There is an epidemic of diabetes in Asia. Type 2 diabetes develops in East Asian patients at a lower mean body mass index (BMI) compared with those of European descent. At any given BMI, East Asians have a greater amount of body fat and a tendency to visceral adiposity. In Asian patients, diabetes develops at a younger age and is characterized by early β cell dysfunction in the setting of insulin resistance, with many requiring early insulin treatment. The increasing proportion of young-onset and childhood type 2 diabetes is posing a particular threat, with these patients being at increased risk of developing diabetic complications. East Asian patients with type 2 diabetes have a higher risk of developing renal complications than Europeans and, with regard to cardiovascular complications, a predisposition for developing strokes. In addition to cardiovascular–renal disease, cancer is emerging as the other main cause of mortality. While more research is needed to explain these interethnic differences, urgent and concerted actions are needed to raise awareness, facilitate early diagnosis, and encourage preventive strategies to combat these growing disease burdens. Diabetes Atlas, an estimated 366 million individuals are affected globally, of whom 36% live in the Western Pacific region, with a significant proportion from East Asia.1The prevalence of diabetes is increasing globally, but the situation is particularly alarming in Asia. In the latest edition of While it is evident that, for the same BMI, Asian populations have a higher prevalence of diabetes than their European counterparts,This review summarizes and discusses the epidemiology, pathophysiology, genetics, and socioeconomic factors that may contribute to these interethnic differences. In addition to drawing on epidemiological and clinical studies performed in Asian populations, we also made reference to lessons learned from Asian subjects living in the United States, Europe, or Australia, notably the Japanese Americans in Seattle who have provided invaluable insight into the pathogenesis of type 2 diabetes (T2D) in people of East Asian origin.Epidemiological studies have documented consistent increases in the prevalence of diabetes across different countries or areas in Asia.7This pattern of increasing prevalence over the last 20 years is mirrored in many Asian countries, as shown by data on the prevalence of known and undiagnosed diabetes, as well as impaired glucose tolerance (IGT) in East Asia .1 In add9In addition to the large number of individuals with diagnosed and undiagnosed diabetes, there are many at-risk subjects with IGT in East Asian countries . The con10Globally, there is a general decrease in the age of diagnosis for diabetes,14Traditionally, the American Diabetes Association (ADA) does not recommend the primary use of the 75 g oral glucose tolerance test (OGTT) to diagnose diabetes in routine clinical practice, although the OGTT remains the gold standard for diagnosis according to the World Health Organization (WHO).1c) ≥ 6.5% as one of the diagnostic criteria for diabetes.12 deficiency may lead to a falsely high HbA1c. Hemoglobinopathies may also affect HbA1c measurements, for example, due to altered amino acids on binding sites of immunoassays for HbA1c, or by causing variable interference in assays that utilize ion exchange chromatography.21The ADA and WHO have both included levels of hemoglobin A1c , ≥25 kg/m2 (overweight), 25–29.9 kg/m2 (preobese), ≥ 30 kg/m2 (obesity), 30–39.9 kg/m2 (obese class I), 35–39.9 kg/m2 (obese class II), and ≥ 40 kg/m2 (obese class III) should be retained as international classification, the cut-off points of 23, 27.5, 32.5, and 37.5 kg/m2 should be considered points for public health action.32One of the most striking observations is the occurrence of diabetes in East Asian countries at a much lower mean BMI.The relationship between BMI and risk of diabetes in Asian populations was recently examined in a large cross-sectional pooled analysis of 900,000 individuals in the Asian Cohorts Consortium.The DECODA study utilized cross-sectional data from 24,515 men and 29,952 women, and noted that the prevalence of diabetes was highest in Asian Indians, lowest in Europeans, and intermediate in Japanese and Chinese patients. The prevalence of undiagnosed diabetes increased with increasing BMI or waist circumference and to a similar extent in all ethnic groups, except Asian Indian women .37372 in white subjects, the BMI was 24 kg/m2 in South Asians and 25 kg/m2 in Chinese subjects. The study concluded that Chinese subjects developed diabetes at a higher rate, at an earlier age, and at lower ranges of BMI compared with Caucasians.40Given the inherent limitations of cross-sectional studies, heterogeneity in pooled analysis, and the large number of other factors associated with diabetes risks, studies that examined relationships between BMI and incident diabetes are more informative. A study that included data from the People's Republic of China Study and the Atherosclerosis Risk in Communities Study found larger associations between BMI and diabetes in Chinese Asians compared with American Whites.One possible reason for this interethnic difference is that, at any given BMI, compared to Caucasians, Asians have more visceral adiposity, which is metabolically more adverse, and contributes to lipotoxicity and insulin resistance.42Central obesity, and in particular, visceral adiposity as measured by abdominal computed tomography or abdominal magnetic resonance imaging (MRI), is strongly associated with the risk of diabetes, independent of BMI, in both Europeans46Multiethnic studies have highlighted that, for any given BMI or waist circumference, Asians have greater adiposity or visceral fat than Caucasians.51While impaired β cell function and insulin resistance are both important in the pathogenesis of T2D, the relative contribution of these two factors in the etiology of diabetes varies in different populations.57In addition to genetic and lifestyle factors, aging also increases the risk of visceral adiposity.Adipose tissue is an active endocrine gland, and the distribution of body fat will affect adipokine production.63Mitochondrial dysfunction has been implicated in visceral adiposity, insulin resistance, and other metabolic abnormalities.68Another feature characterizing T2D in Asian populations is the tendency to develop young-onset diabetes. Studies conducted in different East Asian populations have highlighted the earlier age at diagnosis. Among studies conducted in East Asia, the mean age of diagnosis of T2D is typically around 50 years. For example, in the Hong Kong Diabetes Registry, the mean age of diabetes diagnosis was 52 years.73This increase in young-onset T2D is mainly due to the increasing prevalence of obesity, particularly among young men. In a study conducted in 2001 among 9,243 patients managed in 194 primary care centers across Asia, the proportion of T2D patients diagnosed before the age of 30 varied from 0.5% in Taiwan and 1.5% in Korea, to 5.4% in the Philippines.14There is considerable heterogeneity among subjects with young-onset diabetes in Asia. A study of T2D patients in Hong Kong diagnosed before the age of 40 noted that 4% of patients had autoimmune markers, while half of them had a positive family history and/or obesity, suggesting that genetic factors and obesity play a greater pathogenetic role than autoimmunity.77Studies in different ethnic groups have reported an association of positive family history with a two- to sixfold increased risk of diabetes.6P < 0.001), the former group had lower fasting c-peptide levels despite comparable plasma glucose levels. The association between positive family history and low c-peptide levels, consistent with impaired β cell function, remained significant after adjustment for age, gender, duration of diabetes, BMI, fasting plasma glucose, and free fatty acid levels.83In a study comparing 377 Korean patients with positive family histories (mean age of diagnosis 47.2 ± 10.8 years) with 955 patients with negative family histories  had lower HOMA-β than non-Hispanic whites after controlling for waist circumference, prevalence of IFG, triglycerides, and amount of alcohol consumed.98Reduced amylin release was found to be a characteristic of T2D.102In the United Kingdom Prospective Diabetes Study (UKPDS), 12% of the 3,672 Caucasian patients with T2D had either autoantibodies to GAD or ICA, with another 4% being positive for both antibodies. Compared to older age groups, patients aged 25–34 had a higher frequency of autoantibodies, which may be as high as 21% for ICA and 34% for GAD.diagnosed patients aged 12–40 were positive for autoantibodies to either GAD or IA-2A.76Similar to what has been observed in Western populations,Type 2 diabetes results from complex interactions between multiple genetic susceptibility factors, as well as environmental and behavioral factors. Recent advances have led to the discovery of more than 60 genetic variants associated with T2D.KCNQ1, were first discovered in East Asians and subsequently replicated in European populations. Given the higher frequency of the risk alleles in Asian populations, these loci may be particularly important in East Asian populations.On the other hand, several T2D loci, including Aside from the inheritance of genetic factors, early life events and intrauterine environment can influence the development of β cell dysfunction and insulin resistance, which will affect the risk of obesity, T2D, and cardiovascular disease later in life.116With earlier age at onset of diabetes, the proportion of pregnancies complicated by pre-existing diabetes is increasing in Asian countries124in utero hyperinsulinemia, as reflected by umbilical cord c-peptide concentration, which strongly predicts later risk of obesity and glucose intolerance.117Gestational diabetes (GDM) is also increasing in prevalence, especially in Asian countries.The changes in environmental factors in many East Asian countries mirror those seen in Western populations, but perhaps on a slightly different time scale. For example, there