1.The prevalence of CYP2D6 Gene Polymorphisms among Filipinos and their use as biomarkers for lung cancer risk
Eva Maria Cutiongco-de la Paz ; Corazon A. Ngelangel ; Aileen David-Wang ; Jose B. Nevado Jr. ; Catherine Lynn T. Silao ; Rosalyn Hernandez-Sebastian ; Richmond B. Ceniza ; Leander Linus Philip P. Simpao ; Lakan U. Beratio ; Eleanor A. Dominguez ; Albert B. Albay Jr ; Rey A. Desales ; Nelia Tan-Liu ; Sullian Sy-Naval ; Roberto M. Montevirgen ; Catalina de Siena Gonda-Dimayacyac ; Pedrito Y. Tagayuna ; Elizabeth A. Nuqui ; Arnold Joseph M. Fernandez ; Andrew D. Dimacali ; Maria Constancia Obrerro-Carrillo ; Virgilio P. Banez ; Oliver G. Florendo G. Florendo ; Ma. Cecilia M. Sison ; Francisco T. Roxas ; Alberto B. Roxas ; Orlino C. Bisquera Jr. ; Luminardo M. Ramos ; John A. Coloma ; Higinio T. Mappala ; Alex C. Tapia ; Emmanuel F. Montana Jr. ; Jonathan M. Asprer ; Reynaldo O. Joson ; Sergio P. Paguio ; Conrado C. Cajucom ; Richard C. Tia ; Tristan Chipongian ; Joselito F. David ; Florentino C. Doble ; Maria Noemi G. Pato ; Hans Francis D. Ferraris ; Benito B. Bionat Jr. ; Adonis A. Guancia ; Eriberto R. Layda ; Frances Maureen C. Rocamora ; Roemel Jeusep Bueno ; Carmencita D. Padilla
Acta Medica Philippina 2017;51(3):207-215
Objectives:
The highly polymorphic nature of the CYP2D6 gene and its central role in the metabolism of commonly used drugs make it an ideal candidate for pharmacogenetic screening. This study aims to determine the prevalence of CYP2D6 polymorphisms among Filipinos and their association to lung cancer.
Method:
Forty seven single nucleotide polymorphisms (SNPs) of the CYP2D6 gene were genotyped from DNA samples of 115 cases with lung cancer and age- and sex-matched 115 controls.
Results:
Results show that 18 out of 47 polymorphisms have significant genotypic variability (>1% for at least 2 genotypes). No variant is associated with lung cancer. However, rs1135840,
rs16947 and rs28360521, were found to be highly variable among Filipinos.
Conclusion
This study demonstrated that CYP2D6 polymorphisms are present among Filipinos, which, although not found to be associated with lung cancer, can be useful biomarkers for future pharmacogenetic studies. The SNP rs16947 is found to be associated with cancer and timolol-induced bradycardia; the SNP rs1135840, on the other hand, is only shown to be linked with cancer. The genetic variant rs28360521 is known to be associated with low-dose aspirin-induced lower gastrointestinal bleeding.
Pharmacogenetics
;
Cytochrome P-450 CYP2D6
;
Lung Neoplasms
;
Biomarkers
2.Molecular detection and phylogenetic analysis of Wolbachia infection in common mosquito species in Henan Province.
Y LIU ; D WANG ; Z HE ; D QIAN ; Y LIU ; C YANG ; D LU ; H ZHANG
Chinese Journal of Schistosomiasis Control 2023;35(4):389-393
OBJECTIVE:
To investigate the infection and genotypes of Wolbachia in common mosquito species in Henan Province, so as to provide insights into management of mosquito-borne diseases.
METHODS:
Aedes, Culex and Anopheles samples were collected from cowsheds, sheepfolds and human houses in Puyang, Nanyang City and Xuchang cities of Henan Province from July to September, 2022, and the infection of Wolbachia was detected. The 16S rDNA and wsp genes of Wolbachia were amplified and sequenced. Sequence alignment was performed using the BLAST software, and the obtained 16S rDNA gene sequence was compared with the sequence of the 16S rDNA gene in GenBank database. In addition, the phylogenetic trees were created based on 16S rDNA and wsp gene sequences using the software MEGA 11.0.
