A woman with a normal uterus and duplicated cervices: A case report and review of a Müllerian anomaly.

Müllerian duct anomalies (MDAs) are common and can lead to problems with menstrual flow, pregnancy, and fertility. This is a case report of a 21-year-old woman with an incidentally found bicollis uterus with vaginal septum, which challenges the previously held principles of embryology and further supports the current theories that explain these transitional forms of female reproductive anomalies. Due to the irregularity found during the physical examination, detailed imaging with magnetic resonance helped to delineate the anatomy of the reproductive system and genitourinary (GU) tract, uncovering and confirming the anatomical abnormality. Due to the concern for future implications, especially during pregnancy, surgical excision of the vaginal septum was performed. This unique anomaly bolsters a discussion on the outcomes and implications of these unknown rare anomalies in various settings.

Integration of a Relationship-focused Counseling Intervention with Delivery of the Dapivirine Ring for HIV Prevention to Women in Johannesburg: Results of the CHARISMA Pilot Study.

Biomedical, female-initiated HIV prevention methods can help reduce disproportionately high HIV rates among women in sub-Saharan Africa, but male partner resistance and intimate partner violence (IPV) may impact ability to ensure effective use. To support consistent use of the dapivirine vaginal ring (VR), we pilot-tested the impact of the CHARISMA relationship counseling intervention ("CHARISMA") with women enrolled in the multi-site open-label Microbicide Trials Network (MTN) 025/HOPE trial at the Wits Reproductive Health and HIV Research Institute (Wits RHI) site in Johannesburg, South Africa. Lay counselors used a 42-item tool with five subscales to assess relationships and IPV and provide tailored counseling at enrolment, followed by a booster counselling session at Month 1 and follow-up checks at Months 3 and 6. We evaluated potential impact by examining self-reported ring disclosure to partners, partner clinic attendance, self-reported incident social harms (SH) and IPV, and biomarkers of ring adherence at Wits RHI. We subsequently compared these outcomes at three comparator HOPE study sites using multivariable regression models. Comparator study sites were purposively selected as those most similar to Wits RHI for baseline characteristics identified a priori. At Wits RHI, 95 of 96 (99%) HOPE participants enrolled into the CHARISMA pilot study. Mean age was 30, 36.8% lived with a partner, and 85.3% received their partner's financial support. During the six months of pilot study follow-up, participants reported: ring use disclosure to partners at 72.7% visits; 4.3% partners attending the research clinic; one partner-related SH; and 9.5% experienced incident IPV. The mean level of dapivirine released from returned used rings was 3.4 mg (SD 1.56), suggesting moderate adherence. Participants in the CHARISMA pilot had high background prevalence and incidence of IPV but were nevertheless able to adhere to ring use, and some male partners came to the research clinic. In adjusted regression models, compared to Wits RHI, partner clinic attendance was lower at all comparator sites; and significantly so at Site A (aRR 0.12, 95% CI 0.00-0.98). Sites B and C had lower levels of dapivirine released (suggesting lower adherence), but this difference was not significant. Site B women were more likely to report ring disclosure to partners at FU visits (aRR 1.12, 95% CI 1.00-1.25). IPV reported during follow-up was significantly lower at Site B (aRR 0.20, 95% CI 0.04-0.98, p = 0.047). CHARISMA taught women skills to decide on levels of ring-use disclosure to partners or others; therefore it is difficult to interpret differences in ring disclosure to partners with other sites. Similarly, CHARISMA heightened participants' awareness of abuse, possibly increasing IPV reports. Testing CHARISMA under fully-powered controlled conditions will improve understanding of its impact on women's relationships and ability to use female-initiated HIV prevention methods.

Acceptability and feasibility of the CHARISMA counseling intervention to support women's use of pre-exposure prophylaxis: results of a pilot study.

