What is the impact of targeted therapies given within phase I trials on the cognitive function of patients with advanced cancer: a mixed-methods exploratory study conducted in an early clinical trials unit

INTRODUCTION

Novel therapies such as small protein molecule inhibitors and immunotherapies are tested in early phase trials before moving to later phase trials and ultimately standard practice. A key aim of these clinical trials is to define a toxicity profile, however, the emphasis is often on safety with measurements of organ toxicity. Other subjective side effects can be under-reported because they are not measured formally within the trial protocols. The concern from clinical practice is that cognitive toxicity is poorly studied and may be under-reported in this context. This could lead to toxicity profiles of new treatments not being fully described and patients with unmet need in terms of acknowledgement and support of symptoms. This protocol outlines a framework of an exploratory study with feasibility aspects to investigate the impact and experience of cognitive changes for patients on phase I trials.

METHODS AND ANALYSIS

This is a mixed-methods study, combining quantitative and qualitative approaches. The sample is 30 patients with advanced cancer who are participating in phase I trials of novel therapies in the early clinical trials unit of a specialist cancer centre. A test battery of validated cognitive assessments will be taken alongside patient reported outcome measures at three time points from baseline, day eight and day 28 post start of treatment. At day 28, a semi-structured interview will be conducted and the narrative thematically analysed. Results will be integrated to offer a comprehensive description of cognitive function in this patient group.

ETHICS AND DISSEMINATION

The study has received full HRA and ethical approval. It is the first study to introduce formal cognitive assessments in a cancer phase I trial context. The study has the potential to highlight previously unreported side effects and more importantly unmet need in terms of care for patients who are participating in the trials.

CONSENT - A Randomised Controlled Trial of Enhanced Informed Consent Compared to Standard Informed Consent to Improve Patient Understanding of Early Phase Oncology Clinical Trials – GBM Cohort (Nonrandomised) Analysis

AIMS

Early phase cancer clinical trials have become more complicated and patients often misunderstand their nature and purpose. CONSENT (NCT04407676) is a randomised controlled trial testing whether enhanced informed consent for patient education can improve comprehension – since patients with glioblastoma multiforme (GBM) have a higher rate of baseline cognitive impairment, we studied this group separately.

METHOD

GBM patients (from the ICE-CAP Phase 1 study - NCT03673787), underwent the schedule for the standard CONSENT arm - full length trial PIS, Quality of Informed Consent Questionnaire Parts A and B (QuIC-A and QuIC-B), experimental intervention (2 page study aid and 10 educational videos), and a repeat QuIC-A and QuIC-B. The primary endpoint for this subgroup was the difference in QuIC-A scores before and after the intervention using a paired t-test.

RESULTS

6 patients with GBM were recruited - 3 did not complete any study questionnaires. The three pre intervention QuIC-A scores were 70, 81, 88, with a mean of 75 (unit reference 76). The three pre intervention QuIC-B scores were 69, 62, 75 with a mean of 69 (unit reference is 91). Only one patient completed the post intervention questionnaire - their QuIC-A score moved from 88 to 100.

CONCLUSION

This study demonstrates the significant difficulties in studying comprehension in patients with GBM considering early phase trials. There is a need for creative multi-modality solutions to provide information to GBM patients considering clinical trials, and novel tools to assess the effectiveness of these solutions.

The psychosocial and emotional experiences of cancer patients during the COVID-19 pandemic: A systematic review

BACKGROUND

COVID-19 was declared a pandemic by the World Health Organization on March 11th, 2020. Global social lockdowns were instigated to reduce spread and prevent health-services from becoming overwhelmed. People having treatment for cancer are known to have heightened psychological/emotional burden. The combined impact of managing pandemic regulations alongside this may present additional burden. The purpose of this systematic review is to examine current evidence of the psychological and emotional impact of COVID-19 on people with cancer, early in the pandemic.

METHODS

Five electronic databases were searched (Embase, Global Health, HMIC, PsychINFO, CINAHL) from September 2019 to October 2021. Qualitative, quantitative and mixed-method primary research studies exploring emotional and psychological impacts of COVID-19 on cancer patients, limited to English language, were included. Quality appraisal was conducted using the MMAT.

RESULTS

Fifty-one papers, with 27,356 people from 21 countries treated for cancer, were included. 43 studies were quantitative with a survey method approach, six studies qualitative and four used a mixed methods design. MMAT score was mostly two or three. Four themes were identified: Emotional aspects and Quality of Life; Psychosocial aspects; Impact of COVID-19 on self; Impact of COVID-19 on cancer, with themes overlapping.

