Using the lower limit of normal for the FEV1/FVC ratio reduces the misclassification of airway obstruction

AIM

The prevalence of airway obstruction varies widely with the definition used.

OBJECTIVES

To study differences in the prevalence of airway obstruction when applying four international guidelines to three population samples using four regression equations.

METHODS

We collected predicted values for forced expiratory volume in 1 s/forced vital capacity (FEV(1)/FVC) and its lower limit of normal (LLN) from the literature. FEV(1)/FVC from 40 646 adults (including 13 136 asymptomatic never smokers) aged 17-90+years were available from American, English and Dutch population based surveys. The prevalence of airway obstruction was determined by the LLN for FEV(1)/FVC, and by using the Global Initiative for Chronic Obstructive Lung Disease (GOLD), American Thoracic Society/European Respiratory Society (ATS/ERS) or British Thoracic Society (BTS) guidelines, initially in the healthy subgroup and then in the entire population.

RESULTS

The LLN for FEV(1)/FVC varied between prediction equations (57 available for men and 55 for women), and demonstrated marked negative age dependency. Median age at which the LLN fell below 0.70 in healthy subjects was 42 and 48 years in men and women, respectively. When applying the reference equations (Health Survey for England 1995-1996, National Health and Nutrition Examination Survey (NHANES) III, European Community for Coal and Steel (ECCS)/ERS and a Dutch population study) to the selected population samples, the prevalence of airway obstruction in healthy never smokers aged over 60 years varied for each guideline: 17-45% of men and 7-26% of women for GOLD; 0-18% of men and 0-16% of women for ATS/ERS; and 0-9% of men and 0-11% of women for BTS. GOLD guidelines caused false positive rates of up to 60% when applied to entire populations.

CONCLUSIONS

Airway obstruction should be defined by FEV(1)/FVC and FEV(1) being below the LLN using appropriate reference equations.

The digestibility and accumulation of dietary phytosterols in Atlantic salmon (Salmo salar L.) smolt fed diets with replacement plant oils

Phytosterols occur in high concentration in canola (Brassica napus L.) and other vegetable oils such as from the borage plant Echium (Echium plantagineum L.). We investigated if Atlantic salmon (Salmo salar) digest and accumulate dietary phytosterols in significant amounts in muscle and liver. Phytosterols are lipid soluble, lower cholesterol and reduce the risk of coronary heart disease in humans. We aimed to determine if fatty fish, such as salmon, can be used as a delivery source of this functional food component. Three diets containing canola oil (CO), Echium oil (EO) and fish oil (FO) were fed to Atlantic salmon smolt over 9 weeks. The digestibility of natural abundances of phytosterols by Atlantic salmon was poor compared to cholesterol. However, phytosterols accumulated in liver and muscle of fish. Significantly increased concentrations of 24-methylenecholesterol, campesterol, beta-sitosterol and total phytosterol occurred in livers of EO fed fish compared to FO fed fish. Campesterol concentrations increased in CO fed fish compared to the FO fed fish. We demonstrated that natural abundances of dietary phytosterols are digested by and accumulated in liver and white muscle of Atlantic salmon smolt. However, phytosterol levels in salmon muscle will not be a major source of phytosterols in human diets and would not be expected to significantly effect human cardiovascular health.

Replacement of fish oil with thraustochytrid Schizochytrium sp. L oil in Atlantic salmon parr (Salmo salar L) diets

Replacing fish oil with that from a docosahexaenoic acid (22:6omega3, DHA) rich single cell micro-organism, thraustochytrid Schizochytrium sp. L, in diets for Atlantic salmon (Salmo salar) was investigated. Four experimental diets containing 100% thraustochytrid oil (TO), 100% palm oil (PO) and a 4:1 palm and thraustochytrid oil mixture (MX) were compared to a fish oil (FO) diet over 9 weeks. A saltwater transfer challenge occurred at the end of the trial for 14 days to test the diet treatments on the ability of salmon to smolt. There were no significant differences in the feed consumption of the diets or the digestibility of the omega3 or omega6 PUFA, indicating no differences in the digestibility of fatty acids between diets. No significant differences were noted between the growth of fish on the four diet treatments. Significant differences were noted in the fatty acid profiles of the fish muscle tissues between all diets. Fish on the TO diet had a significantly greater percentage of DHA in muscle tissue compared with fish on all other diets. Blood osmolarity, which is inversely related to the ability of salmon to smolt, from the TO and FO fed fish was significantly lower than that of fish on the PO diet. This study showed that thraustochytrid oil can be used to replace fish oil in Atlantic salmon diets without detriment to the growth of parr. Including thraustochytrid oil in fish diets significantly increases the amount of DHA in Atlantic salmon muscle and therefore is a candidate for use in oil blends for salmon diets. Thraustochytrid oil provides a renewable source of essential fatty acids, in particular DHA, for aquafeeds.

