Right-sizing interprofessional team training for serious-illness communication: A strength-based approach

Objective

Palliative care communication skills help tailor care to patients' goals. With a palliative care physician shortage, non-physicians must gain these serious illness communication skills. Historically, trainings have targeted physician-only groups; our goal was to train interprofessional teams.

Methods

Workshops were conducted to teach palliative care communication skills and interprofessional communication. Participants completed surveys which included questions from the Interpersonal Reactivity Index, the Ekman Faces tool, the Consultation and Relational Empathy measure, open-ended questions about empathy, and measures of effective interprofessional practice.

Results

Participants felt the workshop improved their ability to listen (p < 0.001), understand patients' concerns (p < 0.001), and show compassion (p = 0.008). It increased the perceived value of peer observation (p < 0.001) and ability to reflect (p = 0.02) during complex conversations. Different types of professionals adopted different communication goals, though all affirmed the importance of active listening. Participants felt they improved their ability to work within an interprofessional team.

Conclusions

The course effectively trained 71 clinicians, the majority non-physicians, in serious illness communication and interprofessional team communication skills, and could be reproduced in similar settings.

Innovation

We adapted an approach common to physician-only trainings to diverse interprofessional groups, added a team-based component using Applied Improvisation, and demonstrated its effectiveness.

Visual hallucinations after resection of cerebral metastases: two patients with complex phantom images

PURPOSE

Complex visual hallucinations are rarely seen in neurooncology. They are commonly observed alongside psychotic symptoms in schizophrenia or dementia, in Parkinson's or Lewy-body disease, after opioid medications or anesthesia, and, in particular, they appear with visual impairments.

METHODS

Here we report two normal-sighted and mentally healthy patients with unusual visual hallucinations after the resection and irradiation of brain metastases, the main features of which were persistent colorful and meaningful images with hallucinatory perseveration.

RESULTS

These cases demonstrate the occurrence of complex visual hallucinations after resection of visual cortices as an effect of deafferentation, so-called visual release hallucinations or phantom images, similar to phantom pain after amputation of a limb.

CONCLUSION

This case serves to heighten awareness in the radiooncology practitioner of the occurrence of visual release hallucinations (Charles Bonnet syndrome) related to multidisciplinary treatment of brain metastases.

The Lucy Thermal Emission Spectrometer (L'TES) Instrument

The Lucy Thermal Emission Spectrometer (L'TES) will provide remote measurements of the thermophysical properties of the Trojan asteroids studied by the Lucy mission. L'TES is build-to-print hardware copy of the OTES instrument flown on OSIRIS-REx. It is a Fourier Transform spectrometer covering the spectral range 5.71-100 μm (1750-100 cm-1) with spectral sampling intervals of 8.64, 17.3, and 34.6 cm-1 and a 7.3-mrad field of view. The L'TES telescope is a 15.2-cm diameter Cassegrain telescope that feeds a flat-plate Michelson moving mirror mounted on a linear voice-coil motor assembly to a single uncooled deuterated l-alanine doped triglycine sulfate (DLATGS) pyroelectric detector. A significant firmware change from OTES is the ability to acquire interferograms of different length and spectral resolution with acquisition times of 0.5, 1, and 2 seconds. A single ∼0.851 μm laser diode is used in a metrology interferometer to provide precise moving mirror control and IR sampling at 772 Hz. The beamsplitter is a 38-mm diameter, 1-mm thick chemical vapor deposited diamond with an antireflection microstructure to minimize surface reflection. An internal calibration cone blackbody target, together with observations of space, provides radiometric calibration. The radiometric precision in a single spectrum is ≤2.2 × 10-8 W cm-2 sr-1 /cm-1 between 300 and 1350 cm-1. The absolute temperature error is <2 K for scene temperatures >75 K. The overall L'TES envelope size is 37.6 × 29.0 × 30.4 cm, and the mass is 6.47 kg. The power consumption is 12.6 W average. L'TES was developed by Arizona State University with AZ Space Technologies developing the electronics. L'TES was integrated, tested, and radiometrically calibrated on the Arizona State University campus in Tempe, AZ. Initial data from space have verified the instrument's radiometric and spatial performance.

What MRI Sequences are Necessary for Automated Neural Network-Based Metastasis Segmentation - An Ablation Study

PURPOSE/OBJECTIVE(S)

Brain metastasis (BM) delineation is a time-consuming process in both daily clinical practice and research. Automated BM segmentation algorithms can be used to assist in this task. Most approaches to brain tumor segmentation, such as algorithms trained on the BraTS challenge, use four magnetic resonance imaging (MRI) sequences as input, making them susceptible to missing or corrupted sequences and increase the number of sequences necessary for MRI RT planning. The goal of this project is to compare neural networks with different combinations of input sequences for the segmentation of the contrast-enhancing metastasis and the surrounding FLAIR hyperintense edema. All models were tested in a multicenter international external test cohort. This allows us to determine which MRI sequences are needed for effective automated segmentations.

MATERIALS/METHODS

In total, we had T1-weighted sequences without (T1) and with contrast enhancement (T1-CE), T2-weighted sequences (T2), and T2 fluid-attenuated inversion recovery (FLAIR) sequences from 339 patients with at least one brain metastasis from seven centers available. Preprocessing yielded co-registered, skull-stripped sequences with an isotropic resolution of 1 millimeter. The contrast-enhancing metastasis as well as the surrounding FLAIR hyperintense edema were manually segmented to create reference labels. A baseline 3D U-Net with all four sequences as well as six additional U-Nets with different clinically plausible combinations (T1-CE; T1; FLAIR; T1-CE+FLAIR; T1-CE+T1+FLAIR; T1-CE+T1) of input sequences were trained on a cohort of 239 patients from two centers and subsequently tested on an external cohort of 100 patients from the remaining five centers.

RESULTS

All models that included T1-CE in their selected sequences showed similar performance for metastasis segmentation with a median Dice similarity coefficient (DSC) of 0.93-0.96. T1-CE alone likewise achieved a performance of 0.96 (IQR 0.93-0.97). The model trained with only FLAIR performed worse (DSC = 0.73, IQR 0.54-0.84). For edema segmentation, models that included both T1-CE and FLAIR performed best (median DSC = 0.93), while the remaining four models without simultaneous inclusion of these two sequences (T1-CE; T1; FLAIR; T1-CE+T1) reached a median DSC of 0.81-0.89.

