Involuntary reflexive pelvic floor muscle training in addition to standard training versus standard training alone for women with stress urinary incontinence: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: Although involuntary reflexive pelvic floor muscle contractions seem crucial during stress urinary incontinence-provoking situations, hitherto existing guidelines feature voluntary pelvic floor muscle training only. Two pelvic floor muscle protocols were compared regarding their effect on stress urinary incontinence in women: one focusing on standard physiotherapy with voluntary pelvic floor muscle training, the other additionally including involuntary reflexive pelvic floor muscle training. METHODS: This study was designed as a triple-blind prospective randomized controlled trial with women suffering from stress urinary incontinence with two physiotherapy intervention groups (control group: standard physiotherapy, n = 48, experimental group: standard physiotherapy plus involuntary reflexive pelvic floor muscle training triggered by whole-body movements such as jumps n = 48). Both interventions lasted 16 weeks (9 personal physiotherapy consultations and 78 home training sessions). Group differences and development over time were analyzed concerning the primary outcome International Consultation on Incontinence Modular Questionnaire Urinary Incontinence short form (ICIQ-UIsf) by mixed effect regression models. RESULTS: The ICIQ-UIsf score decreased significantly over time for both groups by about 3 points from about 10 to about 7 points with no group differences at any point in time. DISCUSSION: This trial did not find any additional benefit for stress urinary incontinence by adding involuntary reflexive pelvic floor muscle training to standard training. Both training protocols showed similar clinically relevant improvements; however, there was still moderate incontinence after interventions. Future studies should test and apply pelvic floor muscle function-oriented training methods for pelvic floor muscle hypertrophy, intramuscular coordination, and power, which are more in line with conventional skeletal muscle training, i.e., performed with higher intensities and workout.

Activation patterns of pelvic floor muscles in women with incontinence while running: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: Running is known to cause urinary leakage in women with stress urinary incontinence (SUI). Task-specific fiber-type recruitment while running can be estimated using wavelets. The aim of this study was to compare the effect of a new physiotherapy program including involuntary, reflexive training with a standard physiotherapy program on pelvic floor muscle (PFM) activation patterns and fiber-type recruitment behavior while running. METHODS: In this triple-blinded randomized controlled trial, women with SUI were randomly allocated to the control group (CON), which performed a standard physiotherapy program, or the experimental group (EXP), which received additional involuntary, reflexive training. PFM electromyography (EMG) was recorded during 10 s at three running speeds and analyzed using Morse wavelets. The relative distribution of power (%) over the frequencies from 20 to 200 Hz was extracted and analyzed within six-time intervals of 30 ms. Statistical nonparametric mapping was performed to identify power spectra differences. RESULTS: Thirty-nine (CON) and 38 (EXP) women were included. The power spectra showed no statistically significant group differences. The time intervals from 30 ms before to 30 ms after initial contact showed significantly lower intensities than the intervals from 30 to 150 ms after initial contact in the lowest and higher intensities in the highest frequencies for all running speeds and both groups. CONCLUSIONS: Power spectra shifts toward higher frequency bands in the pre-initial contact phase could indicate a feed-forward anticipation and a muscle tuning for the expected impact of initial contact event in order to maintain continence.

Impact of an Immersive Virtual Reality Curriculum on Medical Students' Clinical Assessment of Infants With Respiratory Distress.

OBJECTIVE: To determine whether exposure to an immersive virtual reality curriculum on pediatric respiratory distress improves medical students' recognition of impending respiratory failure. DESIGN: Randomized, controlled, prospective study conducted from July 2017 to June 2018. Evaluators blinded to student groupings. SETTING: Academic, free-standing children's hospital. PARTICIPANTS: All third-year medical students (n = 168) were eligible. The standard curriculum was delivered to all students during their pediatric rotation with optional inclusion of research data per Institutional Review Board review. A randomized selection of students was exposed to the virtual reality curriculum. INTERVENTION: All students received standard training on respiratory distress through didactics and high-fidelity mannequin simulation. Intervention students underwent an additional 30-minute immersive virtual reality curriculum, experienced through an OculusRift headset, with three simulations of an infant with 1) no distress, 2) respiratory distress, and 3) impending respiratory failure. MEASUREMENTS AND MAIN RESULTS: The impact of the virtual reality curriculum on recognition/interpretation of key examination findings, assignment of an appropriate respiratory status assessment, and recognition of the need for escalation of care for patients in impending respiratory failure was assessed via a free response clinical assessment of video vignettes at the end of the pediatric rotation. Responses were scored on standardized rubrics by physician experts. All eligible students participated (78 intervention and 90 control). Significant differences between intervention and control were demonstrated for consideration/interpretation of mental status (p < 0.01), assignment of the appropriate respiratory status assessment (p < 0.01), and recognition of a need for escalation of care (p = 0.0004). CONCLUSIONS: Exposure to an immersive virtual reality curriculum led to improvement in objective competence at the assessment of respiratory distress and recognition of the need for escalation of care for patients with signs of impending respiratory failure. This study represents a novel application of immersive virtual reality and suggests that it may be effective for clinical assessment training.

