Introduction Red blood cell exchange (RCE) procedures are commonly used for stroke prevention in sickle cell disease (SCD) patients. We compared two different dual lumen ports used for RCE because differences between the port and catheter design may lead to functional variance. Methods We reviewed the RCE parameters of SCD patients following implantable port placement encountered at a single institution. Five Vortex and four Bard ports were used and compared. Patients were followed for 1‐24 exchange procedures over 3‐26 months performed between 2013 and 2015. Results Nine patients underwent 124 RCE procedures with no failures. A total of 74 exchanges used Vortex ports with a mean flow rate of 45.2 mL/min while 50 exchanges used Bard ports with a mean flow rate of 42.1 mL/min which was a significant difference (P = .002). A total of 85 exchanges with tPA administration preprocedure had a mean flow rate of 43.8 mL/min while 39 exchanges without had a mean flow rate of 45.4 mL/min which was not a significant difference (P = .19). Conclusion Both the Bard and Vortex ports functioned well during our study period with no treatment failures, no significant complications requiring removal or replacement, and adequate mean flow rates. While the difference in mean flow rates was statistically significant between Vortex and Bard ports, there may not be a practical difference in performance. There also does not appear to be a significant benefit in flow rates with preprocedure tPA. We conclude that both ports may be a satisfactory choice for vascular access in SCD patients expected to undergo regularly scheduled RCE.

Background Heuristics and cognitive biases are thought to play an important role in diagnostic medical error. How to systematically determine and capture these kinds of errors remains unclear. Morbidity and mortality rounds (MMRs) are generally focused on reducing medical error by identifying and correcting systems failures. However, they may also provide an educational platform for recognizing and raising awareness on cognitive errors. Methods A total of 49 MMR cases spanning the period 2008–2015 in our pathology department were examined for the presence of cognitive errors and/or systems failures by eight study participant raters who were trained on a subset of 16 of these MMR cases (excluded from the main study analysis) to identify such errors. The Delphi method was used to obtain group consensus on error classification on the remaining 33 study cases. Cases with <75% inter-rater agreement were subjected to subsequent rounds of Delphi analysis. Inter-rater agreement at each round was determined by Fleiss’ kappa values. Results Thirty-six percent of the cases presented at our pathology MMRs over an 8-year period were found to contain errors likely due to cognitive bias. Conclusions These data suggest that the errors identified in our pathology MMRs represent not only systems failures but may also be composed of a significant proportion of cognitive errors. Teaching trainees and health professionals to correctly identify different types of cognitive errors may present an opportunity for quality improvement interventions in the interests of patient safety.

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A 57-year-old previously healthy man was referred to our clinic for bilateral vision loss.Six weeks before presentation, the patient developed central graying of vision in his right eye that progressed to blindness over a week. Over the next several weeks, the same occurred in the left eye. There was retro-orbital pain and a new holocephalic headache that was worse in the mornings. He reported lancinating pain down his neck, left arm, back, and left leg with neck movement. An outside ophthalmologist noted bilateral optic disc edema and referred him to our clinic.The patient was employed as a prison guard. Screening for tuberculosis exposure with purified protein derivative testing was negative for at least the last 5 years. He neither drank alcohol nor smoked. His mother had died of a brain tumor in her 70s. He denied fever, chills, cough/dyspnea, epistaxis, recent illness, bowel or bladder dysfunction, hematuria, and any history of neurologic issues. He was current on preventative cancer screening.On examination, the patient had normal vital signs, left-sided anosmia, and a relative afferent pupillary defect (RAPD) on the right with bilateral disc edema. Visual acuity was finger counting at 1 foot OD and 4 feet OS with a large central scotoma in each eye. He had mild nuchal rigidity. The remaining examination was normal.Questions for consideration:

Collision tumors are rare neoplasms that consist of at least two different cell lineages at the same site. Given the many possible combinations that can occur, collision tumors, while rare, have been reported in multiple locations such as the stomach, bladder, and thyroid. Collision tumors are rarely found in breast tissue, with only a few cases reported in the literature. We herein report a unique case of a 79-year-old woman with a history of melanoma who presented with a left breast mass that was subsequently found to have invasive ductal carcinoma (IDC) and metastatic melanoma in the breast tissue. This is one of the first reported combinations of these two malignancies.