Association Between Smoking Status and Opioid Dose in Prescriptions Written for Breast Cancer-related Pain.

BACKGROUND: Cancer-related pain has historically been undertreated. Prescription opioids have been shown to be an integral part of the treatment of cancer pain. Despite the significant amount of scientific evidence that smoking is associated with variation in pain expression and opioid misuse in both cancer and non-cancer populations, little is known about the association between smoking status and opioid utilization in cancer populations. OBJECTIVES: To assess the association between smoking status and high-risk opioid-prescribing behaviors of oncologists prescribing opioids in the outpatient setting to patients with breast cancer-related pain. STUDY DESIGN: A retrospective cross-sectional study of opioid prescriptions written by oncologists for breast cancer-related pain was conducted using the Patient Cohort Explorer (PCE) database at the University of Mississippi Medical Center (UMMC) from March 15, 2015 to March 15, 2017. SETTING: Tertiary academic medical center. METHODS: De-identified data from UMMC PCE were utilized for this study. Patient-level information, such as age, gender, race, insurance status, and smoking status, were also selected for each prescription. Prescription-level data, such as name of opioid, dose, frequency, route, and primary diagnosis, were also obtained. Prescriptions were included if they are written in the outpatient setting, for breast cancer-related pain, and for women 18 years or older. Prescriptions were excluded if they were written by a specialist other than a medical oncologist or if the information necessary to calculate morphine milligram equivalence (MME) was missing. RESULTS: The sample consisted of 577 opioid prescriptions that were written in the outpatient setting to women ages 18 years and older for breast cancer-related pain. The majority of the sample were ages 46 to 64 years (60.5%), Nonwhite (75.2%), publicly insured (66.2%), and with nonmetastatic disease (86.1%). Almost one-fifth (19.6%) of the prescriptions were written to current smokers, 21.3% to former smokers, and 58.1% to nonsmokers. Nonsmoking status predicted an increased odds of receiving a prescription ≥ 50 MME (odds ratio [OR] = 1.98, 95% confidence interval [CI]: 1.08-3.60, P = 0.030) and ≥ 90 MME (OR = 6.29, 95% CI: 1.38-28.58, P = 0.017) compared to current smokers. Nonsmoking status also predicted an increased odds of receiving a prescription ≥ 90 MME (OR = 4.29, 95% CI: 1.43-12.92, P = 0.009) compared to former smokers. LIMITATIONS: This cross-sectional sample was drawn from a single institution and only included the breast cancer population and may not be generalizable to other populations or institutions. Second, our sample was drawn from secondary data not collected for the purposes of our study. This limits the inclusion of other variables that may impact the opioid-prescribing behaviors of oncologists, potentially resulting in bias. CONCLUSIONS: During a time of heightened awareness of opioid-related harm, as well as implementation of national opioid-prescribing guidelines, current smoking may potentially be impacting how oncologists evaluate the need for opioids to treat breast cancer-related pain. Further studies that examine the relationship between smoking status, perceived need for opioids, and evaluative need for opioids in cancer populations are warranted. KEY WORDS: Cancer pain, opioids, smoking, breast cancer, opioid-prescribing guidelines, health policy, oncology, end of life.

Ethical dilemmas in the management of infants with necrotizing enterocolitis totalis.

PURPOSE: Necrotizing enterocolitis (NEC) totalis is a devastating disease of the newborn intestine. A precise clinical definition of the extent of gastrointestinal involvement is lacking in the existing literature, and the clinical outcomes are typically viewed as grim. METHODS: Herein, we present a series of clinical case examples of patients with varying degrees of NEC totalis and other co-morbid conditions, with possible anticipated outcomes based on current data. RESULTS: We define the key ethical issues and provide a framework and discussion of the ethical issues involved in the care of patients with NEC totalis and recommendations of how to approach discussions with the family of these patients We discuss the ethical considerations for both the providers caring for these patients, and the patient's family members. CONCLUSION: The management of patients with NEC totalis is complex and ethically challenging. LEVEL OF EVIDENCE: V.

Implementation of a Novel Structured Social and Wellness Committee in a Surgical Residency Program: A Case Study.

This article provides a theoretical and practical rational for the implementation of an innovative and comprehensive social wellness program in a surgical residency program at a large safety net hospital on the East Coast of the United States. Using basic needs theory, we describe why it is particularly important for surgical residency programs to consider the residents sense of competence, autonomy, and belonging during residence. We describe how we have developed a comprehensive program to address our residents' (and residents' families) psychological needs for competence, autonomy, and belongingness.

