Investigating the impact of milk protein, inulin, and honey on quality attributes of goat milk yoghurt.

In this present study, a three-factor Box-Behnken, response surface methodology (RSM) design was employed to optimize the skimmed milk powder (SMP)/whey protein concentrate (WPC) ratio (0.25-0.75%w/v) as a source of milk protein, inulin (1-2%w/v), and honey (4-6%w/v) for production of high-quality goat milk yoghurt (GMY). The resulting ANOVA and response surface equations revealed the significant effect (p < 0.05) of these variables on the various attributes such as total solid (%), pH, titratable acidity [(LA) % by weight], syneresis (%), DPPH (% inhibition), viscosity (m.Pa⋅s), whiteness index (WI), and overall acceptability (OA). The coefficient of determination (R2) for all response variables ranged from 0.88 to 0.99. Lack-of-fit tests resulted in non-significant F-values. The optimal conditions were determined as SMP/WPC at 0.36%w/v, inulin at 1.00%w/v, and honey at 6.00%w/v. The optimum values for total solid, pH, titratable acidity, syneresis, DPPH, viscosity, WI, and OA were 22.03, 4.46, 0.77, 6.34, 25.20, 182.30, 76.29 and 8.37, respectively with desirability value of 0.95.

Prevalence and approaches to manage iron deficiency anemia (IDA).

Iron is a vital micronutrient required for growth and development at all stages of human life. Its deficiency is the primary cause of anemia that poses a significant global health problem and challenge for developing countries. Various risks are involved during iron deficiency anemia (IDA), such as premature delivery, low birth weight, etc. Further, it affects children's cognitive functioning, delays motor development, hampers physical performance and quality of life. It also speeds up the morbidity and mortality rate among women. The major reasons accountable are elevated iron demand in diet, socio-economic status, and disease condition. Various strategies have been adopted to reduce the IDA occurrence, such as iron supplementation, iron fortificants salts, agronomic practices, dietary diversification, biofortification, disease control measures, and nutritional education. Usually, the staple food groups for fortification are considered, but the selection of food fortificants and their combination must be safe for the consumers and not alter the finished product's stability and acceptability. Genetically modified breeding practices also increase the micronutrient levels of cereal crops. Therefore, multiple strategies could be relied on to combat IDA.

Effect of hybrid drying on the quality attributes of formulated instant banana-milk powders and shakes during storage.

The present research aimed to evaluate the effect of microwave-assisted conventional drying (hybrid drying) on the physico-chemical and functional characteristics of formulated instant banana-milk powders (IBSPs), and organoleptic attributes of banana-milk shakes during storage. The instant powders were prepared from ripe (IBSP1 (control) and IBSP2) and overripe (IBSP3) bananas using hot-air drying (control) and hybrid (microwave assisted hot-air) drying. The water holding capacity, water solubility index, and viscosity of fresh samples, IBSP1, IBSP2, and IBSP3 were 1.97, 1.53 and 0.60 g/g dry sample, 69.48, 75.21 and 76.62 g/mL and 82.29, 86.29 and 72.55 mPas, respectively. A significant (p < 0.05) increase in moisture content, water activity (aw), acidity, and non-enzymatic browning was observed in all the variants/samples during storage. Among various treatments, the shakes prepared by reconstitution (IBSP: water ratio, 1:4) of IBSP2 formulation rated highest organoleptically (significant, p < 0.05).

Modelling and optimization of process parameters for production of desiccated Chhana-murki (Indian cottage cheese-based dessert).

In the present study, process parameters were optimized for the production of desiccated chhana-murki (Indian cottage cheese-based dessert). Response Surface Methodology (RSM) was employed to explore the mutual effects of coagulation temperature (CT) of milk (70-90 °C), % fat level in milk (3.5%-5.5%), and sugar-to-paneer cube (SP) ratio (0.6-0.9) on instrumental hardness (N), water activity (aw), yield (%), sensory sweetness and overall acceptability (on 100-point intensity scale) of chhana-murki. The resulted responses were evaluated by analysis of variance (ANOVA), and the second-order polynomial response surface equations were fitted using multiple regression analysis. Determination coefficients (R 2) were equal to 80% or higher for individual responses stated that the developed models were well fitted to the experimental results. The optimized product was prepared using CT 79.22 °C, milk fat 4.8%, and SP ratio 0.7. Confirmatory experiment values for instrument hardness, water activity (aw), yield (%), sensory sweetness and overall acceptability were 105.05 N, 0.85, 115.2%, 61.2 and 78.8, respectively.