CONCLUSION

Automatic segmentation of brain metastases with less than four input sequences is feasible with minimal or no loss of quality. A T1-CE-only protocol suffices for metastasis segmentation. In contrast, for edema segmentation, the combination of T1-CE and FLAIR seems to be important. Missing either T1-CE or FLAIR decreases performance. These findings may improve future imaging routines by omitting unnecessary sequences, thus speeding up procedures in daily clinical practice while allowing for optimal neural network-based target definitions.

Post-Operative Stereotactic Radiotherapy for Resected Brain Metastases: Results of the Multicenter Analysis (AURORA) of the German Working Group "Stereotactic Radiotherapy"

PURPOSE/OBJECTIVE(S)

While the results of prospective studies support the use of postoperative stereotactic radiotherapy (RT) to the resection cavity (RC) as the standard of care after surgery, there are several issues that need to be investigated such as factors for improving local control, risk of leptomeningeal disease and radiation necrosis. Further, the optimal dose and fractionation is still under debate.

MATERIALS/METHODS

The working group "Stereotactic Radiotherapy" of the German Society of Radiation Oncology (DEGRO) analyzed its multi-institutional database with 661 patients who received postoperative stereotactic RT to the RC. Treatment was performed at 13 centers between 2008 and 2021. Patient characteristics, treatment details, and follow-up data including overall survival (OS), local control (LC) were evaluated. Cox Regression and Kaplan-Meier curves with Log-rank Tests were calculated for selected variables.

RESULTS

In this retrospective study, overall survival was 61.5% at 1 year, 47.6% at 2 years, and 35.5% at 3 years, and local control was 84.6% at 1 year, 74.8% at 2 years, and 72.8% at 3 years. 96% of patients were treated with hypofractionated stereotactic radiotherapy (HSRT), only 26 patients received single fraction radiosurgery (4%). Prognostic factors associated with overall survival were Karnofsky Performance Status, RPA and GPA class, controlled primary tumor and absence of extracranial metastases, whereas prognostic factor associated with local control was planning target volume (23 mL or less).

CONCLUSION

HSRT is the most common fractionation form in the treatment of RCs in this multicenter analysis. This approach results in excellent OS and LC outcomes. OS in patients with resected brain metastases is mainly influenced by performance status. In regard to local control, RT of large cavities remain a challenge with significantly worse outcome.

Induction of cancer neoantigens facilitates development of clinically relevant models for the study of pancreatic cancer immunobiology

Neoantigen burden and CD8 T cell infiltrate are associated with clinical outcome in pancreatic ductal adenocarcinoma (PDAC). A shortcoming of many genetic models of PDAC is the lack of neoantigen burden and limited T cell infiltrate. The goal of the present study was to develop clinically relevant models of PDAC by inducing cancer neoantigens in KP2, a cell line derived from the KPC model of PDAC. KP2 was treated with oxaliplatin and olaparib (OXPARPi), and a resistant cell line was subsequently cloned to generate multiple genetically distinct cell lines (KP2-OXPARPi clones). Clones A and E are sensitive to immune checkpoint inhibition (ICI), exhibit relatively high T cell infiltration, and have significant upregulation of genes involved in antigen presentation, T cell differentiation, and chemokine signaling pathways. Clone B is resistant to ICI and is similar to the parental KP2 cell line in terms of relatively low T cell infiltration and no upregulation of genes involved in the pathways noted above. Tumor/normal exome sequencing and in silico neoantigen prediction confirms successful generation of cancer neoantigens in the KP2-OXPARPi clones and the relative lack of cancer neoantigens in the parental KP2 cell line. Neoantigen vaccine experiments demonstrate that a subset of candidate neoantigens are immunogenic and neoantigen synthetic long peptide vaccines can restrain Clone E tumor growth. Compared to existing models, the KP2-OXPARPi clones better capture the diverse immunobiology of human PDAC and may serve as models for future investigations in cancer immunotherapies and strategies targeting cancer neoantigens in PDAC.

Using human factors principles to redesign a 3D lab workflow during the COVID-19 pandemic

Background

Like most hospitals, our hospital experienced COVID-19 pandemic-related supply chain shortages. Our additive manufacturing lab’s capacity to offset these shortages was soon overwhelmed, leading to a need to improve the efficiency of our existing workflow. We undertook a work system analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) construct which is based on human factors and quality improvement principles. Our objective was to understand the inefficiencies in project submission, review, and acceptance decisions, and make systematic improvements to optimize lab operations.

Methods

Contextual inquiry (interviews and workflow analysis) revealed suboptimal characteristics of the system, specifically, reliance on a single person to facilitate work and, at times, fractured communication with project sponsors, with root causes related to the project intake and evaluation process as identified through SEIPS tools. As interventions, the analysis led us to: 1) enhance an existing but underused project submission form, 2) design and implement an internal project scorecard to standardize evaluation of requests, and 3) distribute the responsibility of submission evaluation across lab members. We implemented these interventions in May 2021 for new projects and compare them to our baseline February 1, 2018 through – April 30, 2021 performance (1184 days).

Results

All project requests were submitted using the enhanced project submission form and all received a standardized evaluation with the project scorecard. Prior to interventions, we completed 35/79 (44%) of projects, compared to 12/20 (60%) of projects after interventions were implemented. Time to review new submissions was reduced from an average of 58 days to 4 days. A more distributed team responsibility structure permitted improved workflow with no increase in staffing, allowing the Lab Manager to devote more time to engineering rather than administrative/decision tasks.

Conclusions

By optimizing our workflows utilizing a human factors approach, we improved the work system of our additive manufacturing lab to be responsive to the urgent needs of the pandemic. The current workflow provides insights for labs aiming to meet the growing demand for point-of-care manufacturing.

Stereotactic radiosurgery and radiotherapy for resected brain metastases: current pattern of care in the Radiosurgery and Stereotactic Radiotherapy Working Group of the German Association for Radiation Oncology (DEGRO)

PURPOSE

Preoperative stereotactic radiosurgery (SRS) of brain metastases may achieve similar local control and better leptomeningeal control rates than postoperative fractionated stereotactic radiotherapy (FSRT) in patients treated with elective metastasectomy. To plan a multicentre trial of preoperative SRS compared with postoperative FSRT, a survey of experts was conducted to determine current practice.

METHODS

A survey with 15 questions was distributed to the DEGRO Radiosurgery and Stereotactic Radiotherapy Working Group. Participants were asked under what circumstances they offered SRS, FSRT, partial and/or whole brain radiotherapy before or after resection of a brain metastasis, as well as the feasibility of preoperative stereotactic radiosurgery and neurosurgical resection within 6 days.