was a marked increase in fat intake among Japanese between 1945 and 1980, which has leveled out over the past two decades. Furthermore, there has also been a dramatic increase in the number of registered automobiles in Japan. These changes have been associated with a steady increase in BMI and cardiometabolic risk factors.57A similar rise in cardiometabolic risk factors has been observed in many other Asian countries, which have undergone rapid economic development over the last few decades. A survey of nationally representative cohorts from the Asia-Pacific region noted that the prevalence of overweight and obese individuals has increased by 46% in Japan from 16.7% in 1976–1980 to 24% in 2000, and by 414% in China from 3.7% in 1982 to 19.0% in 2002, compared to a rise of 20% from the baseline prevalence rate of 50% in Australia over this time period.136One of the major changes driving the diabetes and obesity epidemic is the rapid nutrition transition that is occurring in Asian countries.137White rice is an important component of the daily diet in East Asians. Although the glycemic index of a specific white rice variety depends on a variety of factors, including the amount of processing, white rice in general has a higher glycemic index than whole grain rice.143Smoking is associated with increased risk of diabetes.146The link between sleep disorders and T2D153Helicobacter pylori and increased risk of diabetes,H. pylori infection is prevalent suggested a link between diabetes and gastric cancer.H. pylori titres and diabetes and postprandial blood glucose levels.157Several infections have been associated with increased risk of diabetes or related complications. Recent studies have reported an association between Hepatitis B is endemic in Southeast Asia, and while not associated with increased risk of diabetes, chronic hepatitis B infection has been found to be associated with increased risk of GDM159In many ways, diabetes is a biomedical consequence of rapid urbanization in genetically predisposed individuals. The rapid transitions from energy scarcity to energy abundance, physical activity to sedentary lifestyles, and a disease pattern dominated by infection to noncommunicable disease, are occurring in unprecedented and phenomenal rates in Asia. These factors can lead to biological, psychological, and behavioral maladaptation, possibly with a genetic or epigenetic basis. These (epi)gene–environment–lifestyle interactions are further influenced by socioeconomical factors, such as access to education, care, and support, resulting in a diversity of consequences .In Asia, the increasingly young age of diabetes onset is likely to have significant implications for the pattern of complications and treatment strategies. Apart from genetic predisposition, young patients face long disease duration and greater tendency to β cell failure, which puts them at high risk for microvascular and macrovascular complications.One of the earliest studies that compared the pattern of complications across different ethnicities was the WHO Multinational Study of Vascular Disease in Diabetes. In a subgroup analysis of this study, the incidence of vascular complications was compared among European, Asian, and American Indians patients with T1D or T2D who were diagnosed at less than 30 years of age. Among the Asian subjects, 62% were recruited from Tokyo and 38% from Hong Kong.164This pattern of increased microalbuminuria and renal complications in Asian patients with T2D has been observed across multiple studies, including other multiethnic studies. In the MicroAlbuminuria in Patients with Diabetes (MAP) study, as many as 58% of Asian patients with T2D and hypertension displaying evidence of renal injury, with 38% showing evidence of microalbuminuria, and a further 18% having macroalbuminuria.2 and hypertriglyceridemia resulted in the greatest change in the odds of micro- or macroalbuminuria compared with whites, suggesting that obesity and dyslipidemia may play an important role in the pathogenesis of nephropathy in Asian populations  between 30 and 100 mg/mmol)) in East Asians was 2.9 (95% CI: 2.4–3.4), and advanced albuminuria (defined as UACR >100 mg/mmol) was 4.1 (95% CI: 3.2–5.1), after adjustment of risk factors, including age, gender, duration of diabetes, HbA1c, systolic blood pressure, triglyceride level, BMI, smoking, use of ACEI/ARB, and study site.ulations .170–172Type 2 diabetes in Asian patients is characterized by an increased risk of renal complications but a lower rate of peripheral vascular disease (PVD) and amputations in a longitudinal multiethnic cohort from the Kaiser Permanente Medical Care Program in Northern California, which included 62,432 diabetic patients, 12% of which were Asians.174Other studies supporting the lower incidence of CHD in Asian patients with T2D compared to Caucasians include the overestimation of CHD risk in Asian subjects by the UKPDS Risk Engine developed in Caucasian T2D patients.178In a recent meta-analysis, albuminuria and renal dysfunction were found to be independent predictors for all-cause and cardiovascular mortality, after adjusting for confounders.182In a subanalysis of the Japan Diabetes Complications Study, non-HDL and total/HDL cholesterol were the best predictors of CHD among diabetic men, whereas triglyceride was the best predictor for women.172Apart from microvascular and macrovascular complications, diabetes is associated with multiple morbidities including increased risk of various cancers, depression, mental illnesses, sleep apnea, respiratory disease, pneumonia, infections, osteoporosis, falls, dementia, and other degenerative conditions.185In addition to increased risk of different infections, diabetic patients have increased risk of sepsis that can lead to metabolic decompensation, morbidities, and mortality from infections.187Despite the marked increase in diabetes prevalence in Asia, recent studies have highlighted a lack of awareness in many Asian patients. In the INTERASIA Study, only 24% of those with diabetes were aware of their diagnosis, with a large proportion of them being undiagnosed.189The increasing number of patients with young-onset diabetes calls for urgent actions to empower these young individuals to achieve good glycemic control early to avoid long-term complications. In Asia, subjects with early-onset diabetes (age of diagnosis < 30 years) are characterized by worse glycemic control and higher frequency of eye complications compared to subjects with late onset of disease.74Emotional distress has significant and negative impacts on self-efficacy, treatment compliance, and glycemic control. To this end, there is increasing recognition regarding the frequent co-occurrence of negative emotions including depression, anxiety, and stress in patients with diabetes, which markedly increase the risk of noncompliance, mortality, morbidity, and hospitalization. While the nature of these associations require further elucidation, a multipronged approach, including psychological support and empowerment are needed to improve the clinical outcomes and quality of life of these high-risk individuals.190Most of the antidiabetic medications currently in use in the United States and Europe are available in Asia, with some differences in drug formulations and dosing regimens. Although clinicians in Asia often refer to treatment guidelines developed by the ADA, European Association for the Study of Diabetes,One such example refers to α-glucosidase inhibitors (AGI). While acarbose is the only AGI available in most countries, there are three different AGIs  in Japan. In contrast to western countries where AGIs are used infrequently, acarbose is a popular treatment choice for both diabetes and IGT in China. This class of drug appears to be well tolerated and effective in East Asians, including Chinese and Japanese who tend to have high post-prandial glucose excursion, probably due to a combination of β cell insufficiency and high carbohydrate intake.194Most pharmacoepidemiology studies in Asia date from the early 2000s, which reflect the status of diabetes treatment and drug choices at that time. In a survey conducted from 2000 to 2002 of over 16,000 Japanese diabetes patients registered in clinics and hospitals in the Japan Diabetes Clinical Data Management Study Group (JDDM), half of the patients were treated with oral antidiabetic drugs (OAD), one quarter were on either insulin or insulin plus OADs, and one quarter were treated by diet alone. Among the OADs prescribed, sulphonylureas were the most common drug class.195In a hospital clinic-based cohort of 7,549 Chinese T2D subjects with a mean age of 57 years, mean disease duration of 6 years, and mean HbA1c of 7.7%, 7.9% of patients were on diet alone, 52.8% were on OADs, 6.5% were on insulin alone, and 32.7% were treated with a combination of OADs and insulin.196In the National Health Interview Survey conducted from 2007 to 2009 in the United States among adults with diagnosed with T1D or T2D, 16% were taking neither OAD nor insulin, 58% only took OADs, 14% were on both insulin and OADs, and 12% were only on insulin.197P = 0.0012).204In Asia, there has been much interest in the use of early insulin treatment. In newly diagnosed patients, intensive insulin therapy using continuous subcutaneous insulin infusion (CSII) improved β cell function, and in particular, first-phase insulin secretion.While these studies are not directly comparable, the relatively high utilization of insulin secretagogues and insulin, as well as favorable responses to AGI and incretin-based therapy in Asian patients, support the importance of β cell dysfunction in these populations. On the other hand, glitazones, such as pioglitazone, are also prescribed in Asian populations, albeit at lower doses of 15–30 mg/day. This drug class has a particular place in therapy for subjects with fatty liver and metabolic syndrome, which are also prevalent in Asian subjects and may relieve β cell stress by alleviating insulin resistance. Given the double burden of β cell dysfunction and insulin resistance in Asian T2D patients, mediated