Various studies have reported that excess body weight may increase the risk to various diseases and death. A study reported that adolescents who were overweight were almost 18 times more likely than their leaner peers to be obese in early adulthood and were 8.5 times more likely to have hypertension as young adults. Therefore, this study was conducted to determine the body composition and four dietary factors i.e., prudent diet habits, calorie control habits, dietary fat/ cholesterol and sodium/salt control which may affect blood pressure and the risk of heart disease among year 1 medical students in a public university in Selangor. Body composition was determined by measuring the body mass index (BMI) and body fat percentage. None of the female students showed excellent/good eating habits while majority were fair (37.7%) and poor/very poor (62.3%). Nearly half of the male students showed excellent/good eating habits (42.5%), but more than half (57.5%) were poor/very poor. Majority of the female (85.7%, 85.7% and 94.8% respectively) and male students (80.9%, 57.5% and 93.6% respectively) showed excellent/good eating habits in calorie, dietary fat and salt control. Majority of the students (64.9% female and 61.7% male) have normal BMI values while 24.7% of female and 10.6% of male students were underweight (BMI values less than 18.5). Only a small number of female students were overweight (5.2%) and obese (5.2%). However 14.9% of male students were overweight and another 12.8% were obese.
The purpose of this study was to determine the quality of counter service at the Ministry of Health hospitals as perceived by patients. This was a cross sectional study using selfadrninistered questionnaires distributed to patients at the outpatient departments in all Ministry of Health Hospitals. By the end ofthe data collection period, 118 of 121 hospitals (total number of MOH Hospitals) participated with 93.2% response rate., The hospitals were divided into four categories, for the purpose of this study 1000 sample size were needed in each category, the number of sample size were obtained using Epi Info Program based on assumption that 30% Of patients were dissatisyded with the services provided and with a precision of 10%. In this study the quality were based on clarity and provision of services based on Client Charten deliverance of clear infomation by the healthcare personnel, priority treatment given to urgency of the cases, cleanliness of the facilities and teamwork among the staff This study revealed about 64% of patients perceived that the hospitals had provided quality services at the counter: Only about 11% of patients were not happy with the quality of the services given at the counter. The proportion of happy patients increased from the smaller to the bigger hospitals. In terms of delivering services according to the Client Charter; only about 15% said that service was not provided by the counter staff according to the Client’s Charter On the aspect of priority on the urgent cases, about 64% of the patients perceived that urgent cases were not seen immediately. About 64% of the respondents felt that the hospitah do provide quality services. Strategies should focus on the bigger hospitals because non conformance to quality occurs more frequently there. The post of Counter Supervisor should be created to ensure that quality services are delivered.
Study site: outpatient departments in all Ministry of Health Hospitals
Public health care programme evaluation includes determining the programme effectiveness (outcome assessment), efficiency (economic evaluation), accessibility (reachability of services) and equity (equal provision for equal needs). The purpose of this study was to make comparison on cost·( efficiency and costeffectiveness in managing type 2 diabetes between the Ministry of Health (MOH) health clinics with family medicine specialist (FMS) and health clinics without FMS. A costeffectiveness analysis was conducted alongside across-sectional study at two government health clinics in Machang, Kelantan, one with FMS and the other without FMS. A total of 300 patients, of which 155 from the health clinic without FMS and 145 from the other group were evaluated for sociodemographic and clinical characteristics from August 2005 to May 2006. HbA1c
analysis was measured for each patient during the study period. Macrocosting and microcosting were used to determine costs. The provider cost for diabetic management ranged from RM270.56 to RM4533.04 per diabetic patient per year, withla mean cost of RM1127.91(t906.08) per diabetic patient per year in health clinic with FMS. In health clinic without FMS, the provider cost ranged from RM225.93 to RM4650.13, with a mean cost of RM802.15 (:626.26). Proportion ofgood HbA1c was 17.2% for health clinic with FMS and 10.3% for the health clinic without FMS. The annual mean provider cost per proportion of good HbA1c control (< 7%) (Costefkctiveness ratio/ CER) was RM6557.65.for health clinic with FMS and RM7787.88 for health clinic without FMS. This provider cost-epfectiveness ratio was not different statistically between the health clinic with FMS and health clinic without FMS (p=0.063). The cost of building, equipments, overheads, staff and consumables were higher for FMS group. Sensitivity analysis was performed for three discount rates (0, 5 and 7%). Relative cost-effectiveness of diabetes management in health clinic with FMS and health clinic without FMS was unchanged in all sensitivity scenarios. Even though, there was no significantly difference in provider CER in type 2 diabetes management at Malaysian MOH health clinics, but the provider CER in health clinic with FMS was lower compared to health clinic without FMS. Therefore, we can conclude that the presence of FMS in the health clinic will effectively improved the management of type 2 diabetes.
