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PubMed2002

Specialist health services for people with intellectual disability in Scotland.

BACKGROUND: People with intellectual disability (ID) are known to have a high prevalence of health needs, and to require access to specialist health services in addition to primary care and generic secondary care health services. However, there is no national database of each locality's specialist health service provision. Such a record would highlight variation in provision and enable benchmarking. METHOD: A 15-item questionnaire was developed which included questions on ID health services and staffing levels. This was sent to the chief executive of each of the 15 identified National Health Service primary care trusts/health boards which provide ID services in Scotland. The same questionnaire was also sent to the lead clinician/clinical director of each service. The results were converted to per 100 000 population per trust and presented in cumulative frequency tables to allow benchmarking. RESULTS: A response rate of 100% was achieved. The results show a wide range in the type of services provided by each locality in Scotland. Only three services (21%) have completed the process of resettlement. There was a wide-ranging variability in the number of beds/day places and professionals employed per 100 000 population per trust. CONCLUSIONS: There is widespread diversity in the service provision between different parts of Scotland. Geographical distances and responsibilities for service provision to remote and rural communities did not appear to account for these differences.

Adolescent↗
PubMed1998

Analysis of clonal diversity of the peach-potato aphid, Myzus persicae (Sulzer), in Scotland, UK and evidence for the existence of a predominant clone.

Clones of the peach-potato aphid, Myzus persicae (Sulzer), mostly from Scotland, UK were examined using an rDNA fingerprinting technique. Eighty patterns (genotypes) were found amongst the 276 clones. A large number of clones (30%) from all sample areas in Scotland exhibited the same simple pattern, suggesting the presence of a single M. persicae clone. There was no difference in genotype distributions between M. persicae collected from brassica or potato crops, suggesting that host-adapted genotypes have no advantage in the field. Different fingerprints were randomly distributed in the environment, although clones taken from the same leaf were more often the same fingerprint. Highly distinctive fingerprints, which were more widely distributed, suggest that this technique could be used to follow individual clones. In addition to the common clonal type, multiple fingerprint bands were found over successive years, implying that, in Scotland, local overwintering asexual populations are the most common source of M. persicae in the following year.

Animals↗
PubMed1996

Mortality after transurethral and open prostatectomy in Scotland.

OBJECTIVE: To use the linked medical and death records in Scotland to investigate the possible increased mortality that has been reported after transurethral prostatectomy (TURP) compared with open prostatectomy. PATIENTS AND METHODS: Scotland has maintained linkable hospital, cancer and death records for more than 20 years, representing one of the largest such databases in the world. From these computerized records, data on various cohorts of men aged 55-84 years selected from 81,997 men who underwent prostatectomy in Scotland between 1968 and 1989 were analysed. The risk of late mortality was calculated for each type of operation, whether there was prior comorbidity and for a range of specific causes (cancer, respiratory and circulatory conditions) after prostatectomy. RESULTS: Among the largest cohort, consisting of 65,519 men who underwent prostatectomy between 1968 and June 1989, the relative risk of late mortality after TURP compared with open prostatectomy was 1.13 (95% CI, 1.10-1.16), after controlling for age and the presence of a diagnosis of cancer. A more restricted cohort of 18,732 men who underwent prostatectomy between 1974 and 1979 allowed adjustment for prior hospitalization with, or concurrent diagnosis of, circulatory and respiratory conditions. In this cohort, the relative risk of late mortality after TURP as compared with open prostatectomy was 1.15 (95% CI, 1.11-1.19) after adjusting for prior and comorbidity and age. Finally, a cohort of 'healthy patients' restricted to the 6932 men who underwent prostatectomy from 1974 to 1979 and with no evidence of hospitalization in the previous 5 years or any current diagnosis other than benign hypertrophy of the prostate, showed a relative risk of 1.14 (95% CI, 1.07-1.21). There was no evidence of an increased risk of dying from circulatory disease in general, ischaemic heart disease or acute myocardial infarction after TURP as opposed to open prostatectomy. However, there was an increased risk of dying from respiratory conditions and from cancer, especially of the prostate and bladder. The analysis suggested the possibility that open prostatectomy may have cured some patients with early prostatic cancer, because the late death rate from prostatic cancer was greater in patients who underwent TURP than open prostatectomy. CONCLUSION: The present analysis confirmed the increased risk of late mortality after TURP compared with open prostatectomy, as shown in previous studies based on administrative records. However, limitations in the coding of comorbidities and the absence of coding of more subtle aspects of the condition of the patient which may influence the choice between the forms of prostatectomy mean that the differential mortality after the two procedures could still be a reflection of the pre-operative selection of patients rather than the effects of the surgical procedure.

