Background Ending the HIV epidemic requires linkage of at-risk individuals from diverse health care settings to comprehensive HIV prevention services. Sexually transmitted infections (STIs) are significant biomarkers of HIV risk and should trigger preexposure prophylaxis (PrEP) discussion. We reviewed STI testing practices outside of sexual health clinics to identify opportunities for improvement in the provision of HIV prevention services. Methods An electronic sexual health dashboard was used to identify patient encounters with a positive gonorrhea, chlamydia, and/or rapid plasma reagin test result between January 1, 2019, and August 23, 2019, at a large urban academic medical center. A retrospective chart review was performed to assess HIV testing, completeness of STI screening, and HIV prevention discussion; inadequate screening was defined as no HIV test in 12 months before STI diagnosis. Results A total of 815 patients with 856 patient encounters were included. Patients were predominantly female (64.4%); median age was 24 years (range, 18–85 years). The most common test and most common positive test result was the genitourinary gonorrhea/chlamydia nucleic acid amplification test. Multisite testing was rare (7.5% of patient encounters) and performed more frequently in men than in women (20.3% vs. 0.36%). Women were also more likely to be inadequately screened for HIV (15.1% vs. 25.8%). Documentation of PrEP discussion was rare (4.7% of patient encounters) compared with safe sex (44.6%) and condoms (49.8%). Preexposure prophylaxis was discussed almost exclusively with men compared with women (17% vs. 1.1%). Conclusions In patients diagnosed with bacterial STI outside of sexual health clinics, gaps in HIV prevention exist. HIV screening, multisite STI screening, and discussion of PrEP were particularly infrequent among women.

Background: HIV preexposure prophylaxis (PrEP) remains underutilized despite its efficacy and potential population impact. Achieving PrEP's full potential depends on providers who are knowledgeable and comfortable prescribing it to individuals at risk of acquiring HIV. Previous educational interventions targeting provider-related uptake barriers have had limited success. We designed and tested an electronic medical record (EMR) interpretative comment to improve the delivery of PrEP.Methods: An EMR comment provided information on PrEP eligibility and referral resources to providers delivering positive chlamydia and gonorrhea results. Positive test results for bacterial sexually transmitted infections before intervention (January 1, 2019-August 23, 2019) and after intervention (August 24, 2019-December 31, 2019) were identified. A retrospective chart review was conducted to ascertain provider documentation of PrEP discussions or provision, HIV prevention discussions, and HIV screening. Pretest-posttest analysis was performed to compare the provision of PrEP and HIV prevention services. Results:We reviewed 856 preintervention encounters spanning 8 months and 461 postencounters spanning 4 months. Patient demographics were comparable. We observed an increase in provider documentation of safe sex and condom counseling (odds ratios [ORs], 1.2 [95% confidence interval {CI}, 1.07-1.18] and 1.11 [95% CI, 1.05-1.17], respectively), and the absence of any HIV prevention discussion decreased (OR, 0.85; 95% CI, 0.80-0.90), but not HIV screening or PrEP documentation. Conclusions:We demonstrated that an EMR laboratory comment had a modest effect on increasing risk reduction counseling, although not HIV screening or PrEP prescriptions. Future strategies to encourage provider delivery of sexual health services may benefit from more targeted strategies that combine behavioral and information technology approaches.

We present a patient who had localized chest pain for at least five years and was diagnosed with clear cell chondrosarcoma as an incidental finding on a chest roentgenogram obtained for reasons unrelated to his chest pain.CASE PRESENTATION: A 56-year-old male was seen in primary care for acute on chronic right breast pain. He had multiple prior encounters with atypical chest pain in the same area over the previous five years. He was referred for EKG and cardiac stress testing, which he never completed. Physical exam was notable for right gynecomastia and pseudo-folliculitis. No further evaluation was recommended; he was advised to use warm compresses. As part of a worker's compensation case after exposure to generator fumes, a chest roentgenogram demonstrated a right mid-lung zone partially calcified mass. CT chest revealed an expansile right fourth rib lesion near the costochondral junction measuring 9.8 cm x 7.4 cm. CT guided biopsy demonstrated a mesenchymal neoplasm with epithelioid cells and clear cells. Immunostaining was strongly positive for S100, vimentin, H3 K36M, and clusterin; ALK1 and CD138 negative. A definitive diagnosis could not be made, favored to be chondroblastoma with atypical features, although clear cell chondrosarcoma could not be excluded due to H3 K36M staining. He underwent successful chest wall resection and reconstructive surgery with negative tumor margins. Final pathology was clear cell chondrosarcoma based on the presence of clear cells and areas of invasion. Surveillance CT chest 9 months post-op was negative for signs of recurrence.DISCUSSION: Clear cell chondrosarcoma is a rare, low-grade bone sarcoma, occurring in 2-3% of all chondrosarcoma patients. It tends to involve long bones (90%) and the epiphysis as opposed to chondrosarcomas which involve the pelvis, hip, shoulder, metaphysis and diaphysis. Due to its low-grade activity and indolent course, diagnosis is often delayed a year or longer. It may be difficult to distinguish from chondroblastoma, but clear cell chondrosarcomas occurs mostly in older patients (3rd to 5th decade) as opposed to children and young adults (chondroblastoma). H3 K36M staining occurs primarily in chondroblastoma, but can occur in chondrosarcoma. The most common presenting symptom is localized pain. This patient's intermittent symptoms and missed diagnostic studies delayed his diagnosis, which would have been facilitated with a routine chest roentgenogram. Clear cell chondrosarcomas are notoriously resistant to chemotherapy and radiation; wide surgical resection represents definitive therapy.CONCLUSIONS: Clear cell chondrosarcoma is a challenging tumor to diagnose clinically and pathologically; immunostaining for H3 K36M may help. This case underscores the importance of chest radiography in evaluating any patient with chest pain.