CONCLUSION

Whilst emotional/psychological impacts such as anxiety, isolation, employment fears, and uncertainty about the future were potentially universal concerns early in the pandemic, they may have been particularly acute for people living with cancer and represent complex, overlapping factors. As COVID-19 continues to impact health-services and society, it is important to focus on any ongoing impact to the experience of cancer patients. Most of the studies reviewed used tools that do not provide deeper understanding of how and why emotional states of people with cancer were affected. Further qualitative work may reveal patterns of what was unique to cancer patients during the pandemic, compared to general populations.

A novel mark-recapture-recovery survey using genetic sampling for polar bears Ursus maritimus in Baffin Bay

Changes in sea-ice dynamics are affecting polar bears Ursus maritimus across their circumpolar range, which highlights the importance of periodic demographic assessments to inform management and conservation. We used genetic mark-recapture-recovery to derive estimates of abundance and survival for the Baffin Bay (BB) polar bear subpopulation—the first time this method has been used successfully for this species. Genetic data from tissue samples we collected via biopsy darting were combined with historical physical capture and harvest recovery data. The combined data set consisted of 1410 genetic samples (2011-2013), 914 physical captures (1993-1995, 1997), and 234 harvest returns of marked bears (1993-2013). The estimate of mean subpopulation abundance was 2826 (95% CI = 2284-3367) in 2012-2013. Estimates of annual survival (mean ± SE) were 0.90 ± 0.05 and 0.78 ± 0.06 for females and males age ≥2 yr, respectively. The proportion of total mortality of adult females and males that was attributed to legal harvest was 0.16 ± 0.05 and 0.26 ± 0.06, respectively. Remote sensing sea-ice data, telemetry data, and spatial distribution of onshore sampling indicated that polar bears were more likely to use offshore sea-ice habitat during the 1990s sampling period compared to the 2010s. Furthermore, in the 1990s, sampling of deep fjords and inland areas was limited, and no offshore sampling occurred in either time period, which precluded comparisons of abundance between the 1993-1997 and 2011-2013 study periods. Our findings demonstrate that genetic sampling can be a practical method for demographic assessment of polar bears over large spatial and temporal scales.

Study protocol for a randomised controlled trial of enhanced informed consent compared to standard informed consent to improve patient understanding of early phase oncology clinical trials (CONSENT)

INTRODUCTION

Early phase cancer clinical trials have become increasingly complicated in terms of patient selection and trial procedures-this is reflected in the increasing length of participant information sheets (PIS). Informed consent for early phase clinical trials has been contentious due to the potential ethical issues associated with performing experimental research on a terminally ill population which has exhausted standard treatment options. Empirical studies have demonstrated significant gaps in patient understanding regarding the nature and intent of these trials. This study aims to test whether enhanced informed consent for patient education can improve patient scores on a validated questionnaire testing clinical trial comprehension.

METHODS AND ANALYSIS

This is a randomised controlled trial that will allocate patients who are eligible to participate in one of four investigator-initiated clinical trials at the Royal Marsden Drug Development Unit to either a standard arm or an experimental arm, stratified by age and educational level. The standard arm will involve the full length trial PIS, followed by electronic or paper administration of the Quality of Informed Consent Questionnaire Parts A and B (QuIC-A and QuIC-B). The experimental arm will involve the full length trial PIS, exposure to a two-page study aid and 10 online educational videos, followed by administration of the QuIC-A and QuIC-B. The primary endpoint will be the difference (using a one-sided two-sample t-test) in the QuIC-A score, which measures objective understanding, between the standard and experimental arm. Accrual target is at least 17 patients per arm to detect an 8 point difference (80% power, alpha 0.05).

ETHICS AND DISSEMINATION

Ethics approval was granted by the National Health Service Health Research Authority on 15 June 2020-IRAS Project ID 277065, Protocol Number CCR5165, REC Reference 20/EE/0155. Results will be disseminated via publication in a relevant journal.

TRIAL REGISTRATION NUMBER

NCT04407676; Pre-results.

