Search

Recent studies demonstrate the association of the gut microbiome in regulating interactions between the central nervous system and intestinal function. Individuals with attention-deficit hyperactivity disorder (ADHD) have been shown to have unique gut microbial signature, with depletion of beneficial commensal microbes. Fecal microbiota transplant (FMT) restores the imbalanced gut microbiome and may replete missing microbes to increase production of hormones and neurotransmitters regulating human behavior and cognition.Here, we present an interesting case of a 22-year-old woman treated with FMT primarily to treat recurrentOur case report provides preliminary evidence regarding the use of FMT in a patient with

Intestinal metaplasia (IM) is a pre-malignant condition of the gastric mucosa associated with increased gastric cancer (GC) risk. We analyzed 1256 gastric samples (1152 IMs) from 692 subjects through a prospective 10-year study. We identified 26 IM driver genes in diverse pathways including chromatin regulation (ARID1A) and intestinal homeostasis (SOX9), largely occurring as small clonal events. Analysis of clonal dynamics between and within subjects, and also longitudinally across time, revealed that IM clones are likely transient but increase in size upon progression to dysplasia, with eventual transmission of somatic events to paired GCs. Single-cell and spatial profiling highlighted changes in tissue ecology and lineage heterogeneity in IM, including an intestinal stem-cell dominant cellular compartment linked to early malignancy. Expanded transcriptome profiling revealed expression-based molecular subtypes of IM, including a body-resident “pseudoantralized” subtype associated with incomplete histology, antral/intestinal cell types,ARID1Amutations, inflammation, and microbial communities normally associated with the healthy oral tract. We demonstrate that combined clinical- genomic models outperform clinical-only models in predicting IMs likely to progress. Our results raise opportunities for GC precision prevention and interception by highlighting strategies for accurately identifying IM patients at high GC risk and a role for microbial dysbiosis in IM progression.

Background and Aims Microbiome dysbiosis is associated with inflammatory destruction in Crohn’s disease [CD]. Although gut microbiome dysbiosis is well established in CD, the oral microbiome is comparatively under-studied. This study aims to characterize the oral microbiome of CD patients with/without oral manifestations. Methods Patients with CD were recruited with age-, gender- and race-matched controls. Potential confounders such as dental caries and periodontal condition were recorded. The oral microbiome was collected using saliva samples. Microbial DNA was extracted and sequenced using shotgun sequencing. Metagenomic taxonomic and functional profiles were generated and analysed. Results The study recruited 41 patients with CD and 24 healthy controls. Within the CD subjects, 39.0% had oral manifestations with the majority presenting with cobblestoning and/or oral ulcers. Principal coordinate analysis demonstrated distinct oral microbiome profiles between subjects with and without CD, with four key variables responsible for overall oral microbiome variance: [1] diagnosis of CD, [2] concomitant use of steroids, [3] concomitant use of azathioprine and 4] presence of oral ulcers. Thirty-two significant differentially abundant microbial species were identified, with the majority associated with the diagnosis of CD. A predictive model based on differences in the oral microbiome found that the oral microbiome has strong discriminatory function to distinguish subjects with and without CD [AUROC 0.84]. Functional analysis found that an increased representation of microbial enzymes [n = 5] in the butyrate pathway was positively associated with the presence of oral ulcers. Conclusions The oral microbiome can aid in the diagnosis of CD and its composition was associated with oral manifestations.