RESULTS:
A total 506 female adult mosquitoes were collected from three sampling sites in Nanyang, Xuchang City and Puyang cities from July to September, 2022. The overall detection of Wolbachia was 45.1% (228/506) in mosquitoes, with a higher detection rate in A. albopictus than in Cx. pipiens pallens [97.9% (143/146) vs. 50.6% (85/168); χ2 = 88.064, P < 0.01]. The detection of Wolbachia in Cx. pipiens pallens was higher in Xuchang City (96.8%, 62/64) than in Nanyang (15.6%, 7/45) and Puyang cities (27.1%, 16/59) (χ2 = 89.950, P < 0.01). The homologies of obtained Wolbachia 16S rDNA and wsp gene sequences were 95.3% to 100.0% and 81.7% to 99.8%. Phylogenetic analysis based on wsp gene sequences showed Wolbachia supergroups A and B in mosquito samples, with wAlbA and wMors strains in supergroup A and wPip and wAlbB strains in supergroup B. Wolbachia strain wAlbB infection was detected in A. albopictus in Puyang and Nanyang Cities, while Wolbachia strain wPip infection was identified in A. albopictus in Xuchang City. Wolbachia strain wAlbA infection was detected in Cx. pipiens pallens sampled from three cities, and one Cx. pipiens pallens was found to be infected with Wolbachia strain wMors in Nanyang City.
CONCLUSIONS
Wolbachia infection is commonly prevalent in Ae. albopictus and Cx. pipiens pallens from Henan Province, and Wolbachia strains wAlbB and wAlbA are predominant in Ae. albopictus, while wPip strain is predominant in Cx. pipiens pallens. This is the first report to present Wolbachia wMors strain infection in Cx. pipiens pallens in Henan Province.
Animals
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Humans
;
Phylogeny
;
Wolbachia/genetics*
;
Culex/genetics*
;
Aedes/genetics*
;
DNA, Ribosomal
3.Stratified sampling survey of major human parasitic diseases in Henan province.
B L XU ; H W ZHANG ; Y DENG ; Z L CHEN ; W Q CHEN ; D L LU ; Y L ZHANG ; Y L ZHAO ; X M LIN ; Q HUANG ; C Y YANG ; Y LIU ; R M ZHOU ; P LI ; J S CHEN ; L J HE ; D QIAN
Chinese Journal of Epidemiology 2018;39(3):322-328
Objective: To understand the prevalence of major human parasitic diseases and related factors in Henan province. Methods: This stratified sampling survey was carried out according to the requirement of national survey protocol of major human parasitic diseases, 2014-2015. The prevalence of soil-transmitted helminths infection, taeniasis and intestinal protozoiasis were surveyed in 104 sites selected from 35 counties (districts) and the prevalence of clonorchiasis was surveyed in 62 sites selected from 37 townships. In each survey spot, 250 persons were surveyed. A total of 26 866 persons and 15 893 persons were surveyed. Modified Kato-Katz thick smear was used to detect the eggs of intestinal helminthes. Tube fecal culture was used to identify the species of hookworm. The Enterobius eggs were detected in children aged 3 to 6 years by using adhesive tape. The cyst and trophozoite of intestinal protozoa were examined with physiological saline direct smear method and iodine stain method. Results: The overall infestation rate of intestinal parasites was2.02% in Henan, and the worm infection rate was higher than protozoa infection rate. Fourteen kinds of intestinal parasites were found, including nematode (5 species), trematode (2 species), and protozoan (7 species). The infection rate of Enterobius vermicularis was highest, and Qinba Mountain ecological area had the highest infestation rate of intestinal parasites in 4 ecological areas of Henan. There was no significant difference in intestinal parasite infection rate between males and females (χ(2)=3.630, P=0.057), and the differences in intestinal parasite infection rate among different age groups had significance (χ(2)=124.783, P=0.000 1). The infection rate reached the peak in age group ≤9 years and the major parasite was Enterobius vermicularis. Furthermore the overall human infection rate of parasite showed a downward trend with the increase of educational level of the people (χ(2)=70.969, P=0.000 1), the differences had significance (χ(2)=120.118, P=0.000 1). For different populations, the infection rate of intestinal parasites was highest among preschool children. The infection of intestinal helminth was mainly mild, only 2 severe cases were detected. The infection rate of Clonorchis sinensis in urban residents was only 0.006%. Logistic regression analysis showed that being preschool children (χ(2)=15.765, P=0.000 1) and drinking well water (χ(2)=45.589, P=0.000 1) were the risk factors for intestinal parasite infection, and annual income per capita of farmers was the protective factor against intestinal parasite infection. The infection rates of protozoa and intestinal parasites decreased sharply compared with the results of previous two surveys, and the rate of intestinal helminth infection also dropped sharply compared with the second survey. The numbers of protozoa, helminth and intestinal parasites detected in this survey were all less than the numbers found in the previous two surveys. Conclusions: Compared the results of three surveys in Henan, the infection rate of protozoa and intestinal parasites showed a downward trend. The prevention and treatment of Enterobius vermicularis infection in children should be the key point of parasitic disease control in the future.