Invasive grass negatively affects growth and survival of an imperiled butterfly

With only ~1% of native prairie remaining in North America, populations of many prairie-obligate species, including the imperiled Dakota skipper butterfly, have drastically declined in recent decades. Unfortunately, population recovery is impeded by an insufficient understanding of Dakota skipper biology. Because larvae have never been naturally observed in the wild, even basic life history elements including preferred host plant(s) are not well understood, and potential hosts have been inferred from grasses inhabiting remnant sites rather than direct observations. To improve our understanding of Dakota skipper biology and habitat needs and inform recovery efforts, we conducted a no-choice performance experiment offering larvae 1 of 5 commonly occurring native grasses and 2 pervasive invasive grass species found across their historic range. We monitored larvae during key life history intervals and evaluated host plant quality by measuring larval and pupal mass, time to pupation, and survivorship. Larvae fed on all offered host grasses, but mass, phenology, and survivorship varied among treatments. Larvae reared on prairie dropseed and porcupine grass had the highest survival, the shortest time to adulthood, and the greatest mass, whereas larvae provided smooth brome and Kentucky bluegrass fared poorly for all observed metrics. All other grasses offered during the study were deemed ‘medium’ quality. Our results suggest that although larvae can feed on a variety of potential host plants, these hosts vary in quality. Invasive grasses across prairies in North America may pose an ecological trap to the conservation of Dakota skipper and other prairie-obligate Lepidoptera.

Myosin IIA-mediated forces regulate multicellular integrity during vascular sprouting

Angiogenic sprouting is a critical process involved in vascular network formation within tissues. During sprouting, tip cells and ensuing stalk cells migrate collectively into the extracellular matrix while preserving cell–cell junctions, forming patent structures that support blood flow. Although several signaling pathways have been identified as controlling sprouting, it remains unclear to what extent this process is mechanoregulated. To address this question, we investigated the role of cellular contractility in sprout morphogenesis, using a biomimetic model of angiogenesis. Three-dimensional maps of mechanical deformations generated by sprouts revealed that mainly leader cells, not stalk cells, exert contractile forces on the surrounding matrix. Surprisingly, inhibiting cellular contractility with blebbistatin did not affect the extent of cellular invasion but resulted in cell–cell dissociation primarily between tip and stalk cells. Closer examination of cell–cell junctions revealed that blebbistatin impaired adherens-junction organization, particularly between tip and stalk cells. Using CRISPR/Cas9-mediated gene editing, we further identified NMIIA as the major isoform responsible for regulating multicellularity and cell contractility during sprouting. Together, these studies reveal a critical role for NMIIA-mediated contractile forces in maintaining multicellularity during sprouting and highlight the central role of forces in regulating cell–cell adhesions during collective motility.

Abstract P4-08-31: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Loughman T, Wang C-JA, Dynoodt P, Fender B, Lopez-Ruiz C, Barron S, Stapleton S, O'Leary D, Fabre A, Quinn C, Nodin B, Jirström K, Bracken A, Gallagher WM. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-08-31.

A study of motivations and expectations of patients seen in phase 1 oncology clinics

BACKGROUND

To better inform clinical practice, this study was aimed at capturing patients' motivations for enrolling in phase 1 trials and at quantifying their expectations of the benefits, risks, and commitment associated with clinical trials and the impact of the initial consultation on their expectations.

METHODS

This was a single-center, prospective, quantitative study of newly referred adult patients considering their first phase 1 oncology trial. Participants completed questionnaires before they were seen and an abbreviated follow-up version after their consultation.

RESULTS

Questionnaires were completed by 396 (99%) and 301 (76%) before and after the clinic, respectively. Participants ranked the possibility of tumor shrinkage (84%) as the most important motivation for considering a phase 1 trial; this was followed by no alternative treatments (56%), their physician's recommendation (44%), and the fact that the research might benefit others (38%). When they were asked about the potential personal benefit, 43% predicted tumor shrinkage initially. After the consultation, this increased to 47%. Fourteen percent of patients expected a cure. When asked about risks, 71% of the participants expected moderate side effects. When asked about expectations of time commitments, a majority of patients did not anticipate weekly visits, although this was understood by 93% of patients after the consultation. Overall, patients were keen to consider trials and when asked before and after the consultation 72% and 84% were willing to enroll in studies, respectively.

CONCLUSIONS

This study reports that more than 80% of patients enroll in early-phase clinical oncology trials motivated by the potential of a clinical benefit, with approximately half expecting tumor shrinkage and approximately a tenth anticipating a cure. The typical phase 1 response rate is 4% to 20%, and this discrepancy exemplifies the challenges faced by patients and healthcare professionals during their interactions for phase 1 studies. Cancer 2016;122:3501-3508. © 2016 American Cancer Society.