in part by adiposity, there are strong arguments to advocate the use of phenotypes to guide therapies targeted at the predominant biological defect to achieve glycemic control early and preserve β cell function by reducing gluco-lipotoxicity.Given the burden of cardiorenal complications in Asian populations, multifactorial management to reduce the risk of nephropathy is very important in this population. In a post hoc analysis of the Reduction of End Points in Type 2 Diabetes With the Angiotensin II Antagonist Losartan (RENAAL) Study, which examined the renoprotective effects of angiotensin receptor blockers (ARB) in T2D patients with renal insufficiency, treatment with losartan had a greater effect size in Asian populations, with a relative risk reduction of 35% compared to 18% in the main study cohort.205The potential impact of long-term complications on healthcare costs associated with suboptimal diabetes management is well documented . In a cr206To address the multiple needs of Asian T2D patients with complex phenotypes and to reduce the long-term risk of complications, researchers have developed an innovative and structured framework to facilitate early detection, education, monitoring, and care delivery. Given the broad coverage of internet and mobile technology in Asia, internet-based glucose monitoring systems and other mobile phone–based technologies have been shown to be effective in facilitating doctor–patient communications, enhancing self-monitoring, and improving glycemic control.209Quality improvement initiatives targeted at the healthcare system and self-management were found to be particularly effective in improving risk-factor control in a recent meta-analysis.212Recent work has highlighted the escalating burden of T2D in Asian populations, as well as some of the characteristics of diabetes in Asians. While studies suggest an important role of β cell dysfunction in the pathogenesis of T2D in East Asian populations, more detailed comparative studies are needed to further elucidate the underlying cause and metabolic defects. The search for genetic factors in East Asian and European populations has identified more similarities than differences between the different populations, although these loci only explained 10% of the heritability. From an evolutionary perspective, if the thrifty gene hypothesis, which states that genetic traits conducive to survival during times of hardship may promote risk of diabetes in times of affluence, such genotype(s) remains elusive.On the other hand, there is a growing consensus on the possible causal role of early development and intrauterine environment, especially in regions undergoing rapid socioeconomic transition, with the greatest mismatch between the predicted prenatal and adult environments. How these factors may have contributed to the rapidly increasing prevalence of diabetes warrants further study. The rising prevalence of maternal diabetes, gestational diabetes, and childhood obesity will continue to fuel the epidemic, especially young-onset diabetes. To this end, a life-course approach to the prevention and control of diabetes is urgently needed, including a particular focus on early life opportunities.213From a treatment perspective, clinical trials need to incorporate analyses or specific studies for Asian and other populations in order to identify treatment strategies that are most effective, given the phenotypic heterogeneity and interethnic differences in underlying pathophysiology, cultural, and lifestyle factors, as well as the pattern of diabetic complications.


Concern over the health risks of sedentary behavior has highlighted the need to examine factors associated with screen-based (television/computer) sedentary behavior. The present study examined the association of screen-based sedentary behavior with body weight and sociodemographic attributes among Japanese adults.A population-based cross-sectional study enrolled 1034 Japanese adults aged 40 to 69 years who lived in 2 Japanese cities. Sociodemographic variables, height, weight, and time spent on screen-based sedentary behavior were collected by self-administered questionnaire. Differences in screen time in relation to body mass index and weight gain since age 20 years were assessed by the Mann-Whitney U test. Independent associations of each variable with screen time were examined by forced-entry logistic regression analyses.P = 0.08). Unmarried and unemployed participants had longer screen times. Participants aged 40 to 49 years were less likely than older age groups to spend time on screen-based sedentary behavior during leisure hours.Mean (SD) age and median (interquartile range) duration of screen time per week were 55.6 (8.4) years and 832.0 (368.8–1263.1) minutes, respectively, for men, and 55.3 (8.4) years and 852.6 (426.0–1307.5) minutes, respectively, for women. Screen time among participants with weight gain was longer than among those with a weight gain of less than 10 kg (The present findings imply that strategies are necessary to discourage screen-based sedentary behavior among all demographic groups, especially among adults who are elderly, unmarried, or unemployed. Reducing sedentary time increases opportunities to be physically active, so it is important to focus on screen-based sedentary behavior.Recent studies have reported that the amount of leisure time spent on discretionary screen-based sedentary behavior (as opposed to that required during working hours), such as television viewing and computer use, is associated with increased risks of weight gain, type II diabetes, and cardiovascular disease.14,15 and a recent global statement16 encourage a widespread, population-based approach to decrease sedentary behavior. The guidelines emphasize the consequences of sedentary behavior and the need to tailor interventions to the requirements of specific population groups such as children, adults, men, women, older persons, disabled persons, employees, and diverse cultural groups.14–16 Determining the amount of leisure time spent by specific population groups on screen-based sedentary behavior is also important when designing strategies to decrease such behavior.Physical activity guidelines17 Many studies on the correlates of sedentary behavior have been conducted among children, but studies of adults are less common. The sociodemographic factors associated with screen-based sedentary behavior among Japanese adults remain to be determined. In addition, associations of anthropometric factors such as body mass index (BMI) and weight gain with screen-based sedentary behavior were less evident in the Japanese population. The present study examined the associations of sociodemographic and anthropometric factors with screen-based sedentary behavior among adults in Japan.Screen-based sedentary behavior has been investigated among various demographic groups, especially in the United States, Australia, and Europe. A systematic review found that relationships between sedentary behavior and sociodemographic status vary by country.The present cross-sectional study was conducted from February through March 2011. A total of 3000 residents aged 40 to 69 years and living in 2 Japanese cities, Kanuma and Nerima, were randomly selected from the residential registries of those cities. Potential participants were stratified by sex and age bracket . The plan was to include 1500 participants of each sex, 1000 participants from each age bracket, and 1500 participants from each city. Nerima is an urban area within commuting distance of Tokyo, while Kanuma is a mid-sized city in central Japan. These 2 cities were chosen to reflect urban and suburban lifestyles.A self-administered questionnaire that included questions on sociodemographic variables, sedentary behavior, height, and weight was mailed to participants. To encourage a response, letters explaining the study were sent to all participants 2 weeks before the questionnaire. Nonresponders were sent 1 reminder about the questionnaire. A total of 1105 participants replied to the questionnaire . All participants signed an informed consent document before answering the questionnaire. The Ethics Committee of Waseda University, Japan approved the study before its commencement.Participants provided information on sociodemographic factors such as sex, age, education level, employment status, marital status, living arrangements, and household income level by choosing the most suitable response from a set of predetermined options, as follows: education level , employment status , marital status (married or unmarried), living arrangements , and household income level .BMI was calculated from self-reported height and weight. Weight gain since age 20 years was estimated from self-reported weight at age 20 years.13,18 Participants were asked how many times per week they spent on screen time and the duration of screen time on each of those days. The scale was previously shown to have acceptable reliability and validity.18 The test–retest reliability of the items was found to be moderate (range 0.6–0.8). Validity, as defined by correlations with 3-day behavioral log data, was moderate (range 0.3–0.6). The total time spent on screen time was classified as low or high, based on the median of 841.8 minutes/week.Participants reported duration of screen-based sedentary behavior over a usual week (screen time). Screen-based sedentary behavior comprised computer and Internet use for leisure purposes, television watching, computer gaming, and video or DVD watching.t-test, χ2 test, and Mann-Whitney U test. Differences in screen time between those with a BMI of less than 25 kg/m2 versus 25 kg/m2 or higher, and those with a weight gain of less than 10 kg versus 10 kg or more, since age 20 were assessed by the Mann-Whitney U test. Forced-entry logistic regression analyses were conducted to examine independent relationships of each sociodemographic variable with screen time. Responses to sociodemographic attributes were categorized as follows: sex , age , education level , employment status (employed or not employed), marital status (married or