosterone therapy actually has a demonstrated history of alleviating this damage. The authors conclude that, although no definitive statement can be made about the absolute safety or risk of testosterone therapy, there is no conclusive evidence that it increases cardiovascular risk, and there is strong evidence that higher levels of testosterone ameliorate that risk. The FDA, in contrast, seems unconvinced.—David Carter

Drug Use Among Young People.

Despite some recent declines, the potential for relapse remains strong.

Potassium Monitoring in Young Women Taking Spironolactone for Acne is Unnecessary.

According to this study: * Spironolactone, an effective and inexpensive treatment for hormonally mediated acne, is safe for healthy women to use without being monitored for hyperkalemia. * Of 1,802 serum potassium measurements that were obtained, only 13 (0.72%) indicated hyperkalemia—and all 13 cases were mild.

Chikungunya virus spreads to the United States via Caribbean travel.

Concerns expressed that the disease may become endemic to the mainland.

Quitting smoking also improves mental health.

A lthough it has long been established that tobacco smokers can lessen the harmful effects of smoking on their physical health by quitting, the effects of smoking cessation on mental health haven’t been seen as so clear cut. Smokers are sometimes wary of even attempting to kick the habit because they believe smoking lessens depression, anxiety, and stress, but the opposite may actually be true. A new review of the literature on this subject has found evidence that quitting has significant mental health benefits. The report was based on a meta-analysis of 26 studies. The selected studies involved six different measures of mental health: anxiety, depression, mixed anxiety and depression, positive affect, psychological quality of life, and stress. The median age of the studies’ participants was 44 years; the median length of follow-up was six months. On average, study subjects had moderate nicotine dependence and smoked 20 cigarettes a day. The summary measure used for evaluating the studies’ data was the standardized mean difference (SMD) from baseline to followup between participants who quit smoking and those who continued smoking. According to the analysis, quitting smoking was associated with significant decreases in anxiety (−0.37 SMD), mixed anxiety and depression (−0.31 SMD), depression (−0.25 SMD), and stress (−0.27 SMD), as well a significant improvement in psychological quality of life (+0.22 SMD), when compared with continuing to smoke. The study authors theorize that the ability of smoking cessation to improve mental health may have a biological basis, but they conclude that, regardless of the causal mechanism involved, their analysis shows that “smokers can be reassured that stopping smoking is associated with mental health benefits.”—David Carter

The right balance between hand sanitizers and handwashing.

The use of alcohol-based hand sanitizers (ABHSs) in health care settings has become widespread since 2002, when the Centers for Disease Control and Prevention (CDC) recommended ABHSs for patient contact except when hands are physically soiled. But ABHSs aren’t effective against certain categories of pathogens, including noroviruses and Clostridium difficile. The question has therefore been raised whether overreliance on ABHSs has played a role in precipitating disease outbreaks or in creating more virulent strains of these pathogens. Finding the right answer to this question is urgent, given the severe impact of these diseases: 94% of C. difficile infections are connected to medical care, and between 2000 and 2007 C. difficile– related deaths increased by 400%. According to 2012 CDC data, 14,000 Americans die annually from C. difficile diarrhea. In addition, highly infectious noroviruses are suspected as the causative agent in more than 23 million U.S. gastroenteritis cases annually and cause approximately 60% of all acute gastroenteritis cases. From December 2006 to March 2007, marked increases occurred in norovirus illnesses across the United States in general, all associated with two new strains. Outbreaks in long-term care. A 2011 study in long-term care facilities that experienced norovirus outbreaks showed that facilities whose staff used ABHSs as often as or more often than soap and water were six times more likely to experience an outbreak. The CDC therefore modified its guidelines for hand hygiene, recommending that during outbreaks of norovirus and C. difficile health care workers use soap and water when in contact with patients (in addition to isolation, environmental disinfection, and gloving when treating them). The question remains: did the prevalent use of ABHSs rather than soap and water cause these outbreaks? Aron Hall, a norovirus expert and epidemiologist at the CDC’s Division of Viral Diseases, believes that wasn’t the case with norovirus, noting that “noroviruses mutate quite frequently. Every year a new strain emerges, replaces its predecessor as the predominant strain in circulation.” There’s really no evidence, he says, that ABHSs exert a selective pressure on the evolution of more virulent strains. Similarly, Clifford McDonald, a C. difficile authority and senior adviser for science and integrity at the CDC’s Division of Healthcare Quality Promotion, says there’s no convincing evidence that ABHSs have played a role in C. difficile outbreaks or strain selection. “All available evidence suggests that it was the widespread use of the fluoroquinolone antibiotics that had a role in the emergence and spread of NAP1 [a virulent and predominant epidemic strain].” McDonald recommends against further changes in CDC guidelines so that the significant progress ABHS use has brought about in reducing health care– associated infections won’t be lost. But what is the right overall balance for hand hygiene? The CDC notes that adherence to proper hand hygiene can be increased through ongoing education, reminding staff to rub all hand surfaces for 40 to 60 seconds with soap and water or 20 to 30 seconds with 3 to 5 mL of alcohol (at least).—David Carter