RESULTS

Of 25 participants from 24 centres, 22 completed 100% of the questions. 24 respondents were radiation oncologists and 1 was a neurosurgeon. All 24 centres have one or more dedicated radiosurgery platform and all offer postoperative FSRT. Preoperative SRS is offered by 4/24 (16.7%) centres, and 9/24 (37.5%) sometimes recommend single-fraction postoperative SRS. Partial brain irradiation is offered by 8/24 (33.3%) centres and 12/24 (50%) occasionally recommend whole-brain irradiation. Two centres are participating in clinical trials of preoperative SRS. SRS techniques and fractionation varied between centres.

CONCLUSION

All responding centres currently offer postoperative FSRT after brain metastasectomy. Approximately one third offer single-fraction postoperative SRS and four already perform preoperative SRS. With regard to potential co-investigators, 18 were identified for the PREOP‑2 multicentre trial, which will randomise between preoperative SRS and postoperative FSRT.

Involvement and engagement of seldom-heard communities in big data research

ObjectivesPublic involvement and engagement have been growing within big data research. However, seldom heard voices such as migrant and ethnic minorities communities are often underrepresented. This study explored how Polish and South Asian communities in the United Kingdom could be better included in public involvement and engagement activities. ApproachWe conducted semi-structured interviews with Polish (n=20) and South Asians (n=20) to elicit their views on big data research, public involvement and engagement. We focused on Polish and South Asian communities as they represent some of the United Kingdom’s largest migrant and ethnic minority groups. Data were analysed using inductive thematic analysis. Public advisors were involved in the analysis. They and one of the researchers come from ethnic minority and offered insider insight into participants' perspectives and thus allowing us to unpick the complexity of experiences and backgrounds. ResultsThe majority of participants were willing to become involved or engaged in big data research. However, we found there were multiple barriers to involvement, these included: language (especially for those for whom English is the second language); use of jargon by researchers; time restrictions and unfamiliarity with big data or public involvement. Some participants questioned how much migrants could be involved when they were only in the United Kingdom on a temporary basis. The participants made recommendations for how researchers can mitigate these barriers. Awareness-raising activities would allow people to expand their understanding and build their confidence when speaking about big data research in a second language. Participants spoke of the need for researchers to work more closely with local communities, especially with local gatekeepers. ConclusionsThe results indicate that there is no ‘right’ way to involve and engage seldom heard communities around big data research. Researchers need to engage with communities, establish trust and develop a long-lasting relationships. These partnerships should move beyond single projects and aim to benefit both researchers and seldom heard communities.

The experiences of new mothers accessing feeding support for infants with down syndrome during the COVID-19 pandemic

Infants with Down syndrome are more likely to experience feeding problems and mothers are likely to require more feeding support than mothers of typically developing infants. During the COVID-19 pandemic, many feeding support services changed from face-to-face to online, which impacted some maternal feeding experiences negatively, but no studies to date have explored the impact for mothers of infants with Down syndrome. Thematic analysis was conducted on semi-structured interviews from thirteen new mothers of infants (aged 8-17 months) with Down syndrome in the UK. Three superordinate themes were generated: (1) Every baby with Down syndrome has a unique journey, (2) There's no point asking, they won't know, (3) Lack of in-person support. Many mothers expressed frustrations over health professionals' lack of Down syndrome specific knowledge resulting in unmet needs, further magnified due to the nature of the virtual support being offered. Moreover, mothers struggled with reduced social support from other mothers when encountering feeding problems. These results hold real-world implications for health professionals who could provide more specialised face-to-face feeding support to mothers of infants with Down syndrome. This should be prioritised for children's overall development and mothers' wellbeing.

Parameter inversion of a polydisperse system in small-angle scattering

An accurate and efficient method for model- and form-free inversion of a polydisperse small-angle scattering system is presented. It supports an arbitrary number of model parameters and both 1D and 2D intensity observations.

A general method to invert parameter distributions of a polydisperse system using data acquired from a small-angle scattering (SAS) experiment is presented. The forward problem, i.e. calculating the scattering intensity given the distributions of any causal parameters of a theoretical model, is generalized as a multi-linear map, characterized by a high-dimensional Green tensor that represents the complete scattering physics. The inverse problem, i.e. finding the maximum-likelihood estimation of the parameter distributions (in free form) given the scattering intensity (either a curve or an image) acquired from an experiment, is formulated as a constrained nonlinear programming (NLP) problem. This NLP problem is solved with high accuracy and efficiency via several theoretical and computational enhancements, such as an automatic data scaling for accuracy preservation and GPU acceleration for large-scale multi-parameter systems. Six numerical examples are presented, including both synthetic tests and solutions to real neutron and X-ray data sets, where the method is compared with several existing methods in terms of their generality, accuracy and computational cost. These examples show that SAS inversion is subject to a high degree of non-uniqueness of solution or structural ambiguity. With an ultra-high accuracy, the method can yield a series of near-optimal solutions that fit data to different acceptable levels.

Trends in Management of Children With Acute Gastroenteritis in US Emergency Departments

This repeated cross-sectional analysis examines national trends in emergency department (ED) treatment of children with acute gastroenteritis.

Does Prefrontal Glutamate Index Cognitive Changes in Parkinson's Disease?

Introduction

Cognitive impairment is a highly prevalent non-motor feature of Parkinson's disease (PD). A better understanding of the underlying pathophysiology may help in identifying therapeutic targets to prevent or treat dementia. This study sought to identify metabolic alterations in the prefrontal cortex (PFC), a key region for cognitive functioning that has been implicated in cognitive dysfunction in PD.

Methods

Proton Magnetic Resonance Spectroscopy was used to investigate metabolic changes in the PFC of a cohort of cognitively normal individuals without PD (CTL), as well as PD participants with either normal cognition (PD-NC), mild cognitive impairment (PD-MCI), or dementia (PDD). Ratios to Creatine (Cre) resonance were obtained for glutamate (Glu), glutamine and glutamate combined (Glx), N-acetylaspartate (NAA), myoinositol (mI), and total choline (Cho), and correlated with cognitive scores across multiple domains (executive function, learning and memory, language, attention, visuospatial function, and global cognition) administered to the PD participants only.

Results

When individuals retain cognitive capabilities, the presence of Parkinson's disease does not create metabolic disturbances in the PFC. However, when cognitive symptoms are present, PFC Glu/Cre ratios decrease with significant differences between the PD-NC and PPD groups. In addition, Glu/Cre ratios and memory scores were marginally associated, but not after Bonferroni correction.

