Background: Proton-pump inhibitor (PPI) use for management of gastroesophageal reflux disease (GERD) consists of a short-duration trial, according to guidelines. Long-term usage is appropriate under certain indications. Literature has increasingly documented an adverse effect profile of PPIs, including kidney disease and bone fragility. Objective: To investigate the rate of occurrence of osteopenia, osteoporosis, and chronic kidney disease (CKD) in patients using PPI therapy for longer than the recommended trial period of 8 weeks. Methods: Retrospective cohort analysis of a single-site primary care clinic. Patients aged 18 to 65 years with PPI prescriptions longer than 8 weeks were included. Information regarding PPI prescriptions, demographics, and medical diagnoses was collected. Results: The search discovered 293 PPI-users and 1908 never-PPI-users. Demographics varied, with a P-value <0.05 in age, body mass index (BMI), and black population (higher in PPI group). The PPI cohort featured higher rates of osteoporosis/osteopenia and CKD ( P < 0.001). The odds ratios (ORs) of diagnosis with PPI use was 2.91 (95% CI = [1.692, 4.979]) in osteoporosis/osteopenia. The OR was 1.14 (95% CI = [1.141, 2.229]) in CKD and PPI use but higher with diabetes, elevated BMI, black race, and male gender. Conclusions and Relevance: We observed increased occurrence rates of osteoporosis, or osteopenia, and CKD in patients with prolonged PPI use. Demographics varied in age, BMI, and black race proportion. A logistic regression revealed increased likelihood of kidney disease and osteoporosis/osteopenia in association with PPI use. These results add to the evidence regarding long-term PPI use and the development of these conditions, but additional studies are needed.

Introduction: Appropriate use of Proton Pump Inhibitor (PPI) therapy consists of an 8-week limited-time trial according to ACG guidelines. Due to patient symptomatic relief, PPI prescription length is often extended beyond the recommended therapy window without additional evaluation of symptoms. Despite their acceptance as safe medications, the adverse effect (AE) profile of PPI therapy has been increasingly documented. We aimed to investigate the rate of inappropriate PPI prescriptions, associated adverse events, and the financial implications of prescribing practices in our resident clinic. Methods: The Prisma Health IM residency clinic database was analyzed for active PPI prescriptions between 1/1/22 – 1/1/23. Data collected included: age, BMI, length of prescription, dosage and frequency of PPI, formal GI investigation of GERD symptoms, associated adverse effects. Adverse effects (AE) included osteopenia/osteoporosis, Clostridium Dificile infection, dementia, chronic kidney disease. Exclusion criteria consisted of Barrett’s Esophagus, esophageal strictures, Zollinger-Ellison Syndrome, Eosinophilic Esophagitis, Idiopathic Pulmonary Fibrosis, and chronic NSAID/aspirin use in those with a high risk for gastric bleeding. Results: A preliminary sample of 100 individuals was collected. Average age was 56 years with female gender predominance (n=76). Racial distribution was white (n=51), black/AA (n=49), and Hispanic (n=1). Within the included sample (n=85/100), 39 patients had a formal GI evaluation of their symptoms. All 85 patients exceeded the recommended 8-week trial. One year of therapy was exceeded in 60 patients. The average prescription length was 214 weeks. The most frequently prescribed PPI was pantoprazole. AE Occurrence Rates: Chronic kidney disease (n=15), osteopenia/osteoporosis (n=14), C. Dificile infection (n=8), and dementia (n=0). Conclusion: These results confirm that PPI therapy has been perpetuated at an immense rate within our patient population. While commonly associated adverse effects were noted, we are unable to attribute these to PPI use with the presently available data. Since our clinic features a majorly uninsured population, a cost analysis of our most prescribed PPI was performed. 30-day prescription at 40mg daily ranged from $5-30 monthly. At the lowest cost ($5), the average length of prescription for one patient would total $268. For the entire 85 patient cohort, $22,700. Extrapolated across our 500-patient cohort, the collective payor-burden equates to ∼$134,000.

10584 Background: Tumor suppressing genes BRCA1 and BRCA2 were discovered in 1990 and 1994, respectively, with mutations linked to hereditary breast-ovarian cancer syndromes (HBOCs). The discovery of these mutations has led to screening of at-risk patient populations and their family members. Women with BRCA1 or BRCA2 mutations are generally recommended to have prophylactic bilateral mastectomies and oophorectomies to decrease their future risk of cancer. While the initial discovery mostly focused on cancers in women, research has shown that BRCA mutations increase the risk of other cancers such as prostate cancer and pancreatic cancer, that also affect men. Previous research suggests that men are three times less likely to receive genetic testing in cancer driven by a 10:1 disparity in HBOC genetic testing. This was thought to be due to the lack of information on the importance of HBOC testing along with social roles in health. We wanted to evaluate the magnitude of the potential gender gap in BRCA testing in men compared to women. Methods: This was an IRB-approved, single center retrospective study to evaluate the rate of referrals to genetics for BRCA testing. Eligible patients had a personal history of cancer meeting criteria for BRCA testing per NCCN recommendations. Chart review was performed for patients with ovarian cancer, female breast cancer 45 years and younger, female triple negative breast cancer 60 years and younger, metastatic prostate cancer, all male breast cancer that have made an office visit since 2017, and pancreatic cancer since 2019. Rates of referral for genetic testing was the primary outcome and the groups were compared via the Chi-Square test. Results: 1,320 patients were included in the study, of which 664 were men and 656 were women. 128/664 (19.3%) of men were referred to genetics for screening compared to 527/656 (80.3%) for women ( p <.001). Additionally, 42/128 (32.8%) men who were referred for screening did not complete genetic screening compared to 72/527 (13.7%) women ( p <.001). A total of 62/541 (11.5%) patients who completed screening had either a BRCA1 or BRCA2 mutation. Conclusions: In our study, men were referred for BRCA testing significantly less than women for primary cancers, despite recommendation from the NCCN. In addition, men were also more than twice as likely not to complete genetic screening even if referred. The integration of genetics and oncology will continue to grow as personalized medicine continues to drive more treatment options. Closing this gender gap is important not only for familial screening purposes but also for treatment implications as patients with germline BRCA mutations are eligible for poly ADP ribose polymerase (PARP) inhibitors (e.g. olaparib) in both metastatic prostate cancer and pancreatic cancer. Further quality improvement initiatives are needed in order to close this gap by increasing education of the importance of BRCA testing in men.