BACKGROUND: Women may need or seek male partner approval to safely and consistently use oral antiretroviral pre-exposure prophylaxis (PrEP) or vaginal microbicides. We developed CHARISMA, a counseling intervention to support women's relationships and their ability to consistently use HIV prevention products. METHODS: In a pilot study with 95 female participants in Johannesburg, South Africa, lay counselors implemented CHARISMA, assessing participants' relationship(s) with their male partner(s) and barriers or facilitators to HIV prevention method use, and then providing tailored, interactive counseling. We conducted study participant surveys and clinic staff interviews to evaluate CHARISMA's feasibility and acceptability. RESULTS: The CHARISMA pilot study indicates that a two-session relationship counseling intervention with 6-month follow-up to support women's ability to safely and effectively use vaginal microbicides was generally acceptable and feasible. Most participants thought CHARISMA was relevant, helpful, and about the right length, and that it had a positive impact on their relationships with their partners and their product use. Staff estimated that the intervention took 1.5-2 h to implement at enrollment and 45 min to an hour for the month 1 visit. They thought that overall CHARISMA was generally feasible to implement. CONCLUSIONS: Findings from this study suggest several lessons learned that may be relevant to others developing interventions supporting women's use of oral PrEP or vaginal microbicides. The use of lay counselors instead of nurses to deliver counseling appeared to be successful, but the counselors experienced significant stress from hearing about participants' traumatic experiences and required emotional support to avoid burnout. Although staff and participants felt that having multiple intervention sessions over time was valuable, a similar level of intensity may not be feasible in other settings. Further research is needed to determine an intervention delivery mode and follow-up period that optimally balances participant needs and clinic resources. Male engagement was a challenge, as it has been in previous studies of vaginal microbicides. Alternative strategies to reach men that do not require them to come to the clinic or rely on their female partners may be more effective.

Benign, Borderline, and Malignant Pediatric Adnexal Masses: A 10-Year Review.

STUDY OBJECTIVE: To investigate the incidence, clinical features, tumor markers, radiologic findings, types of surgeries, and histologies for adnexal masses in female pediatric and adolescent patients. DESIGN: Retrospective chart review. SETTING: Children's Health in Dallas and Plano, Texas from 2009 to 2018. PARTICIPANTS: Female patients younger than 19 years old who underwent surgical management of an adnexal mass. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Imaging characteristics, tumor markers, surgical procedures, and histopathology. RESULTS: In total, 752 patients (mean age, 13.7 years) underwent 756 surgical procedures for 781 adnexal masses. Of these, 732/781 (93.7%) were benign, 7/781 (0.9%) were borderline, and 42/781 (5.4%) were malignant. Of all 781 masses, 520/781 (66.6%) were ovarian and 261/781 (33.4%) were paratubal or tubal. Benign masses were associated with Hispanic race, pain, simple or cystic characteristics on imaging, and negative tumor markers. Borderline and malignant masses were associated with white race, pain, mass or distension, larger size, and heterogeneous appearance on imaging. Borderline masses were associated with negative tumor markers. Malignant masses were associated with elevated alpha fetoprotein, beta human chorionic gonadotropin, cancer antigen 125, and lactate dehydrogenase. CONCLUSION: Most adnexal masses in the pediatric and adolescent population are benign. Benign masses were significantly smaller, more likely to have negative tumor markers, and appear simple or cystic. There is little standardization with respect to preoperative tumor markers for adnexal masses. High-yield tumor markers for malignancy include alpha fetoprotein, beta human chorionic gonadotropin, cancer antigen 125, and lactate dehydrogenase. Low-yield tumor markers include inhibin A and B. Gynecologists performed more fertility-preserving surgeries including mini-laparotomies and fewer laparotomies for benign masses than pediatric surgeons.

Squamous Carcinoma of the Cervix in a 15-Year-Old with Congenital HIV: A Case Report.

BACKGROUND: Human papillomavirus (HPV) is the most prevalent sexually transmitted infection (STI) worldwide. Immunocompetent hosts have intact defense mechanisms to prevent HPV infection, but immunocompromised patients are at higher risk for complications, including HPV-related cancers. Most of these cancers originate from high-risk HPV strains in sexually active patients. CASE: Here we present a case of an immunocompromised adolescent who developed cervical cancer despite no prior sexual activity and only ever having had low-risk type HPV on biopsy. SUMMARY AND CONCLUSIONS: To our knowledge, this is the first case report of a cervical cancer arising from a low-risk HPV strain in an immunocompromised, non-sexually active adolescent. This case highlights the importance of preventive and screening mechanisms in immunocompromised populations, as they are have a higher probability of HPV-related complications, even in the absence of traditional risk factors.

