Will it Hurt? The Intrauterine Device Insertion Experience and Long-Term Acceptability Among Adolescents and Young Women.

STUDY OBJECTIVE: To examine how the intrauterine device (IUD) insertion experience affects long-term IUD acceptability among adolescents. DESIGN: Text to Web survey study. SETTING: Boston Children's Hospital and Cambridge Health Alliance in Massachusetts. PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Nulliparous adolescents aged 13-21 years who received an IUD or etonogestrel implant between January 2012 and May 2018. RESULTS: We received survey responses from 95 adolescents (n = 46 IUD; n = 49 implant; response rate = 95/1098 (9%)). Mean current age (20.8 years) and time since device insertion (2.4 years) were similar between groups. Although a large proportion of both groups (64%) experienced moderate to severe preprocedural anxiety, IUD users expected more insertional pain compared with implant users (55.6 vs 39.6; P = .01). Compared with implant users, more IUD users experienced moderate to severe insertional pain (80% vs 18%; P < .0001), recalled that the procedure hurt more than expected (52% vs 4%; P < .0001), and endorsed lower rates of pain management satisfaction (72.4 vs 85.6; P = .04). Most respondents would recommend their method to a friend (75%) or consider getting the same device in the future (63%). When explicitly asked, more IUD users reported that dislike of the insertion procedure might or would probably prevent them from getting the same device in the future (41% vs 14%; P = .005). CONCLUSION: Compared with implant users, IUD users reported more negative insertion experiences, although preprocedural anxiety was prevalent in both groups. Dislike of the insertion experience might negatively affect adolescents' willingness to continue using an IUD in the future. Findings should encourage multimodal interventions to holistically improve the IUD insertion experience.

Pediatric Provider Education and Use of Long-Acting Reversible Contraception in Adolescents.

INTRODUCTION: Pediatric primary care providers prescribe the majority of contraception to adolescents, but they often lack training in long-acting reversible contraception (LARC). Our objective was to assess whether a provider education initiative was associated with a change in LARC use for adolescents. METHOD: Using electronic medical records, we examined LARC use for 7,331 women ages 15 to 21 years with an established primary care provider before and after a provider education initiative on LARC. We used an interrupted time series design to examine trends in LARC use related to the intervention. RESULTS: Before the intervention, 3.4% to 3.8% of adolescents were using a LARC method, and LARC use was declining by 4 devices/10,000 adolescents per month (95% confidence interval = [-5, -2] per 10,000 adolescents). After the intervention, LARC use stabilized. The number of adolescents using a LARC method increased nonsignificantly at 3, 6, 9, and 12 months after the intervention. DISCUSSION: Education of pediatric primary care providers reversed a trend toward decreased use of long-acting reversible contraception.

Provider and Health System Factors Associated with Usage of Long-Acting Reversible Contraception in Adolescents.

STUDY OBJECTIVE: Long-acting reversible contraception (LARC) is recommended as first-line contraception for adolescents. Surveys of primary care providers suggest that physician and clinic factors might influence LARC counseling, but their effect on usage is unknown. Our objective was to explore provider and clinic characteristics associated with LARC usage in adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a cross-sectional study of 5363 women ages 15-21 years receiving primary care within a large health system in Massachusetts in 2015. We used data abstracted from electronic medical records to characterize rates of LARC usage. We analyzed the association of provider (specialty, degree, gender, resident status, LARC credentialing) and clinic (Title X funding, onsite LARC provision, onsite obstetrician-gynecologist) factors with adolescents' LARC usage using multivariate logistic regression. RESULTS: Overall, 3.4% (95% confidence interval [CI], 2.9-3.9) of adolescents were documented as currently using a LARC method. Older adolescents were significantly more likely to use a LARC method (adjusted odds ratio, 2.41; 95% CI, 1.62-3.58 for women ages 20-21 years compared with ages 15-17 years). Adolescents whose primary care provider was a resident were significantly more likely to use a LARC method (adjusted odds ratio, 1.65; 95% CI, 1.02-2.68). Provider specialty, degree, gender, onsite LARC provision, and onsite obstetrician-gynecologist were not significantly associated with LARC usage in adolescents. CONCLUSION: Being older and having a primary care provider early in their training increased the odds of LARC usage among adolescents in a large Massachusetts health system. Across primary care specialties, educating providers about the appropriate uses of LARC methods in nulliparous adolescents might facilitate LARC usage.

Interleukin-17A mediates acquired immunity to pneumococcal colonization.

Although anticapsular antibodies confer serotype-specific immunity to pneumococci, children increase their ability to clear colonization before these antibodies appear, suggesting involvement of other mechanisms. We previously reported that intranasal immunization of mice with pneumococci confers CD4+ T cell-dependent, antibody- and serotype-independent protection against colonization. Here we show that this immunity, rather than preventing initiation of carriage, accelerates clearance over several days, accompanied by neutrophilic infiltration of the nasopharyngeal mucosa. Adoptive transfer of immune CD4+ T cells was sufficient to confer immunity to naïve RAG1(-/-) mice. A critical role of interleukin (IL)-17A was demonstrated: mice lacking interferon-gamma or IL-4 were protected, but not mice lacking IL-17A receptor or mice with neutrophil depletion. In vitro expression of IL-17A in response to pneumococci was assayed: lymphoid tissue from vaccinated mice expressed significantly more IL-17A than controls, and IL-17A expression from peripheral blood samples from immunized mice predicted protection in vivo. IL-17A was elicited by pneumococcal stimulation of tonsillar cells of children or adult blood but not cord blood. IL-17A increased pneumococcal killing by human neutrophils both in the absence and in the presence of antibodies and complement. We conclude that IL-17A mediates pneumococcal immunity in mice and probably in humans; its elicitation in vitro could help in the development of candidate pneumococcal vaccines.