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Pace A, Steiner ME, Vercellotti GM, Somani A. Endothelial cell provenance: an unclear role in transplant medicine. FRONTIERS IN TRANSPLANTATION 2023; 2:1130941. [PMID: 38993867 PMCID: PMC11235371 DOI: 10.3389/frtra.2023.1130941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 04/11/2023] [Indexed: 07/13/2024]
Abstract
An understanding of the interplay between both donor endothelial progenitors and the recipient endothelium (in the case of hematopoietic cell transplant) and recipient endothelial provenance upon the established donor endothelium (in the case of solid organ transplant) is unknown. It is postulated that this interplay and consequences of purported dual endothelial populations may be a component of the post-transplant disease process and contribute to complications of engraftment or rejection. To address this potential confounding and often overlooked arena of vascular biology, a directed brief overview primarily focused on literature presented over the last decade is presented herein.
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Affiliation(s)
- Autumn Pace
- University of Minnesota Medical School, Minneapolis, MN, United States
| | - Marie E. Steiner
- Department of Pediatrics, Division of Hematology/Oncology, University of Minnesota Medical School, Minneapolis, MN, United States
- Department of Pediatrics, Division of Critical Care Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Gregory M. Vercellotti
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Arif Somani
- Department of Pediatrics, Division of Critical Care Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
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2
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Li M, Wang X, Wang Y, Bao S, Chang Q, Liu L, Zhang S, Sun L. Strategies for Remodeling the Tumor Microenvironment Using Active Ingredients of Ginseng-A Promising Approach for Cancer Therapy. Front Pharmacol 2022; 12:797634. [PMID: 35002732 PMCID: PMC8727883 DOI: 10.3389/fphar.2021.797634] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/06/2021] [Indexed: 12/21/2022] Open
Abstract
The tumor microenvironment (TME) plays a key role in promoting the initiation and progression of tumors, leading to chemoradiotherapy resistance and immunotherapy failure. Targeting of the TME is a novel anti-tumor therapeutic approach and is currently a focus of anti-tumor research. Panax ginseng C. A. Meyer (ginseng), an ingredient of well-known traditional Asia medicines, exerts beneficial anti-tumor effects and can regulate the TME. Here, we present a systematic review that describes the current status of research efforts to elucidate the functions and mechanisms of ginseng active components (including ginsenosides and ginseng polysaccharides) for achieving TME regulation. Ginsenosides have variety effects on TME, such as Rg3, Rd and Rk3 can inhibit tumor angiogenesis; Rg3, Rh2 and M4 can regulate the function of immune cells; Rg3, Rd and Rg5 can restrain the stemness of cancer stem cells. Ginseng polysaccharides (such as red ginseng acidic polysaccharides and polysaccharides extracted from ginseng berry and ginseng leaves) can regulate TME mainly by stimulating immune cells. In addition, we propose a potential mechanistic link between ginseng-associated restoration of gut microbiota and the tumor immune microenvironment. Finally, we describe recent advances for improving ginseng efficacy, including the development of a nano-drug delivery system. Taken together, this review provides novel perspectives on potential applications for ginseng active ingredients as anti-cancer adjuvants that achieve anti-cancer effects by reshaping the tumor microenvironment.