Factors influencing women's decisions about pregnancy spacing: Findings from a focus group discussion study.

OBJECTIVES: Very short interpregnancy intervals are associated with negative health outcomes for mothers and children, and pregnancies with very short interpregnancy intervals are more likely to be unintended than pregnancies that are more widely spaced. The objective of this study was to improve understanding of women's motivations regarding pregnancy spacing. METHODS: In 2017, we conducted 8 focus group discussions with 49 English- and Spanish-speaking postpartum women in central North Carolina. The groups explored participants' preferences for birth spacing and factors that influenced their decisions. We recorded, transcribed, and coded the discussions and analyzed these data for core themes. RESULTS: Participants' ideas about when and whether to have more children were fluid-some had specific ideas during pregnancy or after delivery that changed over time; others had no definite plans. The primary reason for close birth spacing was to promote their children's having a closer relationship. Reasons for wider spacing included recovery from the previous pregnancy, challenges related to having 2 babies concurrently, and desire to wait for more favorable life circumstances. Participants did not mention health risks to children of short interpregnancy intervals and said that no health care providers discussed these risks with them. They had mixed perspectives about whether this information would influence their own child-spacing preferences but agreed that it should be shared with women to promote informed decision-making. CONCLUSION: This study adds to limited research regarding the factors that women consider when determining pregnancy spacing. Better understanding of women's motivations can help inform counseling to help women achieve their desired pregnancy spacing.

Age Moderates Perceived COVID-19 Disruption on Well-Being.

BACKGROUND AND OBJECTIVES: It is not fully understood how large-scale events affect well-being. Older adults showed the highest levels of resilience following the September 11th (9/11) terrorist attacks, but during the severe acute respiratory syndrome outbreak, there were no age-related differences in well-being. The current study examined the Coronavirus Disease 2019 (COVID-19) disruption on well-being throughout adulthood. RESEARCH DESIGN AND METHODS: Perceived stress and affect were examined in 166 community-dwelling adults (Mage = 35.65; SD = 15.53; range = 18-79) in relation to the perceived disruption of the COVID-19 pandemic to their lives. RESULTS: A significant moderation was found for age and COVID-19 disruption on perceived stress [F(5, 153) = 8.88, p < .05, R2 = .22] and negative affect [F(5, 154) = 4.91, p < .05, R2 = .14], but not for positive affect. For participants over 50, those who rated COVID-19 as a low or high disruption had similar scores on stress and negative affect, but with younger aged participants, perceiving high disruption corresponded with higher levels of stress and negative affect. DISCUSSION AND IMPLICATIONS: Findings are consistent with the strength and vulnerability integration (SAVI) model, wherein older adults try to maintain positive emotional well-being, with middle-aged and older adults in the current study having experienced less negative impact on well-being. Middle-aged and older adults may be better able to regulate negative emotions from COVID-19 than younger adults. SAVI proposes a greater negative impact on older adults when they experience sustained stressors; as the challenges with COVID-19 continue, further data will need to be examined.

Patients' and Caregivers' Experiences with the Multi-Payer Advanced Primary Care Practice Demonstration.