Optimization of ingredients for preparation of low calorie fiber enriched chhana balls-Sandesh like product.

The present study aimed to optimize the relative proportion of roasted flax seed flour as dietary fiber ingredient (DFI) and jaggery:stevia percent in preparation of chhana balls. Response surface methodology (RSM) was used to determine the optimum DFI proportion and jaggery:stevia percent. Thirteen experimental runs were conducted with varying levels of independent variables viz. dietary fiber ingredient (4.0-8.0%) and jaggery:stevia :: 1:1 (22.5-27.5%), as generated by central composite design. The responses investigated were pH, cooking yield, water activity (aw), Hue angle, Chroma value and sensory attributes of chhana balls. The RSM results showed that the experimental data could be adequately fitted to a second-order polynomial model with a satisfactory Coefficient of determination (R2 > 50%). The study revealed that the effect of all the factors were significant on the studied responses. The optimum formulation obtained using desirability function was 5.92 and 26.42% for DFI proportion and jaggery:stevia respectively. The values of responses at optimum formulation were 6.36 pH, 91.80 cooking yield (%), 0.9481 water activity (aw), - 22.62 Hue angle, 8.71 Chroma value, 6.89 sweetness and 7.10 overall acceptability. These predicted values were validated with experimental values and found be not significantly different.

Evaluation of quality changes in nutritionally enriched extruded snacks during storage.

The aim of this study was to evaluate changes in the physical, chemical and sensory properties of a low fat-high protein, fiber enriched extruded snack. It was packed in metalized polypropylene/polyethylene (PP/PE) laminate pouches, under modified atmosphere packaging (MAP) with nitrogen flushing and without nitrogen flushing (control) and stored for a period of 22 weeks at 37 ± 1 °C and 80% RH. MAP had significant impact on the moisture content, aw, TBA value, Hunter L* value and crispiness of the extruded snacks during storage. The moisture content of the snack significantly increased from 3.68 to 5.16% in control and from 3.66 to 4.31% in MAP. The oxidative rancidity in terms of TBA value of control sample increased from 0.02 to 0.07 while the product packaged under MAP, the value increased to 0.056. The sensory scores for flavour, color and appearance, texture and overall acceptability (OA) of the product significantly decreased during storage, but the product stored under MAP had better flavor (6.51) and OA scores (6.85) compared to control (5.58 and 6.04, respectively), after 22 weeks of storage. Thus, MAP tended to retard the storage induced changes and it could suitably be utilized for the delivery of low fat-high protein, fiber enriched extruded snacks to the consumer, while keeping the sensorial acceptance of the product for 5 months.

Bile Acids in Pancreatic Carcinogenesis.

Pancreatic cancer (PC) is a dangerous digestive tract tumor that is becoming increasingly common and fatal. The most common form of PC is pancreatic ductal adenocarcinoma (PDAC). Bile acids (BAs) are closely linked to the growth and progression of PC. They can change the intestinal flora, increasing intestinal permeability and allowing gut microbes to enter the bloodstream, leading to chronic inflammation. High dietary lipids can increase BA secretion into the duodenum and fecal BA levels. BAs can cause genetic mutations, mitochondrial dysfunction, abnormal activation of intracellular trypsin, cytoskeletal damage, activation of NF-κB, acute pancreatitis, cell injury, and cell necrosis. They can act on different types of pancreatic cells and receptors, altering Ca2+ and iron levels, and related signals. Elevated levels of Ca2+ and iron are associated with cell necrosis and ferroptosis. Bile reflux into the pancreatic ducts can speed up the kinetics of epithelial cells, promoting the development of pancreatic intraductal papillary carcinoma. BAs can cause the enormous secretion of Glucagon-like peptide-1 (GLP-1), leading to the proliferation of pancreatic ß-cells. Using Glucagon-like peptide-1 receptor agonist (GLP-1RA) increases the risk of pancreatitis and PC. Therefore, our objective was to explore various studies and thoroughly examine the role of BAs in PC.