unmarried), living arrangements , and household income level . All statistical analyses were performed with SPSS 18.0J for Windows . A P value of less than 0.05 was considered to indicate statistical significance.Differences in participant characteristics and screen time were compared by sex and city with the Data from the 1034 adults (540 men and 494 women) who fully completed the survey were included in the analysis. Table 2 and 842.9 (405.0–1403.3) among those with a BMI of 25 kg/m2 or higher. The association between screen time and BMI was not statistically significant (P = 0.24). Median screen time per week was greater among participants with a weight gain of 10 kg or more  than among those with a weight gain of less than 10 kg since age 20  (P = 0.08).Median (IQR) screen time/week was 843.8 (403.8–1265.6) among participants with a BMI of less than 25 kg/mTable The present study examined the association of sociodemographic and anthropometric factors such as body weight and weight gain with screen-based sedentary behavior among Japanese adults. The results revealed that the level of screen-based sedentary behavior varied between population subgroups: individuals who were older, unmarried, or unemployed reported more screen time during their leisure hours.5 In addition, determinants associated with sedentary behavior differ by specific domain, such as leisure time versus working time.19 It is thus important to determine when sedentary behavior occurs and to study certain specific time periods, such as leisure time.20,21The present study focused only on leisure screen time rather than total screen-related sedentary behavior. Sedentary behavior tends to occur at specific time points and in specific contexts. Thus, it is difficult to ascertain all the details of such behavior. Furthermore, sedentary behavior is relatively independent of physical activity, and both sedentary and active behaviors can occur at any time of the day.12 and 235.1 minutes/day in Australia13; thus, duration of screen time was shorter in Japan than in other countries. However, the present values for screen time were based on participant recall of the number of days spent on screen time during the previous 7 days and the average amount of screen time on each of those days. Thus, we cannot directly compare the present results with those of studies that used different methods to measure duration of screen time, and our results should be interpreted with caution.The median duration of screen time in the present study was 841.8 minutes/week (about 120.6 minutes/day). In contrast, duration of screen time was 188.0 minutes/day in Scotland2 or higher. In Japan, although the rate of overweight/obesity has rapidly increased during the past decade,22 it is low in comparison with other developed countries. In other developed countries and Japan, body weight is positively associated with the risks of lifestyle-related disease and mortality.23 Therefore, it was important to determine the sociodemographic correlates of screen time associated with weight status in the present study.From the present results, association between screen time and weight gain since age 20 were found among Japanese adults. By contrast, BMI was not associated with screen time, because only a small percentage of participants had a BMI of 25 kg/m7,24–28; however, those studies found no consistently significant relationship between age and general screen-based sedentary behavior.17 The results of the present study show a strong relationship between age and screen time. Therefore, interventions should aim to decrease leisure-time sedentary behavior among older Japanese adults.The present study found a positive association between screen time and age. Because previous studies assessed different age groups of adults, care should be taken in interpreting the present findings and comparing them with the results of earlier studies. Previous studies also reported that screen-based sedentary behavior differed by age29 The present study found that unmarried participants tended to report more screen time. Social support strongly correlates with physical activity level and enhances well-being. Being married is associated with an increased likelihood of engaging in health-promoting behaviors such as exercise, presumably because marital partners exert influence over each other’s behavior.21 However, a previous study found that the association between marital status and screen-based sedentary behavior was weak and that more evidence was needed.17 Thus, the results of the present study are important evidence for an association between marital status and screen-based sedentary behavior.Marriage, or a long-term relationship, significantly contributes to individual quality of life.17 provided evidence of a positive relationship between TV viewing (as part of screen-based sedentary behavior) and being unemployed, but associations between other sedentary behaviors and employment status were less clear. In the present study, unemployed individuals were more likely to report greater screen time. Studies that examined correlates of physical activity among Japanese adults found that unemployed adults were more likely than employed persons to engage in moderate-to-vigorous physical activity.30,31 Therefore, when designing interventions to promote the health of unemployed persons, measures to decrease screen-based sedentary behavior may be required, in addition to those aimed at increasing an already high level of physical activity.A previous study17 reported that current evidence of an association between living with a child and engaging in sedentary behavior was scant. However, only a limited number of studies have investigated this issue; further studies are needed to confirm any association between screen time and living arrangements.Living arrangements, sex, education level, and household income level were not associated with screen time in the present study. Participants were not asked for detailed information about the persons they lived with or about the nature of their relationship. Hence, the explanatory power of this information is limited; participants who answered that they lived with other people may be living with parents, siblings, or children, among other possibilities. A previous study32–38; however, other studies reported that the amount of screen time was greater among men than among women.7,27,39,40 Therefore, any approach to discourage screen time during leisure hours may need to target both Japanese women and men.The present study did not find a statistically significant sex difference in duration of screen-based sedentary behavior. Some previous studies found no evidence of a sex difference in screen-based sedentary behavior17 of data from other countries summarized associations between education, income, and screen-based sedentary behavior. The authors suggested that the association between income and TV viewing was inconclusive, that there was no association between income and amount of computer use, and that educational level may be inversely associated with TV viewing and positively associated with computer use. However, in the present study, neither education status nor household income level were associated with screen time. Therefore, to decrease sedentary behavior in relation to educational status and household income level, an effective approach might be to focus on screen-based sedentary behavior in the relevant segments of the Japanese adult population.Socioeconomic status may be a key factor in determining the health status of an individual. A systematic review41,42 In addition, the reliability and validity of the scale have yet to be demonstrated in Japan. Third, the study respondents slightly differed from the general population. To estimate the representativeness of participant responses, the adjusted prevalences of marital and employment statuses, by age bracket, were compared with data from the Japanese Population Census Survey of 2005.43 In the 2 surveys, the prevalence of married participants was 84.2% and 63.5%, respectively, among men and 85.0% and 63.8% among women. Regarding employment status, 85.6% and 66.3% of men, and 61.5% and 34.9% of women, respectively, worked full-time or part-time.44 Therefore, the basic characteristics of respondents might have been biased, and the findings in such a setting may not be applicable to the general population. However, the characteristics of the present population are sufficiently similar to those of the general population because the present study randomly selected participants from a registry of residential addresses of each city, which allowed an equal number of responses to be obtained from both sexes and from each age group category between age 40 and age 69 years. Fourth, the study included only participants aged 40 to 69 years, so the generalizability of the present study findings to other age groups is unclear and requires further assessment.The present study had limitations. First, the cross-sectional nature of the study limits conclusions regarding the causality of observed relationships of sociodemographic and anthropometric factors with screen time. Second, to estimate screen time, the study relied on self-reported measures that are subject to error, owing to different interpretations of the questions.Despite these limitations, few studies have examined the present topic among a randomly selected Japanese population. The present findings increase understanding of the determinants of screen time and may help in developing new strategies and interventions to promote public health and well-being in Japan.The present study identified sociodemographic and anthropometric factors associated with leisure-time screen-based sedentary behavior among Japanese adults. In the absence of similar studies in Japan, the present results will help in developing interventions to promote health and discourage screen-based sedentary behavior by targeting important determinants of sedentary pursuits in all sociodemographic groups, and especially among elderly, unmarried, and unemployed adults.Abstract in Japanese.