BACKGROUND: The patient-centered medical home (PCMH) model aims to improve primary health care using a patient-centered approach. Little qualitative research has investigated how the PCMH model affects patient experience with care. OBJECTIVE: To understand Medicaid and Medicare patient and caregiver experiences with PCMHs participating in the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration. DESIGN: Qualitative study. PARTICIPANTS: Medicare, Medicaid, and dually eligible patients who were patients in primary care practices participating in the MAPCP Demonstration and caregivers of such patients (N = 490). APPROACH: From July through November 2014, a trained facilitator conducted 81 focus groups in the eight states participating in the MAPCP Demonstration. Separate groups were held for Medicare high-risk, Medicare low-risk, Medicaid, and dually eligible beneficiaries, their caregivers, and caregivers of Medicaid children (or, in Vermont, with patients participating in the Support and Services at Home program), in two different geographical areas in each state. Focus group discussions were recorded, transcribed, and analyzed using NVivo qualitative data analysis software. RESULTS: Participants' experiences with care were generally consistent with the expectations of a PCMH, although some exceptions were noted. Medicaid only and dually eligible beneficiaries generally had less-positive experiences than Medicare beneficiaries. Most participants said their practices had not solicited feedback from them about their experiences with care. Few participants knew what the term "medical home" meant or were aware that their practices were working to become PCMHs, but many had noticed changes in recent years, primarily related to the conversion to electronic health records. CONCLUSIONS: Most participants had positive experiences with their care. Opportunities exist, however, to improve care for Medicaid and dually eligible beneficiaries, and enhance patient awareness of and involvement in PCMH practice transformation.

Technology and rehabilitation training for community health workers: Strengthening health systems in Malawi.

Community health workers (CHWs) have been effectively utilised in resource-limited settings to combat a growing demand for health access that cannot be met by the current workforce. The purpose of this study was to evaluate a CHW training programme in Malawi that integrated technology into rehabilitation care delivery. This was a retrospective cross-sectional study of a training programme conducted in December 2018. The participants were a convenience sample of all active home-based palliative care CHWs at St. Gabriel's Hospital (n = 60). The data collected included the following: a written pre- and post-knowledge test, skills competency checklist and a post-training programme survey. Descriptive frequencies described skill competency and quantitative responses from the post-training programme survey. Paired t test (α = 0.05) analysis determined the significance of knowledge acquisition. Themes in the narrative responses in the post-training survey were identified. Both training programme groups showed significantly greater knowledge on the post-test (M = 9.50, SD = 0.861; M = 9.43, SD = 0.971) compared to the pre-test (M = 7.97, SD = 1.351; M = 7.90, SD = 1.900); t(29) = 6.565, p < .001; t(29) = 4.104, p < .001 for Group 1 and Group 2, respectively. All participants demonstrated skill competency in 100% of the skills. All participants responded that the training programme helped them review skills and understand how to use technology 'A lot' on a Likert scale (no, a little, some, a lot). Facilitators of their work included training programmes, phones, communication with the hospital and collaboration amongst CHWs. Barriers included transportation needs, lack of patient care supplies and lack of caregiver compliance. Overall, utilisation of their knowledge and skills from the training programmes helped their patients make improvements in mobility and function that are meaningful to their quality of life in the village. This study highlights the importance of assessing programmes in low-resource settings with a focus on feasibility and developing local capacity.

Bleeding disorders in adolescents with heavy menstrual bleeding in a multicenter prospective US cohort.

Heavy menstrual bleeding is common in adolescents. The frequency and predictors of bleeding disorders in adolescents, especially with anovulatory bleeding, are unknown. Adolescents referred for heavy menstrual bleeding underwent an evaluation of menstrual bleeding patterns, and bleeding disorders determined a priori The primary outcome was the diagnosis of a bleeding disorder. Two groups were compared: anovulatory and ovulatory bleeding. Multivariable logistic regression analysis of baseline characteristics and predictors was performed. Kaplan Meier curves were constructed for the time from the first bleed to bleeding disorder diagnosis. In 200 adolescents, a bleeding disorder was diagnosed in 33% (n=67): low von Willebrand factor levels in 16%, von Willebrand disease in 11%, and qualitative platelet dysfunction in 4.5%. The prevalence of bleeding disorder was similar between ovulatory and anovulatory groups (31% vs 36%; P=0.45). Predictors of bleeding disorder included: younger age at first bleed (OR: 0.83; 95%CI: 0.73, 0.96), Hispanic ethnicity (OR: 2.48; 95%CI: 1.13, 5.05), non-presentation to emergency department for heavy bleeding (OR: 0.14; 95%CI: 0.05, 0.38), and International Society on Thrombosis and Haemostasis (ISTH) Bleeding Assessment Tool score ≥4 (OR: 8.27; 95%CI: 2.60, 26.44). Time from onset of the first bleed to diagnosis was two years in the anovulatory, and six years in the ovulatory cohort (log-rank test, P<0.001). There is a high prevalence of bleeding disorders in adolescents with heavy periods, irrespective of the bleeding pattern. Among bleeding disorders, the prevalence of qualitative platelet dysfunction is lower than previously reported.