Passive smoking exposure and risk of COPD among adults in China: the Guangzhou Biobank Cohort Study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality in China, where the population is also exposed to high levels of passive smoking, yet little information exists on the effects of such exposure on COPD. We examined the relation between passive smoking and COPD and respiratory symptoms in an adult Chinese population.

METHODS

We used baseline data from the Guangzhou Biobank Cohort Study. Of 20 430 men and women over the age of 50 recruited in 2003-06, 15,379 never smokers (6497 with valid spirometry) were included in this cross-sectional analysis. We measured passive smoking exposure at home and work by two self-reported measures (density and duration of exposure). Diagnosis of COPD was based on spirometry and defined according to the GOLD guidelines.

FINDINGS

There was an association between risk of COPD and self-reported exposure to passive smoking at home and work (adjusted odds ratio 1.48, 95% CI 1.18-1.85 for high level exposure; equivalent to 40 h a week for more than 5 years). There were significant associations between reported respiratory symptoms and increasing passive smoking exposure (1.16, 1.07-1.25 for any symptom).

INTERPRETATION

Exposure to passive smoking is associated with an increased prevalence of COPD and respiratory symptoms. If this association is causal, we estimate that 1.9 million excess deaths from COPD among never smokers could be attributable to passive smoking in the current population in China. Our findings provide strong evidence for urgent measures against passive smoking in China.

WITHDRAWN: Anticoagulants or antiplatelet therapy for non-rheumatic atrial fibrillation and flutter

BACKGROUND

Atrial fibrillation (AF) carries a high risk of stroke and other thromboembolic events. Appropriate use of drugs to prevent thromboembolism in patients with AF involves comparing the patient's risk of stroke to the risk of hemorrhage from medication use.

OBJECTIVES

To quantify risk of stroke, major hemorrhage and death from using medications that have been rigorously evaluated for prevention of thromboembolism in AF.

SEARCH STRATEGY

Articles were identified through the Cochrane Collaboration's CENTRAL database and MEDLINE until December 1999.

SELECTION CRITERIA

Included Randomized controlled trials of drugs to prevent thromboembolism in adults with non-postoperative AF. Excluded RCTS of patients with rheumatic valvular disease.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two reviewers. Odds ratios from all qualitatively similar studies were combined, with weighting by study size, to yield aggregate odds ratios for stroke, major hemorrhage, and death for each drug.

MAIN RESULTS

Fourteen articles were included in this review. Warfarin was more efficacious than placebo for primary stroke prevention {aggregate odds ratio (OR) of stroke=0.30 [95% Confidence Interval (C.I.) 0.19,0.48]}, with moderate evidence of more major bleeding { OR= 1.90 [95% C.I. 0.89,4.04].}. Aspirin was inconclusively more efficacious than placebo for stroke prevention {OR=0.68 [95% C.I. 0.29,1.57]}, with inconclusive evidence regarding more major bleeds {OR=0.81[95% C.I. 0.37,1.78]}. For primary prevention, assuming a baseline risk of 45 strokes per 1000 patient-years, warfarin could prevent 30 strokes at the expense of only 6 additional major bleeds. Aspirin could prevent 17 strokes, without increasing major hemorrhage. In direct comparison, there was moderate evidence for fewer strokes among patients on warfarin than on aspirin {aggregate OR=0.64[95% C.I. 0.43,0.96]}, with only suggestive evidence for more major hemorrhage {OR =1.58 [95% C.I. 0.76,3.27]}. However, in younger patients, with a mean age of 65 years, the absolute reduction in stroke rate with warfarin compared to aspirin was low (5.5 per 1000 person-years) compared to an older group (15 per 1000 person-years). Low-dose warfarin or low-dose warfarin with aspirin was less efficacious for stroke prevention than adjusted-dose warfarin.

