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This study sought to examine the extent to which household income level influences the dropout rate from day secondary schools in Murang'a East Sub-County. This study employed structural strain theory and school dropout and poor family socialization theory and drop outing. The study took pragmatic research philosophy and a descriptive research design to study the phenomena in Murang’a East Sub-County. Using questionnaires, data relating to socio-economic data were collected from about 300 dropouts from Murang’a East Sub-Sub-County who were selected using a convenient and snowballing sampling technique. The research established that the level of household income has a bearing on secondary school dropout from Murang’a East Sub-County. The research concludes that secondary school drop outing has a significant drawback to the educational goals and objectives. Secondary school education continues to be a vital investment despite the challenge of drop out. Most of the students who drop out of secondary schools are social and economic reasons. The study recommends that the government should increase the allocations to the most vulnerable students. Also, the CBOs and NGOs to step in and offer such students the supply of social amenities such as sanitary towels. More efforts should be focused on sensitizing the importance of secondary school education and advocating for child labour to be dealt with fiercely.

Background One of the key strategies to reducing maternal mortality is provision of emergency obstetric care services. This paper describes the results of improving availability of, and access to emergency obstetric care services in underserved rural Tanzania using associate clinicians. Methods A prospective cohort study of emergency obstetric care was implemented in seven health centres in Morogoro region, Tanzania from July 2016 to June 2019. In early 2016, forty-two associate clinicians from five health centres were trained in teams for three months in emergency obstetric care, newborn care and anaesthesia. Two health centres were unexposed to the intervention and served as controls. Following training, virtual teleconsultation, quarterly on-site supportive supervision and continuous mentorship were implemented to reinforce skills and knowledge. Results The met need for emergency obstetric care increased significantly from 45% (459/1025) at baseline (July 2014 – June 2016) to 119% (2010/1691) during the intervention period (Jul 2016 – June 2019). The met need for emergency obstetric care in the control group also increased from 53% (95% CI 49–58%) to 77% (95% CI 74–80%). Forty maternal deaths occurred during the baseline and intervention periods in the control and intervention health centres. The direct obstetric case fatality rate decreased slightly from 1.5% (95% CI 0.6–3.1%) to 1.1% (95% CI 0.7–1.6%) in the intervention group and from 3.3% (95% CI 1.2–7.0%) to 0.8% (95% CI 0.2–1.7%) in the control group. Conclusions When emergency obstetric care services are made available the proportion of obstetric complications treated in the facilities increases. However, the effort to scale up emergency obstetric care services in underserved rural areas should be accompanied by strategies to reinforce skills and the referral system.

Background A distinct serum metabonomic pattern has been previously revealed to be associated with various forms of liver disease. Here, we aimed to apply mass spectrometry to obtain serum metabolomic profiles from individuals with cholangiocarcinoma and benign hepatobiliary diseases to gain an insight into pathogenesis and search for potential early-disease biomarkers. Methods Serum samples were profiled using a hydrophilic interaction liquid chromatography platform, coupled to a mass spectrometer. A total of 47 serum specimens from 8 cholangiocarcinoma cases, 20 healthy controls, 8 benign disease controls (bile duct strictures) and 11 patients with hepatocellular carcinoma (as malignant disease controls) were included. Data analysis was performed using univariate and multivariate statistics. Results The serum metabolome disparities between the metabolite profiles from healthy controls and patients with hepatobiliary disease were predominantly related to changes in lipid and lipid-derived compounds (phospholipids, bile acids and steroids) and amino acid metabolites (phenylalanine). A metabolic pattern indicative of inflammatory response due to cirrhosis and cholestasis was associated with the disease groups. The abundance of phospholipid metabolites was altered in individuals with liver disease, particularly cholangiocarcinoma, but no significant difference was seen between profiles from patients with benign biliary strictures and cholangiocarcinoma. Conclusion The serum metabolome in cholangiocarcinoma exhibited changes in metabolites related to inflammation, altered energy production and phospholipid metabolism. This study serves to highlight future avenues for biomarker research in large-scale studies.

Tanzania has a goat population of about 24.8 million most of which belong to the Small East African breed distributed in almost all agro-ecological zones. The different goat populations and the production system in which they are raised are not well characterized depriving animal breeders useful information in designing and running improvement and conservation programs. Therefore, the study was conducted in all agro-ecological zones in Tanzania to characterize the indigenous goats and the production system in which they are raised. Data on animals were collected from 688 randomly selected adult female goats and for production system description; 220 households were interviewed. Analysis of variance and discriminant analysis were used on quantitative data, while frequency analysis was used on qualitative data. Income generation and meat production were the primary goat rearing objectives. More than 55% of respondents grazed their animals freely in communal lands where natural pasture was the chief feed resource. Mating was mainly uncontrolled with apron and castration being used by goat keepers as mating control methods. Common diseases were contagious caprine pleural pneumonia and helminthiasis. Feed shortage, prevalence of diseases, and water scarcity were the major goat production constraints. There were morphological variations between and within these goat populations, and based on quantitative data, the goats were categorized into two groups. High twinning was observed in Ujiji and Lindi goats and low for Sukuma. The dominant coat color was plain white in Pare, Gogo, Maasai, and Tanga. Other coat color patterns were mixed black and white for Sukuma, reddish-brown for Lindi, black and reddish-brown for Ujiji, and white and reddish-brown for Pwani and Maasai. High within population variation is observed which is important as it can be used as a basis for genetic improvement through selection.