Teaching pediatric otoscopy skills to the medical student in the clinical setting: preceptor perspectives and practice.

BACKGROUND: Acute otitis media (AOM) is the most frequent indication for antibiotic treatment of children in the United States. Its diagnosis relies on visualization of the tympanic membrane, a clinical skill acquired through a deliberate approach. Instruction in pediatric otoscopy begins in medical school. Medical students receive their primary experience with pediatric otoscopy during the required pediatric clerkship, traditionally relying on an immersion, apprentice-type learning model. A better understanding of their preceptors' clinical and teaching practices could lead to improved skill acquisition. This study investigates how pediatric preceptors (PP) and members of the Council on Medical Student Education in Pediatrics (COMSEP) perceive teaching otoscopy. METHODS: A 30-item online survey was administered to a purposeful sample of PP at six institutions in 2017. A comparable 23-item survey was administered to members through the 2018 COMSEP Annual Survey. Only COMSEP members who identified themselves as teaching otoscopy to medical students were asked to complete the otoscopy-related questions on the survey. RESULTS: Survey respondents included 58% of PP (180/310) and 44% (152/348) of COMSEP members. Forty-one percent (62/152) of COMSEP member respondents identified themselves as teaching otoscopy and completed the otoscopy-related questions. The majority agreed that standardized curricula are needed (PP 78%, COMSEP members 97%) and that all graduating medical students should be able to perform pediatric otoscopy (PP 95%, COMSEP members 79%). Most respondents reported usefulness of the American Academy of Pediatrics (AAP) AOM guidelines (PP 95%, COMSEP members 100%). More COMSEP members than PP adhered to the AAP's diagnostic criteria (pediatric preceptors 42%, COMSEP members 93%). The most common barriers to teaching otoscopy were a lack of assistive technology (PP 77%, COMSEP members 56%), presence of cerumen (PP 58%, COMSEP members 60%), time to teach in direct patient care (PP 46%, COMSEP members 48%), and parent anxiety (PP 62%, COMSEP members 54%). CONCLUSIONS: Our study identified systemic and individual practice patterns and barriers to teaching pediatric otoscopy. These results can inform education leaders in supporting and enabling preceptors in their clinical teaching. This approach can be adapted to ensure graduating medical students obtain intended core clinical skills.

Standardized pelvic floor exercises improve stress urinary incontinence in women with intrinsic sphincter deficiency.

OBJECTIVES: Pelvic floor rehabilitation is the conservative therapy of choice for women with stress urinary incontinence (SUI). The success rate of surgical procedures in SUI patients with intrinsic sphincter deficiency (ISD) is low. The aim of this study was to analyse the effect of a standardized physiotherapy on patients with SUI and normotonic urethra and ISD. METHODS: In this study, 64 patients with ISD and 69 patients with normotonic urethra were enrolled. Maximum urethral pressure (MUCP) >20 cm H2 O was considered as normotonic urethral pressure. Before and after physiotherapy MUCP was measured and cough testing was performed. Additionally, patient reported outcome was assessed using the King's Health Questionnaire (KHQ). For statistical analyses Excel 2010 (Microsoft Inc; Redmond, Washington) and SPSS 20 (SPSS Inc; Chicago, Illinois) for Windows were used. Power calculation was based on the primary endpoint incontinence impact and general health. For power calculation, GraphPad Statmate version 2.00 for Windows was used. RESULTS: Sixty-four patients with ISD and 69 patients with normotonic urethra were included in the study. In SUI patients with normotonic and hypotonic urethra KHQ-scores regarding the primary endpoins "general health" and "incontinence impact" significantly improved following standardized physiotherapy. In both groups MUCP increased after physiotherapy. In SUI patients with ISD standardized physiotherapy resulted in a decreased incidence of a positive cough test. CONCLUSIONS: Standardized physiotherapy should be offered to patients with SUI and ISD. Long-term results are subject to future studies. Neurourol. Urodynam. 35:711-716, 2016. © 2015 Wiley Periodicals, Inc.