Contemporary practice among pediatric surgeons in the use of bowel preparation for elective colorectal surgery: A survey of the American Pediatric Surgical Association.

PURPOSE: The goal of this study was to characterize contemporary practice among pediatric surgeons in the use of mechanical bowel preparation (MBP) and oral antibiotics (OA) for elective colorectal surgery. METHODS: A survey of the American Pediatric Surgical Association membership was conducted to characterize variation in the use of MBP and OA for commonly performed elective colorectal procedures in children. RESULTS: Three-hundred thirteen members completed the survey. The most common approach used was MBP alone (31.1%), followed by diet modification only (26.8%), MBP combined with OA (19.6%), no preparation or dietary modification (12.2%), and OA alone (5.4%). The most common MBP used was a polyethylene glycol-based solution (92.6%), and the most common OA approach was neomycin combined with erythromycin (55.9%). Although MBP alone was the preferred approach among pediatric surgeons, the greatest relative change reported over time was in the adoption of dietary modifications only or no preparation at all. CONCLUSIONS: Significant variation exists in the use of bowel preparation among pediatric surgeons. Although use of MBP alone remains the preferred approach for most procedures, an increasing number of surgeons report abandoning this approach in favor of dietary modification alone or no preparation at all.

Variation in bowel preparation among pediatric surgeons for elective colorectal surgery: A problem of equipoise or a knowledge gap of the available clinical evidence?

PURPOSE: Despite rigorous data from adult literature demonstrating that oral antibiotics (OA) reduce infectious complications and mechanical bowel preparation (MBP) alone does not, MBP alone remains the preferred approach among pediatric surgeons. We aimed to explore the nature of this discrepancy through a survey of the American Pediatric Surgical Association membership. METHODS: Surgeons were queried for their choice of bowel preparation, factors influencing their practice, and their impression of the strength and relevance of the adult literature to pediatric practice. RESULTS: Surgeons who used MBP alone (31%) cited a reduction in stool burden and infectious complications as important factors, whereas surgeons choosing not to use OA (70%) reported a lack of benefit in reducing infectious complications as the primary reason. Although 53% of surgeons reported that evidence from adult literature was the most important influence, 73% of surgeons reported there was poor evidence supporting the use of OA (±MBP), and only 25% used a preparation supported by adult randomized data. CONCLUSIONS: Wide variation exists among pediatric surgeons in the perceived utility of MBP and OA. Although the majority of pediatric surgeons cited the adult literature as the strongest influence on their practice, this is not consistent with stated perceptions or practice.

Limb reconstruction with decellularized, non-demineralized bone in a young leporine model.

Limb salvage from a variety of pathological processes in children is often limited by the unavailability of optimal allograft bone, or an appropriate structural bone substitute. In this study, we sought to examine a practical alternative for pediatric limb repair, based on decellularized, non-demineralized bone grafts, and to determine whether controlled recellularization prior to implantation has any impact on outcome. Growing New Zealand rabbits (n = 12) with a complete, critical-size defect on the left tibiofibula were equally divided into two groups. One group received a decellularized, non-demineralized leporine tibiofibula graft. The other group received an equivalent graft seeded with mesenchymal stem cells labeled with green fluorescent protein (GFP), at a fixed density. Animals were euthanized at comparable time points 3-8 weeks post-implantation. Statistical analysis was by the Student t-test and Fisher's exact test (P < 0.05). There was no significant difference in the rate of non-union between the two groups, including on 3D micro-CT. Incorporated grafts achieved adequate axial bending rigidity, torsional rigidity, union yield and flexural strength, with no significant differences or unequal variances between the groups. Correspondingly, there were no significant differences in extracellular calcium levels, or alkaline phosphatase activity. Histology confirmed the presence of neobone in both groups, with GFP-positive cells in the recellularized grafts. It was shown that osseous grafts derived from decellularized, non-demineralized bone undergo adequate remodeling in vivo after the repair of critical-size limb defects in a growing leporine model, irrespective of subsequent recellularization. This methodology may become a practical alternative for pediatric limb reconstruction.

Operative indications in recurrent ileocolic intussusception.