ObjectiveAn unmet need exists for a non-invasive biomarker assay to aid gastric cancer diagnosis. We aimed to develop a serum microRNA (miRNA) panel for identifying patients with all stages of gastric cancer from a high-risk population.DesignWe conducted a three-phase, multicentre study comprising 5248 subjects from Singapore and Korea. Biomarker discovery and verification phases were done through comprehensive serum miRNA profiling and multivariant analysis of 578 miRNA candidates in retrospective cohorts of 682 subjects. A clinical assay was developed and validated in a prospective cohort of 4566 symptomatic subjects who underwent endoscopy. Assay performance was confirmed with histological diagnosis and compared with Helicobacter pylori (HP) serology, serum pepsinogens (PGs), ‘ABC’ method, carcinoembryonic antigen (CEA) and cancer antigen 19–9 (CA19-9). Cost-effectiveness was analysed using a Markov decision model.ResultsWe developed a clinical assay for detection of gastric cancer based on a 12-miRNA biomarker panel. The 12-miRNA panel had area under the curve (AUC)=0.93 (95% CI 0.90 to 0.95) and AUC=0.92 (95% CI 0.88 to 0.96) in the discovery and verification cohorts, respectively. In the prospective study, overall sensitivity was 87.0% (95% CI 79.4% to 92.5%) at specificity of 68.4% (95% CI 67.0% to 69.8%). AUC was 0.848 (95% CI 0.81 to 0.88), higher than HP serology (0.635), PG 1/2 ratio (0.641), PG index (0.576), ABC method (0.647), CEA (0.576) and CA19-9 (0.595). The number needed to screen is 489 annually. It is cost-effective for mass screening relative to current practice (incremental cost-effectiveness ratio=US$44 531/quality-of-life year).ConclusionWe developed and validated a serum 12-miRNA biomarker assay, which may be a cost-effective risk assessment for gastric cancer.Trial registration numberThis study is registered with ClinicalTrials.gov (Registration number: NCT04329299).

Background The human gut harbors trillions of microbes that play dynamic roles in health. While the microbiome contributes to many cardiometabolic traits by modulating host inflammation and metabolism, there is an incomplete understanding regarding the extent that and mechanisms by which individual microbes impact risk and development of cardiovascular disease (CVD). The Framingham Heart Study (FHS) is a multi-generational observational study following participants over decades to identify risk factors for CVD by correlating genetic and phenotypic factors with clinical outcomes. As a large-scale population-based cohort with extensive clinical phenotyping, FHS provides a rich landscape to explore the relationships between the gut microbiome and cardiometabolic traits. Methods We performed 16S rRNA gene sequencing on stool from 1423 participants of the FHS Generation 3, OMNI2, and New Offspring Spouse cohorts. Data processing and taxonomic assignment were performed with the 16S bioBakery workflow using the UPARSE pipeline. We conducted statistical analyses to investigate trends in overall microbiome composition and diversity in relation to disease states and systematically examined taxonomic associations with a variety of clinical traits, disease phenotypes, clinical blood markers, and medications. Results We demonstrate that overall microbial diversity decreases with increasing 10-year CVD risk and body mass index measures. We link lifestyle factors, especially diet and exercise, to microbial diversity. Our association analyses reveal both known and unreported microbial associations with CVD and diabetes, related prescription medications, as well as many anthropometric and blood test measurements. In particular, we observe a set of microbial species that demonstrate significant associations with CVD risk, metabolic syndrome, and type 2 diabetes as well as a number of shared associations between microbial species and cardiometabolic subphenotypes. Conclusions The identification of significant microbial taxa associated with prevalent CVD and diabetes, as well as risk for developing CVD, adds to increasing evidence that the microbiome may contribute to CVD pathogenesis. Our findings support new hypothesis generation around shared microbe-mediated mechanisms that influence metabolic syndrome, diabetes, and CVD risk. Further investigation of the gut microbiomes of CVD patients in a targeted manner may elucidate microbial mechanisms with diagnostic and therapeutic implications.

Background Singapore and Malaysia are neighbouring countries with similar ethnic make-up: Chinese, Indian, and Malays. However, Singapore is a high-income economy while Malaysia is a middle-income economy. Such a difference has resulted in some levels of dichotomy in diet and lifestyles. In this study, we sought to investigate the gut-ethnic variation across the two neighbouring countries with varying levels of economic development. Methods A total of 439 relatively healthy Malaysian (n=190) and Singaporean (n=249) adults (>18) were included, comprising Chinese (n=240), Indian (n=74), Malay (n=40), and the indigenous Jakun community (n=85). The sequences were processed with DADA2 and annotated using the SILVA database. Results Country of origin explained the most variation in the gut microbiota (PERMANOVA, Pseudo-F=80.798, R2=0.156, p=0.001; IDDF2021-ABS-0150 Figure 1. Ordination). Importantly, ethnicity was still significantly associated with the gut microbiota even after adjusting for the country, age and sex (PERMANOVA, Pseudo-F=4.206, R2=0.019, p=0.001). Several taxa were found to be differentially abundant across ethnicity (ANCOM-BC, q Conclusions Gut-ethnic differences persist across geographical regions, which was likely due to similar lifestyle and cultural practices by individuals sharing similar ancestry. These signals provide potential biomarkers on the role of the gut microbiota in the aetiology of the unequal disease burdens affecting the different ethnic groups in this multicultural region.