Higher antigen content improves the immune response to 2009 H1N1 influenza vaccine in HIV-infected adults: a randomized clinical trial.

BACKGROUND: The immunogenicity of a high hemagglutinin (HA) dose or a second dose of influenza vaccine in human immunodeficiency virus (HIV)-infected individuals has not been fully explored. METHODS: One hundered ninety-two HIV-infected individuals aged 18-64 years were stratified by CD4 cell count (<200 cells/mL or ≥200 cells/mL) and randomized to receive 2 doses of 15 µg or 30 µg HA 2009 H1N1 vaccine 21 days apart. Hemagglutination inhibition (HAI) and microneutralization (MN) antibodies were measured on days 0, 10, 21, 31, 42, and 201. RESULTS: Recipients of 30 µg HA had significantly higher HAI geometric mean titers (GMTs), compared with recipients of 15 µg HA on days 10 (139.0 vs 51.9; P = .01), 21 (106.7 vs 51.9; P = .001), and 31 (130.0 vs 73.7; P = .03) but not on days 42 (91.8 vs 61.6; P = .11) and 201 (43.0 vs 27.0; P = .08). When analyzed by CD4 cell count stratum, HAI GMTs were significantly higher among 30 µg HA recipients than among 15 µg HA in the CD4 cell count <200 cells/mL stratum on days 21 and 31 and the MN GMTs on days 10, 21, 31, and 42 (P < .05). In the CD4 cell count ≥200 cells/mL stratum, MN GMTs were significantly higher among recipients of 30 µg HA than among recipients of 15 µg HA on day 10 (P = .03). CONCLUSION: Increasing the HA dose of the 2009 H1N1 vaccine improves the vaccine's immunogenicity in HIV-infected individuals. CLINICAL TRIALS REGISTRATION: NCT00992433.

Attitudes Toward and Experiences With Discussing Pre-exposure Prophylaxis With Sexual Partners Among US Adolescents and Young Adults Living With HIV.

PURPOSE: Sexual partners of youth living with HIV are a key population for pre-exposure prophylaxis (PrEP). Among youth engaged in HIV medical care, we examined awareness of PrEP and experiences with and attitudes toward discussing PrEP with sexual partners. METHODS: We recruited 25 15-24-year olds from an adolescent/young adult HIV clinic to complete individual interviews. Interviews assessed demographics, PrEP knowledge, sexual behaviors, and experiences with, intentions toward, barriers, and facilitating factors to discussing PrEP with partners. Transcripts were analyzed using framework analysis. RESULTS: Mean age was 18.2 years. Twelve participants were cis-female, 11 cis-male, and two transgender female. Seventeen participants (68%) identified as Black, non-Hispanic. Nineteen acquired HIV sexually. Of 22 participants who had ever had sex, eight reported condomless sex in the prior 6 months. Most youth (17/25) were aware of PrEP. Only 11 participants had discussed PrEP with a partner; 16 reported high intention to discuss PrEP with future partners. Barriers to discussing PrEP with partners included participant-related barriers (i.e., discomfort disclosing HIV status), partner-related barriers (i.e., not open to or unfamiliar with PrEP), relationship-related barriers (i.e., new relationship, lack of trust), and stigma about HIV. Facilitating factors included positive relationship factors, educating partners about PrEP, and partners being receptive to learning about PrEP. DISCUSSION: Although many youth living with HIV were aware of PrEP, fewer had discussed PrEP with a partner. PrEP use by partners of these youth may be improved by educating all youth about PrEP and offering opportunities for partners to meet with clinicians to discuss PrEP.

Intervention effects maintenance: 6-month randomized controlled trial follow-up of standard and reflexive pelvic floor muscle training.