Real-time high dynamic range laser scanning microscopy

In conventional confocal/multiphoton fluorescence microscopy, images are typically acquired under ideal settings and after extensive optimization of parameters for a given structure or feature, often resulting in information loss from other image attributes. To overcome the problem of selective data display, we developed a new method that extends the imaging dynamic range in optical microscopy and improves the signal-to-noise ratio. Here we demonstrate how real-time and sequential high dynamic range microscopy facilitates automated three-dimensional neural segmentation. We address reconstruction and segmentation performance on samples with different size, anatomy and complexity. Finally, in vivo real-time high dynamic range imaging is also demonstrated, making the technique particularly relevant for longitudinal imaging in the presence of physiological motion and/or for quantification of in vivo fast tracer kinetics during functional imaging.

Confocal and multiphoton fluorescence microscopy often suffers from low dynamic range. Here the authors develop a high dynamic range, laser scanning fluorescence technique by simultaneously recording different light intensity ranges. The method can be adapted to commercial systems.

Insights into the experiences of patients with cancer in London: framework analysis of free-text data from the National Cancer Patient Experience Survey 2012/2013 from the two London Integrated Cancer Systems

OBJECTIVE

To shed light on experiences of patients with cancer in London National Health Service (NHS) trusts that may not be fully captured in national survey data, to inform improvement action plans by these trusts.

DESIGN

Framework analysis of free-text data from 2012/2013 National Cancer Patient Experience Survey (NCPES) from the 2 London Integrated Cancer Systems.

SETTING AND PARTICIPANTS

Patients with a cancer diagnosis treated by the NHS across 27 trusts in London.

MAIN OUTCOME MEASURES

Free-text data received from patients categorised into what patients found good about their cancer care and what could be improved.

METHODS

Using Framework analysis, a thematic framework was created for 15,403 comments from over 6500 patients. Themes were identified across the London data set, by tumour group and by trust.

RESULTS

Two-thirds of free-text comments from patients in London were positive and one-third of those related to the good quality of care those patients received. However, the majority of comments for improvement related to quality of care, with a focus on poor care, poor communication and waiting times in outpatient departments. Additionally, 577 patients (9% of those who returned free-text data in London) commented on issues pertaining to the questionnaire itself. Some patients who experienced care from multiple trusts were unclear on how to complete the questionnaire for the single trust whose care they were asked to comment on, others said the questions did not fit their experiences.

CONCLUSIONS

NCPES free-text analysis can shed light on the experiences of patients that closed questions might not reveal. It further indicates that there are issues with the survey itself, in terms of ambiguities in the questionnaire and difficulties in identifying patients within specific trusts. Both of these issues have the potential to contribute to knowledge and understanding of the uses and limitations of free-text data in improving cancer services.

The lived experience of men with advanced cancer in relation to their perceptions of masculinity: a qualitative phenomenological study

AIMS AND OBJECTIVES

The aim of this exploratory research was to understand how men experience their advanced cancer in relation to their perceptions of masculinity.

BACKGROUND

There are differences in the way men and women experience illness and health care. There are inequalities in incidence and morbidities of many diseases as well as differences in rates of help-seeking behaviours. Theories on masculinity offer some explanation towards this. Men's experiences of advanced cancer in relation to masculinity are under reported, published literature suggests that there are certain issues or men dealing with advanced disease that justify investigation.

DESIGN

A Qualitative approach using a Husserlian Phenomenological design was conducted.

SAMPLE

Eight men (aged 26-68) all with advanced cancer, defined as advanced or metastatic disease for which the patient had exhausted all standard therapeutic options.

METHODS

In-depth interviews were conducted to capture narratives of the experiences of men. Data were analysed using Colaizzi's seven stage framework.

RESULTS

Themes included thwarted ambition, changing expectations, protection and provision, stoicism and coping, images of illness versus images of masculinity, importance of being a fighter and loss.

CONCLUSION

Findings showed that the experiences of these men were complex and should be handled sensitively. Ideas for gender-specific interventions and further research were developed from the findings in relation to current literature.

RELEVANCE TO CLINICAL PRACTICE

A better understanding and awareness of this in this context will help nurses to consider more subtle challenges that these patients may be dealing with that in turn could affect how they cope with the burden of cancer.