Prescription-based cost analysis of medicines for cardiovascular risk factors at Indian Council of Medical Research-Rational Use of Medicine Centre Hospitals of India.

OBJECTIVES: India has taken several initiatives to provide health care to its population while keeping the related expenditure minimum. Since cardiovascular diseases are the most prevalent chronic conditions, in the present study, we aimed to analyze the difference in prices of medicines prescribed for three cardiovascular risk factors, based on (a) listed and not listed in the National List of Essential Medicines (NLEM) and (b) generic and branded drugs. MATERIALS AND METHODS: Outpatient prescriptions for diabetes mellitus, hypertension, and dyslipidemia were retrospectively analyzed from 12 tertiary centers. The prices of medicines prescribed were compared based on presence or absence in NLEM India-2015 and prescribing by generic versus brand name. The price was standardized and presented as average price per medicine per year for a given medicine. The results are presented in Indian rupee (INR) and as median (range). RESULTS: Of the 4,736 prescriptions collected, 843 contained oral antidiabetic, antihypertensive, and/or hypolipidemic medicines. The price per medicine per year for NLEM oral antidiabetics was INR 2849 (2593-3104) and for non-NLEM was INR 5343 (2964-14364). It was INR 806 (243-2132) for generic and INR 3809 (1968-14364) for branded antidiabetics. Antihypertensives and hypolipidemics followed the trend. The price of branded non-NLEM medicines was 5-22 times higher compared to generic NLEM which, for a population of 1.37 billion, would translate to a potential saving of 346.8 billion INR for statins. The variability was significant for sulfonylureas, angiotensin receptor blockers, beta-blockers, diuretics, and statins (P < 0.0001). CONCLUSION: The study highlights an urgent need for intervention to actualize the maximum benefit of government policies and minimize the out-of-pocket expenditure on medicines.

In vitro antioxidant and antimicrobial activities of clove extract and its effectiveness in bio-composite film on storage stability of goat meat balls.

The aim of this study was to find out clove extract's antimicrobial and antioxidant properties, as well as its efficacy as a bioactive ingredient in the development of bio-composite films to increase the storage stability of goat meat balls stored at 4 ± 1°C. The clove extracts (CLEs) were prepared in ethanol, hydroethanol (1:1), and water and evaluated for antioxidant and antimicrobial potential. In vitro assays of CLEs revealed more susceptibility for gram-positive bacteria than gram-negative bacteria. Among the different extracts, the clove ethanol extract (CLEE) had the highest antimicrobial activity against tested microorganisms as well as total phenolics (1.14 mg GAE/g), flavonoids (8.50 µg catechin/g), and DPPH assay (39.59%). Further, the concentration-dependent effect of CLEE (p < 0.05) on thickness and color values and antimicrobial properties of the bio-composite film were observed. The storage qualities of the product T1 (with film; 450 µl CLEE) such as pH (6.45 ± 0.01), TBARS (0.87 ± 0.06 mg malonaldehyde/kg) value, free fatty acid (0.193 ± 0.001% oleic acid), total mesophilic count (4.98 ± 0.05 log10 CFU/g), and sensory attributes (overall acceptability score: 5.67 on 8-point scale) were better (p < 0.05) than T0 (without film; control) on day 20 of storage. Thus, the ethanolic clove extract has a superior antioxidant and antimicrobial potential. Its inclusion in the bio-composite film prolonged the storage stability of goat meat balls by controlling lipid oxidation and microbial growth. Practical Application Today's consumers are more attracted towards meat products added with natural ingredients having preservative effects. Clove extract is a classic example of a natural preservative and has excellent antimicrobial and antioxidant potential. The present study revealed that by wrapping the ethanolic clove extract-based bio-composite film on goat meat balls extended the storage stability of the product due to controlled lipid oxidation and microbial growth. Thus, such bio-composite films can be successfully applied on goat meat balls that function as a antimicrobial packaging for providing optimum organoleptic quality and better shelf life.