Background Psychological stress, which is associated with poor sleep quality, has a profound effect on the gut microbiome. To better elucidate the gut microbiome changes associated with psychological stress, we measured levels of stress and sleep quality among the healthy stool donors recruited through a national campaign, and further assessed their relationship with the gut microbiome. Methods The gut microbial composition of 272 adults residing in Singapore was determined by 16S rRNA V3-V4 amplicon sequencing. Stress and distress levels of participants were assessed using the Perceived Stress Scale (PSS) and Kessler Psychological Distress Scale (K10) respectively, while sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Multivariate statistical data analyses were conducted to explore the link between the gut microbiome, stress, distress and sleep quality. Results A significant proportion of stool donors exhibited low distress (84.2%) levels. However, nearly one-third of participants reported high-stress levels (33.5%) and poor sleep quality (44.8%) (IDDF2021-ABS-0165 Figure A. Stacked bar plot showing the number of participants under each category of (i) K10 , (ii) PSS and (iii) PSQI). The overall variation in the gut microbiome composition amongst stool donors was predominantly dependent on age and body mass index (BMI), rather than psychosocial stress and sleep quality (IDDF2021-ABS-0165 Figure B. PERMANOVA results of main factors in this study). However, four microbial features (i.e., Streptococcus, Erysipelotrichaceae UCG-003, Sutterella and Parabacteroides) were found to be positively associated with severe distress, of which Erysipelotrichaceae UCG-003 was more abundant in both distressed and stressed donors (DESeq2, p Conclusions One-third of the participants exhibited high stress/distress levels and almost half poor sleep. In this study, we identified several bacterial genera that are significantly altered in the gut microbiome of stressed individuals, with Erysipelotrichaceae UCG-003 being consistently increased across people with high stress and severe distress levels. Erysipelotrichaceae UCG-003 was previously reported to be elevated in individuals with sleep deprivation. Our findings also suggest the need to factor for stress and sleep quality when studying the gut microbiome of healthy individuals.

Background The gut microbiome plays an instrumental role in cardiovascular, metabolic and gastrointestinal health (Valdes et al. 2018). In Traditional Chinese Medicine (TCM), one’s health status can be described by nine body constitutions (BCs) which are broadly classified as ‘Neutral’, indicating optimal health, or ‘Unbalanced’, indicating suboptimal health. Similar to the gut microbiome, BCs are strongly influenced by lifestyle and diet. We evaluated the gut microbial composition of Neutral, Qi-Deficiency (QD), Phlegm-dampness (PD) and Damp Heat (DH) subjects. The latter three are unbalanced BCs, with QD associated with heart disease (Zhu et al. 2017), PD with obesity and metabolic syndrome (Wang et al. 2013), and DH with gastrointestinal disease (Liang et al. 2020). Methods Stool samples were collected from 211 healthy subjects and gut microbial composition was profiled using 16S rRNA amplicon sequencing of the V3-V4 regions. BCs were determined using the Constitution in Chinese Medicine Questionnaire (Wang, 2005). Alpha diversity of QD, PD and DH was inferred and compared against that of Neutral using the Kruskal-Wallis test. Differentially abundant bacterial phyla, family and species were identified by calculating Log2FoldChange of taxa in the unbalanced BCs compared to Neutral. Results There were 135 Neutral, 59 QD, 24 PD and 12 DH subjects. 16 participants exhibited two or more unbalanced BCs. PD exhibited significantly lower alpha diversity (Shannon, Simpson) than Neutral (p Conclusions Varying TCM BCs exhibit unique microbiota signatures. Participants with unbalanced BCs are associated with greater dysbiosis compared to participants with Neutral BC. The lower alpha diversity in PD is consistent with that in obese and metabolic syndrome patients (Stanislawski et al. 2019; Oh et al. 2021). Streptococcus gallolyticus, a species associated with gastrointestinal malignancy (Chand et al. 2016), was significantly higher in all three unbalanced BCs and thus may serve as a potential biomarker for identifying patients with unbalanced BCs.