Retrospective analysis of 49 cases of brain abscess and review of the literature

The case records of 49 patients discharged from St George's Hospital, London, between December 2000 and March 2004 with the diagnosis of brain abscess were reviewed in order to document the epidemiology, causes, treatment, and prognostic factors associated with brain abscess. Brain abscess occurred at all ages, more frequently in men than in women. Headache and altered mental status were common presenting symptoms. The frontal lobe was the most common site. Streptococcal infection was seen most commonly, but staphylococcal infection predominated in cases following neurosurgery. Computed tomography provided sufficient diagnostic information in most cases. All but five patients had early surgical drainage. Cefotaxime and metronidazole were used most often for empirical therapy. Thirty-nine patients recovered fully or had minimal incapacity. Five patients died. Patients with underlying cranial neoplasms or medical conditions had a worse outcome than those with a contiguous focus of infection or post-traumatic abscess. Changes in disease pattern were determined by comparison to a literature review. A PubMed search of the literature using the keywords "brain abscess" was undertaken, and identified papers and relevant citations were reviewed. Compared to earlier series, there was a marked decrease in the number of cases of brain abscess secondary to otitis media and congenital heart disease. There was an increase in the number of cases of brain abscess secondary to neurosurgery and trauma. Changes in the epidemiology of predisposing conditions for brain abscess are associated with changes in the patient population and causative organisms. Though still a potentially fatal infection, there have been recent improvements in diagnosis, treatment, and outcome.

Aneurysmal bone cyst of the spine

The authors present the case of an 11-year-old boy with a painful, rapidly expanding lesion in the posterior triangle of the neck. There was no history of cervical trauma. Computerized tomography of the neck revealed a unicameral (single-chambered) aneurysmal bone cyst involving the C3 vertebra. Treatment was by open resection and curettage; no recurrence was seen at six months. We discuss the natural history, differential diagnosis, radiographic appearance and treatment modalities for this unusual, benign, expanding, osteolytic lesion containing blood-filled cystic cavities.

Phase I Pharmacokinetic and Pharmacodynamic Study of 17-Allylamino, 17-Demethoxygeldanamycin in Patients With Advanced Malignancies

Purpose

To study the toxicity and pharmacokinetic-pharmacodynamic profile of 17-allylamino, 17- demethoxygeldanamycin (17-AAG) and to recommend a dose for phase II trials.

Patients and Methods

This was a phase I study examining a once-weekly dosing schedule of 17-AAG. Thirty patients with advanced malignancies were treated.

Results

The highest dose level reached was 450 mg/m2/week. The dose-limiting toxicities (DLTs) encountered were grade 3 diarrhea in three patients (one at 320 mg/m2/week and two at 450 mg/m2/week) and grade 3 to 4 hepatotoxicity (AST/ALT) in one patient at 450 mg/m2/week. Two of nine DLTs were at the highest dose level. Two patients with metastatic melanoma had stable disease and were treated for 15 and 41 months, respectively. The dose versus area under the curve-relationship for 17-AAG was linear (r2 = .71) over the dose range 10 to 450 mg/m2/week, with peak plasma concentrations of 8,998 μg/L (standard deviation, 2,881) at the highest dose level. After the demonstration of pharmacodynamic changes in peripheral blood leukocytes, pre- and 24 hours post-treatment, tumor biopsies were performed and demonstrated target inhibition (c-RAF-1 inhibition in four of six patients, CDK4 depletion in eight of nine patients and HSP70 induction in eight of nine patients) at the dose levels 320 and 450 mg/m2/week. It was not possible to reproducibly demonstrate these changes in biopsies taken 5 days after treatment.

Conclusion

It has been possible to demonstrate that 17-AAG exhibits a tolerable toxicity profile with therapeutic plasma concentrations and target inhibition for 24 hours after treatment and some indications of clinical activity at the dose level 450 mg/m2/week. We recommend this dose for phase II clinical trials.

Implementation of random set-up errors in Monte Carlo calculated dynamic IMRT treatment plans

The fluence-convolution method for incorporating random set-up errors (RSE) into the Monte Carlo treatment planning dose calculations was previously proposed by Beckham et al, and it was validated for open field radiotherapy treatments. This study confirms the applicability of the fluence-convolution method for dynamic intensity modulated radiotherapy (IMRT) dose calculations and evaluates the impact of set-up uncertainties on a clinical IMRT dose distribution. BEAMnrc and DOSXYZnrc codes were used for Monte Carlo calculations. A sliding window IMRT delivery was simulated using a dynamic multi-leaf collimator (DMLC) transport model developed by Keall et al. The dose distributions were benchmarked for dynamic IMRT fields using extended dose range (EDR) film, accumulating the dose from 16 subsequent fractions shifted randomly. Agreement of calculated and measured relative dose values was well within statistical uncertainty. A clinical seven field sliding window IMRT head and neck treatment was then simulated and the effects of random set-up errors (standard deviation of 2 mm) were evaluated. The dose-volume histograms calculated in the PTV with and without corrections for RSE showed only small differences indicating a reduction of the volume of high dose region due to set-up errors. As well, it showed that adequate coverage of the PTV was maintained when RSE was incorporated. Slice-by-slice comparison of the dose distributions revealed differences of up to 5.6%. The incorporation of set-up errors altered the position of the hot spot in the plan. This work demonstrated validity of implementation of the fluence-convolution method to dynamic IMRT Monte Carlo dose calculations. It also showed that accounting for the set-up errors could be essential for correct identification of the value and position of the hot spot.