Diabetes mellitus is the most common endocrine defect among children. Good diabetes management is important to give better health for both the children and the whole family. The goal of this study was to identify the level of mother involvement in children type·1 Diabetes Mellitus management, to identify factors related with mother involvement and to determine the relationships between mother
involvement and glycemic control. A cross·sectional study was carried out with 92 respondents selected by universal sampling from mothers who had diabetic children aged 5-15 years old and from medical visit appointment at University Kebangsaan Malaysia Medical Centre (UKMMC) and Putrajaya Hospital (HP1). Data was obtained through medical record and self reporting questionnaire. The study shown that 58.6% mothers had high involvement and 41.4% mothers had low involvement. Mothers' education level had a significant (p=0.0Z) relationship with a level of mother involvement. Most mothers gave high involvement in diet management (64.1%) and blood glucose monitoring (52. 7%), however most mothers gave low involvement in exercise management (63.0%) and insulin injection (60.9%). Mothers involvement in four management tasks were not statistically significant (p>0,05) with glycemic control. Mothers involvement in children diabetic management was high. There was high mother involvement in children's insulin injection and dietary intake and low mother involvement in children`s blood glucose monitoring and exercise, This study abo showed that there was no significant relationship between level of mother involvement and glycemic control.
This survey elucidated the perceptions and implementation 0f orthodontic Clinical Practice Guidelines (CPGs) by all ortlmduntistc and dental officers in the Ministry of Health Mahysia (MOH). Two different set: uf xelf-administered questionnaires were targeted at first·year dental officers (FYDO), dental officcrx (DO) and administrative Senior Dental Officers (SDO) in one group and unhocluntists in another group. Only 30% responded from a total of 1,327 MOH dental officers, with no participation from three States. Majority (89%) of officers have heard of CPG: although some were unsure of their purpose and usage. About 69% have read orthodontic CPG; of whom 87% have read other MOH dental CPG:. About 78.6% found CPGs 'gaud to excellenf but 16,0% did not answer this question. Same comments received included: language was confusing, inadequate details and pictures, need improvement, irrelevant, need CPG: for other orthodontic problems, need more knowledge first and requests for mare copies. Only 27.7% used them often, 53% occasionally and 15% hardly follow CPG:. About 82% felt that they were encouraged to use CPGx in their workplace and the majority (86%) knew where they were kept especially SDC: and DO; About 90% in the orthndonzist group have received hard copies of orthodontic CPGs but the majority (76%) has not seen them on the website. Although all felt that CPG; were useful to officers and encouraged their use, only 62.5% have introduced CPGs to their officers. There was generally more awareness and usage of CPGS among SDOs compared with DOs and FY DO; The dissemination and availability of orthodontic CPG: is reasonably good. However, the implementation by mthodontists and administrative officers can be improved for better awareness, understanding and usage by dental officers, especially FYDOs.
Undergoing a Pap smear screening is widely accepted as a costeffective screening for detection of cervical abnormalities. In Peninsular Malaysia, cervical cancer was the second commonest cancer among women with incidence rate of 17.8 per 100,000 populations in 2002. Despite the high incidence of cervical cancer, only 26% of eligible woman had undergone Pap smear screening. To determine the prevalence of Pap smear screening, reasons for not undergoing the screening as well as the associated sociodemographic factors among women in Mukim Jaya Setia, a crass-sectional study was conducted in ]anuary 2005. Two hundred and ninety five from 350 households were randomly selected by using a Random Digit Table. Two hundred and eighty consented married women, aged 18 years and above were interviewed by the trained interviewers using structured
questionnaires. The questionnaires consisted of socio-demographic characteristic, Pap smear screening practice and risk factors of cervical cancer. There were 280 women who responded to the questionnaires. Majority of them were housewives (75%) and with low income (84.3%). Most ofthe women completed their education up to lower secondary school only (95%). Only 144 (51.4%) women undergo Pap smear screening but not on a regular basis. Most of them were screened only once, which was more than 3 years ago. Lack of knowledge, no accommodation, feel unnecessary and shy and no time were among the reasons that deterred the women from Pop smear screening. Women who were younger and with higher education level had more Pap smear screening compared to the older and with low education level. The practices of Pap smear screening among women in these villages were still low and was associated with age and educational level.