Background Strengthening leadership and management is important for building an effective and efficient health system. This paper presents the findings from a L&M capacity building initiative which was implemented as part of a larger study aimed at improving maternal and newborn outcomes within primary health facilities in the Morogoro, Tanzania. Methods The initiative, involving 30 stakeholders from 20 primary health facilities, 4 council health management teams and the regional health management team in the Morogoro region, provided leadership and managerial training through two 5-day in-person workshops, onsite mentoring, and e-learning modules. The initiative was evaluated using a pre-post design. Quantitative instruments included the ‘Big Results Now’ star-rating assessments and a team-developed survey for health providers/managers. The ‘Big Results Now’ star-rating assessments, conducted in 2018 (19 facilities) and 2021 (20 facilities), measured overall facility leadership and management capability, with comparisons of star-ratings from the two time-points providing indication of improvement. The survey was used to measure 3 key leadership indicators - team climate, role clarity/conflict and job satisfaction. The survey was completed by 97 respondents at baseline and 100 at follow up. Paired t-tests were used to examine mean score differences for each indicator. Triangulated findings from focus groups with 99 health providers and health management team members provided support and context for quantitative findings. Results Star-ratings increased in 15 (79%) of 19 facilities, with the number of facilities achieving the target of 3 plus stars increasing from 2 (10%) in 2018 to 10 (50%) in 2021, indicating improved organizational performance. From the survey, team climate, job satisfaction and role clarity improved across the facilities over the 3 project years. Focus group discussions related this improvement to the leadership and managerial capacity-building. Conclusion Improved leadership and managerial capacity in the participating health facilities and enhanced communication between the health facility, council and regional health management teams created a more supportive workplace environment, leading to enhanced teamwork, job satisfaction, productivity, and improved services for mothers and newborns. Leadership and managerial training at all levels is important for ensuring efficient and effective health service provision.

Background Phenotypic diversity in urinary metabolomes of different geographical populations has been recognized recently. In this study, urinary metabolic signatures from Western (United Kingdom) and South-East Asian (Thai) cholangiocarcinoma patients were characterized to understand spectral variability due to host carcinogenic processes and/or exogenous differences (nutritional, environmental and pharmaceutical). Methods Urinary liquid chromatography mass spectroscopy (LC-MS) spectral profiles from Thai (healthy=20 and cholangiocarcinoma=14) and UK cohorts (healthy=22 and cholangiocarcinoma=10) were obtained and modelled using chemometric data analysis. Results Healthy metabolome disparities between the two distinct populations were primarily related to differences in dietary practices and body composition. Metabolites excreted due to drug treatment were dominant in urine specimens from cholangiocarcinoma patients, particularly in Western individuals. Urine from participants with sporadic (UK) cholangiocarcinoma contained greater levels of a nucleotide metabolite (uridine/pseudouridine). Higher relative concentrations of 7-methylguanine were observed in urine specimens from Thai cholangiocarcinoma patients. The urinary excretion of hippurate and methyladenine (gut microbial-host co-metabolites) showed a similar pattern of lower levels in patients with malignant biliary tumours from both countries. Conclusion Intrinsic (body weight and body composition) and extrinsic (xenobiotic metabolism) factors were the main causes of disparities between the two populations. Regardless of the underlying aetiology, biological perturbations associated with cholangiocarcinoma urine metabolome signatures appeared to be influenced by gut microbial community metabolism. Dysregulation in nucleotide metabolism was associated with sporadic cholangiocarcinoma, possibly indicating differences in mitochondrial energy production pathways between cholangiocarcinoma tumour subtypes. Mapping population-specific metabolic disparities may aid in interpretation of disease processes and identification of candidate biomarkers.

BackgroundIn 2017, roughly 540 women in Sub-Saharan Africa died every day from preventable causes related to pregnancy and childbirth. To stem this public-health crisis, the WHO recommends a standard continuity of maternal healthcare, yet most women do not receive this care. Surveys suggest that illiteracy limits the uptake of the recommended care, yet little is understood about why this is so. This gap in understanding why healthcare is not sought by illiterate women compromises the ability of public health experts and healthcare providers to provide culturally relevant policy and practice. This study consequently explores the lived experiences related to care-seeking by illiterate women of reproductive age in rural Tanzania to determine why they may not access maternal healthcare services.MethodsAn exploratory, qualitative study was conducted in four communities encompassing eight focus group discussions with 81 illiterate women, 13 in-depth interviews with illiterate women and seven key-informant interviews with members of these communities who have first-hand experience with the decisions made by women concerning maternal care. Interviews were conducted in the informant’s native language. The interviews were coded, then triangulated.ResultsTwo themes emerged from the analysis: 1) a communication gap arising from a) the women’s inability to read public-health documents provided by health facilities, and b) healthcare providers speaking a language, Swahili, that these women do not understand, and 2) a dependency by these women on family and neighbors to negotiate these barriers. Notably, these women understood of the potential benefits of maternal healthcare.ConclusionsThese women knew they should receive maternal healthcare but could neither read the public-health messaging provided by the clinics nor understand the language of the healthcare providers. More health needs of this group could be met by developing a protocol for healthcare providers to determine who is illiterate, providing translation services for those unable to speak Swahili, and graphic public health messaging that does not require literacy. A failure to address the needs of this at-risk group will likely mean that they will continue to experience barriers to obtaining maternal care with detrimental health outcomes for both mothers and newborns.

