Patient: Female, 51Final Diagnosis: Gastrointestinal histoplasmosisSymptoms: Abdominal pain • nausea • vomitingMedication: —Clinical Procedure: —Specialty: Gastroenterology and HepatologyObjective:Adverse events of drug therapyBackground:Gastrointestinal involvement in patients with disseminated histoplasmosis is considered common since the organism is identified in the GI tract of approximately 70–90% of autopsy cases. This infection is rarely recognized by clinicians due to its non-specific symptoms. Lesions may occur anywhere in the GI tract but most commonly affects the terminal ileum. Patients present with GI bleeding, intestinal obstruction, ulcerations, masses, and peritonitis. Serum and urine serological antigens are useful for diagnosis because they are positive in over 90% of patients with disseminated disease but may be falsely negative in patients with localized GI involvement. Although histopathology and tissue cultures are specific, limitations include insensitivity and need for invasive procedures. Antifungal agents include intravenous amphotericin B for severe or unstable disease and oral itraconazole for stable disease.Case Report:A 51-year-old HIV positive female presented with abdominal pain, nausea and vomiting. A CT scan of the abdomen revealed circumferential narrowing around a segment of the sigmoid colon with the cecum demonstrating irregular thickened walls. A biopsy of an obstructing duodenal mass found on endoscopy revealed granulomatous inflammation and budding yeasts consistent with Histoplasma spp. She was started on intravenous liposomal amphotericin B and after 2 weeks switched to itraconazole oral solution. Urine and serum histoplasma antigens sent out 2 weeks after antifungal treatment were negative.Conclusions:This case report illustrates the importance of recognizing gastrointestinal histoplasmosis in AIDS patients presenting with non-specific GI symptoms.

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Objective To assess knowledge, attitudes, and perceived barriers (KAP) regarding e‐cigarette use counselling among adolescent healthcare clinical staff in an urban system, and to compare results between providers and rooming staff. Methods Primary care clinical staff (n = 169) completed an anonymous survey. Descriptive statistics and Chi‐square tests were used to summarize data and compare KAP between medical providers and rooming staff. Results Staff wanted to learn more about e‐cigarettes (87.6%). The most common knowledge deficits were how to use the 5As + 5Rs model for tobacco cessation counselling (66.7%) and the chemical content of e‐liquids (55.4%), with no differences across groups. Overall, 58% of providers expressed confidence in their ability to talk with adolescent patients about e‐cigarette use. The most common barriers to counselling were low knowledge about e‐cigarettes (74.0%) and how to refer adolescent patients for cessation support (43.8%). Conclusions Provider and rooming staff expressed similar educational needs surrounding e‐cigarettes, counselling, and treatment for adolescent patients. Clinical staff expressed confidence in their ability to affect change. There were no differences in the identified knowledge gaps or barriers to care between rooming staff and providers, suggesting that the same educational format can be used to target both groups.

Background Almost 20% of U.S. women remain at risk for cervical cancer due to their inability or unwillingness to participate in periodic clinic-based screening. Self-sampling has been shown to be an effective strategy for screening women for high-risk human papillomavirus (HR-HPV) infection in specific contexts. However, its effectiveness among medically underserved women in safety net health systems has not been evaluated. Furthermore, it is also unclear whether implementation strategies such as patient navigation can be used to improve the success of self-sample screening programs by addressing patient-level barriers to participation. Methods/design The Prospective Evaluation of Self-Testing to Increase Screening (PRESTIS) trial is a hybrid type 2 effectiveness-implementation pragmatic randomized controlled trial of mailed self-sample HPV testing. The aim is to assess the effectiveness of mailed self-sample HPV testing kits to improve cervical cancer screening participation among patients in a safety net health system who are overdue for clinic-based screening, while simultaneously assessing patient navigation as an implementation strategy. Its setting is a large, urban safety net health system that serves a predominantly racial/ethnic minority patient population. The trial targets recruitment of 2268 participants randomized to telephone recall (enhanced usual care, n = 756), telephone recall with mailed self-sample HPV testing kit (intervention, n = 756), or telephone recall with mailed self-sample HPV testing kit and patient navigation (intervention + implementation strategy, n = 756). The primary effectiveness outcome is completion of primary screening, defined as completion and return of mailed self-sample kit or completion of a clinic-based Pap test. Secondary effectiveness outcomes are predictors of screening and attendance for clinical follow-up among women with a positive screening test. Implementation outcomes are reach, acceptability, fidelity, adaptations, and cost-effectiveness. Discussion Hybrid designs are needed to evaluate the clinical effectiveness of self-sample HPV testing in specific populations and settings, while incorporating and evaluating methods to optimize its real-world implementation. The current manuscript describes the rationale and design of a hybrid type 2 trial of self-sample HPV testing in a safety net health system. Trial findings are expected to provide meaningful data to inform screening strategies to ultimately realize the global goal of eliminating cervical cancer. Trial registration ClinicalTrials.gov NCT03898167. Registered on 01 April 2019. Trial status Study start data: February 13, 2020. Recruitment status: Enrolling by invitation. Estimated primary completion date: February 15, 2023. Estimated study completion date: May 31, 2024. Protocol version 1.6 (February 25, 2020).

Background. Almost 20% of U.S. women (particularly low-income, racial/ethnic minorities) remain at risk for cervical cancer due to their inability or unwillingness to participate in periodic clinic-based screening. Self-sampling has been shown to be an effective strategy for screening women for high-risk human papillomavirus (HR-HPV) infection in specific contexts. However, its effectiveness among medically underserved women in safety net health systems has not been evaluated. Furthermore, it is also unclear whether implementation strategies such as patient navigation can be used to improve the success of self-sample screening programs by addressing patient-level barriers to participation.Methods/Design. The Pr ospective E valuation of S elf- T esting to I ncrease S creening (PRESTIS) trial is a hybrid type 2 effectiveness-implementation pragmatic randomized controlled trial of mailed self-sample HPV testing. The aim is to assess the effectiveness of mailed self-sample HPV testing kits to improve cervical cancer screening participation among patients in a safety net health system who are overdue for clinic-based screening, while simultaneously assessing patient navigation as an implementation strategy. Its setting is a large, urban safety net health system that serves a predominantly racial/ethnic minority patient population. The trial targets recruitment of 2,268 participants randomized to telephone recall (enhanced usual care, n=756), telephone recall with mailed self-sample HPV testing kit (intervention, n=756), or telephone recall with mailed self-sample HPV testing kit and patient navigation (intervention + implementation strategy, n=756). The primary effectiveness outcome is completion of primary screening, defined as completion and return of mailed self-sample kit or completion of a clinic-based Pap test. Secondary effectiveness outcomes are predictors of screening and attendance for clinical follow-up among women with a positive screening test. Implementation outcomes are reach, acceptability, fidelity, adaptations, and cost-effectiveness.Discussion. Hybrid designs are needed to evaluate the clinical effectiveness of self-sample HPV testing in specific populations and settings, while incorporating and evaluating methods to optimize its real-world implementation. The current manuscript describes the rationale and design of a hybrid type 2 trial of self-sample HPV testing in a safety net health system. Trial findings are expected to provide meaningful data to inform the equitable delivery of screening to at-risk populations and ultimately realize the global goal of eliminating cervical cancer.Trial registration: ClinicalTrials.gov NCT03898167. Registered 01 April 2019. https://clinicaltrials.gov/ct2/show/NCT03898167