Fellowship Board Pass Rates Rising: Analysis of Pathology Subspecialty Board Examination Performance

CONTEXT.—

The American Board of Pathology (ABPath) publishes annual performance data for the anatomic pathology (AP) and clinical pathology (CP) board examinations, as well as for ABPath subspecialty examinations. Overall board pass rates for all AP and CP board examinees have increased during the past decade; however, no study has analyzed the board pass rates for pathology subspecialty examinations, and whether these follow the same trend.

OBJECTIVE.—

To evaluate ABPath subspecialty examination pass rates to assess the trend in certification.

DESIGN.—

We analyzed the total number of first-time test takers and board pass rates for 11 pathology subspecialties recognized by the ABPath from 2007 to 2021, acquired from annual reports published by the ABPath. We compared the pass rates in 5-year intervals (2007-2011, 2012-2016, 2017-2021) for each individual specialty. We also analyzed the pass rate of CP subspecialties compared with AP subspecialties.

RESULTS.—

The overall mean pass rate for ABPath subspecialty examinations during the previous 15 years was 89% (range, 78.9%-100%), with the overall pass rate being significantly higher in 2017-2021 (P = .02). The contemporary overall rate of passing was significantly higher for AP subspecialty examinations (P < .001) and was higher, though not significantly, for CP subspecialties (P = .13). There were significant differences between first-time test takers' mean pass rate (92.1%), repeat test takers' mean pass rate (54.5%), and the overall rate (P < .001).

CONCLUSIONS.—

Contemporary pathology subspecialty board examination pass rates are significantly higher than historic rates, possibly reflecting continuously improving and readily available preparatory materials.

Effect of TPE vs medical management on patient outcomes in the setting of hypertriglyceridemia-induced acute pancreatitis with severely elevated triglycerides

OBJECTIVES

Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) accounts for 1 to 10% of pancreatitis cases, and is associated with a more severe clinical course. Therapeutic plasma exchange (TPE) is a potential treatment option for quickly lowering plasma triglycerides (TG). Current ASFA guidelines define HTG-AP as a Category III disorder, indicating the role of apheresis is not firmly established. Here, we examine clinical data regarding its effectiveness on morbidity and mortality in patients with HTG-AP presenting with severely elevated plasma triglycerides (>4000 mg/dl).

METHODS

We retrospectively examined clinical data and outcomes from 67 consecutive episodes of HTG-AP over a 5-year period in which either medical management alone or medical management plus adjunct TPE was employed to reduce plasma triglycerides.

RESULTS

16/67 admissions involved TPE, initiated at a mean of 0.7 days from the time of presentation, while 51 received medical management alone. After only one TPE procedure, the mean TG values decreased from 4103 to 1045 mg/dl (a reduction of 74.7%), and those receiving TPE reached plasma TG < 1000 mg/dl 0.99 days faster than the medical group. One patient in the TPE group died. However, when excluding patients with hospital courses complicated by multiple organ dysfunction, there was no significant difference in mortality or hospital length of stay (LOS) between the groups.

CONCLUSIONS

In uncomplicated cases of HTG-AP with an absence of multiorgan dysfunction, there is no significant benefit to either mortality or LOS when adding adjunct TPE to medical management, even when patients present with severely elevated levels of TG.

Immune checkpoint inhibitor toxicity: A new indication for therapeutic plasma exchange?

Novel immune-modulating anticancer drugs are being used with increasing frequency. With increased use, there are more frequent cases of toxicities caused by these drugs, termed immune-related adverse events (irAEs). We present a case in which we successfully treated a case of severe, steroid-refractory, nivolumab-induced myocarditis with therapeutic plasma exchange (TPE). Nivolumab is an immune checkpoint inhibitor (ICI) which blocks programmed death receptor-1 (PD-1). This blockade allows for enhanced T-cell function and increased anti-tumor response. The patient presented with signs and symptoms of heart failure and was found to have a significantly depressed cardiac ejection fraction. Over the course of her five TPE procedures, she improved clinically and was discharged home with improved left ventricular ejection function. This case suggests an emerging role of TPE in the management of severe ICI-induced toxicity, such as myocarditis.

Therapeutic plasma exchange for hypertriglyceridemia induced pancreatitis: A rapid and practical approach

OBJECTIVES

Acute hypertriglyceridemia induced pancreatitis (HTP) presents with a more severe clinical course compared to other etiologies of pancreatitis. Therapeutic plasma exchange (TPE) is a potential treatment option for lowering plasma triglycerides and possibly decreasing morbidity and mortality. However, clinical data regarding its effectiveness are limited.

METHODS

We retrospectively examined the clinical data and outcomes of 13 consecutive episodes of HTP in which TPE was employed to reduce plasma triglycerides during a 15-month period.