Trichothecenes in food and feed: Occurrence, impact on human health and their detection and management strategies.

Trichothecenes (TCNs) are the mycotoxins produced by many fungal species such as Fusarium, Myrothecium, and Stachybotrys and pose a considerable health risk. Based on their characteristic functional moieties, they are divided into four categories: Type A (T-2, HT-2, diacetoxyscirpenol (DAS), harzianum A, neosolaniol (NEO) and trichodermin), Type B (deoxynivalenol (DON), nivalenol (NIV), trichothecin and fusarenon X), Type C (crotocin) and Type D (satratoxin G & H, roridin A and verrucarin A) with types A and B being the most substantial. TCNs cause growth retardation in eukaryotes, suppress seedling growth or regeneration in plants and could be a reason for animal reproductive failure. Due to the increased frequency of occurrence and widespread distribution of TCNs in food and feed, knowledge of their sources of occurrence is essential to strategise their control and management. Hence, this review provides an overview of various types and sources of TCNs, the associated biosynthetic pathways and genes responsible for production in food and feed. Further, various processing and environmental effects on TCNs production, detection techniques and management strategies are also briefly outlined.

Citrinin Mycotoxin Contamination in Food and Feed: Impact on Agriculture, Human Health, and Detection and Management Strategies.

Citrinin (CIT) is a mycotoxin produced by different species of Aspergillus, Penicillium, and Monascus. CIT can contaminate a wide range of foods and feeds at any time during the pre-harvest, harvest, and post-harvest stages. CIT can be usually found in beans, fruits, fruit and vegetable juices, herbs and spices, and dairy products, as well as red mold rice. CIT exerts nephrotoxic and genotoxic effects in both humans and animals, thereby raising concerns regarding the consumption of CIT-contaminated food and feed. Hence, to minimize the risk of CIT contamination in food and feed, understanding the incidence of CIT occurrence, its sources, and biosynthetic pathways could assist in the effective implementation of detection and mitigation measures. Therefore, this review aims to shed light on sources of CIT, its prevalence in food and feed, biosynthetic pathways, and genes involved, with a major focus on detection and management strategies to ensure the safety and security of food and feed.

Nutritional significance and therapeutic potential of Moringa oleifera: The wonder plant.

Moringa oleifera is a multi-purpose plant and a comprehensive source of dietary components such as proteins, essential amino acids, vitamins, antioxidants, etc. The plant is also a rich source of other bioactive components, including flavonoids, glucosinolates, isothiocyanates, alkaloids, terpenoids, phenolics, etc. Incorporating M. oleifera in diet can improve the nutritional status of pregnant and nursing mothers and helps to combat malnutrition and iron deficiency anemia (IDA) among children. The phytochemicals and secondary metabolites, especially the polyphenolic compounds from Moringa, have a significant free-radical scavenging effect attributed to this plant's therapeutic potential. Investigations targeting to explore M. oleifera for its nutritional makeup, novel bioactive components, and analysis of their health-promoting attributes have received much attention. This review demonstrates an overview of recent (past ten years) advancements and patenting activity in discovering different parts of M. oleifera plant for providing adequate nutritive and bioactive components. The pharmacological potential and action mechanisms of M. oleifera in many diseases like diabetes mellitus, cancer, hypertension, ulcer, etc., are also discussed. PRACTICAL APPLICATIONS: Moringa oleifera is a vital plant that has a varied set of nutritional and therapeutic properties. The indigenous components of Moringa can treat humankind of its diseases and contribute to overall health. The qualitative and functional characteristics of its components indicate possible commercial exploitation of this high-value plant by utilizing its plant parts in many proprietary medicines and nutraceuticals. In conclusion, the Moringa plant needs to be used commercially. It can lead to tremendous economic development if the industries and researchers exploit its potential for highly nutritional super food and therapeutic application by undertaking further research to corroborate earlier studies.

pH-Controlled Efficient Conversion of Hemicellulose to Furfural Using Choline-Based Deep Eutectic Solvents as Catalysts.