Conclusion

These preliminary findings indicate that fluctuations in prefrontal glutamate may constitute a biomarker for the progression of cognitive impairments in PD. We caution for larger MRS investigations of carefully defined PD groups.

Contrasting impacts of mixed nonionic surfactant micelles on plant growth in the delivery of fungicide and herbicide

HYPOTHESIS

Nonionic alkyl ethoxylate surfactants are widely used in agrochemicals to facilitate the permeation of systemic herbicides and fungicides across the plant waxy film. Industrial grade surfactants are often highly mixed and how the mixing affects their interactions with pesticides and wax films remains largely unexplored. A better understanding could enable design of mixed nonionic surfactants for herbicides and fungicides to maximize their efficiency and reduce wastage whilst controlling their impact on plant wax films.

EXPERIMENT

In this study, nonionic surfactants with general structure n-oxyethylene glycol monododecyl ether (C₁₂E_n) were used to form surfactant mixtures with the same average ethoxylate numbers but different hydrophilic-lipophilic balance (HLB) values. Their mixed micellar systems were then used to solubilize a herbicide diuron (DN) and a fungicide cyprodinil (CP), followed by plant wax solubilization upon contact with wax films. These processes were monitored by ¹H NMR and SANS.

FINDING

Pesticide solubilization made surfactant micelles effectively more hydrophobic but subsequent wax dissolution caused pesticide release and the restoration of the micellar amphiphilicity. Nonionic surfactants with lower HLBs form larger nanoaggregates, show enhanced wettability, and have better ability to solubilize and permeate pesticides across the wax film, but may cause significant damage to plant growth. These observations help explain why herbicides applied on weeds would benefit from surfactants with lower HLB values while fungicides require surfactants with HLBs to balance between delivery efficiency and potential phytotoxicity risks.

101 National Trends in Emergency Department Ondansetron Use and Clinical Outcomes Among Children with Acute Gastroenteritis

Primary Subject area

Emergency Medicine - Paediatric

Background

Acute gastroenteritis (AGE) is among the most common illnesses for which children are evaluated in the Emergency Department (ED). Among children with AGE, ondansetron has been shown to reduce vomiting, intravenous (IV) fluid administration and hospitalizations when administered in the ED.

Objectives

To determine whether increasing ondansetron administration is associated with a concomitant decline in IV rehydration and hospitalization among children presenting with AGE in a broad, nationally representative ED sample.

Design/Methods

This was a cross-sectional analysis of the US Centers for Disease Control and Prevention (CDC) National Hospital Ambulatory Medical Care Survey (NHAMCS) database from 2006 to 2015. Children &lt; 18 years old with a discharge diagnosis of AGE were included for analysis. Survey weighting procedures were applied to generate population-level estimates and to perform multivariable logistic regression to identify factors associated with ondansetron administration.

Results

There were an estimated 15.1 million (95% CI 13.5-16.7) visits for AGE during the 10-year study period. AGE visits increased as a proportion of all pediatric ED visits over time (4.6% in 2006, 5.7% in 2015; p-trend=0.013). The mean patient age was 4.7 (95% CI 4.5-5.0) years, and most visits were to non-teaching (86.6%, 95% CI 83.3-89.3%) and non-pediatric (83.4%, 95% CI 78.2-87.5%) hospitals. The proportion of patients receiving ondansetron increased over time (11.8% in 2006, 62.5% in 2015; p-trend &lt; 0 .001), both in the ED (10.6% in 2006, 55.5% in 2015; p-trend &lt; 0 .001) and as outpatient prescriptions (3.3% in 2006, 45.3% in 2015; p-trend &lt; 0 .001). Over the same period, there was no change in hospitalizations (2.9% overall, 95% CI 2.2-3.7%; p-trend=0.144). IV hydration for AGE decreased (31.8% in 2006, 24.9% in 2015; p-trend &lt; 0 .048), as did IV fluid administration across all other pediatric ED visits (10.3% in 2006, 7.8% in 2015; p-trend &lt; 0 .023). After adjustment for patient- and hospital-level factors, the odds ratio for IV rehydration among children with AGE was 0.97 (95% CI 0.92-1.01). Multivariable analysis found younger age (aOR 0.94, 95% CI 1.04-1.09), Medicaid/Medicare insurance (aOR 0.74; 95% CI 0.57-0.97), and presentation to a teaching hospital (aOR 0.74; 95% CI 0.54-0.99) were inversely associated with ondansetron administration. Other antiemetics most commonly used were promethazine (7.4%, 95% CI 5.9-9.2%), metoclopramide (1.8%, 95% CI 1.3-2.5%) and trimethobenzamide (1.5%, 95% CI 1.1-2.1%). Antimotility agents, H2-receptor blockers, and probiotics were infrequently used.

Conclusion

Both ED and outpatient prescribing of ondansetron for children with AGE increased; however, no concomitant decline was observed in hospitalizations or IV rehydration. Guidelines and quality improvement efforts are needed to target ondansetron administration to children most likely to benefit to minimize adverse events and costs associated with overuse.

Tuning the Bulk and Surface Properties of PDMS Networks through Cross-Linker and Surfactant Concentration

The elastic modulus and hydrophilicity of cross-linked poly(dimethylsiloxane) (PDMS) are tunable via cross-linker concentration and the addition of a simple surfactant, C12E4, before curing. However, the surfactant concentration, [C12E4], reduces the elastic modulus (73% lower for 6.3% w/w) because it reduces the extent of curing. This is likely because the hygroscopic surfactant results in water poisoning of the catalyst. Three distinct time-dependent hydrophilicity profiles were identified using water contact angle analysis with [C12E4] determining which profile was observed. This indicates the concentration-dependent phase behavior of C12E4 within PDMS films. Changes in phase behavior were identified using small-angle neutron scattering (SANS) and a compatibility study. No surface excess or surface segregation of surfactant was observed at the PDMS-air interface. However, a surface excess revealed by neutron reflectivity against a D2O interface indicates that the increase in hydrophilicity results from the migration of C12E4 to the film interface when exposed to water.

Clinical utility of correction factors for febrile young infants with traumatic lumbar punctures

Objectives

Correction factors have been proposed for traumatic lumbar punctures (LPs) in febrile young infants. However, no studies have assessed their diagnostic utility. We sought to determine the proportion of traumatic LPs safely reclassified as low risk for bacterial meningitis using recently derived white blood cell (WBC) and protein correction factors.