We describe the patient's clinical presentation, along with his cytogenetic analysis, and we compare the findings to those of similar case reports in the literature. We also perform a bioinformatic analysis in the chromosomal regions of segmental aneuploidy to find genes that could potentially explain the patient's phenotype.We present the case of an 18-month-old boy with dysmorphic facial features, developmental delay, growth retardation, bilateral clubfeet, thrombocytopenia, and strabismus, whose array CGH analysis revealed concurrent  Chromosomal abnormalities are common causes of multiple congenital anomalies. Complete chromosomal trisomies and monosomies of a few chromosomes (such as trisomy 21 and monosomy X) comprise the most common types of chromosomal abnormalities. Partial chromosomal trisomies and monosomies are less common, but are occasionally accounted in individual case reports. In this article, we report the case of a boy with partial trisomy 10p and partial monosomy 7p revealed by comparative genomic hybridization (CGH) analysis. We describe the patient's multiple congenital anomalies, and compare them with those of previously reported cases of either trisomy 10p or monosomy 7p. We also browse the patient's chromosomal regions of aneuploidy to find genes that could potentially give rise to the patient's signs and symptoms.The patient is an 18-month-old male born to a 29-year-old G1P0 Native American mother and a 40-year-old Honduran father at 40 weeks of gestation with several congenital anomalies. Maternal past medical history was significant for a history of a seizure disorder. She had not had a seizure in three years and was no longer on antiseizure medication. She did not take medications during pregnancy. There is no known family history of major developmental disabilities in either side of the family.At time of birth, the patient's Apgar scores were 6, 7, and 8 at 1, 5, and 10 minutes, respectively, weight of 2995 g (25th percentile), length of 50 cm (50th percentile), and occipital-frontal circumference (OFC) of 35 cm (30th percentile). Dysmorphic features included bitemporal narrowing, a very wide sagittal suture consistent with a bifid cranium with a large sagittal and metopic suture, posteriorly rotated ears, highly arched palate, micrognathia, frontal bossing, and redundant skin on the neck with a low-lying hairline in the posterior neck. Other findings of his physical examination included hirsutism on the back, congenital hip and knee dislocation bilaterally, bilateral clubfeet (status postcasting), sacral dimples, and enlarged nipples. Abnormal labs included thrombocytopenia , which spontaneously resolved. Workup for infections including TORCH infections was normal. He has had issues with recurrent otitis media. Imaging tests, head, renal, and sacral ultrasound along with skeletal survey X-rays were normal, and he passed the newborn hearing screening. de novo unbalanced translocation. Parental karyotypes and aCGH were normal. The final revised karyotype is described as 46,XY,der(7)t.arr 7p22.3x1,10 p15.3p11.22 x3, 10p11.22x4 dn.Standard chromosome analysis detected an abnormal male karyogram with additional chromosomal material of unidentifiable origin at the end for the short arm of one chromosome 7; 46,XY,add(7)(p22). Additional whole-genome array-based comparative genomic hybridization (aCGH) was performed on the proband and parental peripheral blood samples using the CMDX Oligo HD Scan to determine the origin of the additional material, and its clinical significance. The array contains 99,000+ probes covering coding and noncoding human genome sequences with content sourced from the UCSC hg18 human genome  and an average probe spatial resolution of ~21 Kb. Complete and partial karyograms are shown in The patient was evaluated at the genetics clinic for followup when he was 4.5 months old. On physical examination, the patient's weight was 6.2 kg (10th to 25th percentile), height was 66 cm (75th percentile), and OFC was 41.5 cm (25th percentile). In general, he looked well-nourished and in no acute distress. At this time, the patient was also noted to have hypertelorism with strabismus. His developmental milestones were delayed. He had some head control, and was starting to spend time with his face down, playing with his hands, cooing, making noises, and taking his hands to the midline grabbing at objects.On followup evaluation at 13.5 months of age, he was found to still have developmental delay. The patient had been receiving visual therapy for his strabismus , which was noted to be improving, and he was followed regularly in an ophthalmology clinic. He was also monitored routinely by orthopedics for his lower extremity anomalies, for which he had underwent postnatal, corrective surgeries.At the most recent genetics evaluation, he was 27 months of age and doing well. He had recurrent infections including otitis media, upper respiratory infections, and aspiration pneumonia. He had recently been diagnosed with asthma. He was growing well and gaining weight easily. He continued to have developmental delay and at 27 months was able to commando crawl and say a few words.http://projects.tcag.ca/variation/) and the Children's Hospital of Philadelphia (CHOP) copy number variation database (http://cnv.chop.edu/) did not yield any overlapping results.Individual cases of partial trisomy 10p11.22p15.3 and monosomy 7p22.3 have been previously reported in the literature. The combination of the two in a single patient, however, has not been reported. The first case of trisomy 10p, due to an unbalanced t  translocation, was that of two siblings described by Schleiermacher et al. 1974 [http://decipher.sanger.ac.uk/) for chromosomal aberrations in the affected chromosomal locations. Although many of the cases in the database reported nonspecific or no phenotypic information, several  mentioned developmental delay as well as micrognathia, hypertelorism, and anomalies in the skin and feet, in agreement with our case.Our patient's signs and symptoms, including his early growth retardation, feet anomaly, low platelet count, wide fontanelle, high-arched palate, micrognathia, and hypertelorism, have been previously associated with trisomy 10p in various case reports , 6, 7. PPFKP, TAF3) and possible hearing (MYO3A) signs and symptoms. PFKP, encoding the platelet isoform of the key regulatory phosphofructokinase enzyme, and TAF3, coding for an important member of the molecular transcription machinery, reported to be necessary for early hematopoiesis [TAF3's contribution to skeletal muscle development [OPTN, though mostly recognized in the literature for its role in the pathophysiology of glaucoma [MYO3A, a member of the myosin superfamily of genes on chromosome 10p, have been linked to progressive nonsyndromic hearing loss [These types of rearrangements are due to 2; 2 malsegregation during meiosis I, adjacent 1, single segment is the most likely type of malsegregation underlying this patient's unbalanced translocation, because one of the segments or the portions exchanged, on chromosome 7, is smaller 0.5 Mb) compared to the chromosome 10 segment . The 33 opoiesis , are pot Mb compaglaucoma , 10, maying loss .FAM20C and platelet-derived growth factor alpha (PDGFA), as genes that have potential roles in our patient's developmental delay and bone findings. FAM20C has been shown to be important for normal bone development, as individuals with loss of function mutations in the gene suffer from Raine syndrome, a fatal bone disorder [FAM20C have been reported to have wide fontanelles, as in our patient [PDGFA is also a critical gene for development, particularly for oligodendrocytes, as knockout mice have been observed to die soon after birth or as embryos, most probably due to myelin loss from abnormal oligodendrocyte development [Investigation of the few genes in the region of monosomy for chromosome 7p also revealed disorder . Patient patient . PDGFA ielopment , making PFKP, TAF3, OPTN, MYO3A, FAM20C, and PDGFA), among ~500 genes in the patient's affected chromosomal regions, which can possibly explain several of his developmentally related signs and symptoms. More patients like ours are expected to be identified through the current use of this powerful, genome-wide, high-resolution array technology. The description of the phenotype and the followup of such patients are critical for the understanding of these new conditions and the counseling of new affected patients. Further research is needed to identify the exact mechanisms by which these genes can cause such clinical findings.The relatively large region of trisomy on chromosome 10p, in addition to monosomy 7p, has caused several congenital anomalies in our patient, which affect almost all of his organ systems. Other examples of concurrent partial trisomy and monosomy of other chromosomes detected by array CGH, prenatally or postnatally, have been previously described in the literature . Althoug