The valorization of hemicellulose isolated from lignocellulosic biomass (wheat straw, rice husk, and bagasse) to furfural was achieved by pH-controlled acid catalysis using choline-based Brønsted acidic (BA) and natural acidic (NA) deep eutectic solvents (DES) serving both as catalyst and solvent. The effect of pH variation on the catalytic activity of various BADES and NADES prepared in 1 : 1 molar ratio was observed, and choline chloride/p-toluene sulfonic acid (ChCl/p-TSA) was found to be the best with lower pH value of 1.0. The yield of furfural decreased from 85 to 51 % with increase in pH from 1.0 to 3.0. The molar ratio of hydrogen bond donor to acceptor components was varied from 1 : 1 to 1 : 9 to achieve the lowest possible pH values of the DESs and to increase the furfural yield. Further optimization of reaction conditions was also done in terms of DES loading, time of reaction, and temperature using the model DES to achieve higher furfural yield. The best results were obtained using 5 mmol DES at pH 1.0 in 1.5 h at 120 °C. ChCl/p-TSA and ChCl/oxalic acid among BADES and ChCl/levulinic acid among NADES investigated in this work yielding 85 % furfural were found to be most efficient. The reported methodology is advantageous in terms of using bio-based green solvents, mild reaction conditions, and efficient scale-up of the reaction. The DESs were found to be efficiently recyclable up to five consecutive runs for the process.

Patulin in food: A mycotoxin concern for human health and its management strategies.

The mycotoxin patulin is primarily produced as a secondary metabolite by numerous fungal species and predominantly by Aspergillus, Byssochlamys, and Penicillium species. It is generally associated with fungal infected food materials. Penicillium expansum is considered the only fungal species liable for patulin contamination in pome fruits, especially in apples and apple-based products. This toxin in food poses serious health concerns and economic threat, which has aroused the need to adopt effective detection and mitigation strategies. Understanding its origin sources and biosynthetic mechanism stands essential for efficiently designing a management strategy against this fungal contamination. This review aims to present an updated outline of the sources of patulin occurrence in different foods and their biosynthetic mechanisms. It further provides information regarding the detrimental effects of patulin on human and agriculture as well as its effective detection, management, and control strategies.

Benefits of surgeon-performed ultrasound for primary hyperparathyroidism.

BACKGROUND: Focused, minimally invasive parathyroidectomy (MIP) is widely accepted when preoperative imaging localizes a single parathyroid adenoma. Many surgeons use (99m)Tc-sestamibi scintigraphy (MIBI) +/-, a cervical ultrasound for preoperative localization. We propose that surgeon-performed ultrasound (SUS) is the only imaging modality required in most patients with primary hyperparathyroidism (pHPT), resulting in patient convenience and reduced cost. MATERIALS AND METHODS: Since July 2006, patients with pHPT underwent MIP based solely on a positive SUS. Intraoperative parathyroid hormone assay was used to determine the extent of operation. A retrospective review from July 2006 through December 2008 identified 160 patients who underwent parathyroidectomy after SUS on their initial office visit. RESULTS: SUS correctly identified an enlarged parathyroid gland in 119/160 (74%) patients. In 41 patients, SUS was the only localizing study. MIBI was done in 119 patients. In 54 patients, SUS confirmed the MIBI, and in 28 patients with a negative MIBI, SUS was positive. In the 41 patients with a negative SUS, an MIBI was positive in ten. Ninety-eight patients had MIP. Theoretically, 85 MIBIs were unnecessary because of a positive SUS corresponding to a potential cost savings of at least $90,000. CONCLUSION: SUS to localize parathyroid adenomas is accurate and facilitates MIP. It provides substantial cost savings and patient convenience and should be the first diagnostic procedure performed for patients suspected to have pHPT. MIBI can be reserved for those patients in whom ultrasound has failed to localize a parathyroid gland.