Introduction In Tanzania, inadequate access to comprehensive emergency obstetric and newborn care (CEmONC) services is the major bottleneck for perinatal care and results in high maternal and perinatal mortality. From 2015 to 2019, the Accessing Safe Deliveries in Tanzania project was implemented to study how to improve access to CEmONC services in underserved rural areas. Methods A five-year longitudinal cohort study was implemented in seven health centres (HCs) and 21 satellite dispensaries in Morogoro region. Five of the health centres received CEmONC interventions and two served as controls. Forty-two associate clinicians from the intervention HCs were trained in teams for three months in CEmONC and anaesthesia. Managers of 20 intervention facilities, members of the district and regional health management teams were trained in leadership and management. Regular supportive supervision was conducted. Results Interventions resulted in improved responsibility and accountability among managers. In intervention HCs, the mean monthly deliveries increased from 183 (95% CI 174–191) at baseline (July 2014 –June 2016) to 358 (95% CI 328–390) during the intervention period (July 2016 –June 2019). The referral rate to district hospitals in intervention HCs decreased from 6.0% (262/4,392) with 95% CI 5.3–6.7 at baseline to 4.0% (516/12,918) with 95% CI 3.7–4.3 during the intervention period while it increased in the control group from 0.8% (48/5,709) to 1.5% (168/11,233). The obstetric case fatality rate decreased slightly from 1.5% (95% CI 0.6–3.1) at baseline to 1.1% (95% CI 0.7–1.6) during the intervention period (not statistically significant). Active engagement strategies and training in leadership and management resulted in uptake and improvement of CEmONC and anaesthesia curricula, and contributed to scale up of CEmONC at health centre level in the country. Conclusions Integration of leadership and managerial capacity building, with CEmONC-specific interventions was associated with health systems strengthening and improved quality of services.

Background: In 2017, an estimated 540 women in Sub-Saharan Africa died every day from preventable causes related to pregnancy and childbirth. To stem this public-health crisis, the WHO recommends a maternal and neonatal health continuity of patient care, yet most women do not meet this recommendation. Surveys suggest that illiteracy limits uptake of the proposed maternal-newborn package, yet little is known about the association between illiteracy and healthcare seeking, particularly in rural regions of low-income countries. This knowledge gap compromises the ability of public health experts and healthcare providers to provide culturally relevant policy and practice. To begin to address this gap this study explores the experiences related to care-seeking by illiterate, pregnant women in rural Tanzania.Methods: A qualitative study was conducted in four communities encompassing eight focus group discussions with 81 illiterate women, 13 interviews with illiterate women of reproductive age and seven interviews with members of these communities perceived to have some influence on women’s decisions concerning perinatal care services. Themes were coded and their relative importance determined using frequency reports and cross-tabulations. Findings: Three key themes emerged, illiterate women (1) could not read their healthcare cards or public health messaging; (2) spoke the local language, not Swahili, the language used by healthcare providers, and (3) have endeavored to develop coping strategies to overcome these obstacles. In addition, health service providers are often unaware of who is illiterate.Recommendations: More health needs of this group could be met, in the short term, by developing a protocol for health service providers to determine who is illiterate, providing translation services for those unable to speak Swahili, and graphic public health messaging that does not require literacy. In the long term, this barrier may be addressed by ensuring that all Tanzanians receive a high-quality, formal education, supporting community health workers, and recruiting healthcare providers from rural areas. A failure of to address the needs of this at-risk group will likely mean that they will continue to experience barriers to achieving the recommended continuity of patient care with detrimental health outcomes for both mothers and newborns.

BACKGROUND While the effectiveness of Helping Babies Breathe (HBB) training in Tanzania has been reported, no published studies of Essential Care for Every Baby (ECEB) and Essential Care for Small Babies (ECSB) in this setting have been found. This study compared knowledge before and after HBB, ECEB and ECSB training in Tanzania. METHODS Training was provided to future facilitators (n=16) and learners (n=24) in Tanzania. Using standardized multiple-choice questions, knowledge was assessed pre- and post-HBB and ECEB courses for both learners and facilitators, while ECSB assessment was conducted with facilitators only. A >80% score was considered to be a pass. Paired t-tests were used for hypothesis testing. RESULTS Knowledge significantly improved for both facilitators and learners on HBB and ECEB (p

BACKGROUND Liver volume (LV) can be non-invasively determined from the analysis of computed tomography (CT) images, and in patients with acute liver injury (ALI) or failure (ALF), it can reflect the balance of structural collapse with hepatic regeneration. We examined its relation to cause of liver injury, measures of liver function and histopathological findings, and utility in prediction of complications and mortality. METHODS Two hundred and seventy-three patients with ALF/ALI admitted to a specialist intensive care unit were studied. One hundred and ninety-nine patients (73%) had non-acetaminophen (NA) aetiologies and 74 (27%) had acetaminophen-induced disease. LV and proportion of predicted LV (PLV%) were determined from admission CT imaging. RESULTS LV and PLV% showed marked variation when aetiologic groups were compared (P

Production and consumption of charcoal play a significant role in enhancing the livelihoods of people in Tanzania but may also lead to adverse environmental impacts. In this chapter, a review is presented of studies of charcoal production and consumption in Tanzania, and promising new research tasks are identified. Many interesting and valuable studies have been done, and it is clearly seen how important charcoal consumption and production are in a social, ecological, and economic perspectives. However, many of the reviewed studies lack clear hypotheses and specifications of behavior theories to be used for developing realistic and testable hypotheses. More research is needed on factors effecting charcoal demand – like changes in prices, income, and policies – and for that, using national household surveys is recommended. More research is needed also about tree regeneration (time and volumes) in miombo woodlands; how various forms of land ownerships influence miombo woodlands management; the possibilities and preferability in Tanzania of establishing forest plantations for producing charcoal; total and distributional impacts of policies; GHG impacts of charcoal production and consumption; and the development of bio-economic models which make possible consistent analyses of ex ante defined interesting changes from the present economic and policy situation.