AUTHORS' CONCLUSIONS

The evidence strongly supports warfarin in AF for patients at average or greater risk of stroke, although clearly there is a risk of hemorrhage. Although not definitively supported by the evidence, aspirin may prove to be useful for stroke prevention in sub-groups with a low risk of stroke, with less risk of hemorrhage than with warfarin. Further studies are needed of low- molecular weight heparin and aspirin in lower risk patients.

Recent developments in nitric oxide donor drugs

During the 1980s, the free radical, nitric oxide (NO), was discovered to be a crucial signalling molecule, with wide-ranging functions in the cardiovascular, nervous and immune systems. Aside from providing a credible explanation for the actions of organic nitrates and sodium nitroprusside that have long been used in the treatment of angina and hypertensive crises respectively, the discovery generated great hopes for new NO-based treatments for a wide variety of ailments. Decades later, however, we are still awaiting novel licensed agents in this arena, despite an enormous research effort to this end. This review explores some of the most promising recent advances in NO donor drug development and addresses the challenges associated with NO as a therapeutic agent.

Replacement of dietary fish oil for Atlantic salmon parr (Salmo salar L.) with a stearidonic acid containing oil has no effect on omega-3 long-chain polyunsaturated fatty acid concentrations

The worldwide increase in aquaculture production and the concurrent decrease of wild fish stocks has made the replacement of fish oil in aquafeeds an industry priority. Oil from a plant source Echium plantagineum L., Boraginaceae, has high levels of stearidonic acid (SDA, 18:4omega3, 14%) a biosynthetic precursor of omega-3 long-chain (> or =C(20)) polyunsaturated fatty acids (omega3 LC-PUFA). Atlantic salmon (Salmo salar L.) parr were fed a control fish oil diet (FO) or one of 3 experimental diets with 100% canola oil (CO) 100% SDA oil (SO), and a 1:1 mix of CO and SDA oil (MX) for 42 days. There were no differences in the growth or feed efficiency between the four diets. However, there were significant differences in the fatty acid (FA) profiles of the red and white muscle tissues. Significantly higher amounts of SDA, eicosapentaenoic acid (20:5omega3, EPA), docosahexaenoic acid (22:6omega3, DHA) and total omega3 FA occurred in both red and white muscle tissues of fish fed SO and FO compared with those fed CO. Feeding SO diet resulted in omega3 LC-PUFA amounts in the white and red muscle being comparable to the FO diet. This study shows that absolute concentration (mug/g) of EPA, DHA and total omega3 have been maintained over 6 weeks for Atlantic salmon fed 14% SDA oil. The balance between increased biosynthesis and retention of omega3 LC-PUFA to maintain the concentrations observed in the SO fed fish remains to be conclusively determined, and further studies are needed to ascertain this.

Down-regulation of vinculin upon MK886-induced apoptosis in LN18 glioblastoma cells

Glioblastomas are a type of malignant brain tumor and are among the most difficult cancers to treat. One strategy to treat aggressive cancers is the use of drugs that target multiple signaling pathways. MK886 is a drug known to inhibit both 5- lipoxygenase-activating-protein (FLAP) and peroxisome proliferator activated receptor-alpha (PPAR-alpha). The objectives of this study were to investigate the ability of MK886 to induce apoptotic cell death in LN18 glioblastoma cells and to characterize the cell death mechanisms. MK886 induced massive apoptotic LN18 cell death that was manifested by the release of nucleosomes, annexinV binding to phosphatidylserine in the absence of nuclear staining, and changes in the fluorescent intensity of Mito Tracker Deep Red 633 indicating changes in mitochondrial oxidative function and mass. The alteration of the mitochondrial function implied that MK886 induced apoptosis in LN18 cells via a mitochondrial pathway. The broad caspases inhibitor ZVAD-FMK inhibited MK886-induced nucleosome release, but not annexinV binding or MK886-altered mitochondrial function. Real time RT-PCR demonstrated that LN18 cells expressed significant levels of FLAP and PPAR- alpha mRNAs. A low level of arachidonate 5-lipoxygenase (ALOX-5) mRNA was detected, but little, if any, arachidonate 12- lipoxygenase (ALOX-12) mRNA was present. In addition, MK886-induced apoptosis in LN18 cells was accompanied by a decrease in the protein and mRNA levels of vinculin, but not other focal adhesion proteins. In summary, the data presented here indicate that disruption of the actin-vinculin-cell-cytoskeleton matrix of the LN18 glioblastoma is a component of the MK886 induced apoptosis. In addition, MK886 treated LN18 cells could provide one model in which to investigate drugs that target lipoxygenase and PPAR-alpha pathways in the chemotherapeutic treatment of glioblastomas.