Methods

We retrospectively analyzed traumatic LPs among all febrile infants ≤60 days old at two tertiary paediatric hospitals from 2006 through 2018. Traumatic LPs were defined as ≥10,000 RBCs/mm³. Abnormal cerebrospinal fluid (CSF) WBCs and protein were adjusted downward using a newly derived correction factor (877 red blood cells [RBCs]: 1 WBC), three commonly used correction factors (500 WBCs: 1 RBC; 1,000 WBCs: 1 WBC; peripheral RBCs: WBCs), and a newly derived protein correction factor (1,000 RBCs: 0.011 g/L protein).

Results

There were 437 traumatic LPs including 357 (82%) with pleocytosis and 4 (0.9%) with bacterial meningitis. Overall, fewer infants were classified as having CSF pleocytosis using 877:1 and 1,000:1 ratios (38% and 43%, respectively), with 100% sensitivity and negative predictive value, and improved specificity (63% for 877:1, 58% for 1,000:1 ratios versus 19% for uncorrected counts). Among infants with pleocytosis, 877:1 and 1,000:1 ratios reclassified 191 (54%) and 171 (48%) as normal with no misclassified bacterial meningitis cases. Ratios of 500:1 and peripheral RBC:WBC misclassified 1 infant that had bacterial meningitis. Corrected CSF protein outperformed uncorrected protein in specificity but did not add diagnostic value following WBC-based correction.

Conclusions

Correction ratios of 877:1 and 1,000:1 safely reclassified half of all febrile infants ≤60 days. These corrections should be considered when interpreting CSF results of traumatic LPs.

1082 Are Trauma and Orthopaedics Consultant Posts Decreasing in Frequency and Increasing in Subspecialisation?

Aim

Changes to the configuration of the NHS Trauma Services in T&O and the level of subspecialisation are changing and could impact training and the number of consultant posts available at CCT. The aim of this study was to review the number of T&O Consultant posts and determine the frequency of the subspecialist requirements of these posts from 2011 to 2020, to assess the perceived reduction in advertised numbers and the increasing sub specialisation as a whole.

Method

451 volumes of the BMJ were reviewed over Jan 2011 - April 2020. The total number of jobs advertised were recorded. Additionally, for each post, sub-specialism, regional analysis and substansive or locum tenure were recorded.

Results

1141 jobs were advertised during this period. There has been a decreasing trend in the total number of advertised posts of 13% per annum. Proportion of specialty jobs remain constant yearly. However, jobs listing Trauma clearly decreased after 2012, when trauma centres were initiated. Clear decreases were present in North-west and Scotland in number of jobs. There has also been an increasing trend of advertisement of substantive posts, with locum posts forming less than 13% of total advertisements.

Conclusions

We found no significant increase in job specialism contradicting previous research. Overall, the total number of Consultant jobs in Trauma and Orthopaedics is decreasing, especially in the north-west and Scotland, two of the biggest employers. Questions must be asked for the future of training in T&O to meet service needs.

Five fraction stereotactic radiotherapy after brain metastasectomy: a single-institution experience and literature review

PURPOSE

The outcomes of five fraction stereotactic radiotherapy (hfSRT) following brain metastasectomy were evaluated and compared with published series.

METHODS

30 Gy in 5 fractions HfSRT prescribed to the surgical cavity was reduced to 25 Gy if the volume of 'brain-GTV' receiving 20 Gy exceeded 20 cm³. Endpoints were local recurrence, nodular leptomeningeal recurrence, new brain metastases and radionecrosis. The literature was searched for reports of clinical and dosimetric outcomes following postoperative hfSRT in 3-5 fractions.

RESULTS

39 patients with 40 surgical cavities were analyzed. Cavity local control rate at 1 year was 33/40 (82.5%). 3 local failures followed 30 Gy/5 fractions and 4 with 25 Gy/5 fractions. The incidence of leptomeningeal disease (LMD) was 7/40 (17.5%). No grade 3-4 toxicities, particularly no radionecrosis, were reported. The incidence of distant brain metastases was 15/40 (37.5%). The median overall survival was 15 months. Across 13 published series, the weighted mean local control was 83.1% (adjusted for sample size), the mean incidence of LMD was 14.9% (7-34%) and the mean rate of radionecrosis was 10.3% (0-20.6%).

CONCLUSION

Postoperative hfSRT can be delivered with 25-30 Gy in 5 fractions with efficacy in excess of 82% and no significant toxicity when the dose to 'brain-GTV' does not exceed 20 cm³.

P–123 How to develop accurate Computer Assisted Sperm Analysis (CASA) AI in the absence of protocol standardization and abundance of human error when performing semen analyses?

Study question

How can an automation & artificial intelligent tools be developed to perform according to WHO recommendations?

Summary answer

Developing CASA performs at &lt; 20% error margin requires AI trained with high quality datasets and a robotic system adheres to WHO guidelines.

What is known already

A survey of 40 andrology laboratories, in 22 countries, revealed that &gt; 90% had nonconformities in correct use of equipment, standardisation of protocols and quality control, leading to a lack of compliance to WHO protocols. Conventional CASA systems can standardize analysis, but controversy has occurred due to differences between manual and automated analyses stemming from: 1) all cells in a semen sample are detected including debris; 2) protocol variation when compared to top-notch manual analysis. The first point can be addressed by AI. The second point can be addressed by robotics designed to adhere to WHO guidelines.

Study design, size, duration

A mojo AISA (AI-powered semen analysis) system was placed in four clinical laboratories mentioned above capturing images of over 300 samples, one million images were generated over a course of 2 years. Mojo AISA’s AI was trained on data collected from the four clinics using robotic system is developed according to WHO guidelines.

Participants/materials, setting, methods

For an AI to detect sperm accurately, sperm samples were captured using mojo AISA smart microscopy and then the extracted sperm images expertly annotated. To evaluate the system-ability for semen analysis, fresh sample were analysed for concentration and motility by a manual operator and compared to a mojo AISA test.

Main results and the role of chance

To train the sperm detection AI, representative sperm images were carefully captured using mojo AISA and processed according to the following criteria: the number of images and videos to train and to test the model: 50,000 spermatozoon head and tails with various variations the variety of images: data used to train the AI has to be representative of the population that will undergo the analysis: 1) wide concentration ranges from 0 to 300 M/ml, 2) high and low density of debris and cells, 3) Presence of slight aggregations careful and precise annotation: expert andrology scientists annotated sperm images and identify objects to exclude, such as debris in seminal plasma, Mojo AISA is an attempt strictly build CASA AI system to WHO-guidelines. The marriage of AI and robotics automation has shown a promising results to mimic humans when measuring a semen sample and attempt to obtain results comparable to the manual analysis.

mojo AISA’s performance improved three-fold (from 0,85 to 0,95 Pearson sperm count correlation and from &gt;100% means relative error to 25% mean relative error).