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Affiliation(s)
- Mo Li
- Department of Radiotherapy, The Second Hospital of Jilin University, Changchun, China.,Department of Thyroid Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Xin Wang
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Ying Wang
- Department of Breast Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Shunchao Bao
- Department of Radiotherapy, The Second Hospital of Jilin University, Changchun, China
| | - Qing Chang
- Department of Radiotherapy, The Second Hospital of Jilin University, Changchun, China
| | - Linlin Liu
- Department of Radiotherapy, The Second Hospital of Jilin University, Changchun, China
| | - Shuai Zhang
- Jilin Ginseng Academy, Changchun University of Chinese Medicine, Changchun, China
| | - Liwei Sun
- Research Center of Traditional Chinese Medicine, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, China
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3
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Zhang YL, Zhou TY, Ai J, Chen SQ, Chen F, Nie CH, Chen XH, Zhou GH, Wang HL, Zhu TY, Wang BQ, Yu ZN, Jing L, Wu LM, Zheng SS, Sun JH. Gene Therapy with Cytosine Deaminase and Endostatin Fusion Gene Mediated by Endothelial Progenitor Cells in Hepatomas. Cancer Manag Res 2020; 12:3023-3031. [PMID: 32431545 PMCID: PMC7198450 DOI: 10.2147/cmar.s245998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/05/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose Gene-targeting therapy provides a novel therapeutic approach for tumor treatment using genetically modified endothelial progenitor cells (EPCs) as cellular carriers. This study applied EPCs armed with cytosine deaminase (CD) and endostatin (ES) fusion gene in liver cancer to explore its therapeutic effect. Materials and Methods EPCs from heart blood of male BALB/c nude mice were cultured and transfected with CD and ES fusion gene. Subsequently, these genetically modified cells were injected into mice bearing hepatoma through their tail veins. The tumor volumes and cell apoptosis were followed up. Results Tumor volume in the group injected CD/ES-EPCs greatly decreased. The positive rate of VEGF and CD31 in the tumor tissue was lowest in the CD/ES-EPC group. Furthermore, the number of apoptotic cells was highest in the CD/ES-EPC group. Conclusion The EPCs transfected with CD/ES inhibited tumor growth and preferentially induced tumor cell apoptosis, providing a novel methodology for cancer-targeting therapy.
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Affiliation(s)
- Yue-Lin Zhang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, Zhejiang Province, People's Republic of China
| | - Tan-Yang Zhou
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, Zhejiang Province, People's Republic of China
| | - Jing Ai
- Eye Centre, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang Province, People's Republic of China
| | - Sheng-Qun Chen
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, Zhejiang Province, People's Republic of China
| | - Feng Chen
- Department of Radiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China
| | - Chun-Hui Nie
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, Zhejiang Province, People's Republic of China
| | - Xin-Hua Chen
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, Zhejiang Province, People's Republic of China
| | - Guan-Hui Zhou
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, Zhejiang Province, People's Republic of China
| | - Hong-Liang Wang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, Zhejiang Province, People's Republic of China
| | - Tong-Yin Zhu
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, Zhejiang Province, People's Republic of China
| | - Bao-Quan Wang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, Zhejiang Province, People's Republic of China
| | - Zi-Niu Yu
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, Zhejiang Province, People's Republic of China
| | - Li Jing
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, Zhejiang Province, People's Republic of China
| | - Li-Ming Wu
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, Zhejiang Province, People's Republic of China
| | - Shu-Sen Zheng
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, Zhejiang Province, People's Republic of China
| | - Jun-Hui Sun
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, People's Republic of China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, Zhejiang Province, People's Republic of China
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4
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Phillippi B, Singh M, Loftus T, Smith H, Muccioli M, Wright J, Pate M, Benencia F. Effect of laminin environments and tumor factors on the biology of myeloid dendritic cells. Immunobiology 2019; 225:151854. [PMID: 31753553 DOI: 10.1016/j.imbio.2019.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/26/2019] [Accepted: 10/01/2019] [Indexed: 12/25/2022]
Abstract
Dendritic cells (DCs) are immune cells that surveil the organism for infections or malignancies and activate specific T lymphocytes initiating specific immune responses. Contrariwise, DCs have been show to participate in the development of diseases, among them some types of cancer by inducing angiogenesis or immunosuppression. The ultimate fate of DC functions regarding their role in disease or health is prompted by signals from the microenvironment. We have previously shown that the interaction of DCs with various extracellular matrix components modifies the immune properties and angiogenic potential of these cells. The objective of the current studies was to investigate the angiogenic and immune profile of murine myeloid DCs upon interaction with laminin environments, with a particular emphasis on ovarian cancer. Our results show that murine ovarian tumors produce several types of laminins, as determined by PCR analysis, and also that tumor-associated DCs, both from ascites or solid tumors express adhesion molecules capable of interacting with these molecules as determined by flow cytometry and PCR analysis. Further, we established that DCs cultured on laminin upregulate both AKT and MEK signaling pathways, and that long-term culture on laminin surfaces decreases the immunological capacities of these cells when compared to the same cells cultured on synthetic substrates. In addition, we observed that tumor conditioned media was able to modify the metabolic status of these cells, and also reprogram the development of DCs from bone marrow precursors towards the generation of myeloid-derived suppressor cells. Overall, these studies demonstrate that the interaction between soluble factors and extracellular matrix components of the ovarian cancer microenvironment shape the biology of DCs and thus help them become co-conspirators of tumor growth.