Background and aims Understanding of the significant genetic risk factors for Cholangiocarcinoma (CC) remains limited. Polymorphisms in the natural killer cell receptor G2D (NKG2D) gene have been shown to increase risk of CC transformation in patients with Primary Sclerosing Cholangitis (PSC). We present a validation study of NKG2D polymorphisms in CC patients without PSC. Methods Seven common Single Nucleotide Polymorphisms (SNPs) of the NKG2D gene were genotyped in 164 non-PSC related CC subjects and 257 controls with HaploView. The two SNPs that were positively identified in the previous Scandinavian study, rs11053781 and rs2617167, were included. Results The seven genotyped SNPs were not associated with risk of CC. Furthermore, haplotype analysis revealed that there was no evidence to suggest that any haplotype differs in frequency between cases and controls (P > 0.1). Conclusion The common genetic variation in NKG2D does not correlate significantly with sporadic CC risk. This is in contrast to the previous positive findings in the Scandinavian study with PSC-patients. The failure to reproduce the association may reflect an important difference between the pathogenesis of sporadic CC and that of PSC-related CC. Given that genetic susceptibility is likely to be multifaceted and complex, further validation studies that include both sporadic and PSC-related CC are required.

Cholangiocarcinoma is a fatal cancer of the biliary epithelium and has an incidence that is increasing worldwide. Survival beyond a year of diagnosis is less than 5%, and therapeutic options are few. Known risk factors include biliary diseases such as primary sclerosing cholangitis and parasitic infestation of the biliary tree, but most cases are not associated with any of these underlying diseases. Numerous in vitro and in vivo models, as well as novel analytical techniques for human samples, are helping to delineate the many pathways implicated in this disease, albeit at a frustratingly slow pace. As yet, however, none of these studies has been translated into improved patient outcome and, overall, the pathophysiology of cholangiocarcinoma is still poorly understood. There remains an urgent need for new approaches and models to improve management of this insidious and devastating disease. In this review, we take a bedside-to-bench approach to discussing cholangiocarcinoma and outline research opportunities for the future in this field.

Accurate differentiation between benign and malignant causes of biliary obstruction remains challenging and reliable biomarkers are urgently needed. Bile is a potential source of such biomarkers. Our aim was to apply a proteomic approach to identify a potential biomarker in bile that differentiates between malignant and benign disease, and to assess its diagnostic accuracy. Neutrophil gelatinase-associated lipocalin (NGAL) is multi-functional protein, released from activated neutrophils, with roles in inflammation, immune function, and carcinogenesis. It has not previously been described in bile.Bile, urine, and serum were collected prospectively from 38 patients undergoing endoscopic retrograde cholangiopancreatography ("discovery" cohort); 22 had benign and 16 had malignant pancreatobiliary disease. Initially, label-free proteomics and immunoblotting were performed in samples from a subset of these patients. Enzyme-linked immunosorbent assay was then performed for NGAL as a potential biomarker on all samples in this cohort. The diagnostic performance of biliary NGAL was then validated in a second, independent group ("validation" cohort) of 21 patients with pancreatobiliary disease (benign n=14, malignant n=7).NGAL levels were significantly raised in bile from the malignant disease group, compared with bile from the benign disease group in the discovery cohort (median 1,556 vs. 480 ng/ml, P=0.007). Biliary NGAL levels had a receiver operating characteristic area under curve of 0.76, sensitivity 94%, specificity 55%, positive predictive value 60%, and negative predictive value 92% for distinguishing malignant from benign causes. Biliary NGAL was independent of serum biochemistry and carbohydrate antigen 19-9 (CA 19-9) in differentiating between underlying benign and malignant disease. No significant differences in serum and urine NGAL levels were found between benign and malignant disease. Combining biliary NGAL and serum CA 19-9 improved diagnostic accuracy for malignancy (sensitivity 85%, specificity 82%, positive predictive value 79%, and negative predictive value 87%). The diagnostic accuracy of biliary NGAL was confirmed in the second independent validation cohort.NGAL in bile is a novel potential biomarker to help distinguish benign from malignant biliary obstruction.

Background The currently available tumour markers used in the management of patients with colorectal metastases are of limited value. Tumour M2-pyruvate kinase (TuM2-PK), a tumour-associated isoenzyme of pyruvate kinase, is elevated in patients with gastrointestinal cancer. This study has measured TuIVI2-PK levels in patients before and after resection of colorectal liver metastases (CLM).Materials and methods Fifty patients with CLM and no local residual disease had TuM2-PK levels measured before liver resection. In 20 patients, TuM2-PK levels were repeated at 2 weeks, 5 weeks and 5 months after resection. Plasma levels were analysed by enzyme-linked immunosorbent assay (ScheBo, Giessen, Germany). Carcinoembryonic antigen (CEA) and CA19-9 levels were measured at the same time periods by electrochemiluminescence immunoassay. CEA, CA19-9 and TuM2-PK levels were compared with the tumour number, volume, differentiation and stage. Cut-off values used for TuM2-PK, CEA and CA19-9 were 15 IU/ml, 10 ng/ml and 391 U/ml, respectively.Results TuM2-PK was elevated in 68%, CEA in 62% and CA19-9 in 40% of patients with CLM. TuM2-PK+CEA was elevated in 88% and TuM2-PK + CA19-9 in 78% of patients. A significant correlation was observed between tumour volume and CEA (r= 0.34, P< 0.05) and CA19-9 (r= 0.49, P