BACKGROUND: Air-contrast enema (ACE) is standard treatment for primary ileocolic intussusception. Management of recurrences is less clear. This study aimed to delineate appropriate therapy by quantifying the relationship between recurrence and need for bowel resection, pathologic lead points (PLP), and complication rates. METHODS: After IRB approval, a single institution review of patients with ileocolic intussusception from 1997 to 2013 was performed, noting recurrences, outcomes, and complications. Fisher's exact and t-tests were used. RESULTS: Of 716 intussusceptions, 666 were ileocecal. Forty-four underwent bowel resection, with 29 PLPs and 9 ischemia/perforation. Recurrence after ACE occurred in 96 (14%). Recurrence did not predict PLP (P=0.25). Recurrence (≥3) was associated with higher resection rate (P=0.03), but not ischemia/perforation (P=0.75). ACE-related complications occurred in 4 (0.5%) patients. Successful initial ACE had 98% negative predictive value for resection and PLP (e.g., after successful ACE, 2% had resections, 2% PLP). After failed initial ACE, 36% received resection, and 23% had PLP (P<0.001). CONCLUSIONS: Recurrence is associated with a greater risk of resection but not PLP or ACE-complication. Failed ACE is associated with increased risk for harboring PLP and receiving resection. ACE should be the standard treatment in recurrent intussusception, regardless of number of recurrences.

The impact of gestational age on targeted amniotic cell profiling in experimental neural tube defects.

PURPOSE: The proportions of select stem cells in term amniotic fluid have been shown to correlate with the type and size of experimental neural tube defects (NTDs). We sought to determine the impact of gestational age upon this form of targeted amniotic cell profiling. METHODS: Sprague-Dawley fetuses with retinoic acid-induced NTDs (n = 110) underwent amniotic fluid procurement at four time points in gestation. Samples were analyzed by flow cytometry for the presence of cells concomitantly expressing Nestin and Sox-2 (neural stem cells, aNSCs) and cells concomitantly expressing CD29 and CD44 (mesenchymal stem cells, aMSCs). Statistical analysis was by nonparametric Kruskal-Wallis ANOVA (p < 0.05). RESULTS: There was a statistically significant impact of gestational age on the proportions of both aMSCs (p = 0.01) and aNSCs (p < 0.01) in fetuses with isolated spina bifida. No such impact was noted in normal fetuses (p > 0.10 for both cells), in isolated exencephaly (p > 0.10 for both cells), or in combination defects (p > 0.10 for both cells). Gestational age had no effect on aNSC/aMSC ratios. CONCLUSIONS: Targeted quantitative amniotic cell profiling varies with gestational age in experimental isolated spina bifida. This finding should be considered prior to the eventual translation of this diagnostic adjunct into the prenatal evaluation of these anomalies. © 2014 S. Karger AG, Basel.

A comparative analysis of human mesenchymal stem cell response to hypoxia in vitro: Implications to translational strategies.

PURPOSE: Mesenchymal stem cells (MSCs) are particularly valuable for structural tissue replacement. We compared the response to hypoxia among human MSCs derived from four different clinically relevant sources as an adjunct to translational developments. METHODS: Immunophenotypically indistinguishable human MSC lineages derived from bone marrow (bmMSCs), adipose tissue (adMSCs), amniotic fluid (afMSCs), and umbilical cord blood (cbMSCs) were submitted to either room air or 1% O2, under otherwise standard culture conditions. Cell expansion and quantitative RT-PCR data were obtained at different time points. Statistical analysis was by two-way mixed model and the F-test (P<0.05). RESULTS: The effect of hypoxia on expansion kinetics was dependent on cell source. Only prenatal sources of MSCs - afMSCs (P=0.002) and cbMSCs (P<0.001) - proliferated significantly faster under hypoxia than normoxia. Increased HIF1-alpha expression correlated consistently with increased cell expansion only among afMSCs. There were no significant variabilities in Survivin, Oct-4, and VEGF expressions. CONCLUSIONS: Mesenchymal stem cell tolerance to hypoxia in vitro varies with cell source. Prenatal cells, particularly those derived from amniotic fluid, are more robust than their postnatal counterparts. HIF1-alpha may play a role in the amniotic fluid-derived cells' enhanced response. These findings should inform the choice of mesenchymal stem cells for prospective regenerative strategies.

Use of mechanical bowel preparation and oral antibiotics for elective colorectal procedures in children: is current practice evidence-based?