Regiospecificity profiles of storage and membrane lipids from the gill and muscle tissue of atlantic salmon (Salmo salar L.) grown at elevated temperature

Regiospecific and traditional analysis, of both storage and membrane lipids, was performed on gill, white muscle, and red muscle samples taken from Atlantic salmon (Salmo salar) to gauge the effect of elevated water temperature. The fish, fed a commercial diet, were held at an elevated water temperature of 19 degrees C. Total n-3 PUFA, total PUFA, and n-3/n-6 and unsaturated/saturated fatty acid (UFA/SFA) ratios in the FA profile of the total lipid extract in the white muscle were fairly low compared with fish grown at 15 degrees C. Adaptation of structural and storage lipids at elevated temperatures was shown by a significant (P < 0.01) reduction in PUFA especially in the percentage of EPA (6-8%). Further adaptation was indicated by the percentages of SFA, which were significantly (P< 0.05) higher in gill (56%) and white muscle (58%) polar lipid fractions and coincided with lower percentages of n-3, n-6, and total PUFA. The regiospecific profiles indicated a high affinity of DHA to the sn-2 position in both the TAG (61-68%) and polar lipid (35-60%) fractions. The combination of detailed regiospecific and lipid analyses demonstrated adaptation of cell membrane structure in Atlantic salmon grown at an elevated water temperature.

Computer based medication error reporting: insights and implications

BACKGROUND

Despite the growing use of error reporting tools, the healthcare industry is inexperienced in receiving, understanding, and analyzing these reports.

OBJECTIVE

To assess the accuracy and define the epidemiology of medication error reports.

DESIGN, SETTING, AND PATIENTS

A retrospective cohort study of 581 error reports containing 1010 medication errors reported between July 2001 and January 2003 at a large academic children's institution.

MAIN OUTCOME MEASURES

Correct classification and types of medication errors.

RESULTS

Of the 1010 medication errors reviewed, 298 (30%) were prescribing errors, 245 (24%) were dispensing errors, 410 (41%) were administration errors, and 57 (6%) involved medication administration records (MAR). Following expert review, 208 errors (21%) were deleted because they had been inappropriately coded as errors and 97 (10%) were added as they were not initially coded despite having occurred. In addition, 352 medication error reports needed to have the subtype of error reclassified; 207 (59%) of these involved the reporter choosing the non-descript "other" category on the reporting tool (such as "Prescribing other") which was able to be reclassified by expert review. The overall distribution of error type categories did not change significantly with expert review, although only MAR errors were underreported by the reporters. The most common medications were anti-infectives (17%), pain/sedative agents (15%), nutritional agents (11%), gastrointestinal agents (8%), and cardiovascular agents (7%).

CONCLUSIONS

Despite clear imperfections in the data captured, medication error reporting tools are effective as a means of collecting reliable information on errors rapidly and in real time. Our data suggest that administration errors are at least as common as prescribing errors in children. Further research is needed, not only in the area of computerized physician order entry (CPOE) for children, but also on ways to make the dispensing and administration of medications safer.

Treatment of painful advanced internal lumbar disc derangement with intradiscal injection of hypertonic dextrose

BACKGROUND

Degenerative discs are thought to produce nerve root pain either mechanically or chemically. Particularly in the case of advanced degenerative disc disease, this clinical entity has often proven to be symptomatically resistant to peridural steroids, Intra-discal Electrothermoplasty (IDET) and direct surgical intervention. Exposure of irritated nerves to hypertonic dextrose is thought to have chemoneuromodulatory potential. Sustained pain reduction has been demonstrated in a pilot study involving injection of a combination of dextrose, glucosamine, chondroitin and dimethylsulfoxide into degenerative discs of patients with chronic low back pain of discogenic origin.