Summary Background Chronic biochemical cholestasis has been shown to be associated with a fivefold increase in histologically advanced liver disease in patients receiving home parenteral nutrition. Aims To investigate prevalence of chronic biochemical cholestasis in home parenteral nutrition patients and examine factors influencing its occurrence. Methods Records of all patients receiving home parenteral nutrition for >6 months treated at a single centre were reviewed and plasma biochemistry recorded. Logistic regression analysis was employed to identify factors associated with prevalence of chronic biochemical cholestasis. Results Records of 113 patients were reviewed. The point prevalence of chronic biochemical cholestasis was 24%, increasing to 28% if patients receiving parenteral fluid and electrolytes only were excluded. In multivariate analysis, presence of colon in continuity was associated with a significantly lower prevalence of chronic biochemical cholestasis, while total parenteral calorie intake was associated with a higher prevalence of chronic biochemical cholestasis. No association was seen between small intestinal lengths or between parenteral lipid intake and chronic biochemical cholestasis in multivariate analysis. Conclusions Chronic biochemical cholestasis is common in patients receiving home parenteral nutrition. High parenteral calorie intake and lack of a colon in continuity with small intestine are independently associated with an increased risk of chronic biochemical cholestasis.

The gas transport, triboelectrostatic beneficiation of coal combustion fly ash into carbon-rich and ash-rich products was studied relative to the effect of ash surface moisture. Increasing the humidity to which the ashes from American and Italian coal-fired utilities were exposed under process and ambient conditions affected carbon and ash separability. The effect of humidity and particle surface moisture became more important as particle size decreased: particles greater than 75 μm in diameter were nearly unaffected whereas particles smaller than 45 μm experienced up to a four-fold change in their separability upon changing their surface moisture contents. Although particle size influences the moisture adsorption, which in turn affects tribocharging, the decrease in adhesive forces between carbon and ash from otherwise intractable clusters during drying also may be a factor influencing triboelectrostatic beneficiation performance.

This review will discuss the immediate- and long-term success, complications and overall benefits of self-expandable metal stents (SEMSs) in malignant or benign obstruction of the oesophagus, stomach and duodenum. Over recent years, indications such as benign disease have expanded, as has SEMS diversity with self-expandable plastic stents (SEPSs) or fully covered and biodegradable stents, for example.SEMSs have been increasingly used in malignant upper gastrointestinal obstruction with many reports confirming efficacy, despite a significant complication rate. Fully covered stents are increasingly used for a variety of benign oesophageal disease, but their place in gastric outlet obstruction is still unclear. Covered and uncovered stents have different functional characteristics and stent type must be selected on an individual basis. Biodegradable stents show promise and the outcome of experience in larger patient cohorts is eagerly awaited.This area is an evolving field, in which the clinician requires up-to-date knowledge of therapeutic options to make individualized treatment choices in difficult clinical circumstances. Technical and clinical success for oesophageal or gastroduodenal SEMSs are then above 90%. Minor complications are common, but serious complications seldom occur. Biodegradable stents may be useful, especially when stenting is needed for a short period of time.

Chronic biochemical cholestasis has been shown to be associated with a fivefold increase in histologically advanced liver disease in patients receiving home parenteral nutrition.To investigate prevalence of chronic biochemical cholestasis in home parenteral nutrition patients and examine factors influencing its occurrence.Records of all patients receiving home parenteral nutrition for6 months treated at a single centre were reviewed and plasma biochemistry recorded. Logistic regression analysis was employed to identify factors associated with prevalence of chronic biochemical cholestasis.Records of 113 patients were reviewed. The point prevalence of chronic biochemical cholestasis was 24%, increasing to 28% if patients receiving parenteral fluid and electrolytes only were excluded. In multivariate analysis, presence of colon in continuity was associated with a significantly lower prevalence of chronic biochemical cholestasis, while total parenteral calorie intake was associated with a higher prevalence of chronic biochemical cholestasis. No association was seen between small intestinal lengths or between parenteral lipid intake and chronic biochemical cholestasis in multivariate analysis.Chronic biochemical cholestasis is common in patients receiving home parenteral nutrition. High parenteral calorie intake and lack of a colon in continuity with small intestine are independently associated with an increased risk of chronic biochemical cholestasis.

Introduction Pancreatobiliary malignancies are amongst the commonest causes of cancer-related death worldwide and usually present with biliary obstruction. Accurate differentiation between benign and malignant causes of obstruction is likely to improve outcome in pancreatobiliary disease and reliable biomarkers are urgently needed. Bile is a potential source of such biomarkers due to its anatomical proximity to the site of pathology. Our aim was to apply a proteomic approach to identify potential biomarkers in bile which could differentiate between malignant and benign disease. Methods Bile, urine and serum were collected prospectively from 59 patients undergoing ERCP (endoscopic retrograde cholangiopancreatography) for benign (n = 36) or malignant (n = 23) pancreatobiliary disease at our centre. Initially, label-free proteomics and immunoblotting were performed in a sub-set of patients. Candidate biomarkers were selected on the basis of increased abundance of peptide fragments, and immunoblotting performed on an expanded cohort. ELISA was then performed for our potential biomarker on all samples in bile, blood and urine. Results Neutrophil gelatinase associated lipocalin (NGAL) levels were significantly raised in bile from the malignant disease group, compared to bile from the benign disease group (median 1839 ng/mL vs 472 ng/mL, p Conclusion NGAL in bile is a novel potential biomarker to distinguish benign from malignant biliary obstruction, particularly in combination with serum tumour markers.