Aged↗
PubMed2000

Rising incidence of prostate cancer in Scotland: increased risk or increased detection?

OBJECTIVE: To assess the extent to which the increasing incidence of prostate cancer in Scotland can be explained by increased detection, particularly through transurethral resection of the prostate (TURP) and use of the prostate-specific antigen (PSA) test. Subjects and methods This population-based study was confined to men resident in Scotland and aged > or =50 years. Temporal trends were examined in age-specific and age-standardized incidence, mortality and TURP rates, and PSA testing rates during 1981-1996. Also analysed were the geographical variations in age-standardized incidence and mortality rates during two distinct periods, 1984-1986 (before PSA testing) and 1994-1996 (after PSA testing). Finally, incidence rates and relative survival at 5 years were calculated by age group and 5-year periods of diagnosis during 1968-1992. RESULTS: The incidence of prostate cancer in men aged > or = 50 years increased from an age-standardized rate of 142.0 per 100 000 in 1981 to 240.9 in 1996, with the steepest increase occurring between 1992 and 1993. The mortality rate increased similarly until 1993, but was relatively stable thereafter, falling slightly in 1996. In 1981-1988, incidence rates were closely correlated with TURP rates (r = 0.98, P<0.001). In 1989-1996, incidence was closely correlated with PSA testing rates (r = 0.98, P<0.001). By 1994-1996, incidence rates varied substantially between Scottish mainland health boards (range 167.7-303.0 per 100 000), with much less variation in mortality rates (90.7-110.0). Relative survival has increased recently in all age groups although, in the era before PSA testing, survival was reasonably stable despite increasing incidence. CONCLUSION: Although there may have been a true increase in risk, much of the observed increase in the incidence of prostate cancer in Scotland between 1981 and 1996 has been caused by increased detection, leading recently to considerable variation among different areas of the country. The extent to which this represents the early diagnosis of tumours which would eventually cause symptoms or be life-threatening, or detection of latent disease which would never have become symptomatic, is not clear. There is no evidence so far that the increased incidence is associated with any substantial reduction in mortality.

Age Distribution↗
PubMed2002

The experience of collaboration: a comparison of health visiting in Scotland and Norway.

This investigation compared health visiting in Scotland and Norway by focusing on collaboration in health visiting. The data are based upon in-depth interviews with a non-probability sample, with voluntary participation of nine health visitors from Scotland and 12 health visitors from Norway. The results showed that there were more similarities than differences between the Scottish and Norwegian health visitors' experience of collaboration in their work. Both groups had a complex role-set and experienced dependency on role partners. Collaborative strain was experienced through lack of recognition and system deficiencies. Tensions in collaboration evolved from the definition and question of responsibility in grey areas, jurisdictional threats and conflicts. Within these areas the degree and importance of collaboration differed. The Scottish health visitors were more dependent on client referrals to them and their referrals to other agencies, whereas the Norwegians health visitors experienced an asymmetrical relationship, as they were more dependent on the capacity of the agency to accept the referrals. Lack of recognition seemed to be a stronger experience in Norway than in Scotland. All of this had a marked influence on the performance of the health visitors. Further research should address the question of collaboration in health visiting work and to what degree it influences the quality of health visiting and consequences for clients, the community and health visiting service.

Adult↗
PubMed2004

Incidence of juvenile-onset Crohn's disease in Scotland: association with northern latitude and affluence.