Limitations, reasons for caution

Lack of standardization for semen analysis laboratory process globally is a bottleneck towards building a robust multi-center study, on-site CASA testing and generating an actionable data pool for studying the causes behind male fertility declineWider implications of the findings: Key learnings for parties advancing developing AI based on images and videos for application in the fertility space.

Trial registration number

Not applicable

Charge transport physics of a unique class of rigid-rod conjugated polymers with fused-ring conjugated units linked by double carbon-carbon bonds

We investigate the charge transport physics of a previously unidentified class of electron-deficient conjugated polymers that do not contain any single bonds linking monomer units along the backbone but only double-bond linkages. Such polymers would be expected to behave as rigid rods, but little is known about their actual chain conformations and electronic structure. Here, we present a detailed study of the structural and charge transport properties of a family of four such polymers. By adopting a copolymer design, we achieve high electron mobilities up to 0.5 cm2 V-1 s-1 Field-induced electron spin resonance measurements of charge dynamics provide evidence for relatively slow hopping over, however, long distances. Our work provides important insights into the factors that limit charge transport in this unique class of polymers and allows us to identify molecular design strategies for achieving even higher levels of performance.

Erratum to: Clinical utility of correction factors for febrile young infants with traumatic lumbar punctures

[This corrects the article DOI: 10.1093/pch/pxaa114.].

Referral, Assessment and Use of Screening Measures Related to Autism Spectrum Disorder at a Tertiary Hospital Setting

Children with developmental concerns in Australia continue to experience inequitable healthcare and service-related delays, even when diagnostic risk is identified. This study sought to explore service and demographic pathway factors leading up to autism spectrum disorder (ASD) assessment, including value of screening measures applied at triage. Following a trial of centralised intake for referred young children with suspected ASD, observational, retrospective pathway data was explored using bivariate and regression analyses. The mean age of 159 children referred with autism symptoms was 3.6 years, and 64% were diagnosed with ASD. Service allocation was associated with diagnosis, whilst screening tool results were not. Improved pathways are needed to limit wasted waiting times and direct each child to needs-based services.

74 MULTICENTER VALIDATION OF CORRECTION FACTORS FOR CEREBROSPINAL FLUID LABORATORY VALUES IN YOUNG INFANTS WITH A TRAUMATIC LUMBAR PUNCTURE

Background

The evaluation of fever among infants in the first months of life remains one of the most common problems in pediatric healthcare. Approximately 10% harbor potentially life-threatening infections including bacterial meningitis, frequently necessitating invasive cerebrospinal fluid (CSF) testing by lumbar puncture (LP). LPs are often traumatic leading to uninterpretable results and consequently, broad-spectrum antibiotic exposure and prolonged hospitalization. Several strategies have been proposed to identify low-risk infants with traumatic LPs, including recently-derived correction factors, however studies validating the safety and diagnostic utility of such approaches are lacking.

Objectives

To evaluate the test characteristics and misclassification rates of recently described ratio-based correction methods for the interpretation of CSF results among young infants with traumatic LPs.

Design/Methods

We undertook a multicenter cohort study of infants aged ≤60 days with a traumatic LP performed at two urban tertiary Pediatric hospitals from 2006 to 2018. Traumatic LPs were defined as CSF specimens with ≥10,000 RBCs/mm3, and for infants aged ≤28 days and 29-60 days, pleocytosis was defined as ≥20 and ≥10 WBC/mm3, respectively, and abnormal protein ≥1.15 and ≥0.89 g/L, respectively. CSF WBCs and protein were adjusted downward for traumatic LPs using RBC ratio-based correction methods (newly derived 877:1, commonly used 500 and 1000:1, peripheral RBC:WBC ratio, and newly derived 1000 RBCs:0.011g/L protein). Descriptive statistics are presented with sensitivity, specificity, and negative predictive values of unadjusted and adjusted CSF for predicting culture-proven bacterial meningitis.

Results

Of 4,912 LPs meeting inclusion criteria, 437 (8.9%) were traumatic, among which 4 (0.9%) were positive for bacterial meningitis. Compared to uncorrected CSF WBC counts, both 877 and 1000 correction factors classified fewer infants with pleocytosis (38.0% and 42.6% vs 81.7%). These correction factors both maintained 100% sensitivity and 100% negative predictive value, and performed with greater specificity for bacterial meningitis than the uncorrected WBC count (62.6% and 58.0% vs 18.5%). No infants with bacterial meningitis were misclassified using either 877 or 1000:1 correction factors. CSF 500:1 and peripheral RBC:WBC correction ratios performed with the lowest sensitivity and negative predictive values and both misclassified 1 infant with bacterial meningitis. Corrected CSF protein outperformed uncorrected protein in specificity (66.8% vs 33.9%), but did not add diagnostic value when used in combination with WBC correction ratios.

Conclusion

Correction of the CSF WBC count substantially reduced the number of infants classified with CSF pleocytosis. The newly-derived 877:1 correction factor performed with the best test characteristics, safely reclassifying nearly half of all infants with a traumatic LP. It may be appropriate to use a correction factor in the evaluation of CSF cell counts in traumatic LPs in order to more effectively risk-stratify febrile young infants, reduce antibiotic exposure and admission duration.

Imaging digital arteries in systemic sclerosis by tomographic 3-dimensional ultrasound

Objective methods are needed to quantify digital artery disease in systemic sclerosis (SSc) for clinical trials of vascular therapies. Our primary aim was to examine feasibility of a novel tomographic three-dimensional-(3-D) ultrasound (tUS) with high-frequency ultrasound (HFUS) or ultra-high-frequency ultrasound (UHFUS) to assess the digital arteries in patients with SSc compared to healthy controls. A secondary objective was to compare the total wall volume (TWV) as a measure of intimal/medial thickness. Eighteen patients with a confirmed diagnosis of SSc were studied by tUS HFUS (17.5 MHz, n = 10) or tUS UHFUS (48 and 70 MHz, n = 8) with equal numbers of healthy controls of similar age and gender. The majority of patients had limited cutaneous SSc and were representative of a spectrum of digital vasculopathy, with over half (n = 6 HFUS and n = 5 UHFUS) having previous digital ulceration. Over half were receiving oral vasodilatory therapy. TWV was measured in both digital arteries of the middle finger bilaterally. At least, two digital arteries could be identified at 17.5 MHz in all patients and healthy controls. Whereas, at least two digital arteries could be identified in relatively fewer patients compared to healthy controls using 48 MHz (n = 6 and 10) and especially 70 MHz (n = 4 and 10) UHFUS. The median difference in TWV between patients and healthy controls was -6.49 mm³ using 17.5 MHz, 1.9 mm³ at 48 MHz, and -0.4 mm³ at 70 MHz. tUS using UHFUS is a feasible method to measure TWV of digital arteries in SSc. Transducer frequency plays an important factor in successful digital artery measurement, with 48 MHz being the optimal frequency.