Animals
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Child
;
Child, Preschool
;
Clonorchiasis/epidemiology*
;
Farmers
;
Feces/parasitology*
;
Female
;
Helminthiasis/epidemiology*
;
Helminths
;
Humans
;
Intestinal Diseases, Parasitic/parasitology*
;
Male
;
Prevalence
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Protective Factors
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Risk Factors
;
Rural Population
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Soil Microbiology
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Surveys and Questionnaires
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Taeniasis/epidemiology*
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Trematode Infections/parasitology*
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Urban Population
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Water Wells
4.Study on the super-antigen genes of group A Streptococcus pyogenes strains isolated from patients with scarlet fever and pharyngeal infection, in Beijing, 2015-2017.
C N MA ; X M PENG ; S S WU ; D T ZHANG ; J C ZHAO ; G L LU ; Y PAN ; S J CUI ; Y M LIU ; W X SHI ; M ZHANG ; Q Y WANG ; P YANG
Chinese Journal of Epidemiology 2018;39(10):1375-1380
Objective: To analyze the characteristics of super-antigen (SAg) of group A Streptococcus pyogenes (GAS), isolated from patients with scarlet fever or pharyngeal infections in Beijing between 2015-2017. Methods: Throat swab specimens from patients with scarlet fever or pharyngeal infections were collected and tested for GAS. Eleven currently known SAg genes including SpeA, speC, speG, speH, speI, speJ, speK, speL, speM, smeZ and ssa were tested by real-time PCR while M protein genes (emm genes) were amplified and sequenced by PCR. Results: A total of 377 GAS were isolated from 6 801 throat swab specimens, with the positive rate as 5.5%. There were obvious changes noticed among speC, speG, speH and speK in three years. A total of 45 SAg genes profiles were observed, according to the SAgs inclusion. There were significant differences appeared in the frequencies among two of the highest SAg genes profiles between emm1 and emm12 strains (χ(2)=38.196, P<0.001; χ(2)=72.310, P<0.001). There also appeared significant differences in the frequencies of speA, speH, speI and speJ between emm1 and emm12 strains (χ(2)=146.154, P<0.001; χ(2)=52.31, P<0.001; χ(2)=58.43, P<0.001; χ(2)=144.70, P<0.001). Conclusions: Obvious changes were noticed among SAg genes including speC, speG, speH and speK from patients with scarlet fever or pharyngeal infections in Beijing between 2015-2017. SAg genes including speA, speH, speI and speJ appeared to be associated with the emm 1 and emm 12 strains. More kinds of SAg genes profiles were isolated form GAS but with no significant differences seen in the main SAg genes profiles, during the epidemic period.