BACKGROUND: To date, the focus of pelvic floor muscle training for women suffering from stress urinary incontinence has been on voluntary contractions although involuntary pelvic floor muscle contractions are crucial to guarantee continence in high-impact situations typically triggering this condition. The authors developed 2 pelvic floor muscle home training programs, one including standard voluntary pelvic floor muscle training and one including involuntary reflexive pelvic floor muscle training. OBJECTIVE: This study aimed to test 2 pelvic floor muscle home training programs regarding maintenance of effects of a previous 16-week intervention in terms of stress urinary incontinence symptoms (International Consultation on Incontinence Modular Questionnaire-Urinary Incontinence short form, modified 20-minute pad test), impact on quality of life (Lower Urinary Tract Symptoms Quality of Life module), and digitally assessed pelvic floor muscle strength. STUDY DESIGN: This trial was a continuation of a previously published triple-blind prospective randomized controlled trial with a 6-month evaluation endpoint with 2 intervention groups (experimental group with involuntary reflexive home pelvic floor muscle training and control group with standard voluntary home pelvic floor muscle training). RESULTS: From the originally included 96 randomized and allocated participants (experimental group=46, control group=46), 33 control and 27 experimental participants completed the 6-month follow-up. From post-16-week physiotherapy intervention to 6-month follow-up (home pelvic floor muscle training), there were statistically significant improvements in pelvic floor muscle strength (control and experimental group), and no difference in the International Consultation on Incontinence Modular Questionnaire-Urinary Incontinence short form and pad test, or the Lower Urinary Tract Symptoms Quality of Life module Part B (control and experimental group) and Part A (control group). However, there was a statistically significant improvement in the Lower Urinary Tract Symptoms Quality of Life module Part A (experimental group). At no point in time (pre, post, follow-up) was there any statistically significant difference between the groups. CONCLUSION: Both groups could maintain their intervention training effects. This trial investigated involuntary reflexive pelvic floor muscle training alone, which proved to be an effective alternative to standard voluntary pelvic floor muscle training for maintenance of training effects among women suffering from stress urinary incontinence.

Integration of a Pilot Oral Health Curriculum into a Medical School Pediatric Rotation.

Purpose: The purpose of this study was to assess changes in medical student knowledge, skills, and beliefs in oral health after participating in an oral health curriculum that included an online learning module, shadowing pediatric dental residents, and applying fluoride varnish. Methods: Third-year medical students completed a precurriculum questionnaire. After completing the online module and clinical experience, students completed a postcurriculum questionnaire. Data were analyzed via descriptive statistics, and outcomes were assessed. Results: There was an improvement in knowledge and oral health-related skills questions postcurriculum. All questions on beliefs toward oral health showed a more agreeable response following the oral health curriculum. Conclusion: Interprofessional collaboration and oral health curriculum integration lead to positively changing the knowledge, attitudes, and skills of medical students.

Establishing Objective Measures of Clinical Competence in Undergraduate Medical Education Through Immersive Virtual Reality.

OBJECTIVE: The Association of American Medical Colleges defines recognition of the need for urgent or emergent escalation of care as a key Entrustable Professional Activity (EPA) for entering residency (EPA#10). This study pilots the use of an immersive virtual reality (VR) platform for defining objective observable behaviors as standards for evaluation of medical student recognition of impending respiratory failure. METHODS: A cross-sectional observational study was conducted from July 2018 to December 2019, evaluating student performance during a VR scenario of an infant in impending respiratory failure using the OculusRift VR platform. Video recordings were rated by 2 pair of physician reviewers blinded to student identity. One pair provided a consensus global assessment of performance (not competent, borderline, or competent) while the other used a checklist of observable behaviors to rate performance. Binary discriminant analysis was used to identify the observable behaviors that predicted the global assessment rating. RESULTS: Twenty-six fourth year medical students participated. Student performance of 8 observable behaviors was found to be most predictive of a rating of competent, with a 91% probability. Correctly stating that the patient required an escalation of care had the largest contribution toward predicting a rating of competent, followed by commenting on the patient's increased heart rate, low oxygen saturation, increased respiratory rate, and stating that the patient was in respiratory distress. CONCLUSIONS: This study demonstrates that VR can be used to establish objective and observable performance standards for assessment of EPA attainment - a key step in moving towards competency based medical education.

Adolescent Depression Curriculum Impact on Pediatric Residents' Knowledge and Confidence to Diagnose and Manage Depression.