PURPOSE: It is well established through randomized trials that oral antibiotics given with or without a mechanical bowel preparation (MBP) prior to colorectal procedures reduce complications, while MBP given alone provides no benefit. We aimed to characterize trends surrounding bowel preparation in children and determine whether contemporary practice is evidence-based. METHODS: Retrospective analysis of patients undergoing colorectal procedures at 42 children's hospitals (1/2/2007-12/31/2011) was performed. Patients were analyzed for diagnosis, pre-admission status, and inpatient bowel preparation. Bowel preparation was considered evidence-based if oral antibiotics were utilized with or without a MBP. RESULTS: 49% of all patients were pre-admitted (n=5,473), and the most common diagnoses were anorectal malformations (55%), inflammatory bowel disease (26%), and Hirschsprung's Disease (19%). The most common preparation approaches were MBP alone (54.3%), MBP+oral antibiotics (18.8%), and oral antibiotics alone (4.2%), although significant variation was found in hospital-specific rates for each approach (MBP alone: 0-96.1%, MBP+oral antibiotics: 0-83.6%, orals alone: 0-91.6%, p<0.0001). Only 22.9% of all patients received an evidence-based preparation (range by hospital: 0-92.3%, p<0.0001), and this rate decreased significantly during the five-year study period (27.6% in 2007 vs. 17.3% in 2011, p<0.0001). CONCLUSION: According to the best available clinical evidence, less than a quarter of all children pre-admitted for elective colorectal procedures receive a bowel preparation proven to reduce infectious complications.

Targeted quantitative amniotic cell profiling: a potential diagnostic tool in the prenatal management of neural tube defects.

PURPOSE: We sought to determine whether amniotic cell profiles correlate quantitatively with neural tube defect (NTD) type and/or size. METHODS: Sprague-Dawley fetuses exposed to retinoic acid (n=61) underwent amniotic fluid sample procurement before term. Samples were analyzed by flow cytometry for the presence of cells concomitantly expressing Nestin and Sox-2 (neural stem cells, aNSCs), and cells concomitantly expressing CD29 and CD44 (mesenchymal stem cells, aMSCs). Statistical analysis included ANOVA and post-hoc Bonferroni adjusted comparisons (P<0.05). RESULTS: There was a statistically significant increase in the proportion of aNSCs in fetuses with spina bifida (6.78%± 1.87%) when compared to those with exencephaly (0.64%± 0.23%) or with both spina bifida and exencephaly (0.22%± 0.09%). Conversely, there was a statistically significant decrease in the proportion of aMSCs in fetuses with exencephaly, either isolated (1.09%± 0.42%) or in combination defects (2.37%± 0.63%) when compared with normal fetuses (8.83%± 1.38%). In fetuses with isolated exencephaly, there was a statistically significant inverse correlation between the proportion of aNSCs and defect size. CONCLUSIONS: The proportions of neural and mesenchymal stem cells in the amniotic fluid correlate with the type and size of experimental NTDs. Targeted quantitative amniotic cell profiling may become a useful diagnostic tool in the prenatal evaluation of these anomalies.

Intra-amniotic delivery of amniotic-derived neural stem cells in a syngeneic model of spina bifida.

OBJECTIVE: Neural stem cells (NSCs) may promote spinal cord repair in fetuses with experimental spina bifida. We sought to determine the fate of amniotic-derived NSCs (aNSCs) after simple intra-amniotic injection in a syngeneic model of spina bifida. METHODS: Fetal neural tube defects were induced on 20 pregnant Lewis dams by prenatal administration of retinoic acid. Ten dams served as amniotic fluid donors for epigenetic isolation of aNSCs, which were expanded and labeled with 5-bromo-2'-deoxyuridine. The remaining 10 dams received intra-amniotic injections of the processed aNSCs, blindly in all their fetuses (n = 37) on gestational day 17 (term = E21-22). Fetuses with spina bifida underwent screening for the presence of donor aNSCs in the spinal cord at term. RESULTS: Donor cells were identified in 93.3% of the animals with spina bifida, selectively populating the neural placode, typically in clusters, retaining an undifferentiated morphology, and predominantly on exposed neural surfaces, though some were detected deeper in neighboring neural tissue. CONCLUSIONS: The amniotic cavity can serve as a route of administration of NSCs in experimental spina bifida. Simple intra-amniotic delivery of NSCs may be a practical adjuvant to regenerative strategies for the treatment of spina bifida.