INTRODUCTION: Acute fatty liver of pregnancy (AFLP) is a rare and potentially fatal condition characterized by microvesicular steatosis and liver failure. It typically presents in the third trimester or early postpartum period, but several cases have been described in the second trimester, with the earliest reported case at 18 weeks gestation. Diagnosis is based on the Swansea Criteria, though liver biopsy can be performed under certain circumstances. Treatment involves supportive care and prompt fetal delivery, with recovery expected over the ensuing days to weeks. We present the earliest known case of AFLP at 15 weeks gestation and detail how its clinical course masqueraded as autoimmune hepatitis (AH). CASE DESCRIPTION/METHODS: A 41-year-old G4P2103 with morbid obesity was transferred to our institution with jaundice, scleral icterus, and vomiting after laboratory testing revealed AST 51 IU/L, ALT 88 IU/L, ALP 191 IU/L, and TB 15 mg/dL. On admission she was alert and oriented with stable vital signs. Laboratory testing was notable for an ANA with >1:1280 titer. Additional autoantibodies, anti-cardiolipin, and ADAMTS13 were negative. Blood smear showed no hemolysis. On day 2 an abdominal ultrasound revealed intrauterine fetal demise, so dilation and evacuation were performed. There was no evidence of preeclampsia or hemolysis with elevated liver enzymes and low platelets, so she was treated with methylprednisolone out of concern for AH. She did not improve with steroids so liver biopsy was performed which revealed mixed micro- and macrovesicular steatosis consistent with AFLP and nonalcoholic fatty liver disease (NAFLD). She was transferred to a liver transplant center where she expired without further intervention. DISCUSSION: This case was challenging because AFLP has never been reported in the early second trimester and the presence of high ANA titers suggested an autoimmune etiology. The biopsy showed mixed micro- and macrovesicular steatosis with cytoplasmic ballooning, mild inflammation, and no fibrosis. AH was excluded due to the lack of interface hepatitis, rosettes, plasma cell inflammatory changes, or improvement with steroids. Although NAFLD is associated with autoantibodies it does not cause acute liver failure, which this patient experienced despite receiving the standard of care. Therefore, based on the patient's clinical course and biopsy we present the earliest case of AFLP complicated by concomitant NAFLD.Figure 1.: Low power, hematoxylin and eosin (H&E) stained section showing mild steatosis in a zonal pattern, primarily involving zone 3. The inflammation is mild with a lobular predominance, composed principally of lymphocytes and plasma cells with smaller populations of neutrophils and eosinophils.Figure 2.: High power, hematoxylin and eosin (H&E) stained section showing cytoplasmic ballooning of hepatocytes with the presence of Mallory's Hyaline (arrows).Figure 3.: High power, hematoxylin and eosin (H&E) stained section of microvesicular (arrowheads) and macrovesicular (asterisk) steatosis.

The incidence of inappropriate cardiac catheterization lab activation for treatment of a false ST-segment elevation myocardial infarction (STEMI) has been reported to be 2.6%-36%. Excessive inappropriate catheterization lab activation may be associated with risks to patients, provider fatigue and improper resource usage.HYPOTHESIS:To derive and validate a prediction score to more accurately classify patients with STEMI.METHODS AND RESULTS:We conducted a retrospective cohort analysis of 1144 consecutive patients initially diagnosed with STEMI between September 2008 and January 2013. The incidence of catheterization laboratory activation for false STEMI was 21.4%. Multiple logistic regression identified 8 factors as important for prediction of false STEMI. Using a prediction rule derived from these factors, the area under the curve for differentiating false from true STEMI patients was 0.80 (95% CI: 0.75-0.84). Using objective standards, criteria were defined that had 95% specificity for detecting patients with an incorrect diagnosis of STEMI.IN CONCLUSION:A prediction rule has been derived and validated in a large, racially diverse group to identify false STEMI patients with an incorrect classification rate of 5%, which is an improvement over current clinical practice. Prediction rules may be particularly useful in patients with atypical presentations in which emergent catheterization cannot be achieved rapidly or carries significant patient risk.