Background The impact of non-dietary lifestyle factors on the gut microbiota, such as physical activity, has not been frequently reported. Recent studies have suggested that exercise can increase the number of beneficial microbial species which enhance short-chain fatty acid synthesis and carbohydrate metabolism. Therefore, we investigated the relationship between physical activity and gut microbiome composition within a cohort of multi-ethnic healthy Singaporeans. Methods 257 individuals completed the Global Physical Activity Questionnaire (GPAQ) (Armstrong et al. 2006) and Food Frequency Questionnaire (FFQ) (Whitton et al. 2017), to obtain quantitative measures of their physical activity, nutrition and dietary habits, respectively. They also provided paired stool samples, which underwent 16S rRNA V3-4 amplicon sequencing. Community and individual microbial features associated with physical activity were assessed using microbial ecology measures such as α-diversity and principal coordinate analysis (PCA), as well as, multivariate sparse Partial Least Squares analyses, whilst confounding for nutritional and dietary habits. Results Using the GPAQ, 57% of the individuals were deemed to have an active lifestyle. Active individuals have increased microbial α-diversity, although not statistically significant. Unsupervised PCA analysis identified a subset of active individuals with distinct microbiome signatures, whereby these individuals, compared to those with sedentary lifestyles, have increased abundances of Prevotella spp., which is in keeping with their increased fibre intake. Sedentary lifestyle individuals were found to have increased abundance of Lachnoclostridium spp., whereby phylogenetic similar microbial features (such as Roseburia and Subdoligranulum spp.) were significantly correlated with more frequent eating out at hawker stalls and fast-food establishments (IDDF2021-ABS-0169 Figure 1. Correlation between gut microbiome with (a) nutrient intake; and (b) food habit). Studying the metabolic potential of the microbiome, active individuals had increased abundances of gene content related to energy production, whereby sedentary individuals had increased abundances of gene content related to degradation of aromatic compounds. Conclusions Our study reaffirms that increased physical activity is associated with increased microbial diversity and beneficial microbial features. However, the differences in gut microbiota associated with physical activity may be due to differences in dietary intake and practices, rather than the exercise itself. Further studies investigating the link of gut microbiome and physical activity should control and standardize the dietary intake of participants.

ObjectiveTo investigate the incidence of gastric cancer (GC) attributed to gastric intestinal metaplasia (IM), and validate the Operative Link on Gastric Intestinal Metaplasia (OLGIM) for targeted endoscopic surveillance in regions with low-intermediate incidence of GC.MethodsA prospective, longitudinal and multicentre study was carried out in Singapore. The study participants comprised 2980 patients undergoing screening gastroscopy with standardised gastric mucosal sampling, from January 2004 and December 2010, with scheduled surveillance endoscopies at year 3 and 5. Participants were also matched against the National Registry of Diseases Office for missed diagnoses of early gastric neoplasia (EGN).ResultsThere were 21 participants diagnosed with EGN. IM was a significant risk factor for EGN (adjusted-HR 5.36; 95% CI 1.51 to 19.0; pH. pylori. Participants with OLGIM II were also at significant risk of EGN (adjusted-HR 7.34; 95% CI 1.60 to 33.7; p=0.02). A significant smoking history further increases the risk of EGN among patients with OLGIM stages II–IV.ConclusionsWe suggest a risk-stratified approach and recommend that high-risk patients (OLGIM III–IV) have endoscopic surveillance in 2 years, intermediate-risk patients (OLGIM II) in 5 years.

Background Blastocystis is a common anaerobic colonic protist in humans with controversial pathogenicity. Clostridium difficile (C. difficile) is the commonest cause of infectious diarrhea in healthcare settings. The prevalence and subtype (ST) characteristics of Blastocystis in patients with C. difficile infection (CDI) are rarely documented. Therefore, the present study was conducted to investigate the prevalence and subtype characteristics of Blastocystis in patients with suspicion of CDI in Singapore. Methods Fecal samples were collected from 248 patients presenting with suspected CDI from a single tertiary hospital in Singapore. C. difficile was diagnosed through positive glutamate dehydrogenase (GDH) with or without toxin A/B using enzyme immunoassay methods. The prevalence and subtype genetic characteristics of Blastocystis were determined by polymerase chain reaction (PCR) amplification and analysis of the barcode region of the SSU rRNA gene. Results The proportion of C. difficile in patients with healthcare-associated diarrhea in this study was 44% (109/248). Among the 109 C. difficile-positive patients, 59 (54.1%, 59/109) tested positive for toxigenic C. difficile, which was considered CDI. Based on the sequence analyses of the barcode region of the SSU rRNA gene, 10.1% (25/248) of the patients were found to be Blastocystis-positive, and three subtypes were identified: ST7 (64%, 16/25), ST1 (20%, 5/25), and ST3 (16%, 4/25). Remarkably, we found five patients with Blastocystis and C. difficile coinfection, and further subtype analysis showed two with ST7, two with ST1, and one with ST3. Conclusions To the best of our knowledge, this is the first study to investigate the subtype distributions of Blastocystis in patients with CDI in Singapore. We found ST7 to be the predominant subtype in diarrheal patients. The pathogenicity of ST7 has been strongly suggested in previous in vitro and mouse model experiments, further confirming its potential pathogenicity to humans. Graphical Abstract