Introduction Sporadic cholangiocarcinoma (CC) occurs in subjects with no known risk factor for the disease. Its pathogenesis is likely to involve complex interaction of environmental and human factors, including genetic variation. Polymorphisms in natural killer cell receptor protein G2D (NKG2D) have been associated CC in subjects with primary sclerosing cholangitis (PSC). In a recent study, comparing 49 subjects with CC to 316 subjects with PSC and no CC, two single nucleotide polymorphisms (SNPs) in NKG2D were associated with an increased risk of CC: rs11053781 (OR 2.08, p value 0.011) and rs2617167 (OR 2.32, p value 0.0020). We aimed to test whether variation in NKG2D also modifies susceptibility to sporadic CC. Methods DNA was collected from 172 subjects with sporadic CC and a matched control cohort of 256. Haploview v 4.2 was used to select SNPs capturing common genetic variation around the NKG2D gene (MAF >0.05, pair-wise comparisons). This identified 7 SNPs to be genotyped, including rs11053781 and rs2617167. Genotyping was performed with a PCR based, robotic system. Hardy–Weinberg equilibrium testing, Armitage trend testing and haplotype frequency comparisons were undertaken. Correction for multiple testing was performed using a permutation method. Results All genotypes were in Hardy–Weinberg equilibrium. None of the individual SNPs were significantly associated with altered susceptibility to CC. Haplotype analysis revealed that no haplotypes significantly modified risk of CC. Conclusion This is the first study to examine NKG2D polymorphisms in sporadic CC. The study was well powered. We found no relationship between variation in NKG2D and susceptibility to CC, in contrast to prior findings in PSC patients with CC. This finding may reflect an important difference between the pathogenesis of sporadic CC and that of PSC related CC. It might point to a false-positive result in the prior study of PSC related CC, but it was well executed and produced strong, positive results. This could be elucidated in an additional candidate-gene validation study. However, with increasing availability and affordability, a genome wide association study (GWAS) may prove a more efficient method for further exploring genetic factors in cholangiocarcinoma.

Introduction MicroRNAs (miRNAs) are short, non-coding RNAs with a key role in post-transcriptional regulation, and regulate multiple pathways of tumorogenesis. Expression profiling of malignant cell lines, fresh and formalin-fixed tumour have identified potential miRNA signatures for pancreatic ductal adenocarcinoma (PDAC), and RNA deep sequencing has demonstrated that miRNAs can be quantified from bile, in bilary tract cancers 1 . Here, we report the first study of biliary miRNAs in PDAC. Methods 3 target miRNAs known to be overexpressed in PDAC were selected. Bile was collected at endoscopic retrograde cholangiopancreatography (ERCP) from patients with PDAC (n = 10) or gallstones (n = 8; used as a benign control). Bile was prepared as described1 and total RNA isolated using TRIzol (Invitrogen, Paisley, UK). Quantitative real-time reverse-transcription polymerase chain reaction (RT-qPCR) was performed using Taqman mature miRNA primers and probes (Applied Biosystems, Cheshire, UK). Expression of oncomiR-21, miR-155 and miR-106a was measured. Cycle passing threshold (Ct) was recorded and normalised to RNU6B expression. Relative expression was calculated as 2Ct_miRNA-Ct_RNU6B. PCR reactions were carried out in duplicate. Results miR-106a and oncomiR-21 were both highly expressed in the bile of patients with PDAC, compared to those with gallstones. miR-155 was not significantly upregulated in PDAC bile. Using miR-106a (cut-off level > 8.02), we discriminated PDAC from benign disease with a sensitivity and specificity of 80% [95% CI 44–98] and 100% [95% CI 63–100], respectively with an area under the curve (AUC) value of 0.88. OncomiR-21 was also upregulated in bile, but was not as reliable in discriminating diagnosis. Conclusion This study demonstrates that bile miRNAs are well-suited analytes for the development of sensitive and specific tests in PDAC. Although tumour breach of the biliary epithelium was not always suspected in our cohort from clinical investigations, malignancy-specific miRNAs were found intraluminally. Of the 3 miRNAs tested, ROC analysis identified miR-106a as the best potential PDAC biomarker, with reliable diagnostic specificity and sensitivity. However, further study may also identify miRNAs that also discriminate prognoses and response to therapy, guiding individualised treatment. Disclosure of Interest None Declared Reference Shigehara K, Yokomuro S, Ishibashi O, et al. Real-time PCR-based analysis of the human bile microRNAome identifies miR-9 as a potential diagnostic biomarker for biliary tract cancer. PloS one. 2011; 6(8):e23584.