PURPOSE: Despite the need for pediatricians to diagnose and manage adolescent depression, few pediatric residency curricula exist. This study evaluated the impact of an adolescent depression curriculum on pediatric residents' knowledge and confidence to manage depression. METHODS: A novel, case-based, adolescent depression curriculum simulating patient-provider continuity was developed and implemented within an adolescent medicine (AM) rotation. The curriculum addressed seven domains critical for diagnosis and management of adolescent depression. Participants were recruited from the pediatric residency at one institution. A survey assessed residents' demographics, prior training, and self-assessed knowledge and confidence within each domain using a retrospective pre-post evaluation. Wilcoxon signed-rank test evaluated changes in knowledge and confidence. RESULTS: Forty-two of a total 51 residents (82%) completed the curriculum and survey during their AM rotation. Residents reported that within their continuity clinic, 45% (n = 19) had never initiated medication for depression, and 60% (n = 25) did not manage their adolescent patients' depression medications. Comparisons before and after participation in the curriculum, using the retrospective pre-post survey, demonstrated increased self-assessed knowledge (p < .001, for each domain) and confidence (p < .001, for each domain). CONCLUSIONS: In this study, few residents reported experience initiating medication or managing adolescent depression in the continuity clinic. Residents demonstrated increased self-assessed knowledge and confidence to diagnose and manage adolescent depression after participation in a case-based adolescent depression curriculum simulating patient-provider continuity. Incorporation of training on management of adolescent depression into AM rotation may be a feasible option to standardize training within pediatric residency.

Oral Pre-Exposure Prophylaxis (PrEP) for HIV Prevention in Adolescents and Young Adults.

PURPOSE OF REVIEW: To review the literature about oral pre-exposure prophylaxis (PrEP) for HIV prevention, with specific focus on adolescents. RECENT FINDINGS: Use of PrEP reduces new HIV infections among men who have sex with men, heterosexuals, and people who inject drugs. One combination antiretroviral medication is approved for PrEP in the U.S. for adults. Limited data suggest that PrEP is safe for use in youth, although declines in adherence to PrEP over time suggest the need for adherence interventions specifically targeting youth. Safety concerns related to PrEP include potential negative impacts on bone density and renal function, as well as potential increases in riskier sexual behaviors. The U.S. Public Health Service has published guidelines for PrEP use in adults. SUMMARY: Current data suggest that PrEP use is safe in adolescents; however, further research is needed on the potential impact of long-term PrEP use on bone density and kidney function.

Adolescent Vaccination Strategies: Interventions to Increase Coverage.

While vaccines have decreased the burden of disease, many adolescents still remain under-immunized, particularly for human papillomavirus (HPV) and influenza. We review the most current data regarding adolescent immunizations in the United States and discuss proven strategies that work for increasing vaccination rates. Strategies that have been shown to improve rates include provider feedback, immunization information systems (or registries), and enhanced access outside of provider offices, such as school-based immunization programs. Overall, practices may want to consider multimodal quality improvement approaches to enhance practice vaccination rates. The public health and cost benefits of immunizing adolescents are well known, yet recent measles outbreaks in the United States have highlighted issues with state immunization laws and vaccine refusals. Providers should be clear in their advice regarding vaccines and use effective reminder strategies as parents commonly cite not having enough information or knowledge that a vaccine was needed for their adolescent. Additional research is needed regarding adolescent consent for vaccines, as well as adolescent and parental refusal, in order to design systems that will help inform families and allow for widespread vaccine availability.

Involuntary reflexive pelvic floor muscle training in addition to standard training versus standard training alone for women with stress urinary incontinence: study protocol for a randomized controlled trial.

BACKGROUND: Pelvic floor muscle training is effective and recommended as first-line therapy for female patients with stress urinary incontinence. However, standard pelvic floor physiotherapy concentrates on voluntary contractions even though the situations provoking stress urinary incontinence (for example, sneezing, coughing, running) require involuntary fast reflexive pelvic floor muscle contractions. Training procedures for involuntary reflexive muscle contractions are widely implemented in rehabilitation and sports but not yet in pelvic floor rehabilitation. Therefore, the research group developed a training protocol including standard physiotherapy and in addition focused on involuntary reflexive pelvic floor muscle contractions. METHODS/DESIGN: The aim of the planned study is to compare this newly developed physiotherapy program (experimental group) and the standard physiotherapy program (control group) regarding their effect on stress urinary incontinence. The working hypothesis is that the experimental group focusing on involuntary reflexive muscle contractions will have a higher improvement of continence measured by the International Consultation on Incontinence Modular Questionnaire Urinary Incontinence (short form), and - regarding secondary and tertiary outcomes - higher pelvic floor muscle activity during stress urinary incontinence provoking activities, better pad-test results, higher quality of life scores (International Consultation on Incontinence Modular Questionnaire) and higher intravaginal muscle strength (digitally tested) from before to after the intervention phase. This study is designed as a prospective, triple-blinded (participant, investigator, outcome assessor), randomized controlled trial with two physiotherapy intervention groups with a 6-month follow-up including 48 stress urinary incontinent women per group. For both groups the intervention will last 16 weeks and will include 9 personal physiotherapy consultations and 78 short home training sessions (weeks 1-5 3x/week, 3x/day; weeks 6-16 3x/week, 1x/day). Thereafter both groups will continue with home training sessions (3x/week, 1x/day) until the 6-month follow-up. To compare the primary outcome, International Consultation on Incontinence Modular Questionnaire (short form) between and within the two groups at ten time points (before intervention, physiotherapy sessions 2-9, after intervention) ANOVA models for longitudinal data will be applied. DISCUSSION: This study closes a gap, as involuntary reflexive pelvic floor muscle training has not yet been included in stress urinary incontinence physiotherapy, and if shown successful could be implemented in clinical practice immediately. TRIAL REGISTRATION: NCT02318251 ; 4 December 2014 First patient randomized: 11 March 2015.