Merokok merupakan amalan yang dimulakan sewaktu usia remaja. Beberapa kajian yang dijalankan terdahulu di negara maju mendapati keluarga mernpakan faktor penyumbang kepada amalan ini. Meskipun pelbagai kajian di negara·negara rnaju, namun tidak banyak kajian berkaitan aspek ini yang dilaporkan di negara ini. Data kajian lverkait dengan pembolehubah kekeluargaan iaitu hubungan kekeluargaan, pandangan remaja tentang reaksi ibu bapa terhadap amalan rnerokok, struktur keluarga, jumlah ahli keluarga, status merokok di kalangan ibu bapa dan jantina dengan amalan merokok diperolehi dari 251 pelajarpelajar sekolah menengah (Tingkatan 5) (48.2% lelaki dan 51.8%
perempuan} di Daerah Kota Ting?. Johon Kajian ini mendapati sikap ibu bapa yang negatif dan bapa yang tidak merokok merupakan faktor pelindung dari amalan merokok. Hasil kajian mencadangkan faktor kekeluargaan memainkan peranan dalam mempengaruhi amalan merokok di kalangan jantina. Institusi kekeluargaan hendaklah dilibatkan dalam program pencegahan amalan merokok di kalangan remaja.
This study was conducted to study the blood pressure pattern and the prevalence of hypertension and its associated factors in a rural community in two coastal villages in rural Kedah, Mahysia. Out of the total population 504 were above 20 years of age and were eligible to participate. There were 227 males and 252 females. The mean systolic blood pressure was found to rise with age, peaking in the 6l·70 years age group, For women the mean blood pressure rose earlier from the age group of 4-l· 50 years. Mean blood pressures rose with increasing body mass index. lt also varied with occupation and education. The retired and unemployed had a higher blood pressure than those employed and there was an inverse relationship with increasing education. The prevalence of hypertension was 33.6%. More females were hypertensive (36.5%) as compared to males (3 0.4%) and this finding was the same for both systolic and diastolic hypertension. Majority (71.4%) of the hypertensives were undiagnosed. 72.5% of hypertensives who were on treatment were not under control. Hypertension was more prevalent among retirees and illiterates. Prevalence of hypertension increased correspondingly with age. Obesity was associated with hypertension. There was no association with family history of hypertension. Multiple logistic regression showed a positive association only for obesity. ln conclusion, given the high prevalence of hypertension at
present, it appears that the prevalence will increase as each age cohort grows older. Obesity, especially among housewives is a significant assorted factor.
Cancer screening is an important part of any cancer control program and the success of any screening program is partly dependent on having large numbers of the high risk population availing themselves of the service. The purpose of this study was to assess the cancer screening behavior of fulbtime employed women staff of an institute of higher learning using the Health Belief Model (HBM) construct. The results showed that the rate of reported regular cancer screening behavior (Pap smear screening, breast self examination (BSE), clinical breast examination (CBE) and mammography screening) were low. The rates for regular screening were 42.5% (Pap smear), 20.9% (BSE), 15.5% (CBE) and 9.4% (mammography). There were differences in the dimensions of the HBM between the women who reported regular screening and those that did not. The perceived barriers", "perceived benefits” and “motivation” dimensions were different in Pap smear screening, whereas the "confidence” dimension was different in BSE. Recommendations were made for a health education program targeting both women and men to increase uptake of cancer screening services by women.