BACKGROUND & AIMS: The incidence of Crohn's disease in Scottish children has increased steadily over 30 years. Many studies have investigated genetic influence or possible links with childhood events. We aimed to study sociodemographic and/or geographic distribution of juvenile=onset Crohn's disease in Scotland. METHODS: Using a previously established and validated database covering the entire Scottish population, 580 Scottish children (<16 years of age at symptom onset) with inflammatory bowel disease incident between 1981 and 1995 were identified. Postcodes of incident cases were classed for geographic location and material deprivation. Incidence rates (/100,000/year) were sex standardized to the 1991 census population. The effects of sex, geographic location, time, and deprivation category were estimated from a multifactorial Poisson regression model. RESULTS: The incidence of juvenile-onset Crohn's disease was 2.3 (95% CI: 2.0-2.5) for the time period 1981 to 1995 and was significantly higher in northern (3.1, 95% CI: 2.6-3.8) than in southern Scotland (2.1, 95% CI: 1.9-2.4, P < 0.001). The incidence of juvenile-onset ulcerative colitis did not show north/south variation ( P = 0.677). The relative risks of developing CD were significantly lower in postcode areas with deprivation categories 2-7 as compared with deprivation score 1 (most affluent, P = 0.033). This pattern was not seen for UC. CONCLUSIONS: There was an increased incidence of juvenile-onset Crohn's disease in northern compared with southern Scotland. Children from more affluent areas had a higher relative risk of developing Crohn's disease. Juvenile onset ulcerative colitis did not show north/south variation in incidence or association with affluence.

Adolescent↗
PubMed2001

Competencies of midwives with single or dual qualifications at the point of registration in Scotland.

OBJECTIVE: to compare and contrast competencies of midwives with single or dual qualifications at the point of registration in Scotland. DESIGN: self-completing survey using the Glasgow Royal Maternity Hospital's Skills' Inventory by midwives at the point of registration and by Supervisors of Midwives analysed using non-parametric statistical tests. Content analysis of semi-structured interviews with experienced midwives and Supervisors of Midwives. SETTING: midwifery education and practice settings throughout Scotland. PARTICIPANTS: 157 midwives at the point of registration, 166 Supervisors of Midwives. MEASUREMENTS: Mann-Whitney and Kruskal Wallis analysis of skills of midwives at the point of registration in prenatal, labour, post-natal, neonatal areas and extended skills areas. FINDINGS/IMPLICATIONS FOR PRACTICE: all newly qualified midwives in Scotland, regardless of their educational preparation, are capable of providing care for women and babies in normal midwifery situations. While support for the direct entry programmes has been clearly demonstrated, this is not unanimous, although as more direct entry midwives take up positions, attitudes are becoming more positive.

Adult↗
PubMed2002

Choice and control as experienced by Chinese and Scottish childbearing women in Scotland.

OBJECTIVE: to provide some insights as to how women's childbearing experiences might be improved. DESIGN: a qualitative comparative approach. SETTING: maternity units in Scotland. METHOD: two case comparison, four tape-recorded semi-structured interviews with each of ten Chinese and ten Scottish women, and one unstructured interview with 45 health workers, women's relatives and friends. This study was set against the background of existing literature and the author's personal experience as a midwife in both Chinese and Scottish societies and as a Chinese mother having her first baby in Scotland. FINDINGS: the issues of 'choice' and 'control' in childbearing regulated the social relationships between women, women's bodies, their babies, health workers, obstetric technology and the wider social context. Although the Chinese and Scottish women under investigation were in Scotland, their different cultural backgrounds gave them different expectations, choices and experiences. These differences are further examples of the social and cultural construction of choice and control. CONCLUSION: 'choice' and 'control' offered some new dimension for the women to achieve; for the health workers and society to facilitate a new dynamic and stimulating childbearing experience. Women's bodies' cues, their babies and their feeling of being in control could be important in the management and their experience of care.

Adult↗
PubMed1987

A seroepidemiological survey of toxoplasmosis in Scotland and England.

The Sabin-Feldman dye test was used to detect the presence of Toxoplasma antibodies in two groups of blood donors in central Scotland, one group from a rural area and one from an urban area, and in patients attending a medical outpatients clinic and females attending an antenatal clinic serving a mixed urban and rural area in the midlands of England. Results obtained from these four groups showed that 7.6, 7.8, 35.7 and 14.9% respectively had antibody titres of 1: greater than or equal to 10. A group of travelling people, defined in the Local Government and Planning (Scotland) Act, 1982, as '...persons of nomadic habit of life, whatever their race or origin...', from Scotland were also surveyed and 28% of this group had antibodies of 1: greater than or equal to 10. Individuals in this latter group were reported to have minimal contact with cats because of their lifestyles. The prevalences of the travelling people were analysed by age group and showed no correlation with age, but other groups did show an increasing prevalence with age. The significance of these results is discussed.