Syphilis among adolescents and young adults in Cincinnati, Ohio: testing, infection and characteristics of youth with syphilis infection.

Little is known about the epidemiology of syphilis among adolescents and young adults. This study examined, among more than 17000 young people aged 13-22 years old, trends in rates of syphilis testing and infection; characteristics of infected adolescents; and agreement about syphilis staging and treatment between provider and chart reviewer. Rates of syphilis testing increased but rates of syphilis infection did not increase significantly over a 5-year period. A majority of infected men reported only opposite-sex sexual contact. High agreement between providers and chart reviewers was found. These findings demonstrate the need for complete assessment of risk factors and use of local epidemiology in screening practices.

Human immunodeficiency virus infection in adolescents.

Despite advances in human immunodeficiency virus (HIV) treatment and discovery of effective prevention programs, HIV infection in American youth continues to rise, especially in minority youth. The crisis underscores the lack of access to care and wellness of our adolescent and young adult populations. Primary care practitioners who care for young adults will diagnose and/or encounter HIV-infected patients in their practice. Providers need to become familiar with the basics of HIV prevention and treatment, as well as how adolescence presents unique challenges in HIV care.

Changes in human immunodeficiency virus testing rates among urban adolescents after introduction of routine and rapid testing.

OBJECTIVES: To examine human immunodeficiency virus (HIV) testing rates among adolescents during a 3-year period to determine (1) if the rate of testing increased after publication of national recommendations for routine HIV testing in 2006, and again after the introduction of rapid testing in the clinic in 2007, and (2) factors associated with HIV testing. DESIGN: Retrospective medical record review. SETTING: Urban hospital-based adolescent primary care clinic. PARTICIPANTS: Thirteen- to 22-year-old sexually experienced patients who had computerized billing data reflecting testing for sexually transmitted infections, including HIV. OUTCOME MEASURES: Rates of HIV testing for each of 3 one-year phases-phase 1 (pre-routine testing recommendations), phase 2 (post-routine testing recommendations but pre-rapid testing), and phase 3 (post-rapid testing)-and factors associated with HIV testing. RESULTS: In total, 9491 patients were included. The rate of HIV testing in phase 2 was significantly higher than the rate of testing in phase 1 (27.7% vs 12.6%, P < .001). The rate of testing in phase 3 was significantly higher than the rate of testing in phase 2 (44.6% vs 27.7%, P < .001) and phase 1 (P < .001). Factors independently associated with HIV testing included phase, older age, male sex, race, public insurance status, and having a genitourinary-related diagnosis during the same phase. CONCLUSIONS: The HIV testing rates increased significantly following publication of recommendations for routine testing and further increased following introduction of rapid testing. Combining routine and rapid testing strategies may increase uptake of HIV testing among adolescents in primary care settings.

Vaccine adherence in adolescents.

Although a number of routine and catch-up vaccinations are currently recommended for adolescents, coverage rates of these vaccines are currently suboptimal. Routine recommended immunizations for this cohort include vaccines for influenza, human papillomavirus, and meningococcal disease, as well as a booster for tetanus, diphtheria, and acellular pertussis. Adolescence is also a critical period for administration of catch-up vaccines for those not fully immunized during childhood. Adolescents who do not seek appropriate preventive healthcare are at risk for significant morbidity and possible mortality. Increasing adolescent adherence to recommended vaccine schedules presents a challenge and opportunity for pediatricians and public health advocates. This article outlines barriers to vaccine compliance among adolescents and discusses strategies to increase vaccine uptake.