A cost-utility analysis was performed desferrioxamine treatment in thalctssaemia patients at two tertiary hospitals in Malaysia in 2004. A hundred and twelve transfusion dependent thalassaemia patients were grouped according to the status of desferrioxamine; optimum and sulwptimum. Cost analysis was from a patient and hospital perspectives while Quality Adjusted Life Years (QALYs) was the health outcome of choice. Incremental Cost·Effectiveness Ratio (ICER) was also stipulated to show the difference in cost for an additional QALY if patient currently on suboptimum desferrioxamine to switch using optimum desferrioxamine. Results on cost analysis showed the mean cost of treatment for thalassaemia patients on optimum desferrioxamirie was higher than those on sub·optimum desferrioxamine; (RM14, 775.00+SDRM4,737.00 and RM10,780+RM3,655, respectively). QALYs were 19.186+6.591 and 9.859+5275 in the optimum and suboptirnum group, respectively. Costutility analysis showed the cost per QALYs in optimum desferrioxamine group was RM59,045.00 compared to RM44,665.00 in suboptimum desferrioxamine group. ICER of patients on sub-optimum desferrioxamine switching to optimum desferrioxarnine was only RM420.39. Sensitivity analysis showed that the results were robust in the best and worst scenarios. In conclusion, although it is expensive for thalassaemia patients to use optimum desferrioxamine compared to sub-optimum desferrioxamine, the cost per QALYs gained was undoubtedly low.
To examine the reliability and construct validity of the Malay Version of the Depression Anxiety Stress Scales (DASS), a validation study was conducted in 184 automotive assembly workers. The internal consistency and construct validity were assessed using Cronbach's alpha coefficient
and exploratory factor analysis. The Cronbach's alpha coefficients for DASS-Depression, DASS-Anxiety and DASS-Stress were 0.91, 0.88 and j 0.89, respectively, indicating satisfactory internal consistency Exploratory factor analysis showed three meaningful common factors that could
explain the three theoretical constructs of this instrument. These results suggested that the Malay version DASS is reliable and valid for assessing, the self perceived depression, anxiety and stress among Malaysian automotive workers.
Study site: Two automotive assembly plants, Pahang, Malaysia
Health services are considered to be of good quality if customers’ expectations and perceptions are well balanced. Determinants confirming customers’ expectations will lead to satisfaction, while factors disconfirming it will result in customers’ dissatisfaction, reduced compliance to physicians’ treatment and deterioration in overall disease management. A cross-sectional comparative study was carried out from September till October 2008 to determine population satisfaction with health services provided by the public health clinics in Selangor. A total of 3840 respondents from the urban Health Clinics (HCs) and 4768 respondents from rural HCs were selected applying multi-stage random sampling from 54 HCs in nine districts from Selangor. Self-administrated questionnaires formulated by adopting SERVQUAL method based on modified five dimensions plus four dimensions of Clinics Corporation were used . Results showed the proportion of satisfaction among the population towards services provided by the public HCs was high at 86.1%. From X2 bivariate analysis; satisfied respondents were significantly from Indian and Chinese ethnic community more than the Malays, more among the less educated, the older age category (more than 33 years old) and males’ were slightly more satisfied than females. Patients who visited HCs more than three times were more satisfied than one time visitors. Occupation, marital status and HCs urban-rural locality were not significantly associated with customers’ satisfaction level. All dimensions showed high satisfaction level especially on treatment outcome, except on health care workers (HCWs) caring and professionalism domains. Working as a team was slightly higher in the urban areas compared to rural area. Overall, the SERVQUAL score of all dimensions were higher among the urban respondents albeit not significant. Clients’ perceptions were generally higher than expectations reflecting the high satisfactions among clients at 86.1%. Much improvement needs to be put into training HCWs to be more caring and adapting a professional attitude towards clients. Clients’ satisfactions in the urban and rural HCs were almost equal and did not reflect a decrease of health services priority in the rural areas.
Increasing prevalence of chronic diseases is a major contributor for rapid rise in healthcare cost in developing countries since the last decade. It was estimated that around 54% of deaths in developing countries are due to chronic non-communicable diseases which is predicted to rise by 65% by 2030. Diabetes mellitus is among the most prevalent chronic diseases suffered by more than 180 million people worldwide. By 2030 it is estimated that around 400 million people in the world will be afflicted with diabetes. Annual deaths attributable to diabetes are probably as high as 3 million with more than 80% occur in developing countries. India, China and Indonesia are three countries in the Asian region with most number of people with diabetes. The total number of cases in these three countries is expected to increase more than double from 61 million in 2000 to 163 million in 2030. China and India will suffer cumulative GDP loss of 13.8% and 16.7% respectively, over the next ten year period. Assessing economic burden of diabetes is a challenging task for researchers because identification of direct and indirect cost of the disease is often complex since patients with diabetes also suffers from other complications and co-morbidities. In conclusion, the heavy economic burden of diabetes pose major challenges to health policy makers in developing countries to assess the current approach in managing this chronic disease. Serious efforts should be made on focusing and up-scaling activities on health promotion and prevention of diabetes so that to provide a more cost-effective solution to this condition with huge and increasing economic loss.