Adolescent↗
PubMed2004

Practice of and attitudes toward breast self-examination (BSE): a cross-cultural comparison between younger women in Scotland and Greece.

Breast self-examination (BSE) is a method of early detection of breast cancer. Although BSE is recommended for all women, it is mostly suitable and readily available for younger women. BSE beliefs and practices of women in Scotland, a country with organised health campaigns about BSE, were compared with those of women in Greece, a country without such campaigns. Our sample consisted of 68 university students in Scotland and Greece, aged 18 to 26 years old. All participants completed a questionnaire assessing demographics, health history, knowledge, BSE practice, health beliefs, and health-related personality. BSE practice was found to be associated with different variables across the two cultural groups. Adherence rates were found particularly higher than previous reports and BSE practice did not differ significantly between women in Scotland and Greece. Nevertheless, the two groups differed significantly in their knowledge, attitudes toward BSE, and health-related personality. On the basis of these findings, cultural factors should be considered in organising BSE campaigns. Also the present findings identified BSE-related beliefs and practices specific to younger age groups. These could be considered and addressed in order to organise BSE campaigns in Greece and improve future UK programs especially tailored for this age group.

Adolescent↗
PubMed2003

Total registration of non-Hodgkin's lymphoma and Hodgkin's disease in Scotland: effect of deprivation and caseload on outcome.

All cases S16 years of age with a histological diagnosis of non-Hodgkin's lymphoma (NHL) and Hodgkin's disease (HD) presented in Scotland between 1 January 1994 and 31 December 1996 were registered prospectively in the Scotland and Newcastle Lymphoma Group database by a process of total registration. The census population of Scotland in 1996-1997 was 5.1 million. One thousand seven hundred and sixty three patients were registered with NHL and 350 patients with HD. These patients have been followed up for a median of 47 months in the case of NHL and 51 months for HD cases. Actuarial 5-year survival for adult NHL was 35% and for HD, 75%. Outcome for both NHL and HD was particularly poor in the population over 60 years with median survival of 18 months for NHL and 27 months for HD. When analysis of survival was related to degree of material deprivation using the Carstairs score a significantly poorer survival was seen for NHL with increasing deprivation that could not be explained by a different pattern of age or stage at presentation. Deprivation had no impact on incidence or survival in HD. Analysis of impact of caseload of the physician initiating therapy showed no significant difference in 5-year survival.

Adolescent↗
PubMed2002

A capture-recapture model to estimate prevalence of children born in Scotland with developmental eye defects.

BACKGROUND: Microphthalmia, anophthalmia and coloboma (MAC) are closely related structural developmental eye defects that have caused public concern in the UK following media reports of apparent clusters of cases. An extensive search was carried out to identify potential cases, and diagnoses were confirmed by ophthalmological review. Despite this effort, it was recognised that some cases would remain unidentified. Capture-recapture methods could improve the accuracy of the study's birth prevalence estimate. METHODS: A register of all children born with the developmental eye defects of MAC in Scotland (1981-96) was compiled. This identified 188 cases from eight national ascertainment sources. The methods described by Hook and Regal were used to determine possible estimates for each source. A log-linear method of capture-recapture was used to fit a model to the number of children identified by the different combinations of the eight national sources, and the individual sources were included in the model as main effects. RESULTS: Maximum-likelihood estimates were calculated for tables of captured/not captured by one source versus any other source. The estimated number of unobserved cases for the most complete source, the register of congenital anomalies for Scotland, and the seven others combined is 78 (95% CI 53-115). Estimates calculated from two different log-linear models of the numbers of cases unobserved by all sources were 61 (95% CI 43-86) and 175 (95% CI 106-287). An external check with an independent congenital-anomalies register in one region, which is known to have high completeness, gave an estimate of 120. The study found a birth prevalence of MAC in Scotland of 1.9/10000, based on total live births during the study period. The capture-recapture analysis suggests that the true birth prevalence lies between 2.4/10 000 and 3.5/10000. DISCUSSION: Our experience shows that, even with multiple sources of ascertainment and considerable resources directed at case identification, a considerable level of under-ascertainment of congenital eye-anomalies still results, and suggests that the use of capture-recapture analysis would be a useful addition to congenital anomalies registers for needs assessment, disease-burden estimates and health-service planning.