Transarterial embolization in children with blunt splenic injury results in postembolization syndrome: a matched case-control study.

BACKGROUND: Postembolization syndrome (PES) has been reported in adults following transarterial embolization (TAE) for blunt splenic injury (BSI), but not in children. We report the incidence of PES in a group of children who underwent TAE. METHODS: Children who underwent TAE were identified, and each case of TAE was matched by grade of splenic injury and Injury Severity Score with four similar patients who did not. Data collected included demographics, vital signs, laboratory data, the presence of contrast blush, the hemoperitoneum score, hospital course, and outcome. The subgroup with a high hemoperitoneum score was analyzed separately. RESULTS: Within 12 years, of 448 patients diagnosed as having BSI, 11 (2.5%) underwent TAE. Children undergoing TAE had lower preprocedure hemoglobin (10.4 vs. 11.8 g/dL, p = 0.02) and platelet counts (194.8 vs. 267.9 cells/µL, p = 0.006) and received more packed red blood cells (3.1 vs. 0.11 units, p < 0.001) and fresh-frozen plasma (0.24 vs. 0 units, p = 0.04). Postprocedure hemoglobin and platelet counts were not different, but white blood cell count was elevated in the TAE group (13.5 vs. 9.1 cells/µL, p = 0.04). The TAE group had longer intensive care unit (2.82 vs. 1.18 days, p < 0.001) and hospital (8.6 vs. 5.2 days, p < 0.001) stays and took longer to tolerate a full diet (5.4 vs. 1.6 days, p < 0.001). These relationships persisted when only children with high hemoperitoneum scores were considered.PES occurred in 90.1% of those who underwent TAE and in 2.3% of those who did not. Late complications were noted in 27.3% of the TAE group versus none and correlated with the length of hospital stay (10.67 vs. 5.63 days, p < 0.001). CONCLUSION: TAE is a valuable tool in the management of BSI in children but leads to PES in most children. PES is self-limited but is associated with longer hospital stays and more complications and readmissions, with no effect on operative rate or mortality. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic study, level IV.

Ambulance personnel perceptions of near misses and adverse events in pediatric patients.

OBJECTIVE: To identify emergency medical services (EMS) provider perceptions of factors that may affect the occurrence, identification, reporting, and reduction of near misses and adverse events in the pediatric EMS patient. METHODS: This was a subgroup analysis of a qualitative study examining the nature of near misses and adverse events in EMS as it relates to pediatric prehospital care. Complementary qualitative methods of focus groups, interviews, and anonymous event reporting were used to collect results and emerging themes were identified and assigned to specific analytic domains. RESULTS: Eleven anonymous event reports, 17 semistructured interviews, and two focus groups identified 61 total events, of which 12 were child-related. Eight of those were characterized by participants as having resulted in no injury, two resulted in potential injury, and two involved an ultimate fatality. Three analytic domains were identified, which included the following five themes: reporting is uncommon, blaming errors on others, provider stress/discomfort, errors of omission, and limited training. Among perceived causes of events, participants noted factors relating to management problems specific to pediatrics, problems with procedural skill performance, medication problems/calculation errors, improper equipment size, parental interference, and omission of treatment related to providers' discomfort with the patient's age. Few participants spoke about errors they had committed themselves; most discussions centered on errors participants had observed being made by others. CONCLUSIONS: It appears that adverse events and near misses in the pediatric EMS environment may go unreported in a large proportion of cases. Participants attributed the occurrence of errors to the stress and anxiety produced by a lack of familiarity with pediatric patients and to a reluctance to cause pain or potential harm, as well as to inadequate practical training and experience in caring for the pediatric population. Errors of omission, rather than those of commission, were perceived to predominate. This study provides a foundation on which to base additional studies of both a qualitative and quantitative nature that will shed further light on the factors contributing to the occurrence, reporting, and mitigation of adverse events and near misses in the pediatric EMS setting.

Unique sexual assault examiner program utilizing mid-level providers.