Antigens, Bacterial/genetics*
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Bacterial Outer Membrane Proteins
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Bacterial Proteins
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Beijing/epidemiology*
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China/epidemiology*
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Exotoxins
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Female
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Humans
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Membrane Proteins
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Pharyngitis/microbiology*
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Pharynx/microbiology*
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Pregnancy
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Pregnancy Complications, Infectious/microbiology*
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Real-Time Polymerase Chain Reaction
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Scarlet Fever/microbiology*
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Streptococcal Infections
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Streptococcus pyogenes/isolation & purification*
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Superantigens/genetics*
5.Genetic polymorphisms in NAT1, NAT2, GSTM1, GSTP1 and GSTT1 and susceptibility to colorectal cancer among Filipinos
Eva Maria C. Cutiongco-de la Paz ; Corazon A. Ngelangel ; Virgilio P. Bañ ; ez ; Francisco T. Roxas ; Catherine Lynn T. Silao ; Jose B. Nevado Jr. ; Alberto B. Roxas ; Oliver G. , Florendo ; Ma. Cecilia M. Sison ; Orlino Bisquera, Jr ; Luminardo M. Ramos ; Elizabeth A. Nuqui ; Arnold Joseph M. Fernandez ; Maria Constancia O. Carrillo ; Beatriz J. Tiangco ; Aileen D. Wang ; Rosalyn H. Sebastian ; Richmond B. Ceniza ; Leander Linus Philip P. Simpao ; Lakan U. Beratio ; Eleanor A. Dominguez ; Albert B. Albay Jr. ; Alfredo Y. Pontejos Jr. ; Nathaniel W. Yang ; Arsenio A. Cabungcal ; Rey A. Desales ; Nelia S. Tan-Liu ; Sullian S. Naval ; Roberto M. Montevirge ; Catalina de Siena E. Gonda-Dimayacyac ; Pedrito Y. Tagayuna ; John A. Coloma ; Gil M. Vicente ; Higinio T. Mappala ; Alex C. Tapia ; Emmanuel F. Montana Jr. ; Jonathan M. Asprer ; Reynaldo O. Joson ; Sergio P. Paguio ; Tristan T. Chipongian ; Joselito F. David ; Florentino C. Doble ; Maria Noemi G. Pato ; Benito B. Bionat Jr ; Hans Francis D. Ferraris ; Adonis A. Guancia ; Eriberto R. Layda ; Andrew D. Dimacali ; Conrado C. Cajucom ; Richard C. Tia ; Mark U. Javelosa ; Regie Lyn P. Santos-Cortez ; Frances Maureen C. Rocamora ; Roemel Jeusep Bueno ; Carmencita D. Padilla
Acta Medica Philippina 2017;51(3):216-222
Objectives. Polymorphisms in metabolic genes which alter rates of bioactivation and detoxification have been shown to modulate susceptibility to colorectal cancer. This study sought to evaluate the colorectal cancer risk from environmental factors and to do polymorphism studies on genes that code for Phase I and II xenobiotic metabolic enzymes among Filipino colorectal cancer patients and matched controls. Methods. A total of 224 colorectal cancer cases and 276 controls from the Filipino population were genotyped for selected polymorphisms in GSTM1, GSTP1, GSTT1, NAT1 and NAT2. Medical and diet histories, occupational exposure and demographic data were also collected for all subject participants.Results. Univariate logistic regression of non-genetic factors identified exposure to UV (sunlight) (OR 1.99, 95% CI: 1.16-3.39) and wood dust (OR 2.66, 95% CI: 1.21-5.83) and moldy food exposure (OR 1.61, 95% CI:1.11-2.35) as risk factors; while the NAT2*6B allele (recessive model OR 1.51, 95% CI :1.06-2.16; dominant model OR 1.87, 95% CI: 1.05-3.33) and homozygous genotype (OR 2.19, 95% CI: 1.19-4.03) were found to be significant among the genetic factors. After multivariate logistic regression of both environmental and genetic factors, only UV radiation exposure (OR 2.08, 95% CI: 1.21-3.58) and wood dust exposure (OR 2.08, 95% CI: 0.95-5.30) remained to be significantly associated with increasing colorectal cancer risk in the study population.Conclusion. This study demonstrated that UV sunlight and wood dust exposure play a greater role in influencing colorectal cancer susceptibility than genotype status from genetic polymorphisms of the GST and the NAT` genes.
Colorectal Neoplasms
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Polymorphism, Genetic
6.A cohort study on body mass index and risk of all-cause mortality among hypertensive population.
X J LIU ; B Y WANG ; Y C REN ; Y ZHAO ; D C LIU ; D D ZHANG ; X CHEN ; L L LIU ; C CHENG ; F Y LIU ; Q G ZHOU ; G Z CHEN ; S H HONG ; D LIU ; S Q HU ; M ZHANG ; D S HU
Chinese Journal of Epidemiology 2018;39(7):914-919
Objective: To investigate the relationship between body mass index (BMI) and all-cause mortality in hypertensive population. Methods: All participants were selected from a prospective cohort study based on a rural population from Henan province, China. Cox proportional hazards regression models were used to estimate the associations of different levels of BMI stratification with all-cause mortality. Restricted cubic spline models were used to detect the dose-response relation. Results: Among the 5 461 hypertensive patients, a total of 31 048.38 person-years follow-up was conducted. The median of follow-up time was 6 years, and 589 deaths occurred during the follow-up period. Compared to normal weight group (18.5 kg/m(2)
Adult
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Asian People/statistics & numerical data*
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Blood Pressure/physiology*
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Body Mass Index
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Cause of Death
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China/epidemiology*
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Humans
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Hypertension/mortality*
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Middle Aged
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Mortality
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Obesity/mortality*
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Overweight
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Prospective Studies
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Risk Factors
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Young Adult
7.Cases diagnosis of imported malaria in Jiangsu province, 2014-2016.