From Mount Sinai to Mount Scopus: differences in the role and value of fine needle aspiration for evaluating thyroid nodules.

BACKGROUND: Fine needle aspiration is the main diagnostic tool used to assess thyroid nodules. OBJECTIVES: To correlate FNA cytology results with surgical pathological findings in two teaching medical centers across the Atlantic. METHODS: We retrospectively identified 484 patients at Hadassah Hebrew University Medical Center, Jerusalem and Mount Sinai Hospital, New York, by means of both preoperative FNA cytology and a final histopathological report. Results compared FNA diagnosis, histological findings and frozen section results (Mt. Sinai only). RESULTS: The sensitivity value of FNA at Hadassah was 83.0% compared with 79.1% at Mt. Sinai (NS). Specificity values were 86.6 vs. 98.5% (P < 0.05), negative predictive value 78.7 vs. 77.6% (NS) and positive predictive value 89.7 vs. 98.6% (P < 0.05), respectively. "Follicular lesion" was diagnosed on FNA in 33.1% of the patients at Hadassah and in 21.5% at Mt Sinai (P < 0.005) with a malignancy rate of 42.5 vs. 23.1% (P < 0.05), respectively. Frozen section was used in 190 patients at Mt. Sinai (78.5%) with sensitivity and specificity values of 72.3% and 100%. Frozen section results altered the planned operative course in only 6 patients (2.5%). Follicular carcinoma was diagnosed in 12 patients at Hadassah vs. 2 patients at Mt. Sinai (P < 0.05). CONCLUSION: The sensitivity of FNA at the two institutions was comparable. While malignancy on frozen section is highly specific, it should be used selectively for suspicious FNA results. Follicular lesions and the rate of malignancy in such lesions were more common at Hadassah, favoring a more aggressive surgical approach.

Atypical ductal hyperplasia at margin of breast biopsy--is re-excision indicated?

BACKGROUND: Atypical duct hyperplasia (ADH) observed during core needle biopsy is associated with a high rate of cancer upon excision. Controversy exists regarding the need to re-excise ADH involving a margin. The purpose of this study was to determine the rate of residual pathology in patients that underwent re-excision for ADH involving the margin. METHODS: In a retrospective review of the pathology database from 1 January 2000 to 1 June 2006, we identified 44 lumpectomy specimens with ADH involving the margin; 24 patients (55%) had a re-excision. Slides were reviewed to verify the diagnosis of ADH near the margin and the presence of residual disease on re-excision associated with the biopsy cavity. RESULTS: Patients had pure ADH (15, 63%), ADH and ductal carcinoma in situ (DCIS) (7, 29%) or ADH with invasive carcinoma (2, 8%). Residual ADH or cancer was found in 14 of 24 patients (58%). Of 15 patients with pure ADH, 6 (40%) had residual pathology: ADH (2), DCIS (2) and invasive carcinoma (2). In this group, 27% of patients were reassessed as having DCIS or invasive carcinoma. Of the 9 patients with cancer, 8 (89%) had residual disease in the form of ADH (4) or DCIS (4). CONCLUSIONS: ADH found at the margin of a lumpectomy specimen is associated with a high rate of residual ADH and cancer. Over one quarter of the patients with an initial diagnosis of ADH were reassessed as having DCIS or invasive carcinoma. Re-excision in all patients with ADH involving the margin is recommended.

The moderating role of negative affect on objective verbal memory performance and subjective memory complaints in healthy older adults.

Subjective memory complaints (SMCs) are part of the diagnostic criteria for Mild Cognitive Impairment (MCI), yet little is known about their etiology. In some previous studies, no direct relation has been found between SMCs and objective memory performance, yet significant correlations have been identified between SMCs and psychological factors such as depression and anxiety. In the current study, we examined whether negative affect moderated the relation between objective memory functioning and SMCs in a sample of healthy, non-demented participants aged 65 and older. As predicted, several negative affect measures moderated the relationship between objective cognitive functioning and SMCs. In the absence of objective memory impairment as indexed by the Rey Auditory Verbal Learning Test (RAVLT) and the Dementia Rating Scale-2nd Edition (DRS-2), higher levels of negative affect were associated with increased levels of SMCs. Moreover, a lower order negative affect factor, anxiety sensitivity, significantly moderated the relation between objective memory functioning and SMCs, after controlling for higher order measures of general negative affectivity. Findings suggest that negative affect, particularly anxiety sensitivity, distorts the subjective appraisal of one's own memory, such that people high on negative affect factors report more episodes of forgetting, even in the absence of objective cognitive impairments.