BACKGROUND: We implemented a unique sexual assault examiner (SAE) program utilizing Emergency Department (ED)-based mid-level providers. Sexual assault forensic evidence collection processes and training are not uniform in all EDs, with varying models in place. METHODS: Our study evaluated the quality of SAE evidentiary collection in standardized evidence kits (Kits), compared to Kits from other EDs without the SAE program. We prospectively studied Kits from November 2004-October 2005. All Kits were evaluated for quantity (numbers of slides, envelopes, swabs), and quality (compliance with forensic standards) of evidence. RESULTS: Although SAE Kits had similar total numbers of pieces of evidence, they had higher quality as measured by a greater number of compliant envelopes (5.44 vs. 1.44, p < 0.001) and a greater number of compliant slides (6.4 vs. 4.5, p < 0.001). SAE Kits had two measures with higher quality forensic evidence than non-SAE Kits. CONCLUSION: An integrated program of SAE-trained mid-level providers collect sexual assault Kits with a higher quality of forensic evidence than non-SAE providers.

Emergency medical services provider perceptions of the nature of adverse events and near-misses in out-of-hospital care: an ethnographic view.

OBJECTIVES: The objectives were to examine the perceptions of emergency medical services (EMS) providers regarding near-misses and adverse events in out-of-hospital care. METHODS: This study uses qualitative methods (focus groups, interviews, event reporting) to examine the perceptions of EMS providers regarding near-misses and adverse events in out-of-hospital care. Results were reviewed by five researchers; analytic domains were assigned and emerging themes were identified. Descriptive statistics were calculated. RESULTS: Fifteen in-depth interviews (73% advanced life support [ALS], 40% volunteer, and 87% male) resulted in 50 event descriptions. Eleven additional event reports were obtained from the anonymous reporting system. Of the 61 total events, 27 (44%) were near-misses and 34 (56%) were adverse events. Fourteen (23%) involved a child (< 19 years). Types of error included 33 clinical judgment (54%), 13 skill performance (21%), 9 medication event (15%), 3 destination choice (5%), and 3 others (5%). For the 21 cases where the provider discussed the event, 10 (48%) were reported to a physician, and 9 (43%) to a supervisor; 4 (19%) were not reported, and none were reported to the patient. Focus groups supported interview and event report data. Emerging themes included a focus on the errors of others and a "blame-and-shame" culture. CONCLUSIONS: Adverse events and near-misses were common among the EMS providers who participated in this study, but the culture discourages sharing of this information. Participants attributed many events to systems issues and to inadequacies of other provider groups. Further study is necessary to investigate whether these hypothesis-generating themes are generalizable to the EMS community as a whole.

Epidemiology and outcomes of out-of-hospital cardiac arrest in Rochester, New York.

OBJECTIVE: To characterize out-of-hospital cardiac arrest (OHCA) and factors that affect survival in a medium sized city that uses system status management for dispatch. METHODS: A retrospective cohort study of all adult OHCA patients treated by EMS between 1998 and 2001 was conducted using Utstein definitions. The primary endpoint was 1-year survival. RESULTS: Of the 1177 patients who experienced OHCA during the study period, 539 (46%) met inclusion criteria. Age ranged from 18 to 98 years (median 67). The median call-response interval was 5 min (range 0-21), and 93% were 9 min or less. There was no significant difference in the median call-response intervals between call location zip (Post) codes (p=0.07). Twenty percent of experienced ROSC (95% CI 17-23), 7% survived more than 30 days (95% CI 5-9%), and 5% survived to 1 year (95% CI 3-7%). In bivariate analysis, first rhythm and bystander CPR affected survival to 1 year. There was no significant difference in survival between male (4%) and female (7%), black (4%) and white (6%), or witnessed (7%) and unwitnessed arrest (4%). Logistic regression identified younger age, CPR initiated by bystander (19%) or first responder (41%), and presenting rhythm of VF/VT (32%) as factors associated with survival to 1 year. CONCLUSIONS: This study finds a 5% survival to 1 year among OHCA patients in Rochester, NY. A presenting rhythm of VF/VT and bystander CPR were associated with increased survival.

Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.

This article uses a case report and discussion to demonstrate the concept of active and latent failures, and the "systems approach" to the reduction of adverse events in medicine. The case involves an inadvertently misplaced and retained guidewire during femoral vein catheterization using the Seldinger technique, and the subsequent failure to identify the guidewire in the chest despite several chest radiographs and a computed tomography (CT) scan read by radiologists, emergency physicians, and intensivists. This event reveals active failures in the performance of the Seldinger technique, latent failures in the design of the catheter kit, and problems with the current system of interpretation of radiographs. The authors conclude that the design of the catheter kit and the Seldinger technique should be critically examined from a human factors standpoint and that radiographic interpretation is still heavily subject to human error.