Generating CHARISMA: Development of an Intervention to Help Women Build Agency and Safety in Their Relationships While Using PrEP for HIV Prevention.

This article describes the development of the Community Health clinic model for Agency in Relationships and Safer Microbicide Adherence intervention (CHARISMA), an intervention designed to address the ways in which gender norms and power differentials within relationships affect women's ability to safely and consistently use HIV pre-exposure prophylaxis (PrEP). CHARISMA development involved three main activities: (1) a literature review to identify appropriate evidence-based relationship dynamic scales and interventions; (2) the analysis of primary and secondary data collected from completed PrEP studies, surveys and cognitive interviews with PrEP-experienced and naïve women, and in-depth interviews with former vaginal ring trial participants and male partners; and (3) the conduct of workshops to test and refine key intervention activities prior to pilot testing. These steps are described along with the final clinic and community-based intervention, which was tested for feasibility, acceptability, and preliminary effectiveness in Johannesburg, South Africa.

Therapy for anogenital verrucae in preadolescent children with topical and systemic treatment.

BACKGROUND/OBJECTIVES: Anogenital verrucae (AV) are benign, human papillomavirus (HPV)-induced tumors of the anogenital skin and mucosa. Medical therapy for AV in preadolescents has not been well studied. We explore the efficacy and safety profile of sinecatechins 15% ointment and imiquimod 5% cream in the treatment of AV, alone and in combination therapy with other commonly used medications. METHODS: A single-institution, retrospective review of children under 12 years of age with AV treated with imiquimod 5% cream and sinecatechins 15% ointment was performed. Demographic data, side effects, and outcomes of therapy were recorded for each patient, and overall efficacy was determined. RESULTS: A total of 37 patients met inclusion criteria. Responses were seen in 8 out of 9 patients treated with sinecatechins 15% ointment (5 full, 3 partial, and 1 no response) and 9 out of 17 patients treated with imiquimod 5% cream (4 full, 5 partial, and 8 no response). Combination therapy with one or more of the following treatments (podophyllin, cimetidine, candida antigen injection, and HPV vaccine) were evaluated, but no combination was objectively superior to the others. No significant difference was found in overall efficacy between sinecatechins and imiquimod. Side effects were mild and limited to irritation and erythema. CONCLUSIONS: Both imiquimod 5% cream and sinecatechins 15% ointment are moderately effective in the treatment of AV in preadolescent children, with a trend toward greater effectiveness of sinecatechins. Combination therapy with other treatments did not significantly increase the effectiveness of topical therapies. Each modality has a tolerable side effect profile with a low risk of serious complications.

Female reproductive structures found in inguinal hernia sacs: A retrospective review.

BACKGROUND: In female infants undergoing herniorrhaphy, there is a reported incidence of 15%-20% of prolapsed adnexal structures. Our primary aim is to confirm the incidence of adnexal tissue in hernia sacs at the time of repair and to further delineate the clinical characteristics of this population at a major pediatric institution. METHODS: Retrospective chart review of all cases of herniorrhaphy in female patients less than the age of 18 from June 2009 to December 2015 in a large tertiary referral children's hospital. RESULTS: The overall incidence of patients with gynecological findings during herniorrhaphy was 11.2%. For patients with positive findings, the average gestational age at birth was 34.07 weeks, the age at surgery was 0.99 years, and the rate of right-sided hernias was 43.2%. For patients with negative findings, the average gestational age at birth was 38.23 weeks, the age at surgery was 5.14 years, and the rate of right-sided hernias was 23.2%. CONCLUSIONS: Incidence of adnexal structures found in hernia sacs is comparable to previously reported figures. These patients had a significantly lower gestational age at birth, lower age at surgery, and lower rate of right-sided hernias from the general population and from those without gynecological findings during herniorrhaphy. LEVEL OF EVIDENCE: Level II.