P1450Deep vein thrombosis after right sided catheter ablation; more common then previously thought?

Funding Acknowledgements

Bristol-Myers Squibb

Background

Right sided cardiac catheter ablation has become an indispensable tool to treat supraventricular cardiac dysrhythmias, with ablation of certain arrhythmias having cure rates over 90%. Due to this the frequency of these procedures is increasing annually and it is imperative we understand the incidence of all complication. One lesser studied complication is that of deep vein thrombosis (DVT), for which catheter ablation demonstrates all elements of Virchow"s triad.  As right sided ablations are carried out to treat troublesome palpitations, not to reduce mortality, it is important all risks are identified, especially those which are themselves potentially life threatening and can be modified.

Purpose

 

To determine the incidence of DVT after right sided cardiac catheter ablation.

Methods

 

We undertook a prospective multi-center study recruiting adult patients undergoing clinically indicated cardiac ablation for atrioventricular nodal re-entrant tachycardia and atrioventricular re-entrant tachycardia with right sided accessory pathway. Important exclusion criteria included patients on anticoagulation or antiplatelet therapy. Participants underwent bilateral compression venous duplex ultrasonography from the inferior vena cava to the popliteal vein to access for DVT at 24 hours and between 10 to 14 days post-procedure. The uncannulated contralateral leg acted as a control.

Result

 

At interim analysis 71 participants had completed the study with average age 47 year (+/- 14), procedure duration 67 minutes, and with a female predominance. Seven patients developed acute DVT in either the femoral or internal iliac vein in the access leg. No thrombus was seen in the control leg. This gives an incidence of 10% (95% CI 4-19%) with p value of 0.023 on Chi-square testing.

Conclusion

We found a statistically significant proportion of patients undergoing right sided cardiac catheter ablation developed acute proximal DVT on ultrasound. All patients were treated with 3 to 6 months of anticoagulation therapy in accordance with NICE guidelines. These results suggest that DVT may occur at a high frequency then previously thought in this cohort and supports the consideration of peri-procedural prophylactic anticoagulation.

Abstract Figure. Acute thrombus in the femoral vein

The influence of directed hydrogen bonds on the self-assembly of amphiphilic polymers in water

HYPOTHESIS

Molecules forming directed intermolecular hydrogen bonds, such as the well-known benzene-1,3,5-tricarboxamides (BTA) motif, are known to self-assemble into long fibrous structures. However, only a few of these systems have so far demonstrated the ability to form such anisotropic nanostructures, if they are combined with hydrophilic polymers to create an amphiphilic material. Here, we designed BTA-polymer conjugates to investigate whether the directionality of the hydrogen bonds or the ratio of hydrophobic to hydrophilic parts of the molecule, and thus the packing parameter, is decisive for obtaining anisotropic supramolecular structures in water.

EXPERIMENTS

Poly(ethylene glycol) was conjugated to BTA moieties with varying lengths of hydrophobic alkyl spacers ranging from two to twelve methylene units. The resulting amphiphilic materials were characterized in aqueous solution by light and small-angle neutron scattering, analytical ultracentrifugation, and cryo-transmission electron microscopy.

FINDINGS

While spherical micelles were observed for C₆ and C₁₀ alkyl spacers, anisotropic structures were only present in case of the C₁₂ spacer. The comparison to an analogous material, which lacks the directed hydrogen bonds, revealed that the BTA motif cannot provide a sufficient driving force to induce anisotropic structures, but increases the packing density in the hydrophobic part. Therefore, the packing parameter governs the appearance of anisotropic aggregates.

Enumeration of Total Coliforms and E. coli in Foods by the SimPlate® Coliform and E. coli Color Indicator Method and Conventional Culture Methods: Collaborative Study

The relative effectiveness of the SimPlate® Coliform and E. coli Color Indicator (CEc-CI) method was compared to the AOAC 3-tube Most Probable Number (MPN) methods for enumerating and confirming coliforms and Escherichia coli in foods (966.23 and 966.24). In this study, test portions were prepared and analyzed according to the conditions stated in both the AOAC methods and SimPlate directions for use. Six food types were artificially contaminated with coliform bacteria and E. coli: frozen burritos, frozen broccoli, fluid pasteurized milk, whole almond nut meats, cheese, and powdered cake mix. Method comparisons were conducted. Overall, the SimPlate method demonstrated &lt;0.3 log difference for total coliform and E. coli counts compared to the AOAC reference methods for the majority of food types and levels analyzed. In all cases, the repeatability and reproducibility of the SimPlate CEc-CI method were not different from those of the reference methods and in certain cases, were statistically better than those of the AOAC 3-tube MPN methods. These results indicate that the SimPlate CEc-CI method and the reference culture methods are comparable for enumeration of both total coliforms and E. coli in foods.

Using chirality to influence supramolecular gelation

Most low molecular weight gelators are chiral, with racemic mixtures often unable to form gels. Here, we show an example where all enantiomers, diastereomers and racemates of a single functionalized dipeptide can form gels. At high pH, different self-assembled aggregates are formed and these directly template the structures formed in the gel. Hence, solutions and gels with different properties can be accessed simply by varying the chirality. This opens up new design rules for the field.

In Vivo Water Dynamics in Shewanella oneidensis Bacteria at High Pressure

Following observations of survival of microbes and other life forms in deep subsurface environments it is necessary to understand their biological functioning under high pressure conditions. Key aspects of biochemical reactions and transport processes within cells are determined by the intracellular water dynamics. We studied water diffusion and rotational relaxation in live Shewanella oneidensis bacteria at pressures up to 500 MPa using quasi-elastic neutron scattering (QENS). The intracellular diffusion exhibits a significantly greater slowdown (by −10–30%) and an increase in rotational relaxation times (+10–40%) compared with water dynamics in the aqueous solutions used to resuspend the bacterial samples. Those results indicate both a pressure-induced viscosity increase and slowdown in ionic/macromolecular transport properties within the cells affecting the rates of metabolic and other biological processes. Our new data support emerging models for intracellular organisation with nanoscale water channels threading between macromolecular regions within a dynamically organized structure rather than a homogenous gel-like cytoplasm.