OBJECTIVE

To assess the effects of disc space injections of hypertonic dextrose in patients experiencing chronic advanced degenerative discogenic leg pain, with or without low back pain.

STUDY DESIGN

Prospective consecutive patient series.

METHODS

Patients with moderate to severe degenerative disc disease without herniation and with concordant pain reproduction with CT discography were included. All had failure of a physical therapy trial and substantial but temporary relief with two fluoroscopically guided epidural steroid injections. Patients underwent bi-weekly disc space injection of a solution consisting of 50% dextrose and 0.25% Bupivacaine in the disc(s) found positive on discography. The study was performed in an out-patient surgery center in the United States. Outcome measures included an 11-scale numeric pain score (0-10).

RESULTS

Each patient was injected an average of 3.5 times. Overall, 43.4% of patients fell into the sustained improvement group with an average improvement in numeric pain scores of 71%, comparing pretreatment and 18 month measurements.

CONCLUSION

The results suggest that intradiscal injection of hypertonic dextrose may have a place in the management of pain arising from advanced lumbar degenerative disc disease.

The evolution of host resistance: tolerance and control as distinct strategies

In response to parasitic infection, hosts may evolve defences that reduce the deleterious effects on survivorship. This may be interpreted as a form of resistance, as long as infected hosts are able to either recover or reproduce. Here we distinguish two important routes to this form of resistance. An infected host may either: (1) tolerate pathogen damage, or (2) control the pathogen by inhibiting its growth. A model is constructed to examine the evolutionary dynamics of tolerance and control to a free-living microparasite, where both forms of resistance are costly in terms of other life-history traits. We do not observe polymorphism of tolerant genotypes. In contrast, the evolution of control may lead to disruptive selection, and ultimately dimorphism of extreme strains. The optimal host genotype also varies with the type of resistance-individuals invest more in tolerance and pay a greater cost. The free-living framework used makes the distinction between tolerance and control explicit but the distinction applies equally to directly transmitted parasites. Due to the evolutionary differences exhibited, it is important to design experiments that distinguish between the two forms of resistance.

Cold adaptation in the Antarctic Archaeon Methanococcoides burtonii involves membrane lipid unsaturation

Direct analysis of membrane lipids by liquid chromatography-electrospray mass spectrometry was used to demonstrate the role of unsaturation in ether lipids in the adaptation of Methanococcoides burtonii to low temperature. A proteomics approach using two-dimensional liquid chromatography-mass spectrometry was used to identify enzymes involved in lipid biosynthesis, and a pathway for lipid biosynthesis was reconstructed from the M. burtonii draft genome sequence. The major phospholipids were archaeol phosphatidylglycerol, archaeol phosphatidylinositol, hydroxyarchaeol phosphatidylglycerol, and hydroxyarchaeol phosphatidylinositol. All phospholipid classes contained a series of unsaturated analogues, with the degree of unsaturation dependent on phospholipid class. The proportion of unsaturated lipids from cells grown at 4 degrees C was significantly higher than for cells grown at 23 degrees C. 3-Hydroxy-3-methylglutaryl coenzyme A synthase, farnesyl diphosphate synthase, and geranylgeranyl diphosphate synthase were identified in the expressed proteome, and most genes involved in the mevalonate pathway and processes leading to the formation of phosphatidylinositol and phosphatidylglycerol were identified in the genome sequence. In addition, M. burtonii encodes CDP-inositol and CDP-glycerol transferases and a number of homologs of the plant geranylgeranyl reductase. It therefore appears that the unsaturation of lipids may be due to incomplete reduction of an archaeol precursor rather than to a desaturase mechanism. This study shows that cold adaptation in M. burtonii involves specific changes in membrane lipid unsaturation. It also demonstrates that global methods of analysis for lipids and proteomics linked to a draft genome sequence can be effectively combined to infer specific mechanisms of key biological processes.

Unsaturated diether lipids in the psychrotrophic archaeon Halorubrum lacusprofundi

The major phospholipids of Halorubrum lacusprofundi grown at 25 degrees C were archaeol phosphatidylglycerol, archaeol phosphatidylglycerylsulphate and archaeol phosphatidylglycerylphosphate methyl ester. Glycolipids included a monoglycosyl archaeol and the sulphate ester of a diglycosyl archaeol. Cultures grown at 12 degrees C contained the same suite of phospho- and glycolipids, with the addition of a series of unsaturated analogues with up to six double bonds. The patterns of unsaturation were similar for all the phospholipid series, but a different pattern occurred in the glycolipids. The analytical techniques used in this study allow facile detection of unsaturated archaeal cell membrane lipids that are degraded by commonly used chemical derivatization procedures.