Eye Abnormalities↗
PubMed2006

Procedure-specific surgical site infection rates and postdischarge surveillance in Scotland.

OBJECTIVE: To investigate the impact of postdischarge surveillance (PDS) on surgical-site infection (SSI) rates for selected surgical procedures in acute care hospitals in Scotland. DESIGN: Prospective surveillance of SSI after selected surgical procedures. SETTING: The Scottish Surveillance of Healthcare Associated Infection Programme (SSHAIP), which is based on the methodology of the Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance system (NNIS). Thirty-two of 46 acute care hospitals throughout Scotland contributed data to SSHAIP for this study. METHODS: Data were from 21,710 operations that took place between April 1, 2002, and June 30, 2004; nine categories of surgical procedures were analyzed. CDC NNIS system definitions and methods were used for SSI PDS. PDS is a voluntary component of the mandatory SSI surveillance program in Scotland. PDS was categorized as none, passive, active without direct observation, and active with direct observation. RESULTS: From our study information, PDS data were available for 12,885 operations (59%). A total of 2,793 procedures (13%) were associated with passive PDS and 10,092 (46%) with active PDS. The SSI rate among the 8,825 operations with no PDS was 2.61% (95% confidence interval [CI], 2.3%-3.0%), which was significantly lower than the SSI rate found among the 12,885 operations for which PDS was performed (6.34% [95% CI, 5.9%-6.8%]). For breast surgery, cesarean section, hip replacement, and abdominal hysterectomy, the rate of SSI when PDS was performed was significantly higher than that when PDS was not performed (P<.01 for each procedure). No differences in SSI rates were found for surgery to repair fractured neck of the femur or for knee replacement. SSI rates were examined according to procedure type, performance of PDS, and NNIS risk index; rates of SSI increased with NNIS risk index within procedure group and PDS group. Logistic regression analyses confirmed that procedure type, performance of PDS, and NNIS risk index were all statistically independent predictors of report of an SSI (P<.05). CONCLUSIONS: This Scottish national data set incorporates a substantial amount of PDS data. We recommend a procedure-specific approach to PDS, with direct observation of patients after breast surgery, cesarean section, and hysterectomy, for which the length of stay is typically short. Readmission surveillance may be adequate to detect most SSIs after orthopedic surgery or vascular surgery, for which the length of stay is typically longer.

Cohort Studies↗
PubMed1993

Trends in hospitalization for heart failure in Scotland 1980-1990.

Heart failure is a growing public health problem in industrialized countries with ageing populations. Scotland has a relatively stable population of approximately 5 million and a well described system for recording details of hospitalizations (Scottish Hospital In-Patients Statistics-SHIPS). We have examined SHIPS data for hospitalizations for heart failure in Scotland 1980-1990. Discharges for heart failure as the primary diagnosis increased by almost 60%, from 1.30 to 2.12/1000 population in this period (as either primary or secondary diagnosis the rate increased from 2.51 to 4.24/1000). Seventy-eight percent of discharges were in persons aged > or = 65 years and 48% of discharges were male. Heart failure (primary diagnosis) accounted for almost 4% of all general (internal) medicine discharges. In-patient case fatality was 18% in 1990. Mean duration of in-patient stay on Internal Medicine wards was approximately 11 days. The number of hospitalizations for heart failure is now almost identical to those for myocardial infarction. These trends mirror those recently reported from the United States. Heart failure is an increasingly common and costly cause of hospitalization in Scotland. Approaches which can reduce this burden on the hospital service require urgent attention.

Adult↗
PubMed2003

Increasing mortality among adults in Scotland 1981 to 1999.

BACKGROUND: The aim of the study was to describe the change in overall and cause-specific mortality in Scotland between the early 1980s and late 1990s, with particular reference to the mortality experience of young adults. METHOD: The study was based on death records for Scottish residents. Changes in age and cause-specific death rates between 1981-83, 1989-91 and 1997-99 were compared. RESULTS: Between 1981-83 and 1989-91 death rates in Scotland began to rise among young men aged 20-24 while for those aged over 25 rates declined. The greatest fall in rates was experienced at ages 40 to 59. When death rates during 1997-99 were compared to rates in 1989-91 this pattern had changed. During the 1990s death rates among 20 to 34-year-olds increased, with a slight rise at ages 35-44. At older ages overall mortality continued to decline but the greatest fall was at ages 60 and over. Trends among women shared similarities with men. For both men and women falls in mortality from heart disease, stroke, and cancers were being differentially offset by increases in other causes of death across all age groups. The causes of death that contributed to the increased death rate among young adults include to various degrees, suicides, drug deaths, alcohol and violence. CONCLUSION: In Scotland changes in mortality result from a complex combination of different trends in mortality from various causes of death. The rate of decline in mortality among men aged 59 and below is slowing down, and death rates among young men aged 15-44 are increasing. If these trends continue there is a suggestion that future death rates may begin to rise at older ages.