Y Y CAO ; W M WANG ; H Y ZHOU ; G D ZHU ; S XU ; Y P GU ; C ZHANG ; Y B LIU ; J CAO
Chinese Journal of Epidemiology 2018;39(2):218-221
Objective: To understand the situation related to health seeking and diagnosis of imported malaria and to provide practical measures for malaria elimination in Jiangsu province. Methods: Data on imported malaria cases in Jiangsu province was retrieved in CISDCP from 2014 to 2016. Relevant information on health seeking behavior, diagnosis and treatment of the disease was gathered. Results: A total of 1 068 imported cases were reported in Jiangsu province from 2014 to 2016. Except for one malaria case that was caused by blood transfusion, the rest patients were all recognized as 'imported'. Majority of the cases were migrant laborers working in African countries. The accurate rates on the diagnosis of ovale, vivax and quartan malaria and mixed infection were relatively low, as 79.3% (107/135), 29.5% (18/61), 52.9% (18/34) and 0.0% (0/2) at the primary health care settings, respectively. Rate of seeking health care on the same day of onset was more in 2015 than in 2014 and 2016 (χ(2)=18.6, P=0.001). While only 65.4% (699/1 068) of the patients were diagnosed correctly at the primary health care settings. There appeared no statistical difference in the 3-year-study period (χ(2)=5.4, P=0.246). Capacity on 'correct diagnosis' seemed stronger at the CDC than at the hospital levels (χ(2)=13.2, P=0.000; χ(2)=5.4, P=0.020). Totally, 72.7% (32/44) of the severe falciparum malaria cases did not immediately seek for health care when the symptoms started. Conclusions: Migrant workers returning from the high endemic malaria areas seemed to have poor awareness in seeking health care services. Capability on correct diagnosis for malaria at the primary health care settings remained unsatisfactory and staff from these settings needs to receive adequate training.
Adult
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China/epidemiology*
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Female
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Human Migration
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Humans
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Malaria/transmission*
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Male
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Middle Aged
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Plasmodium/isolation & purification*
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Prevalence
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Seasons
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Transients and Migrants
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Travel
8.Development of Human in vitro Brain-blood Barrier Model from Induced Pluripotent Stem Cell-derived Endothelial Cells to Predict the in vivo Permeability of Drugs.
Yuan LI ; Xueying SUN ; Houfu LIU ; Liang HUANG ; Guofeng MENG ; Yu DING ; Wenji SU ; Jiaqi LU ; Sophie GONG ; Georg C TERSTAPPEN ; Ru ZHANG ; Wandong ZHANG
Neuroscience Bulletin 2019;35(6):996-1010
An in vitro blood-brain barrier (BBB) model is critical for enabling rapid screening of the BBB permeability of the drugs targeting on the central nervous system. Though many models have been developed, their reproducibility and renewability remain a challenge. Furthermore, drug transport data from many of the models do not correlate well with the data for in vivo BBB drug transport. Induced-pluripotent stem cell (iPSC) technology provides reproducible cell resources for in vitro BBB modeling. Here, we generated a human in vitro BBB model by differentiating the human iPSC (hiPSC) line GM25256 into brain endothelial-type cells. The model displayed BBB characteristics including tight junction proteins (ZO-1, claudin-5, and occludin) and endothelial markers (von Willebrand factor and Ulex), as well as high trans-endothelial electrical resistance (TEER) (1560 Ω.cm ± 230 Ω.cm) and γ-GTPase activity. Co-culture with primary rat astrocytes significantly increased the TEER of the model (2970 Ω.cm to 4185 Ω.cm). RNAseq analysis confirmed the expression of key BBB-related genes in the hiPSC-derived endothelial cells in comparison with primary human brain microvascular endothelial cells, including P-glycoprotein (Pgp) and breast cancer resistant protein (BCRP). Drug transport assays for nine CNS compounds showed that the permeability of non-Pgp/BCRP and Pgp/BCRP substrates across the model was strongly correlated with rodent in situ brain perfusion data for these compounds (R = 0.982 and R = 0.9973, respectively), demonstrating the functionality of the drug transporters in the model. Thus, this model may be used to rapidly screen CNS compounds, to predict the in vivo BBB permeability of these compounds and to study the biology of the BBB.