Extracellular nitric oxide release mediates soluble guanylate cyclase-independent vasodilator action of spermine NONOate: comparison with other nitric oxide donors in isolated rat femoral arteries

Nitric oxide (NO) and NO donors exhibit actions that are not entirely mediated by soluble guanylate cyclase (sGC). The site of NO release may influence the involvement of sGC-independent effects. Here we use spermine NONOate (SPER/NO) to release NO extracellularly, compared with other NO donors. Isolated rat femoral arteries were perfused luminally and perfusion pressure monitored. Vessels were contracted with phenylephrine (2-14 microM) in the presence of an NO synthase inhibitor (N(omega)-nitro-L-arginine methyl ester; 20 microM). Vasodilator responses to NO donors were assessed before and after perfusion of an sGC inhibitor (1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one; ODQ; 20 microM), NO scavengers (hemoglobin; Hb & hydroquinone; HQ), and a superoxide generator (duroquinone; DQ). ODQ (20 microM) abolished the vasodilator responses to glyceryl trinitrate (10(-8) - 10(-3) M), and sodium nitroprusside (10(-8) - 10(-4) M), which release NO intracellularly. ODQ (20 microM) attenuated, but failed to abolish, the vasodilator responses to SPER/NO (10(-6) - 10(-3) M). ODQ abolished responses to S-nitrosoglutathione and S-nitroso-N-valeryl-D-penicillamine (10(-8) - 10(-4) M), but a small residual vasodilatation remained in response to 10(-3) M. In the presence of ODQ, the remaining vasodilatation to SPER/NO was all but abolished by scavengers of extracellular NO (Hb; 10 microM, HQ; 100 microM). Superoxide generation (DQ; 100 microM) also attenuated ODQ-resistant vasodilatation. The data suggest that, in rat femoral arteries, NO donors that are capable of releasing extracellular NO cause vasodilatation that is only partially mediated by sGC. Lack of augmentation of sGC-independent effects by superoxide suggests that they are not mediated by peroxynitrite.

Ozone exposure decreases the effect of a deep inhalation on forced expiratory flow in normal subjects

Sixteen healthy nonsmoking subjects (7 women), 21-49 yr old, were exposed in a climate chamber to either clean air or 300 parts/billion ozone on 4 days for 5 h each day. Before each exposure, the subjects had been pretreated with either oxidants (fish oil) or antioxidants (multivitamins). The study design was double-blind crossover with randomized allocation to the exposure regime. Full and partial flow-volume curves were recorded in the morning and before and during a histamine provocation at the end of the day. Nasal cavity volume and inflammatory markers in nasal lavage fluid were also measured. Compared with air, ozone exposure decreased peak expiratory flow, forced expiratory volume in 1 s, and forced vital capacity (FVC), with no significant effect from the pretreatment regimens. Ozone decreased the ratio of maximal to partial flow at 40% FVC by 0.08 ± 0.03 (mean ± SE, analysis of variance: P = 0.018) and at 30% FVC by 0.10 ± 0.05 ( P = 0.070). Ozone exposure did not significantly increase bronchial responsiveness, but, after treatment with fish oil, partial flows decreased more than after vitamins during the histamine test, without changing the maximal-to-partial flow ratio. The decreased effect of a deep inhalation after ozone exposure can be explained by changes in airway hysteresis relative to parenchymal hysteresis, due either to ozone-induced airway inflammation or to less deep inspiration after ozone, not significantly influenced by multivitamins or fish oil.

Administrative data based patient safety research: a critical review

Administrative data are readily available, inexpensive, computer readable, and cover large populations. Despite coding irregularities and limited clinical details, administrative data supplemented by tools such as the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) could serve as a screen for potential patient safety problems that merit further investigation, offer valuable insights into adverse impacts and risks of medical errors and, to some extent, provide benchmarks for tracking progress in patient safety efforts at local, state, or national levels.