Water constitutes one of the basic necessities of life. Around 71% of the Earth is covered by water, however, not all of it is readily available as fresh water for daily consumption. Fresh water scarcity is a chronic issue which poses a threat to all living things on Earth. Seawater, as a natural resource abundantly available all around the world, is a potential water source to fulfil the increasing water demand. Climate-independent seawater desalination has been touted as a crucial alternative to provide fresh water. While the membrane-based desalination process continues to dominate the global desalination market, the currently employed membrane fabrication materials and processes inevitably bring adverse impacts to the environment. This review aims to elucidate and provide a comprehensive outlook of the recent efforts based on greener approaches used for desalination membrane fabrication, which paves the way towards achieving sustainable and eco-friendly processes. Membrane fabrication using green chemistry effectively minimizes the generation of hazardous compounds during membrane preparation. The future trends and recommendations which could potentially be beneficial for researchers in this field are also highlighted.

Freshwater scarcity is a global issue that is further exacerbated by both economic and population growth. Membrane desalination possesses the potential to address water stress issues, but membrane fouling has affected its performance and widespread application in the desalination industry. An integrated/hybrid membrane system, a process in which membrane filtration unit (microfiltration/ultrafiltration/nanofiltration/reverse osmosis) is combined with other techniques like adsorption and ion exchange, has been shown to improve the desalination performance. In this chapter, the integrated/hybrid membrane systems used in desalination plants are reviewed with special emphasis on the improved performance, and cost benefits. The comprehensive literature review shows that there are many benefits could be achieved by using such integrated systems in desalination plants, namely, an improvement in water quality produced, energy efficiency, reduced fouling, and others. Hence, such systems can be inferred to enhance the potential of membrane desalination and provide a breakthrough in resolving the issue of global water stress.

Summary The intestinal microbiome is a key determinant of responses to biologic therapy in inflammatory bowel disease (IBD). However, diverse therapeutics and variable responses among IBD patients have posed challenges in predicting clinical therapeutic success. In this prospective study, we profiled baseline stool and blood in patients with moderate-to-severe Crohn's disease or ulcerative colitis initiating anti-cytokine therapy (anti-TNF or -IL12/23) or anti-integrin therapy. Patients were assessed at 14 weeks for clinical remission and 52 weeks for clinical and endoscopic remission. Baseline microbial richness indicated preferential responses to anti-cytokine therapy and correlated with the abundance of microbial species capable of 7α/β-dehydroxylation of primary to secondary bile acids. Serum signatures of immune proteins reflecting microbial diversity identified patients more likely to achieve remission with anti-cytokine therapy. Remission-associated multi-omic profiles were unique to each therapeutic class. These profiles may facilitate a priori determination of optimal therapeutics for patients and serve as targets for newer therapies.