Staphylococcus and Streptococcus) and Actinobacteria  were over-represented in the ICU with respect to the Hall. The phyllum Proteobacteria was also well represented in the ICU, mainly by members of the families Enterobacteriaceae, Methylobacteriaceae and Sphingomonadaceae. In the Hall sample, the phyla Proteobacteria, Bacteroidetes, Deinococcus-Thermus and Cyanobacteria were over-represented with respect to the ICU. Over-representation of Proteobacteria was mainly due to the high abundance of Enterobacteriaceae members. The presented results demonstrate that bacterial diversity differs at the ICU and entrance hall locations. Reduced diversity detected at ICU, relative to the entrance hall, can be explained by its confined character and by the existence of antimicrobial selective pressure. This is the first study using deep sequencing techniques made in hospital wards showing substantial hospital microbial diversity.Understanding microbial populations in hospital environments is crucial for improving human health. Hospital-acquired infections are an increasing problem in intensive care units (ICU). In this work we present an exploration of bacterial diversity at inanimate surfaces of the ICU wards of the University Hospital A Coruña (Spain), as an example of confined hospital environment subjected to selective pressure, taking the entrance hall of the hospital, an open and crowded environment, as reference. Surface swab samples were collected from both locations and recovered DNA used as template to amplify a hypervariable region of the bacterial 16S rRNA gene. Sequencing of the amplicons was performed at the Roche 454 Sequencing Center using GS-FLX Titanium procedures. Reads were pre-processed and clustered into OTUs , which were further classified. A total of 16 canonical bacterial phyla were detected in both locations. Members of the phyla Firmicutes (mainly  Direct studies of microorganisms that are difficult to culture  may now be performed by these modern techniques. Prokaryotic 16S ribosomal RNA genes (18S rRNA genes in the case of eukarya) have been commonly used for studying biodiversity since they are universally distributed in all cellular organisms and allow the identification and comparison of microorganisms present in a wide variety of environmental samples et al., In the last decade, many studies have been performed to describe microbial populations of samples ranging from the abyssal sea floor Enterococcus spp. (including VRE), Staphylococcus aureus (including MRSA), Clostridium difficile or Streptococcus pyogenes, and many gram-negative bacteria, such as Acinetobacter spp., Klebsiella spp., Pseudomonas aeruginosa, Serratia marcescens, or Shigella spp., may indeed survive for months on dry surfaces. A few others, such as Bordetella pertussis, Haemophilus influenzae, Proteus vulgaris, or Vibrio cholerae, however, persist only for days. In the present work we describe for the first time bacterial diversity in hospital environments using modern deep sequencing technologies. We present an exploration of the bacterial diversity at the ICU wards of the University Hospital A Coruña (Spain), as an example of confined hospital environment subjected to selective pressure, using 16S rRNA gene hypervariable region pyrosequencing. As a contrasting reference, we have also studied bacterial diversity at an open and crowded environment, the entrance hall of the hospital.Hospital-acquired infections are the sixth leading cause of death in the United States and similar data have been reported from Europe mp16S2f and mp16S2r from genomic DNA obtained from surface swab samples collected at ICU ward and at the entrance hall of the University Hospital A Coruña (Spain). The two collections of amplicons were subjected to 454 pyrosequencing at the Roche Sequencing Center. The number of reads obtained was 501707 and 346427 for ICU and Hall samples, respectively  were defined by clustering pre-processed, grouped and normalized reads as described in Materials and Methods. The number of OTUs detected at a distance of 0.03, which is assumed to correspond to the species level, was 1145 for the ICU sample and 2499 for Hall sample . The tothttp://www.cab.inta-csic.es/usb/HMG/. Supporting Information are interactive files therefore they have been included in an author’s website). Only 11 OTU representative sequences, corresponding to 34 individual reads, could not be classified (http://www.cab.inta-csic.es/usb/HMG/).Representative sequences from the 3000 OTUs detected at a distance of 0.03, corresponding to a total of 190174 sequence reads from the two samples, were classified up to genus level, as described in Materials and Methods  were calculated for each taxonomic node. The statistical significance of the differences was independently assessed by computing a Chi-Square test. A total of 16 canonical phyla were detected in the present study, including both locations, and, as illustrated in rd = 65; p-value = 0), which was mainly consequence of the high abundance of members of the Staphylococcus genus ; (ii) Lactobacillales, mainly represented by Streptococcus ; and (iii) Clostridiales, mainly represented by the family Veillonellaceae . The over representation of the phylum Actinobacteria was consequence of the high number of members of the order Actinomycetales  which was due to the abundant presence of members of the family Micrococcaceae , as well as the family Corynebacteriaceae  and Brevibacteriaceae . Other abundant group in ICU, although not over represented with respect to Hall, was phyllum Proteobacteria. Proteobacteria were mainly represented in ICU by the family Enterobacteriaceae and by four orders that were indeed over represented in ICU with respect to Hall; (i) Rhizobiales , specially members of the Methylobacterium genus ; (ii) Sphingomonadales, mainly from the Sphingomonas genus ; (iii) Pasteurellales ; and (iiii) Vibrionales . The phyla Proteobacteria, Bacteroidetes, Deinococcus-Thermus and Cyanobacteria were over represented in the Hall relative to ICU. The phylum Proteobacteria  was highly represented in the Hall as consequence of the abundance of Enterobacteriales , mainly as result of the predominant presence of unclassified members of the Enterobacteriaceae family . Other orders of Proteobacteria over represented in the Hall were: (i) Burkholderiales , specially the families Oxalobacteraceae  and Comamonadaceae ; (ii) Rhodobacteriales , mainly represented by the Paracoccus genus and (iii) Rhodospirillales . The phylum Bacteroidetes was over represented in the Hall mainly because of the abundance of Sphingobacteriales , especially members of the Hymenobacter genus  and, in a lesser degree, to the order Flavobacteriales . The phylum Deinococcus-Thermus was basically represented by the order Deinococcales, mainly from the Deinococcus genus . Finally, the over representation of the phylum Cyanobacteria  was mainly due to unclassified bacteria. For more details see Table A (http://www.cab.inta-csic.es/usb/HMG/). Although not over represented with respect to ICU, Firmicutes and Actinobacteria were also significantly present in the Hall. Among Firmicutes, the most abundant orders were Bacillales, mainly represented by the Staphylococcus genus, and Lactobacillales, mainly Streptococcus. Among Actinobacteria, the most abundant order was Actinomicetales, mainly represented in the Hall by the genera Corynebacterium and Propionibacterium (for more information see Dataset A in http://www.cab.inta-csic.es/usb/HMG/). In general, the Hall sample was associated to a higher diversity than that from ICU, in agreement with richness estimations (Ace and Chao1 indices), which were approximately two times higher for the first location (http://www.cab.inta-csic.es/usb/HMG/).To identify taxonomic nodes with differential presence in any of the two environments, observed frequencies were further normalized and relative differences (location . Howeverhttp://www.cab.inta-csic.es/usb/HMG/). Among Gammaproteobacteria, the predominant groups were the family Enterobacteriaceae, mainly members of the genera Escherichia, Enterobacter, Proteus, Citrobacter, Klebsiella, Serratia, Morganella and Salmonella, and the orders Pseudomonadales, mainly Pseudomonas, Acinetobacter and Moraxella, Pasteurellales, mainly Haemophilus, and Xanthomonadales, mainly Stenotrophomonas. The class Betaproteobacteria was mainly represented by the order Burkholderiales and specifically by members of the genus Bordetella. Other phylum detected in patient’s samples was Firmicutes, mainly represented by the orders Bacillales and Lactobacillales, with a predominance of the genera Staphylococcus, Enterococcus and Streptococcus. The phylum Bacteroidetes was also detected and represented by the order Bacteroidales, mainly Bacteroides, and the family Prevotellaceae, mainly Prevotella. Finally, the phylum Actinobacteria was represented in ICU patient samples by Corynebacterium members. All the microorganisms isolated from clinical samples are listed in Table B (http://www.cab.inta-csic.es/usb/HMG/).To recover information about infections caused in the ICU wards during the experimental period, data obtained from clinical isolates collected from ICU-hospitalized patients was analyzed. Most of the microorganisms isolated from clinical samples belonged to the phylum Proteobacteria, mainly from the classes Gammaproteobacteria and Betaproteobacteria  was not positively correlated with the diversity found. Although ICU ward is routinely strictly cleaned and supervised, a total of 15 canonical bacterial phyla were detected in this confined area in the present work. It was found that most of the microorganisms found in ICU belonged to the phyla Actinobacteria, Firmicutes, Proteobacteria and Bacteroidetes, that constituted 18.5%, 46.4%, 32.7%, and 1.4% of the bacterial community, respectively. These data agree with previous results obtained for microbial communities found in the human body Staphylococcus or Streptococcus, which are pathogens located