Introduction Cholangiocarcinoma (CCA) is a primary biliary ductal cancer which is often difficult to diagnose and which carries a poor prognosis. New diagnostic tests are urgently needed to improve patient outcome. Bile is a rich source of potential novel biomarkers for CCA, due to its intimate proximity to the malignant lesion. However, there are no biliary biomarkers for CCA currently available. MicroRNAs (miRNAs) are key post-transcriptional regulators, and influence tumorogenesis. Studies on cell lines and tissue have identified several potential miRNA signatures for CCA, and recently miR-9 was identified as elevated in bile from CCA compared with benign disease 1 . In this study we aimed to measure specific miRNA expression in bile from patients with CCA, gallstone disease and pancreatic adenocarcinoma (PA) and to assess their performance in differentiating these causes of biliary obstruction. Methods Bile was collected at endoscopic retrograde cholangiopancreatography (ERCP) from patients with CCA (n = 6), PA (n = 10) and gallstones (n = 8; benign control). Bile was prepared as previously described1 and total RNA was isolated using TRIzol (Invitrogen, Paisley, UK). Quantitative real-time reverse-transcription polymerase chain reaction (RT-qPCR) was performed using Taqman mature miRNA primers and probes (Applied Biosystems, Cheshire, UK). Expression of oncomiR-21, miR-155 and miR-106a was measured. Cycle passing threshold (Ct) was recorded and normalised to RNU6B expression. Relative expression was calculated as 2Ct_miRNA-Ct_RNU6B. PCR reactions were carried out in duplicate. Results MiR-106a and oncomiR-21 were highly expressed in bile from patients with CCA compared to those with gallstones. MiR-155 was not significantly upregulated in malignancy. In discriminating CCA from benign disease, miR-106a had sensitivity and specificity of 83.3% [95% CI 36–100] and 88% [95% CI 47–100] respectively, with an AUC of 0.83 (cut-off level > 6.05). OncomiR-21 was also upregulated in the bile of both tumour types, but was not as reliable. Neither miRNA discriminated significantly between PA and CCA. Conclusion MiRNA can be reliably isolated from bile pellets. Both miR-106a and oncomiR-21 are potential novel biliary biomarkers for CCA, and could improve differentiation of benign from malignant disease at ERCP. Further work is required to validate these findings in a larger cohort and against other disease groups, and to investigate possible correlations between miRNA profile and disease course. Disclosure of Interest None Declared Reference Shigehara K, Yokomuro S, Ishibashi O, et al. Real-time PCR-based analysis of the human bile microRNAome identifies miR-9 as a potential diagnostic biomarker for biliary tract cancer. PloS one . 2011; 6(8):e23584.

Introduction Cholangiocarcinoma (CC) is a malignant neoplasm of the bile duct. Diagnosis of CC is hampered by the inadequate performance of current plasma markers of disease, particularly in patients with preexisting primary sclerosing cholangitis (PSC). We aimed to identify potential new protein biomarkers of CC Methods In an initial discovery study, blood plasma samples from 18 subjects with CC, 17 with PSC and 10 healthy controls were subjected to SELDI-TOF MS. Comparisons of m/z peak intensity were made between groups using the Mann-Whitney U test. Differentiating m/z peaks were then confirmed in a further validation study of 81 subjects with CC, 54 with PSC and 90 healthy controls. Pearson´s correlation was used to investigate the relationship of each m/z peak´s intensity to routine laboratory indices. Diagnostic performance was investigated using receiver operator characteristic area-under-the curve (ROC-AUC) analyses. Multiple linear regression was used to investigate the performance of combinations of differentiating m/z peaks, as well as the combination of m/z peaks with routine laboratory markers (including CA19–9). Results Seven differentially expressed m/z peaks were identified in the CC group and these were subsequently confirmed in the validation study (p = 2.6 × 10–4 to 9.4 × 10–13). The intensity of the seven m/z peaks of interest did not correlate with creatinine, ALP, bilirubin, CRP, white cell count or CA19–9. A panel of three peaks discriminated CC from PSC subjects with ROC-AUC of 0.76 (sensitivity 75%, specificity 64%). A panel of five peaks discriminated CC subjects from healthy controls with ROC-AUC of 0.90 (sensitivity 95%, specificity 74%). Addition of routine laboratory indices did not change the diagnostic performance of these models significantly. Conclusion SELDI-TOF has been used to successfully identify seven m/z peaks that are differentially intense in CC subjects (total n = 99), when compared to PSC subjects (n = 64) and healthy controls (n = 107). These peaks appear to be independent of standard markers of renal impairment, cholestasis, sepsis and inflammation, as well as CA19–9. Individually, and more so in combination, these peaks exceed the expected diagnostic performance of CA19–9, particularly in discriminating CC from PSC. Work to identify the proteins represented by these m/z peaks is ongoing. Disclosure of Interest None Declared

Introduction Better biomarkers are urgently needed to assist accurate diagnosis and appropriate treatment of malignant biliary obstruction, as, although malignancy is a common cause of obstructive jaundice, current diagnostic techniques often fail to differentiate benign from malignant disease. Molecular analysis of bile has recently produced promising candidate biomarkers. Previous work from our group found that biliary neutrophil gelatinase-associated lipocalin (NGAL), a small extracellular 25-kDa protein with several biological functions, differentiates obstructive jaundice from malignancy from that in benign disease. The mechanism of NGAL in hepatopancreatobiliary (HPB) malignancy is unknown, although in other systems it promotes neoplastic diffusion by complexing and stabilising matrix metalloproteinase-9 (MMP9), enabling local invasion. Aims (1) To investigate possible biliary complexing of MMP9 and NGAL as a mechanism of tumorigenesis. (2) To validate our previous findings of biliary NGAL as a novel biomarker of malignancy in biliary obstruction. Methods Bile samples were collected from 77 patients undergoing ERCP (n=77, 22 with malignant disease and 55 with benign disease) at Imperial College London. ELISA was used to quantify levels of MMP9/NGAL complexes and of NGAL and MMP9 occurring independently in bile. Pearson9s correlation analysis was used to determine the relationship between NGAL, MMP9 and NGAL/MMP9 complex levels, and statistical significance assessed by the Mann–Whitney U test. Results Biliary NGAL levels were significantly higher in malignant biliary obstruction compared to benign disease (median 1555 ng/ml vs 402 ng/ml, p=0.003), giving a ROC AUC of 0.74. Biliary MMP9 and NGAL/MMP9 complex levels were not different between these groups (p=0.527, p=0.760). Unbound biliary NGAL and MMP9 levels correlated poorly (r 2 =0.03, p>0.05). Unbound NGAL correlated poorly with complex (r 2 =0.07, p>0.05) whereas unbound MMP9 correlated with NGAL/MMP9 complex level (r 2 =0.73, p Conclusion This study is novel in confirming the presence of MMP9 in bile, alone and in complex with NGAL. However, although NGAL was increased in malignancy, MMP9 and MMP9/NGAL complex were not, suggesting that NGAL acts independently of MMP9 in endobiliary HPB malignancy. Mechanisms remain to be elucidated. This study also supports previous reports of NGAL as a novel and independent bile biomarker of malignant biliary obstruction. Competing interests None declared.