Background While many studies have found an association between irritable bowel syndrome (IBS) and obesity, many others did not. Hence, this systematic review with meta-analysis aims to evaluate the relationship between obesity and IBS, and determine whether obesity correlates differently with the various IBS endotypes. Methods A systematic review of published literature was conducted in concordance with the PRISMA guidelines and followed by a meta-analysis of relevant studies using the random-effects model. The 34 included studies assessed obesity among non-IBS controls and IBS subjects, either as continuous or dichotomous outcomes, using body mass index (BMI) and waist circumference (WC). The standardized mean difference (SMD) and 95% confidence interval (CI); and the odds ratio (OR) and 95% CI were obtained for continuous and dichotomous outcomes respectively. Meta-regression was performed to identify sources of heterogeneity. Results We found a weak association between IBS and obesity, but this was not statistically significant. For BMI, the overall SMD was +0.227 (95% CI: –0.093 to 0.547, p = 0.164) and OR was 1.312 (95% CI: 0.974 to 1.767, p = 0.074). For WC, the overall SMD was +1.020 cm (95% CI: –1.768 to 3.807, p = 0.473). However, subgroup analysis revealed significantly higher BMI among IBS-diarrhoea (IBS-D) subjects compared to controls (SMD = +1.940; 95% CI: 0.679 to 3.200, p = 0.003) and significantly lower BMI among IBS-constipation (IBS-C) subjects compared to IBS-D subjects (SMD = –1.720; 95% CI: –2.489 to –0.950, p Conclusions In conclusion, our systematic review with meta-analysis showed that obesity is positively associated with diarrhoea-predominant IBS, but not IBS in general. Our findings support the exploration of shared pathophysiology between IBS-D and obesity.

Freshwater scarcity is one of the grand challenges that has posed threats to the global economy, societal stability and ecosystem balance. Desalination has been long recognized as an effective approach for fresh water production from seawater and brackish water. Forward osmosis (FO) is currently one of the most studied technologies for seawater and brackish water desalination due to its intrinsic advantages compared to reverse osmosis. On the other hand, membrane distillation (MD) is an emerging technology to offer a potentially cost effective thermally-driven desalination process, especially when coupled with waste heat and solar thermal. One major and inevitable challenge for FO and MD is membrane fouling. For decades, fouling and its related topics have gained extensive attention from the desalination communities and various strategies have been implemented to tackle this long standing issue. In this contribution, the fouling mitigation strategies in terms of pretreatment, membrane surface modification and operating conditions for both FO and MD processes are comprehensively reviewed.

Second forward view (SFV) examination of the right colon (RC) in colonoscopy was suggested to improve the adenoma detection rate (ADR), but multicenter data to inform its routine use remain limited. We performed an international multicenter randomized trial comparing SFV vs a standard single forward view examination of the RC on adenoma detection.Asymptomatic individuals undergoing screening or surveillance colonoscopies from 6 Asia Pacific regions were invited for study. A forward view examination of the RC was first performed in all patients, followed by randomization at the hepatic flexure to either SFV examination of the RC and standard withdrawal examination from the hepatic flexure to rectum, or a standard withdrawal colonoscopy (SWC) examination from the hepatic flexure to rectum. The primary outcome was RC ADR.Between 2016 and 2019, there were 1011 patients randomized (SFV group, 502 patients; SWC group, 509 patients). Forty-five endoscopists performed the colonoscopies. The RC ADR was significantly higher in the SFV group than in the SWC group (27.1% vs 21.6%; P = .042). The whole-colon ADR was high in both groups (49.0% vs 45.0%; P =.201). The SFV examination identified 58 additional adenomas in 49 patients (9.8%), leading to a change in surveillance recommendations in 15 patients (3.0%). The median overall withdrawal time was 1.5 minutes longer in the SFV group (12.0 vs 10.5 min; P.001). Older age, male sex, ever smoking, and longer RC withdrawal time were independent predictors of right-sided adenoma detection.In this multicenter trial, SFV examination significantly increased the RC ADR in screening and surveillance colonoscopies. Routine RC SFV examination should be considered. ClinicalTrials.gov ID: NCT03121495.

A significant proportion of the non-alcoholic fatty liver disease (NAFLD) population is non-obese. Prior studies reporting the severity of NAFLD amongst non-obese patients were heterogenous. Our study, using data from the largest biopsy-proven NAFLD international registry within Asia, aims to characterize the demographic, metabolic and histological differences between non-obese and obese NAFLD patients.1812 biopsy-proven NAFLD patients across nine countries in Asia assessed between 2006 and 2019 were pooled into a curated clinical registry. Demographic, metabolic and histological differences between non-obese and obese NAFLD patients were evaluated. The performance of Fibrosis-4 index for liver fibrosis (FIB-4) and NAFLD fibrosis score (NFS) to identify advanced liver disease across the varying obesity subgroups was compared. A random forest analysis was performed to identify novel predictors of fibrosis and steatohepatitis in non-obese patients.One-fifth (21.6%) of NAFLD patients were non-obese. Non-obese NAFLD patients had lower proportions of NASH (50.5% vs 56.5%, p = 0.033) and advanced fibrosis (14.0% vs 18.7%, p = 0.033). Metabolic syndrome in non-obese individuals was associated with NASH (OR 1.59, 95% CI 1.01-2.54, p = 0.047) and advanced fibrosis (OR 1.88, 95% CI 0.99-3.54, p = 0.051). FIB-4 performed better than the NFS score (AUROC 81.5% vs 73.7%, p 0.001) when classifying patients with F2-4 fibrosis amongst non-obese NAFLD patients. Haemoglobin, GGT, waist circumference and cholesterol are additional variables found on random forest analysis useful for identifying non-obese NAFLD patients with advanced liver disease.A substantial proportion of non-obese NAFLD patients has NASH or advanced fibrosis. FIB-4, compared to NFS better identifies non-obese NAFLD patients with advanced liver disease. Serum GGT, cholesterol, haemoglobin and waist circumference, which are neither components of NFS nor FIB-4, are important biomarkers for advanced liver disease in non-obese patients.