Time-resolved small-angle neutron scattering as a probe for the dynamics of lipid exchange between human lipoproteins and naturally derived membranes

Atherosclerosis is the main killer in the western world. Today’s clinical markers include the total level of cholesterol and high-/low-density lipoproteins, which often fails to accurately predict the disease. The relationship between the lipid exchange capacity and lipoprotein structure should explain the extent by which they release or accept lipid cargo and should relate to the risk for developing atherosclerosis. Here, small-angle neutron scattering and tailored deuteration have been used to follow the molecular lipid exchange between human lipoprotein particles and cellular membrane mimics made of natural, “neutron invisible” phosphatidylcholines. We show that lipid exchange occurs via two different processes that include lipid transfer via collision and upon direct particle tethering to the membrane, and that high-density lipoprotein excels at exchanging the human-like unsaturated phosphatidylcholine. By mapping the specific lipid content and level of glycation/oxidation, the mode of action of specific lipoproteins can now be deciphered. This information can prove important for the development of improved diagnostic tools and in the treatment of atherosclerosis.

Surfactant modulated interaction of hydrophobically modified ethoxylated urethane (HEUR) polymers with impenetrable surfaces

HYPOTHESIS

The presence of surfactant modulates the surface-chemistry-specific interaction of hard colloidal particles (latex) with HEUR polymers, principally through introducing a preferential solution interaction rather than a competitive surface interaction; addition of surfactant leads to a preponderance of polymer/surfactant solution complexes rather than surface-bound complexes.

EXPERIMENTS

A range of model formulations comprising a hexyl end-capped urethane polymer (C₆-L-(EO₁₀₀-L)₉-C₆), sodium dodecylsulfate (SDS) and a series of polystyrene-butylacrylate latices (PS-BA-L) have been characterised in terms of rheology, particle surface area (solvent relaxation NMR), polymer conformation (small-angle neutron scattering) and solution composition to build up a detailed picture of the distribution of the HEUR in the presence of both surfactant and latex.

FINDINGS

There is very weak adsorption of C₆-L-(EO₁₀₀-L)₉-C₆ to only the most hydrophobic latex surface studied, an adsorption that is further weakened by the addition of low levels of surfactant. Macroscopic changes in the hydrophobic latex system may be interpreted in terms of bridging flocculation at low polymer concentrations. No adsorption of C₆-L-(EO₁₀₀-L)₉-C₆ is observed in the case of hydrophilic surfaces. In most cases, the observed behaviour of the ternary system (polymer/surfactant/particle) is highly reminiscent of the binary (polymer/surfactant) system at the appropriate composition, suggesting that the polymer/surfactant solution interaction is the dominant one.

Interfacial properties of lipid sponge-like nanoparticles and the role of stabilizer on particle structure and surface interactions

The advantage of using nonlamellar lipid liquid crystalline phases has been demonstrated in many applications, such as drug delivery, protein encapsulation and crystallisation. We have recently reported that a mixture of mono- and diglycerides is able to form sponge-like nanoparticles (L3-NPs) with large enough aqueous pores to encapsulate macromolecules such as proteins. Here we use small angle neutron scattering (SANS) to reveal morphology, structural and chemical composition of these polysorbate 80 (P80) stabilized sponge phase nanoparticles, not previously known. Our results suggest that L3-NPs have a core-shell sphere structure, with a shell rich in P80. It was also found that even if P80 is mostly located on the surface, it also contributes to the formation of the inner sponge phase structure. An important aspect for the application and colloidal stability of these particles is their interfacial properties. Therefore, the interfacial behaviour of the nanoparticles on hydrophilic silica was revealed by Quartz crystal microbalance with dissipation (QCM-D) and neutron reflectivity (NR). Adsorption experiments reveal the formation of a thin lipid layer, with the dimension corresponding to a lipid bilayer after L3-NPs are in contact with hydrophilic silica. This suggests that the diglycerol monoleate/Capmul GMO-50/P80 particles reorganize themselves on this surface, probably due to interactions between P80 head group and SiO2.

Mechanism of E. coli Inactivation by Direct-in-liquid Electrical Discharge Plasma in Low Conductivity Solutions

This work investigates and reveals the main mechanism(s) responsible for inactivation of E. coli by in-liquid pulsed electrical discharge plasma in low conductivity solutions. Experiments were designed and performed to explore the effects of plasma-emitted UV light, oxidative radicals, and electric field on E. coli inactivation curves, rate of DNA leakage and visual appearance of the treated microorganisms. Results showed that electric field had the main role in inactivation; scanning electron microscopy images revealed that both plasma and the isolated electric field result in extensive cell wall disruptions. While this damage in the case of plasma treatment was extensive and distributed randomly along the envelope, the electric field-induced damage resulted in disruption primarily at the poles of the bacterial rods. Subsequent experiments conducted with an oxidative radical scavenger suggested that plasma-generated radicals do not contribute directly to the inactivation but assist in cell wall deterioration and extension of the ruptures first generated by the electric field.

Drugs/lamellae interface influences the inner structure of double-loaded liposomes for inhaled anti-TB therapy: An in-depth small-angle neutron scattering investigation

With the aim of developing new drug carriers for inhalation therapy, we report here an in depth investigation of the structure of multilamellar liposomes loaded with two well-established anti-tubercular (anti-TB) drugs, isoniazid (INH) and rifampicin (RIF), by means of small-angle neutron-scattering (SANS) analysis. Unloaded, single drug-loaded and co-loaded liposomes were prepared using different amounts of drugs and characterized regarding size, encapsulation efficiency and drug release. Detailed information on relevant properties of the investigated host-guest structures, namely the steric bilayer thickness, particle dispersion, number of lamellae and drug localization was studied by SANS. Results showed that RIF-liposomes were less ordered than unloaded liposomes. INH induced a change in the inter-bilayer periodical spacing, while RIF-INH co-loading stabilized the multilamellar liposome architecture, as confirmed by the increment of the drug loading capacity. These findings could be useful for the understanding of in vitro and in vivo behavior of these systems and for the design of new drug carriers, intended for inhaled therapy.