Study Objective Long-acting reversible contraceptive (LARC) methods are the most effective form of reversible contraception but are underutilized by adolescents. The purpose of this study is to identify the context-specific barriers to providing adolescents with LARC that are experienced by pediatricians, family medicine physicians, and advanced practice nurses (APNs). Design/Settings/Participants Pediatricians, family medicine providers and APN's (n=16) who care for adolescents participated in semi-structured qualitative interviews. Interview data were analyzed through a modified grounded theory approach. Main Outcome Measures Pediatricians, family medicine physicians and APNs' self-reported attitudes and practices regarding LARC provision to adolescents. Results Provider confidence in LARC, patient-centered counseling on LARC and instrumental supports for LARC all work interdependently either in support of or in opposition to provision of LARC to adolescents. Low provider confidence in LARC for adolescents was characterized by confusion about LARC eligibility criteria and perceptions of LARC insertion as traumatic for adolescents. Patient-centered counseling on LARC required providers' ability to elicit patient priorities, highlight the advantages of LARC over other methods and address patients' concerns about these methods. Instrumental supports for LARC included provider training on LARC, access to and financial support for LARC devices and opportunity to practice LARC insertion and counseling skills. Conclusions While none of the identified essential components of LARC provision to adolescents exist in isolation, instrumental supports like provider training on LARC and access to LARC devices have the most fundamental impact on the other components and on providers' attitudes and practices regarding LARC for adolescents.

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Little is known about hepatic T lymphocyte subpopulations in the human liver. The aim of this study was to document the various subpopulations present in the liver and compare them to peripheral T lymphocytes in the same patients. Normal hepatic tissue was obained at time of transplant from five patients, and a single cell suspension of lymphocytes were prepared by standard methods. Ceils were stained with monoclonal antibodies specific for CD8ct and CD8B chains, CD4, CD8, CD3, o~BTCR, and ySTCR, and analyzed by two and three colour flow cytometry. Of the hepatic CD3+ cells, 71% were CD8+ and 25% were CD4+, with a CD4/CD8 ratio of 1:3 in contrast to the peripheral CD4/CD8 ratio of 2:1.18% of the hepatic CD3+ cells expressed ySTCR. Significantly, CD8~ct accounted for 27% [mean] of the total hepatic CD8+ population. Conclusion: There is now evidence that the adult human gut can support extrathymic T cell differentation. A significant population of hepatic CD8txct cells would suggest that the liver is also a site of extrathymic differentiation, which may have important implications for the understanding of autoimmunity and graft tolerance.

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