Objective There has been an increase in the number and complexity of patient complaints against healthcare institutions. An understanding of the resources needed in this area is important for proper planning. Design Cohort study. Setting A 1250-bed tertiary-care teaching hospital. Participants All patient complaints received between 1 February 2014 and 31 January 2015 were prospectively included in this cohort study. Main Outcome Measures The amount of time spent on the investigation and liaising with the complainant for each case was recorded. The complainant's personal details and characteristics were recorded anonymously. Results In total, 908 patient complaints were recorded from 801 individuals during the study period. Longer median person-hours were spent on managing complaints that were brought forward by men (1.48 h), those who were distant relatives of the patients (2.08 h), foreigners (1.58 h) and non-subsidised patients (1.83 h). Patient complaints falling into the categories of clinical domain (3.00 h) and patient rights (2.54 h), quality (3.00 h) and safety (2.83 h) required the longest median time to manage. Multiple logistic regression analysis revealed that the total amount of time spent on the complaints was predicted by the gender of the complainant, the relationship of the complainant with the patient, the subsidy status of the patient, the severity and the domain of the complaint. Conclusions This study reported the time required to manage patient complaints in a larger tertiary-care academic medical centre. Predictors of the time spent on resolving patient complaints can be used as parameters for resource planning.

The substrate of RO thin film composite membranes offers support for rejection layer formation. It remarkably affects the physicochemical and structural properties of the developed rejection layer. This denotes the relevance of substrates modification in realizing optimized substrate structure in terms of porosity, thickness and tortuosity with the goal of obtaining highly selective and enhanced hydrophilic membrane. Polyamide thin film nanocomposite (TFN) membranes with its polysulfone (PSF) substrate embedded with palygorskite-chitin (PAL-CH) hybrid nanomaterial have been fabricated in this study. The hybridization of palygorskite and chitin nanofibers was performed under the collision as well as the shear force of ball mill. The TFN membranes with different loadings of PAL-CH in the PSF layer were characterized and applied for desalination process. The incorporation of PAL-CH hybrid increased the finger like structure formation and improved the overall hydrophilicity besides highly cross linked and thinner PA layer. The flux of the neat and PAL-CH membranes was 0.82 L m−2 h−1 and 2.4 L m−2 h−1 respectively. The developed membranes exhibited remarkably improved pure water flux without compromising the salt rejection. Flux enhancement of 192.7% was achieved using 0.01 wt% PAL-CH3 hybrid nanomaterial.

The effects of biological co-pretreatment on biogas production from anaerobic co-digestion of food waste (FW) and waste activated sludge (WAS) were investigated. FW and WAS underwent anaerobic co-pretreatment to improve hydrolysis efficiency followed by co-digestion. Results showed that the methane yield from co-digestion of co-pretreated FW and WAS was 24.6% higher than that of control substrates without pretreatment. An increase of 10.1% in solids reduction was achieved in the anaerobic digester under the optimum pretreatment time of 24 h. Compared to mono-digestion of FW with pretreatment, the combination of anaerobic co-digestion and co-pretreatment of FW and WAS resulted in a higher treatment performance and methane production due to synergistic effects of pH amendment and enhancement of WAS particles solubilization. Pyrosequencing analysis indicated that anaerobic co-pretreatment reduced the abundance of filamentous bacteria of genus Levilinea in the subsequent co-digestion, which was liable to cause a decrease in anaerobic digestion performance.