Analysis of count event data such as mortality cases, were often modelled using Poisson regression model. Maximum likelihood procedures were used by using SAS software to estimate the model parameters of a Poisson regression model. However, the Negative Binomial distribution has been widely suggested as the alternative to the Poisson when there is proof of overdispersion phenomenon. We modelled the mortality cases as the dependent variable using Poisson and Negative Binomial regression and compare both of the models. The procedures were done in SAS by using the function PROC GENMOD. The results showed that the mortality data in Poisson regression exhibit large ratio values between deviance to degree of freedom which indicate model misspecification or overdispersion. This large ratio was found to be reduced in Negative Binomial regression. The Normal probability plot of Pearson residual confirmed that the Negative Binomial regression is a better model than Poisson regression in modelling the mortality data. The objective of this study is to compare the goodness of fit of Poisson regression model and Negative Binomial regression model in the application of air pollution epidemiologic time series study by using SAS software.
Many studies on adolescent smoking have been conducted in Malaysia, but very limited information is available on smoking amongst lower secondary school male students (Forms 1 and 2). We present data from a baseline study in Kota Tinggi District, Johor on the psychosocial factors, stages of smoking acquisition and susceptibility to smoking initiation and their relationship to adolescent smoking. The study is the first wave of a 3-year longitudinal study which was conducted from March 2007 to May 2009, aimed to describe the prevalence of smoking among students in the lower secondary classes. A three stage stratified sampling was performed to obtain a sample. The Bogus Pipeline Method was employed to confirm smoking status. Prevalence of smoking was 35.5%. Smoking prevalence among students of schools located in the Federal Land Development Authority (FELDA) settlement areas (42.9%) was two-fold higher than in the rural and town schools combined (20.29%). Using the Fagerstrom scale, 90% of current smokers had lower addiction to nicotine. Smoking was associated with peer smoking [OR, 4.19 (95% CI, 2.57-6.82)], having a brother smoking [2.17 (1.31-3.61)], parental smoking [1.73 (1.17-2.80)] and locality where respondents attend school [1.94(1.11-3.39)]. The study indicates that, the prevalence of smoking was high in all areas especially FELDA settlement areas. Measures such as teaching of skills to resist social pressure to smoke, establishment of peer support groups and involvement of parents in anti-smoking programs are recommended to curb the high prevalence of smoking among lower secondary school students in Kota Tinggi.
Osteoporosis is a global health problem both in the developed and developing countries. Patient education forms an important part in the management of osteoporosis. The objective of this study was to evaluate knowledge about osteoporosis and its correlates among women aged ≥ 40 years attending an urban health centre in India and to identify their sources of information on osteoporosis. Knowledge about osteoporosis was assessed using the Osteoporosis Questionnaire (OPQ) in 243 women over 40 years of age, attending an urban health centre in the city of Mumbai located in the state of Maharashtra in western India. This exploratory cross-sectional study was conducted over a period of eight months. The OPQ analysis was performed using SPSS for Windows Version 13.0. The scores were expressed as mean ± SD (Standard Deviation). The one sample-t test was used to study the differences in the mean scores between socio-demographic variables. The mean total OPQ score was 0.91 (SD ± 5; range -9 to 10; maximum possible score 20). There was a significant difference in the total OPQ scores by the level of education and family history of osteoporosis (p
Dengue is one of the main vector-borne diseases affecting tropical countries and spreading to other countries at the global scenario without cease. The impact of climate variability on vector-borne diseases is well documented. The increasing morbidity, mortality and health costs of dengue and dengue haemorrhagic fever (DHF) are escalating at an alarming rate. Numerous efforts have been taken by the ministry of health and local authorities to prevent and control dengue. However dengue is still one of the main public health threats in Malaysia. This study was carried out from October 2009 by a research group on climate change and vector-borne diseases. The objective of this research project is to assess the community vulnerability to climate variability effect on dengue, and to promote COMBI as the community responses in controlling dengue. This project also aims to identify the community adaptive measures for the control of dengue. Various research methodologies were applied in this research project in different localities. Site visits, review on surveillance data and mapping on Aedes population, dengue cases and climate variability, community survey on the knowledge prevalence , opinions and practices (KOP) and mosquito ecology were carried out during pre- and post intervention phases. Community vulnerability towards Aedes and dengue were mapped out applying GIS. A series of workshops, group discussions and activities such as COMBI activities to promote Aedes control were conducted involving the Ledang communities, the health district officers and UKM researchers. These activities also included interventions and documentation of community responses and their adaptive capacities towards dengue. Trends on Aedes population, dengue cases and community surveys pre and post-interventions, the processes for dengue control activities were analysed. The research findings could provide understanding on the community vulnerability to dengue against climate variability, their responses and adaptive measures. The community advocacy on combats against Aedes is a possible effective solution in dengue control. This research could provide other dimensions in public health management to address the impacts of climate change on vector-borne diseases.