"Anorexia saved my life": coincidental anorexia nervosa and cerebral meningioma

OBJECTIVE

We report on a 13-year-old girl with coincidental occult intracranial tumor and early-onset anorexia nervosa.

METHOD

The cerebral meningioma was discovered fortuitously as the result of a research project using SPECT imaging to locate a neurobiological substrate in patients with anorexia nervosa. Without SPECT, the meningioma would have remained undiagnosed until it had become symptomatic. The two conditions appear to have been completely unrelated.

RESULTS AND DISCUSSION

The case highlights two important points. First, intracranial pathology should also be considered however certain is the diagnosis of early-onset anorexia nervosa. Second, neuroimaging plays an important part in diagnosing early-onset anorexia nervosa, both from a clinical and a research prospective.

Gliomatosis cerebri: pitfalls in diagnosis

We report two young patients with obscure presentations of gliomatosis cerebri. Initial CT scanning was inconclusive and in one case showed intraventricular haemorrhage, a feature not previously described. Magnetic resonance imaging was required to show the lesions with greater definition; however, in both cases, a biopsy was needed to confirm the diagnosis.

Acquired immune deficiency syndrome (AIDS) and cerebral astrocytoma

The presence of cerebral lesions in patients affected by the acquired immune deficiency syndrome (AIDS) has been estimated to be around 10%, with the majority being infective lesions or primary central nervous system lymphomas. The co-occurrence of a cerebral glioma in such patients is rare. The aim of this report is to present four more cases, discussing their clinical and neuroradiological features, as well as the outcome and the possible pathogenesis.

Continuous arteriovenous hemofiltration: an alternative dialysis therapy in neonates

Modifications have made it possible to perform CAVH in the neonate. One of these is decreasing the extravascular volume in the tubing and filter to a minimal amount to allow for adequate intravascular blood volume in the infant. Another is utilizing predilutional fluid to decrease the need for heparinization. A third modification is utilizing the suction-assist pumps to help control the amount of fluid removed from the infant. With modifications of this system to fit the special needs of neonates and intensive nursing and medical management, CAVH can be a successful alternative to traditional dialysis therapies in neonates.

Outcomes of care in birth centers. The National Birth Center Study

We studied 11,814 women admitted for labor and delivery to 84 free-standing birth centers in the United States and followed their course and that of their infants through delivery or transfer to a hospital and for at least four weeks thereafter. The women were at lower-than-average risk of a poor outcome of pregnancy, according to many but not all of the recognized demographic and behavioral risk factors. Among the women, 70.7 percent had only minor complications or none; 7.9 percent had serious emergency complications during labor and delivery or soon thereafter, such as thick meconium or severe shoulder dystocia. One woman in six (15.8 percent) was transferred to a hospital; 2.4 percent had emergency transfers. Twenty-nine percent of nulliparous women and only 7 percent of parous women were transferred, but the frequency of emergency transfers was the same. The rate of cesarean section was 4.4 percent. There were no maternal deaths. The overall intrapartum and neonatal mortality rate was 1.3 per 1000 births. The rates of infant mortality and low Apgar scores were similar to those reported in large studies of low-risk hospital births. We conclude that birth centers offer a safe and acceptable alternative to hospital confinement for selected pregnant women, particularly those who have previously had children, and that such care leads to relatively few cesarean sections.

Specular microscopic observations of the clinically normal canine corneal endothelium

Specular microscopy and pachometry were performed on seven clinically normal anesthetized young adult dogs. Endothelial cells of the central cornea formed a mosaic-like pattern of hexagonal cells 15 to 20 micrometers in diameter; the average number of cells per millimeters squared was 2,816 +/- 187 SD. Average corneal thickness of 0.62 +/- 0.047 SD mm.