in any area of the skin, hands or oral flora) except for the cases of Pseudomonas, Klebsiella, Haemophilus, Enterobacter, Citrobacter or Proteus, which are common pathogens well represented in the data obtained from the clinical samples and not very well represented in ICU environment as assessed by pyrosequencing data. This could be due to the type of samples collected for pyrosequencing in this study: samples were not collected from the mechanically controlled ventilation systems, catheters or other areas of highest colonization of the ICU patients including orofaringea, perineal-inguinal, umbilical cord, axillary, cervical or lower limbs, where most of these pathogens are presumably living. Moreover, genera as Haemophilus or Proteus persist only for days in dry surfaces Staphylococcus, Methylobacterium, Sphingomonas, Streptococcus or Corynebacterium. Staphylococcus, normal inhabitant of skin and mucosae, usually infects immunocompromised humans. As an extremely versatile pathogen, this genus has developed a broad spectrum of mechanisms leading to resistance to our most powerful antimicrobial agents which could explain its presence in ICU wards. S. aureus is, in fact, one of the major causes of hospital acquired infection, being normal flora of ICUs Methylobacterium members are methylotrophic bacteria that constitute part of the natural human foot and mouth flora. Certain species of Methylobacterium have been described in ICU wards causing bacteraemia in inmunosupressed patients Sphingomonas members are metabolically versatile and can use a wide range of naturally occurring compounds as carbon source, as well as some types of environmental contaminants. Its abundant presence in ICU could be explained because this genus has a good ability to utilize a wide range of organic compounds and to grow and survive under low-nutrient conditions, including toxic compounds S. paucimobilis has been previously detected in hospital equipment Streptococcus, a diverse and versatile genus that causes a broad range of diseases, is highly over-represented in ICU with respect to Hall sample. In the last years, antibiotic-resistant Streptococcus strains have started appearing and causing epidemics Corynebacterium genus, normal flora of human skin, is found in a broad variety of habitats such as soil, plant material, food products and marine and animal sources. During the last years, a very considerable number of new corynebacterial species have been described as causing diseases to both healthy and inmunocomprised hosts Microbiology has experienced a transformation during the last 30 years that has altered the microbiologistś point of view about microbial populations. Metagenomics opened new fields of research by providing access to far more microbial diversity than has been ever viewed in the Petri dish Cyanobacteria, Spirochaeta or Thiobacillus) have been detected in the Hall sample which could be due to the hospital location near the sea accompanied by the mild and damp climate of A Coruña.Strikingly, typical microorganisms naturally living in humid environments (i.e. Streptococcus or Staphylococcus). However, one of the most serious limitations of the present study lies on the sample size. It has to be taken into account that a bigger sample size including different hospital locations would improve or even modify the results. Even so, we could infer from the present study that the environment at ICU could be selecting for the presence of some species able to live in unfavourable conditions. We may conclude that the microbial biodiversity differs and it is reduced in a confined ward subjected to selective pressure (ICU) with respect to an outward-facing and crowded hospital entrance hall. Finally, in this study performed using new pyrosequencing technologies, we have found much more microbial diversity in hospital environments than ever seen before by classical methods. This study showed for the first time that hospital environments may act as filters selecting specific bacterial populations and creating special and confined areas where microbiota clearly differs from that present in nature.All over the data showed that in the Hall sample there is much more biodiversity than in the ICU sample and that the most represented groups in ICU are more abundant in this ward than in the entrance Hall in many cases (i.e. 2) and at the entrance hall (around 50 m2) of the University Hospital A Coruña, Spain. No specific permissions or ethics approval were required for these activities made at inanimate surfaces. No human samples were used. Sterile lints and gloves were used for swabbing all ICU surfaces. In the Boxes where patients are in bed, computer touch screens, monitors, drawers, infusion pumps, button panels of beds and respirator surfaces were swabbed. In the Pixies, computer touch screens and keyboards, door handles, drawers and gasometer surfaces were among the variety of sources from which samples were collected. In common areas and apparatus of the ICU wards, computer screens and keyboards, doors handles, cleaning room surfaces, medicine distributor surfaces, keyboard and electrodes of electrocardiographs, wreckers surfaces, knobs of refrigerators and drawers, microwaves and other surfaces were also cleaned with sterile lints. In the case of the entrance hall, all the accessible surfaces were combed and cleaned using sterile lints.Samples were collected in three consecutive days of June 2009 at 8:00 a.m., before the routine cleaning, in the ICU ward  containing sterile isotonic saline solution and incubated for 2–3 h at room temperature with gentle shaking. Then, lints were wringed out and the saline solution was filtered through 0.45 µm membranes (Millipore) and centrifuged 30 min a 4000 rpm in sterile tubes to recover the particulate fraction. At this point, all pellets from ICU and Hall samples were pooled into a single sample from each location.Both fraction pellets were resuspended in a buffer containing 20 mM Tris, pH 8, 2 mM EDTA and 1,2% Triton X-100. To digest the cell wall of the microorganisms supposedly present in the samples, the suspension was subjected to digestion using 10 mg/mL of lysozyme, 10 mg/mL of lysostaphin and 20 mg/mL of lyticase . Digestions were performed for 1 h, at 37°C, in all cases. The Genomic Purification Kit (Promega) was then employed to recover total DNA from both samples, following the manufacturer’s instructions for each microbial type.16Sforw; 5′-AGA GTT TGA TCC TGG CTC AG-3′ and 16Srev; 5′- GAC GGG CGG TGT GTR CA-3′, commonly used to amplify the complete 16S rRNA gene (ca. 1300 bp) as described by Grice et al., 2, 1 µL of a 40 mM of a mix of dNTPs, 5 µL of polymerase buffer, 0.5 µL of BioTaq polymerase (Bioline) and sterile water until 50 µL. The PCR program was as follows; one cycle of 95°C, 5 min followed by 20 cycles of 94°C, 30 s, 52°C, 30 s and 72°C, 1 min, and a final extension of 72°C, 2 min.In order to check the integrity of the 16S rRNA gene in the samples, oligonucleotides mp16S2f 5′-GCA TGG ITG TCG TCA GCT CGT G and mp16S2r 5′-ACG GIT ACC TTG TTA CGA CTT, using the primary DNA samples as template. The reaction mixture was as described above but using 1 µL of Expand High Fidelity polymerase (Roche). The PCR program was as follows; one cycle of 94°C, 2 min followed by 10 cycles of 94°C, 15 s, 52°C, 30 s and 72°C, 45 s and 20 cycles of 94°C, 15 s, 52°C, 30 s and 72°C, 2 min 25 s, with a final extension of 72°C during 7 min. Controls were performed without template.A segment of around 450–480 bp, containing the V7–V9 hypervariable regions of bacterial 16s rRNA gene PCR products were purified using the MinElute Purification kit (Qiagen) being the DNA finally resuspended in ultrapure nuclease-free water (Sigma-Aldrich).The concentration and the purity grade of the samples were finally evaluated using a NanoDrop ND-1000 (Thermo scientific) and a BIOANALYZER 2100 employing the Agilent High Sensitivity DNA kit .ca. 2 µg of each pure sample) was conducted in the Roche 454 Sequencing Center  using the GS-FLX Titanium chemistry and following the manufacturer’s protocol. Both ICU and Hall samples were sequenced in the same run.Sequencing of amplicons  between the numbers of reads classified in each sample was calculated and expressed as a percentage of the total number of reads classified in both samples for that taxonomic node. A Chi-Square test for homogeneity was also computed for each taxonomic node, to determine whether the normalized frequencies calculated for each sample were consistent with the null hypothesis that it is equally probable to detect a given taxon in any of the two samples.To identify taxonomic nodes for which a significant difference was observed in the number of reads associated to the ICU and Hall samples, the number of reads associated to each taxonomic node, for each of the samples, was further normalized by the total number of reads analysed classified by Mothur, after pre-processing and sub-sampling, for each sample. Then, for each taxonomic node, the relative difference A list of microorganisms isolated from clinical samples obtained from patients staying in ICU wards during the experimental period  was obtained from the records of the Microbiology Department of the University Hospital A Coruña. No specific permissions or ethics approval were required for these activities.The pyrosequencing-derived 16S rRNA gene sequence datasets have been deposited in the GenBank short-read archive under accession number SRA046412.1.