Background and Objectives: Unmet need for contraception is the gap between women's reproductive intentions and their contraceptive behavior. This community based interventional study was carried out to determine the unmet needs for contraception, the reasons for this and to assess the impact of interventional measures on acceptance of contraception.
Subjects and Methods: This study was conducted in 52 villages in the state of Maharashtra, India, among 363 married women selected by cluster sampling. Data was collected using an interview guide. An intervention was done for the women who had an unmet need and an assessment of the change was done subsequently. Data was analyzed by using SPSS.
Results The prevalence of contraceptive usage was 59.2% and the prevalence of unmet need for contraception was 44% (160). The unmet need for spacing births was 53.8%, 38.7% for limiting births and 7.5% women were dissatisfied with the current contraceptive method. The reasons ranged from side effects to contraceptives to source of obtaining contraceptives. Age of the respondents, education and number of living children showed statistically significant association with unmet needs. Post intervention, the contraceptive prevalence rate increased significantly 85.7% and there was a significant reduction in the unmet needs for spacing and limiting births, equally there was a significant reduction of dissatisfaction with using contraception.
Conclusion: Improvement in the use of contraception and addressing the unmet need for contraception requires community involvement and ongoing, sustained efforts by health workers to ensure quality care to the beneficiaries.
Introduction: Anemia in pregnancy is still a public health problem in developing countries including Malaysia. Early screening of pregnant mothers who have risk factors of anemia could help identifying these potential anemic mothers and hence targeted for intervention.
Methodology: A cross sectional study IN 2008 was conducted among pregnant women who attended government health clinics in Johor Bahru district to assess the prevalence of anemia in pregnancy and factors associated with it using a structured questionnaire.
Result: Prevalence of anemia in pregnancy (Hb<11.0 g/dl) was 36.6% and majority in mild category (Hb 9-<11 g/dl). The associated factors of anemia in pregnancy were birth spacing, dietary intake with high iron content and iron pill consumption. Multivariate analyses revealed that iron pill intake was the most important factor influencing anemia in pregnancy.
Discussion and conclusion: Even though Johor Bahru is a big town with good health facilities, the prevalence of anemia in pregnancy was quite high. Results were compared with previous studies. Emphasis on compliance to iron pills is very important in prevention and treating anemia in pregnancy
Key Words: anemia in pregnancy, birth spacing and iron pill intake
Study site: Four urban and two rural klinik kesihatan, Johor, Malaysia
Whole-cell Pertussis (wcPertussis) vaccines combined with diphtheria and tetanus toxoids are effective in preventing clinical pertussis. The study aimed at determining the cost of managing fever and convulsions and cost of adverse events associated with wcPertussis. Parents who brought their children to health clinics and parents of children who were admitted for febrile convulsions were interviewed using structured questionnaire and the information were used to determine the cost of managing adverse events. Mean cost of managing mild fever per case was RM249, mean cost of managing high fever per case was RM1,036 and mean cost of managing convulsions was RM1,225. Total cost of managing adverse events was RM261 million for mild fever, RM66.7 million for high fever and RM1.3 million for convulsions. Costs of managing mild and high fever were less than the cost of managing convulsions. Total cost of managing mild fever was highest at RM261 million compared with RM66.7 million for high fever and RM1.3 million for convulsions. Thus, lower risk of adverse events actually contributed to higher costs of managing the adverse event.