Managing chronic conditions care across primary care and hospital systems: lessons from an Australian Hospital Avoidance Risk Program using the Flinders Chronic Condition Management Program.

Objective The study aimed to determine the impact of the Flinders Chronic Condition Management Program for chronic condition self-management care planning and how to improve its use with Bendigo Health's Hospital Admission Risk Program (HARP). Methods A retrospective analysis of hospital admission data collected by Bendigo Health from July 2012 to September 2013 was undertaken. Length of stay during admission and total contacts post-discharge by hospital staff for 253 patients with 644 admissions were considered as outcome variables. For statistical modelling we used the generalised linear model. Results The combination of the HARP and Flinders Program was able to achieve significant reductions in hospital admissions and non-significant reduction in emergency department presentations and length of stay. The generalised linear model predicted that vulnerable patient groups such as those with heart disease (P=0.037) and complex needs (P<0.001) received more post-discharge contacts by HARP staff than those suffering from diabetes, renal conditions and psychosocial needs when they lived alone. Similarly, respiratory (P<0.001), heart disease (P=0.015) and complex needs (P=0.050) patients had more contacts, with an increased number of episodes than those suffering from diabetes, renal conditions and psychosocial needs. Conclusion The Flinders Program appeared to have significant positive impacts on HARP patients that could be more effective if high-risk groups, such as respiratory patients with no carers and respiratory and heart disease patients aged 0-65, had received more targeted care. What is known about the topic? Chronic conditions are common causes of premature death and disability in Australia. Besides mental and physical impacts at the individual level, chronic conditions are strongly linked to high costs and health service utilisation. Hospital avoidance programs such as HARP can better manage chronic conditions through a greater focus on coordination and integration of care across primary care and hospital systems. In support of HARP, self-management interventions such as the Flinders Program aim to help individuals better manage their medical treatment and cope with the impact of the condition on their physical and mental wellbeing and thus reduce health services utilisation. What does this paper add? This paper sheds light on which patients might be more or less likely to benefit from the combination of the HARP and Flinders Program, with regard to their impact on reductions in hospital admissions, emergency department presentations and length of stay. This study also sheds light on how the Flinders Program could be better targeted towards and implemented among high-need and high-cost patients to lessen chronic disease burden on Australia's health system. What are the implications for practitioners? Programs targeting vulnerable populations and applying evidence-based chronic condition management and self-management support achieve significant reductions in potentially avoidable hospitalisation and emergency department presentation rates, though sex, type of chronic condition and living situation appear to matter. Benefits might also accrue from the combination of contextual factors (such as the Flinders Program, supportive service management, clinical champions in the team) that work synergistically.

Vulvar Nodules: A Rare Presentation of Mastocytosis.

BACKGROUND: Mastocytosis is a rare benign disorder characterized by the finding of mast cells in the skin and other organs, occurring in adult as well as pediatric age groups. The cutaneous form is the most common presentation in childhood and is rarely located on the vulva. CASE: A 9-year-old prepubertal girl presented with bilateral vulvar nodules found incidentally by her pediatrician. Biopsy and histopathologic review confirmed mastocytosis. Her lesions significantly diminished over the following year. SUMMARY AND CONCLUSION: Mastocytosis should be on the differential for lesions on the vulva in children, in addition to the more common disorders such as condyloma acuminata and molluscum contagiosum. It is a benign condition in children, and conservative, symptomatic management is recommended.

A Computerized Family Planning Counseling Aid: A Pilot Study Evaluation of Smart Choices.