9.Effects of genipin on the proliferation and mitochondrial function of hypopharyngeal carcinoma FaDu cells
PENG Yao1a ; ZHOU Ying1b ; GAO Yu1c ; LIU Ying1a ; XU Aofeng2 ; ZHANG Chang1b ; ZHANG Chunjing1a ; YU Haitao1d
Chinese Journal of Cancer Biotherapy 2024;31(7):681-686
[摘 要] 目的:探讨解偶联蛋白2(UCP2)抑制剂京尼平(GEN)对人下咽癌FaDu细胞增殖及线粒体功能的影响。方法:使用不同浓度的GEN作用于FaDu细胞24 h,实验分为GEN 0(对照)、50、100、200和400 μmol/L组。采用CCK-8法检测各组细胞增殖能力,DCFH-DA探针及JC-1染色联合流式细胞术检测GEN对FaDu细胞活性氧(ROS)含量及线粒体膜电位的影响,激光共聚焦显微镜观察GEN对FaDu细胞线粒体膜通透性转换孔的影响,可见分光光度法检测细胞中乳酸的含量,WB法检测细胞中UCP2蛋白的表达变化。结果:与对照组相比,GEN可显著抑制FaDu细胞的增殖活力(P<0.05或P<0.01)、细胞中UCP2蛋白的表达(P<0.05),降低线粒体膜电位(P<0.05或P<0.01)、乳酸含量(P<0.000 1),改变细胞线粒体膜孔道通透性,提高细胞中ROS水平(P<0.05或P<0.01)。结论:GEN通过调节细胞中UCP2的表达水平进而影响细胞的氧化还原能力及线粒体功能,从而发挥抑制人下咽癌FaDu细胞增殖并诱导细胞凋亡的作用。
10.Age-related modification effect on the association between body mass index and the risk of hypertension: A Cohort Study on Chinese people living in the rural areas.
D D ZHANG ; X J LIU ; B Y WANG ; Y C REN ; Y ZHAO ; F Y LIU ; D C LIU ; C CHENG ; X CHEN ; L L LIU ; Q G ZHOU ; Q H XU ; Y H XIONG ; J L LIU ; Z Y YOU ; M ZHANG ; D S HU
Chinese Journal of Epidemiology 2018;39(6):765-769
Objective: To study the modification effect of age on the association between body mass index and the risk of hypertension. Methods: People age ≥18 years old were selected by clusters, from a rural area of Henan province. In total, 20 194 people were recruited at baseline during 2007 and 2008, and the follow-up study was completed from 2013 to 2014. Logistic regression model was used to assess the risk of incident hypertension by baseline BMI and age-specific BMI. Results: During the 6-year follow-up period, 1 950 hypertensive persons were detected, including 784 men and 1 166 women, with cumulative incidence rates as 19.96%, 20.51%, and 19.61%, respectively. Compared with those whose BMI<22 kg/m(2), the RRs of hypertension were 1.09 (0.93-1.27), 1.17 (1.01-1.37), 1.34 (1.14-1.58) and 1.31 (1.09-1.56) for participants with BMI as 22-, 24-, 26- and ≥28 kg/m(2), respectively. In young and middle-aged populations, the risk of hypertension gradually increased with the rise of BMI (trend P<0.05). However, in the elderly, the increasing trend on the risk of hypertension risk was not as significantly obvious (trend P>0.05). Conclusion: The effect of BMI on the incidence of hypertension seemed to depend on age. Our findings suggested that a weight reduction program would be more effective on young or middle-aged populations, to prevent the development of hypertension.
Adolescent
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Age Factors
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Aged
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Asian People/statistics & numerical data*
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Body Mass Index
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Cohort Studies
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Female
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Follow-Up Studies
;
Humans
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Hypertension/ethnology*
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Incidence
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Logistic Models
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Male
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Middle Aged
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Risk Factors
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Rural Population