Introduction We have previously demonstrated that the level of neutrophil gelatinase-associated lipocalin (NGAL) is increased in the bile of patients with pancreatobiliary malignancy. NGAL is expressed by activated neutrophils and many other cell types and is thought to have bacteriostatic, pro-proliferative and pro-metastatic functions. NGAL can be detected in the blood plasma. We hypothesised that the plasma NGAL level is elevated in patients with cholangiocarcinoma (CC) compared with patients with primary sclerosing cholangitis (PSC), and with healthy volunteers. Methods Plasma samples were collected from 97 patients with confirmed CC, 62 patients with PSC and no CC and 82 healthy controls. Plasma NGAL quantification was performed in duplicate on plasma from each subject using a Quantikine ELISA kit (R&D Systems, Minneapolis, Minnesota, USA). CC and healthy control cohorts were compared using the Student t test and receiver operator characteristic (ROC) analysis. Differences between CC and PSC cohorts were then sought. Pearson9s correlation analysis was used to assess relationships between the levels of NGAL and other plasma markers. Results Median NGAL concentrations (range) in CC, PSC and healthy controls were 92 ng/ml (14–644), 83 (43–171) and 64 (29–132) respectively. NGAL levels were significantly higher in plasma from CC patients compared with healthy controls (p 2 =0.14), white cell count (r 2 =0.09), bilirubin (r 2 =0.01), ALP (r 2 =0.02) or creatinine (r 2 =0.03). There was moderate correlation between NGAL and Ca19-9 concentrations (r 2 =0.38). Conclusion NGAL is expressed at significantly higher concentrations in the plasma of patients with CC compared to plasma from healthy controls and from subjects with PSC. This finding appears to be independent of renal impairment, cholestasis or systemic inflammatory response, suggesting that NGAL may represent a novel plasma biomarker of CC. Competing interests None declared.

Introduction Obstruction of the biliary tree has a variety of aetiologies. The correct diagnosis is crucial for appropriate definitive therapy. A major differential diagnosis of biliary obstruction is pancreatic adenocarcinoma (PA). PA is the 10th most common cancer in the UK with mortality similar to incidence. Diagnosis of PA relies on a combination of cross-sectional imaging and serum biomarkers, but only a minority of cases are diagnosed correctly and early enough for curative resection. Earlier diagnostic certainty would be likely to improve outcome and guide therapeutic strategy. Proteomic profiling is a promising technique for new biomarker discovery, but has rarely been successfully carried out in human bile. This project (1) analyses and compares the proteomes of bile from PA patients vs. bile from patients with benign biliary disease and (2) seeks to identify potential protein biomarkers that can differentiate PA from benign biliary disease. Methods Bile was aspirated at ERCP from patients with benign or malignant biliary obstruction. Particulate matter was removed by centrifugation and equal volumes subjected to SDS-PAGE. In-gel trypsin digestion was performed and the resulting peptides analysed by tandem mass spectrometry. Proteins were identified using SEQUEST to search the human RefSeq protein sequence database. Progenesis software was used to compare relative levels of proteins between patient groups. Results Proteomic analysis of bile from four patients with PA and four with benign biliary obstruction was performed. Over 100 different proteins were identified, including pancreatic gastric triacylglycerol lipase, carboxypeptidase B and bile salt-activated lipase, confirming that the profile of proteins represents the biliary proteome. Several differentially expressed proteins were identified including upregulation of carcinoembryonic antigen–related cell adhesion molecule 6 (CEACAM6) in the malignant group. Conclusion This work confirms that bile is amenable to proteomic analysis and that differences in the biliary proteome can be detected in malignant and non-malignant cases. We confirmed earlier reports of CEACAM6 overexpression in PA. We are currently analysing the data further to identify additional candidate biomarker proteins. Future work will extend this approach to the study of bile in other diseases, such as cholangiocarcinoma.

Additional file 4: Appendix 4 KII Guide.

Additional file 3: Appendix 3 IDI Guide.

Additional file 2: Appendix 2 FGD Guide for illiterate women.

Additional file1: Appendix 1. Table 2. Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist1.

Additional file 3: Appendix 3 IDI Guide.

Additional file1: Appendix 1. Table 2. Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist1.

Additional file 2: Appendix 2 FGD Guide for illiterate women.

Additional file 4: Appendix 4 KII Guide.