Adolescent↗
PubMed1996

Cardiac rehabilitation in Scotland: is current provision satisfactory?

BACKGROUND: Cardiac rehabilitation is an effective intervention, lowering mortality following myocardial infarction and reducing morbidity in patients with coronary heart disease. However, its level of provision was unclear. This study aimed to provide a comprehensive description in Scotland. METHODS: A national survey of hospital, general practice and community sources was conducted in 1994 to identify cardiac rehabilitation programmes in Scotland. Detailed information about each programme was collected by computer-assisted telephone interviews. RESULTS: Sixty-nine programmes were identified, providing out-patient cardiac rehabilitation to 4980 patients and in-patient cardiac rehabilitation to 8920 patients. This represented 17 per cent and 30 per cent of patients admitted to hospital with coronary heart disease (excluding heart failure), respectively. There was considerable geographical variation in provision and dependence on sources outside the health service for much funding. CONCLUSIONS: Despite evidence of benefits from randomized trials, the overall provision of cardiac rehabilitation in Scotland was low. Considerable inequity was demonstrated between different health board areas. There is opportunity for better provision, which would improve care for many patients with coronary heart disease.

Catchment Area, Health↗
PubMed2006

Legislation on smoking in enclosed public places in Scotland: how will we evaluate the impact?

BACKGROUND: From 26 March 2006, smoking will be prohibited in wholly and substantially enclosed public places in Scotland, and it will be an offence to permit smoking or to smoke in no-smoking premises. We anticipate that implementation of the smoke-free legislation will result in significant health gains associated with reductions in exposure to both environmental tobacco smoke (ETS) and personal tobacco consumption as well as other social and economic impacts. METHODS: Health Scotland in conjunction with the Information Services Division (ISD) Scotland and the Scottish Executive have developed a comprehensive evaluation strategy to assess the expected short-term, intermediate and long-term outcomes. Using routine health, behavioural and economic data and commissioned research, we will assess the impact of the smoke-free legislation in eight key outcome areas--knowledge and attitudes, ETS exposure, compliance, culture, smoking prevalence and tobacco consumption, tobacco-related morbidity and mortality, economic impacts on the hospitality sector and health inequalities. CONCLUSION: The findings from this evaluation will make a significant contribution to the international understanding of the health effects of exposure to ETS and the broader social, cultural and economic impacts of smoke-free legislation.

Air Pollution, Indoor↗
PubMed2003

Changes in paracetamol, antidepressants and opioid poisoning in Scotland during the 1990s.

BACKGROUND: Overdose is one of the commonest causes of medical admissions to UK hospitals. In Scotland (pop. 5.1 million), all NHS hospital discharge data is uniquely linked to enable identification of individuals re-presenting with the same diagnosis. AIM: To examine trends in discharges for poisoning, in particular paracetamol, antidepressants and opioids from 1990-99. DESIGN: Retrospective analysis. METHODS: Discharge data from the Scottish Morbidity Record (SMR01) and mortality data from the General Register Office for Scotland (GROS) were analysed for 1990-99 by age and gender for the relevant codes. RESULTS: Overall discharge rates increased until 1997, after which they fell. This pattern was seen in paracetamol-related discharges, but not for antidepressants or for opioids. Overdose was more common in females, except for opioids. Discharges related to opioids increased in an exponential manner over the decade, five-fold in women and six-fold in men in 10 years. DISCUSSION: Increases in opioid-related presentations are of major concern. Changes in paracetamol pack-size have been associated with reduced discharge rates. In Scotland the age group with the highest rate of discharge (15-24 years) with paracetamol overdose is not the one with the highest mortality.

Acetaminophen↗