RESULTS

The TPE was initiated at a median of 19 hours from the time of presentation. We performed 1.2-1.5 volume TPEs with 5% albumin as the replacement fluid. After only one TPE procedure, the mean plasma triglycerides values decreased from 2993 mg/dl to 487 mg/dl with a reduction of 84%. All 13 patients survived with a mean length of hospital stay of 9.5 days. There were no complications related to TPE.

CONCLUSIONS

One TPE procedure is an effective method for reducing plasma triglycerides and possibly decreases the length of hospital stay in patients admitted with HTP.

Thromboembolic outcomes after use of a four-factor prothrombin complex concentrate for vitamin K antagonist reversal in a real-world setting

BACKGROUND

A four-factor prothrombin complex concentrate (4F-PCC) was recently licensed in the United States for urgent vitamin K antagonist (VKA) reversal based on two randomized clinical trials. These studies excluded patients at high risk of thrombosis; therefore, the risk of thrombotic complications in unselected patients remains a concern.

STUDY DESIGN AND METHODS

This study retrospectively evaluated the incidence of thromboembolic events (TEEs) and death in patients who received 4F-PCC for VKA reversal. The study included 113 consecutive patients who were 18 years of age and older and were administered 4F-PCC for VKA reversal. The incidence of TEE and deaths was evaluated for up to 60 days after PCC administration or until the end of hospitalization, whichever came later.

RESULTS

Seven (6.2%) patients developed TEEs and 17 (15%) patients died. PCC administration was probably related to TEE and subsequent death in two (1.8%) patients. Multivariate analysis revealed that a diagnosis of Factor V Leiden or antiphospholipid syndrome was predictive of TEE, and active malignancy was predictive of death.

CONCLUSION

This study supports the safety of 4F-PCC for urgent VKA reversal even in unselected patients. The underlying type of hypercoagulable state and the dose of PCC may influence the incidence of TEE.

The HI-STAR study: resource utilization and costs associated with serologic testing for antibody-positive patients at four United States medical centers

BACKGROUND

Little is known about how the resource utilization and costs of serologic work ups for positive antibody screens vary across subpopulations based on diagnosis, transfusion history, and serologic testing history.

STUDY DESIGN AND METHODS

Detailed data were collected on patient demographics, diagnoses, transfusion history, history of known allo- and autoantibodies, and specific serologic tests performed for 6077 consecutive serologic work ups in 3608 antibody-positive patients between 2009 and 2011 at four US academic medical centers. Direct testing costs were also determined at each site for each serologic test performed to calculate total costs per work up and per patient over the duration of the study.

RESULTS

The mean direct cost of serologic testing was $114 per work up and $195 per patient. The mean cost per patient was significantly higher for 12 of 19 diagnostic categories evaluated, including autoimmune hemolytic anemia (mean cost per patient, $1490; p < 0.001), hematologic malignancies ($640, p < 0.001), and transplant recipients ($462, p = 0.019). Patient transfusion and serologic testing characteristics associated with greatest increases in costs included history of a warm autoantibody ($626, p < 0.001) and more than five prior transfusions ($404, p < 0.001).

CONCLUSION

Antibody-positive patients with complex diagnoses or transfusion histories require significantly more resources and incur greater cost to assess red blood cell antibody status.

Higher optical density of an antigen assay predicts thrombosis in patients with heparin-induced thrombocytopenia

OBJECTIVES

To correlate optical density and percent inhibition of a two-step heparin-induced thrombocytopenia (HIT) antigen assay with thrombosis; the assay utilizes reaction inhibition characteristics of a high heparin concentration.

PATIENTS AND METHODS

Patients with more than 50% decrease in platelet count or thrombocytopenia (<150 x 10(9)/L) after exposure to heparin, who had a positive two-step antigen assay [optical density (OD) >0.4 and >50 inhibition with high concentration of heparin] were included in the study.

RESULTS

Forty of 94 HIT patients had thrombosis at diagnosis; 54/94 had isolated-HIT without thrombosis. Eight of the isolated-HIT patients developed thrombosis within the next 30 d; thus, a total of 48 patients had thrombosis at day 30. At diagnosis there was no significant difference in OD between HIT patients with thrombosis and those with isolated-HIT. However, OD was significantly higher in all patients with thrombosis (n = 48, 1.34 +/- 0.89), including isolated-HIT patients who later developed thrombosis within 30 d (n = 8, 1.84 +/- 0.64) as compared to isolated-HIT patients who did not develop thrombosis (0.96 +/- 0.75; P = 0.011 and P = 0.008). The Receiver Operative Characteristic Curve showed that OD >1.27 in the isolated-HIT group had a significantly higher chance of developing thrombosis by day 30. None of these groups showed significant difference in percent inhibition. Multivariate analysis showed a 2.8-fold increased risk of thrombosis in females. Similarly, thrombotic risk increased with age and OD values.

CONCLUSION

Higher OD is associated with significant risk of subsequent thrombosis in patients with isolated-HIT; percent inhibition, however, was not predictive.