Caution Ahead: Research Challenges of a Randomized Controlled Trial Implemented to Improve Breast Cancer Treatment at Safety-Net Hospitals.

PURPOSE: To implement and test a Web-based tracking and feedback (T&F) tool to close referral loops and reduce adjuvant breast cancer treatment underuse in safety-net hospitals (SNHs). PATIENT AND METHODS: We randomly assigned 10 SNHs, identified patients with new stage 1 to stage 3 breast cancer, assessed their connection with the oncologist, and relayed this information to surgeons for follow-up. We interviewed key informants about the tool's usefulness. We conducted intention-to-treat and pre- and poststudy analyses to assess the T&F tool and implementation effectiveness, respectively. RESULTS: Between the study start and intervention implementation, several hospitals reorganized care delivery and 49% of patients scheduled to undergo breast cancer surgery were ineligible because they already were in contact with an oncologist. One high-volume hospital closed. Despite randomization of hospitals, intervention (INT) hospitals had fewer white patients (5% v 16%; P = .0005), and more underuse (28% v 15%; P = .002) compared with usual care (UC) hospitals. Over time, INT hospitals with poorer follow-up significantly reduced underuse compared with UC hospitals (INT hospitals, from 33% to 9%, P = .001 v UC hospitals, from 15% to 11%, P = .5). There was no difference in underuse (9% at INT hospitals, 11% at UC hospitals; P = .8). Hospitals with better follow-up (odds ratio, 0.85; 95% CI, 0.73 to 0.98) had less underuse. In settings with poor follow-up and tracking approaches, key informants found the tool useful. The rapidly changing delivery landscape posed significant challenges to this implementation research. CONCLUSION: A T&F tool did not significantly reduce adjuvant underuse but may help reduce underuse in SNHs with poor follow-up capabilities. Inability to discern T&F effectiveness is likely due to encountered challenges that inform lessons for future implementation research.

Bone Health in Patients with Epilepsy: A Community-based Pilot Nested Case-control Study.

BACKGROUND: Antiepileptic drugs (AEDs) adversely affect bone health and there are reports describing association of alternations of bone and mineral metabolism in epileptic patients. OBJECTIVES: This study was undertaken to evaluate the bone profile (bone mineral parameters and bone mineral density [BMD]) of patients with epilepsy and compare them to their age-, gender-, and socioeconomic status-matched healthy controls in a community. MATERIALS AND METHODS: This was a nested case-control study conducted in fifty individuals, which included 25 cases (age above 18 years and on AEDs for at least 3 years) for which 25 controls were selected from the same community. Bone mineral parameters (serum calcium, proteins, phosphorous, alkaline phosphate, parathyroid hormone, and Vitamin D) and BMD were measured. RESULTS: There was significant hypocalcemia (P = 0.003), hypoproteinemia (P = 0.014), hyperparathyroidism (P = 0.048), and increased levels of serum alkaline phosphatase (P = 0.019) in cases as compared to controls. The difference was insignificant in the serum levels of Vitamin D and phosphorous among both the groups. Vitamin D was significantly low in female patients as compared to males (P = 0.043). There was no significant difference in BMD at the lumbar spine and femur neck among both the groups. Mean duration of epilepsy was longest in patients with osteoporosis (23.6 years), and increasing duration of epilepsy was associated with reduction in age- and sex-corrected total BMD mean Z-score anteroposterior spine. There was negative correlation between cumulative drug load and T-score of patients with epilepsy. CONCLUSION: Patients on long-term AED treatment have altered bone profile as evident from biochemical parameters and reduced BMD. There is a need for more extensive research and that too on a larger sample size.