The purpose of this study was preparation and evaluation of sustained release matrix type ocular mini-tablets of timolol maleate, as a potential formulation for the treatment of glaucoma.in-vitro drug release.Following the initial studies on timolol maleate powder, it was formulated into ocular mini-tablets. The polymers investigated in this study included cellulose derivatives  and Carbopol 971P. Mannitol was used as the solubilizing agent and magnesium stearate as the lubricant. Mini-tablets were prepared by through mixing of the ingredients, followed by direct compression. All the prepared formulations were evaluated in terms of physicochemical tests, including uniformity of weight, thickness, crushing strength, friability and 1) contained ethyl cellulose, Carbopol 971P, mannitol and magnesium stearate, which showed almost 100% drug release over 5 h. Based on kinetic studies, this formulation was found to best fit the zero-order model of drug release. However, the Higuchi and Hixson -Crowell models also showed a good fit. Hence, overall, formulation C1 was chosen as the best formulation.Four groups of formulations were prepared. The presence of different amounts of cellulose derivatives or Carbopol 971P, alone, was studied in group A formulations. In group B formulations, the effect of adding Carbopol 971P alongside different cellulose derivatives was investigated. Group C formulations were made by including mannitol as the solubilizing agent, alongside Carbopol 971P and a cellulose derivative. In group D formulations, mini-tablets were made using Carbopol 971P, alongside two different cellulose derivative. The selected formulation (C Timolol maleate is a non-selective beta-adrenergic receptor antagonist indicated for treating glaucoma. Glaucoma is a disease in which the optic nerve is damaged, leading to progressive, irreversible loss of vision and topical beta-blockers are often used as a front line drugs for the treatment of glaucoma .Timolol maleate’s chemical name is (-)-l-(tert-butylamino)-3- [ oxy]-2-propanol maleate 1:1) . Timolol maleate has a molecular weight of 432.50. It is a white, odorless, crystalline powder which is soluble in water, methanol, and alcohol in-vitro methods . The rotating vial method was found to be the best match for in-vivo results, showing particularly high in-vitro/in-vivo correlation , hydroxyl ethyl cellulose  and Carbopol 971P were all purchased from Acros Co.. Magnesium stearate was obtained from JRS Pharma . Timolol maleate was gifted by Sina Daru . Mannitol and sodium chloride were supplied by the Merck Chemical Co. . Preparation of mini-tabletsGroup A formulations were made using individual polymers. Group B formulations were prepared by adding a cellulose derivative alongside Carbopol 971P, in order to prepare the mini-tablets. Group C formulations were prepared by including mannitol (as a solubilizing agent), besides Carbopol 971P and a cellulose derivative. Finally, group D formulations were made by combining three polymers, with all having Carbopol 971P and two different cellulose derivative. Characterization of the prepared mini-tablet formulationsin-vitro drug release, as follows:The prepared mini-tablets underwent various physiochemical tests, including the uniformity of weight, crushing strength, friability and Uniformity of weightThe uniformity of weight of the prepared mini-tablets was determined through weighing 10 tablets individually, using an electrical balance with an accuracy of 0.0001 g , and then calculating the average weight and standard deviation .Crushing strength (Hardness)Mini-tablets require a certain amount of strength (hardness) and resistance to friability, to withstand mechanical shocks of handling during manufacturing, packaging and transportation. The crushing strength of the mini-tablets was determined using a hardness tester   in a pharma-test friabilator , set at a speed of 25 rpm and faced falling shocks for 10 min. After 10 min, the glass beads were removed and tablets were re-weighed in order to determine the percentage of friability, based on the following equation  water bath at 32 ± 1 °C. Throughout the experiment, 300 µL aliquots were withdrawn at 20, 40, 60, 80, 120, 180, 240 and 300 min intervals, and subsequently replaced by an equal volume of NaCl 0.9%. The samples were measured using a UV spectrophotometer  at 294 nm  at 294 nm (Complementary studies on the selected formulationx), with the aid of solver tool. Statistical evaluation of the different properties of formulated minitablets was performed, using the one-way analysis of variance (ANOVA), along with the TuckE post Hoc test. For this purpose SPSS version 20 software was used. A statistical significance was defined at p < 0.05. The selected formulation underwent additional studies, including the assay of active ingredient and kinetic profile of drug release. The kinetic models  investigThe assay method used was based on that explained in a previous study, using a UV spectrophotometer  at 294 nm . The highest crushing strength in group B formulations was observed in formulation B1, since the combination of Carbopol 971P and EC hardens the mini-tablets. The uniformity of weight in all the group B formulations was found to be within the acceptable range of 7-8 mg . Hence, In terms of the friability, all the three formulations examined produced friabilities above 1%, which is not acceptable and is in excess of the acceptable limit of 1%.1 released 74% of its drug content within 5 h, which was found to be the greatest amount of drug release between the three formulations investigated in this group. This is probably due to the fact that EC is a highly hydrophobic polymer, which when used alongside the hydrophilic polymer, Carbopol 971P, provides a more porous structure which can help to enhance the entry of water within the tablet matrix and therefore a greater amount of drug release. The other two polymers, namely CMC and HEC, are hydrophilic polymers and when placed in contact with an aqueous medium, absorb water and form a dense and highly viscous gel-like matrix which hinders the exit of drug. Therefore, the amount of drug release from these two formulations was less than formulation B1.Finally, when considering the percentage of drug released from this group of formulations , formulaOverall, based on the results obtained from group B formulations, none were found to be acceptable in term of all the studies conducted.Results of group C ocular mini-tablet formulationsIn this group, the aim was to improve the release profile of drug release by reducing the amount of Carbopol 971P within the formulations and adding mannitol as the solubilizing agent . For thi1 showed the greatest crushing strength and the lowest friability among the formulations investigated. This could be due to the presence of mannitol, which can presumably increase the hardness as a result of having a good degree of compactibility. Formulations C2 and C3 had friability values in excess of 1%, making them unsuitable for further studies. The greater friability values of these two formulations could be due to the presence of CMC and HEC alongside mannitol. These polymers have lower compactibilities compared to mannitol and hence lowered the hardness and increased the friabilities of mini-tablets prepared.The uniformity of weight in group C formulations was in the normal range of 7-8 mg . Based on this finding, it seems that the combination of CMC along with EC can produce mini-tablets with a greater strength.In group C formulations it was found that the presence of HEC and CMC resulted in quick drug release from the mini-tablets, which is undesirable. Hence, it was decided to omit mannitol from these formulations. As a result, combinations of different cellulose derivatives  alongside Carbopol 971P were prepared . The res2 and D3 released all their drug content within 20 min and 80 min, respectively. Moreover, formulation D1 only managed to release around 50% of it’s drug content after 5 h , which was found to be within the acceptable range of 90-110% , again fitting the profile of drug release from formulation C1 to zero order kinetics, can be justified (1 is capable of releasing its’ drug content in a controlled manner, and hence is expected to provide a steady drug concentration in the eye for an extended period of time. Based on the results obtained, formulation C 90-110% . Hence, mulation . The matmulation  showed tustified . This woIn conclusion, it seems that the use of the hydrophobic polymer ethyl cellulose in combination with the hydrophilic polymer Carbopol 971P, alongside mannitol, could provide a good template for the preparation of a desirable matrix type ocular Timolol maleate mini-tablet. This combination could provide a controlled profile of drug release, which can presumably help to manage the disease much better than the conventional Timolol maleate eye drop formulation.