CONTEXT: Resource constraints may make it challenging for family planning clinics to provide comprehensive contraceptive counseling; technological tools that help providers follow recommended practices without straining resources merit evaluation. METHODS: A pilot study using a two-group, posttest-only experimental design evaluated Smart Choices, a computer-based tool designed to help providers offer more patient-centered counseling and enable patients to participate proactively in the counseling session. In two North Carolina family planning clinics, 214 women received usual counseling in March-May 2013, and 126 women used Smart Choices in May-July 2013. Exit interviews provided data for the evaluation. Multivariate Poisson and multinomial logistic regression analyses were performed to examine group differences in counseling outcomes. RESULTS: Three of 12 hypotheses tested were supported: Compared with controls, women in the intervention group knew more contraceptive methods (adjusted mean, 11.1 vs. 10.7); discussed more topics related to sexual health during counseling (1.2 vs. 0.9 among those reporting any discussion); and rated counseling as more patient-centered, an indication of how well they felt providers understood their family planning circumstances and ideas (3.9 vs. 3.7 on a scale of 1-4). Contrary to another hypothesis, controls were more likely than women in the intervention group to choose IUDs and implants. CONCLUSIONS: Computerized counseling aids like Smart Choices are in an early stage of development. Future research is warranted to develop tools that lead to more productive and individualized clinic visits and, ultimately, to more effective contraceptive use and reduced levels of unintended pregnancy.

Argentina's Successful Implementation Of A National Human Papillomavirus Vaccination Program.

Every year around fourteen million people globally are infected with human papillomavirus (HPV), the sexually transmitted virus that is the cause of most cervical cancers. A number of vaccines have been developed to protect against HPV, but in many countries, HPV vaccination rates have been low compared with rates for other recommended vaccines. Parental concerns, cost, and lack of information and awareness among both health professionals and parents are cited as important barriers to HPV vaccination. In Argentina the HPV vaccine has been provided to all eleven-year-old girls since 2011 as part of a comprehensive national program to prevent cervical cancer. Coverage increased from negligible levels before 2011 to a national average of 87.9 percent for the first dose, 71.6 percent for the second dose, and 52.2 percent for the third dose in 2013. There was a large variance in HPV vaccine coverage across the country's provinces. This article describes key strategies to overcome barriers to implementation of HPV vaccination and provides recommendations for policy makers.

Feasibility and acceptability of a computer-based tool to improve contraceptive counseling.

OBJECTIVE: The objective was to test the feasibility and acceptability of a computerized tool, Smart Choices, designed to enhance the quality of contraceptive counseling in family planning clinics. The tool includes (a) a questionnaire completed by patients and summarized in a printout for providers and (b) a birth control guide patients explore to learn about various contraceptive methods. STUDY DESIGN: In 2 family planning clinics, we conducted interviews with 125 women who used the Smart Choices computerized tool and 7 providers. RESULTS: Smart Choices integrated into clinic flow well in one clinic, but less well in the other, which had very short waiting times. Patients were generally enthusiastic about Smart Choices, including its helpfulness in preparing them and their providers for the counseling session and increasing their knowledge of contraceptive methods. Providers varied in how much they used the printout and in their opinions about its usefulness. Some felt its usefulness was limited because it overlapped with the clinic's intake forms or because it did not match with their concept of counseling needs. Others felt it provided valuable information not collected by intake forms and more honest information. Some found Smart Choices to be most helpful with patients who were unsure what method they wanted. CONCLUSIONS: Smart Choices is feasible to implement and well received by patients, but modifications are needed to increase provider enthusiasm for this tool. IMPLICATIONS: The Smart Choices tool requires refinement before widespread dissemination.

From mission to measures: performance measure development for a Teen Pregnancy Prevention Program.

The Office of Adolescent Health (OAH) sought to create a comprehensive set of performance measures to capture the performance of the Teen Pregnancy Prevention (TPP) program. This performance measurement system needed to provide measures that could be used internally (by both OAH and the TPP grantees) for management and program improvement as well as externally to communicate the program's progress to other interested stakeholders and Congress. This article describes the selected measures and outlines the considerations behind the TPP measurement development process. Issues faced, challenges encountered, and lessons learned have broad applicability for other federal agencies and, specifically, for TPP programs interested in assessing their own performance and progress.

Risk of early sexual initiation and pregnancy among youth reported to the child welfare system.

This study found that youth involved with the child welfare system have high rates of sexual risk behaviors and outcomes, including forced sex, early age at first sex, low contraceptive use, and pregnancy, which are more than double those of adolescents from the general population. Caseworkers may need training in how to address sexual risk factors and may need to support caregivers in addressing these issues with their children. Findings highlight the importance for case-workers, caregivers, and others to address the sexual and reproductive health needs of maltreated youth.