Milestones and controversies in maternal and child health: examining a brief history of micronutrient fortification in the US

Fortification of our food and drinking supply has decreased morbidity rates related to micronutrient deficiencies among mothers and their children, particularly during the perinatal and neonatal periods of development. The purpose of this historical review is to examine the impact of public policy changes related to micronutrient fortification. We provide a historical investigation of achievements and controversies related to iodine, vitamin D, fluoride and folic acid fortifications in our food and drinking supply. We also discuss the current status of fortification recommendations and their significance to maternal and child health.

Abstract P5-13-03: Fulvestrant plus anastrozole as neoadjuvant therapy in postmenopausal women with hormone receptor positive early breast cancer

Background: Aromatase inhibitors (AIs) are effective in reducing the risk of recurrence from breast cancer (BC) but 20% of patients (pts) with early BC still recur despite adjuvant AIs. Thus more effective endocrine therapies (HTs) are needed. In metastatic BC (MBC), combination of lower dose fulvestrant plus anastrozole improves survival compared to anastrozole alone. The 21-gene Recurrence Score® (RS; Oncotype DX®) has been validated to predict benefit from adding chemotherapy (CT) to HT where pts with a low score have little benefit from CT and derive a large benefit from HT. Ki-67 response to neo-adjuvant HT may predict adjuvant outcomes to HT. Postoperative Endocrine Prognostic Index (PEPI) and modified PEPI may further identify a subset of HT sensitive cancers that do not require adjuvant CT (PEPI 0 category). We conducted a single arm phase II trial to assess the efficacy of fulvestrant plus anastrozole as neoadjuvant HT in pts with operable BC.

Methods: Postmenopausal pts with stage II and III, ER/PR+, HER2 (-) BC with a RS<25 (performed on initial core bx) were included. Duration of neo-adjuvant HT was 4 months. Pts received anastrozole 1mg (PO) daily continuously from day 1 until surgery + fulvestrant (IM) 500mg on day 1, 14 and 28 of cycle 1, and on the last day of three subsequent 28 day cycles (total 6 doses of fulvestrant). At week 4, an optional core bx was repeated to assess change in Ki-67. Response assessments were made clinically every 4 wks. All pts had breast/axillary surgery after the 6th dose of fulvestrant. Ki-67, histologic grade, ER/PR status, and RS were assessed at baseline, core bx at 4 wks, and at definitive surgery. Primary end points were pathologic complete response (pCR) rate and change in Ki-67. Adjuvant CT was left to the discretion of treating physician.

Results: 42 pts were enrolled 7/2009 to 11/2014. Median age was 62. 32 (76%) patients had stage IIA, 7 (17%) had stage IIB and 3 (7%) had stage III disease. 14% had clinically node positive disease. The median RS was 12 (0-24). Median tumor size was 3.5cm. 21%, 74%, and 5% had grade 1, 2 and 3 tumors respectively. Mean ER expression was 95%. 16 (38%) pts had a clinical complete response (cCR), 13 (31%) had a clinical partial response (cPR) and 12 (29%) had stable disease. One pt had progression on therapy. There were no pCRs. Median baseline Ki-67 was 5% (1-36%). 94% of pts had decrease in Ki-67 from baseline to 4-week bx and 97% of pts had decrease in Ki-67 from baseline to surgery. Modified PEPI score at surgery was 0 in 53% of patients. 78% of pts did not receive adjuvant CT. At median follow up of 38 mos only 1 pt had a recurrence with 98% free of a recurrence. There were no grade 3 or grade 4 toxicities.

Conclusions: The neoadjuvant combination of anastrozole and fulvestrant in pts with RS<25 markedly improves Ki-67 response with more than half of pts achieving a modified PEPI score of 0 at surgery. At a relatively short median follow up, recurrence rate is very low. Given the efficacy and tolerability of anastrozole plus fulvestrant in MBC and now in the neo-adjuvant setting, an adjuvant trial of this combination is warranted in pts with ER+ BC.

Citation Format: Khan QJ, Barr JA, Britt AS, Kimler BF, Connor CS, McGinness M, Mammen JMV, Wagner JL, Amin A, Springer M, Baccaray S, Fabian CJ, Sing AP, Sharma P. Fulvestrant plus anastrozole as neoadjuvant therapy in postmenopausal women with hormone receptor positive early breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-13-03.

Diet and feeding behaviour of the black-and-white ruffed lemur (Varecia variegata variegata) in the Betampona Reserve, eastern Madagascar

The feeding behaviour and diet of the black-and-white ruffed lemur (Varecia variegata variegata) was investigated in the Betampona Reserve, eastern Madagascar. The highly frugivorous diet of this subspecies was confirmed - feeding on fruits accounting for 92.0% of feeding records. Most feeding at Betampona was observed at 10-25 m above the forest floor amongst flexible, small (0.5-5.0 cm diameter) and oblique/horizontal (0-45 degrees ) supports. The Varecia spent on average 21.7% (+/- 1.5) of their daily activity budget feeding and employ a variety of postures that enable them to harvest fruits in the rain forest canopy. The suspensory postures were the most important in allowing Varecia to compete with other smaller-bodied frugivores.

Naja naja cobra bite

Most venomous snakes in the United States are of the Crotalidae family. Another family of snakes, the Elapidae, are not so common, but their bites may be a threat to zoo keepers and persons who have exotic snakes as pets. Because Elapidae envenomation is not common, signs and symptoms of such envenomation may not be recognized. Elapidae venom, because of a curare-like property, can produce respiratory compromise followed by death within 10 minutes. Antivenin, cholinesterase inhibitors, and mechanical ventilation are treatments to consider in such envenomations. Unlike Crotalidae antivenin, Elapidae antivenin may not confer protection against species not used in its preparation. Identification of the involved snake, by family and specie, should be an early priority. Correct management of the envenomated patient is dependent on the prompt administration of the most specific antivenin available when indicated.

Pulmonary toxicity following exposure to an aerosolized leather protector

BACKGROUND

An aerosol spray for leather protection was reformulated to remove trichloroethane. The new formulation contained isobutane, n-heptane, ethyl acetate and fluoroaliphatics.

RETROSPECTIVE REVIEW

Thirty-nine patients reported symptoms to the regional poison center. Respiratory symptoms developed within hours of exposure. Most symptoms resolved within two days. Abnormal pulmonary function tests, including obstructive disease or diminished diffusing capacity, were demonstrated in three of the four tested patients.

CONCLUSIONS

The mechanism for the pulmonary toxicity has not been determined.

Management of illness and temporary disability in children enrolled in day-care centers. The Health House experience

Alternative care arrangements are often necessary when children enrolled in day-care centers experience illness or temporary disability. To meet this need, a new facility named Health House was established by the Child Development Program of the Pomona (Calif) Unified School District. This report describes the organization, operation, and costs of the program, and reviews the management of 179 episodes of illness or temporary disability in 99 children served by the program during the 1983-1984 school year. The medical conditions of patients cared for were comparable with those seen in physicians' offices as reported in a national survey. The daily cost of care per child for the sponsoring agency was $38. The service enabled an average daily salary saving of $39.80 for the working parent. Health House may serve as a model for the management of illness or temporary disability in children enrolled in day-care centers.