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Affiliation(s)
- Ben Phillippi
- Department of Biomedical Sciences, Heritage College of Osteopathic Medicine, Ohio University, United States
| | - Manindra Singh
- Molecular and Cellular Biology Program, Ohio University, United States
| | - Tiffany Loftus
- Department of Biomedical Sciences, Heritage College of Osteopathic Medicine, Ohio University, United States
| | - Hannah Smith
- Department of Biomedical Sciences, Heritage College of Osteopathic Medicine, Ohio University, United States
| | - Maria Muccioli
- Molecular and Cellular Biology Program, Ohio University, United States
| | - Julia Wright
- Department of Biomedical Sciences, Heritage College of Osteopathic Medicine, Ohio University, United States
| | - Michelle Pate
- Department of Biomedical Sciences, Heritage College of Osteopathic Medicine, Ohio University, United States
| | - Fabian Benencia
- Department of Biomedical Sciences, Heritage College of Osteopathic Medicine, Ohio University, United States; Molecular and Cellular Biology Program, Ohio University, United States; Biomedical Engineering Program, Russ College of Engineering and Technology, Ohio University, United States; The Diabetes Institute at Ohio University, United States.
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5
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Lebaschi A, Nakagawa Y, Wada S, Cong GT, Rodeo SA. Tissue-specific endothelial cells: a promising approach for augmentation of soft tissue repair in orthopedics. Ann N Y Acad Sci 2018; 1410:44-56. [PMID: 29265420 DOI: 10.1111/nyas.13575] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 11/12/2017] [Accepted: 11/13/2017] [Indexed: 12/13/2022]
Abstract
Biologics are playing an increasingly significant role in the practice of modern medicine and surgery in general and orthopedics in particular. Cell-based approaches are among the most important and widely used modalities in orthopedic biologics, with mesenchymal stem cells and other multi/pluripotent cells undergoing evaluation in numerous preclinical and clinical studies. On the other hand, fully differentiated endothelial cells (ECs) have been found to perform critical roles in homeostasis of visceral tissues through production of an adaptive panel of so-called "angiocrine factors." This newly discovered function of ECs renders them excellent candidates for novel approaches in cell-based biologics. Here, we present a review of the role of ECs and angiocrine factors in some visceral tissues, followed by an overview of current cell-based approaches and a discussion of the potential applications of ECs in soft tissue repair.
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Affiliation(s)
- Amir Lebaschi
- Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, New York
| | - Yusuke Nakagawa
- Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, New York
| | - Susumu Wada
- Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, New York
| | - Guang-Ting Cong
- Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, New York
| | - Scott A Rodeo
- Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, New York.,Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York
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Chen H, Wang X, Zhou Q, Xu P, Liu Y, Wan M, Zhou M, Mao C. Preparation of Vascular Endothelial Cadherin Loaded-Amphoteric Copolymer Decorated Coronary Stents for Anticoagulation and Endothelialization. LANGMUIR : THE ACS JOURNAL OF SURFACES AND COLLOIDS 2017; 33:13430-13437. [PMID: 29084430 DOI: 10.1021/acs.langmuir.7b03064] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
A new strategy for preparation of blood-contact materials, with their short-term anticoagulation depending on zwitterionic structure and long-term hemocompatibility based on endothelialization, was proposed, performed, and proved. The copolymer made of sulfonamide zwitterionic and acrylic acid was designed and synthesized, and grafted to the surface of the bare metal coronary stent. Then, the vascular endothelial cadherin (VE-Cad), one of the specific antibodies of endothelial progenitor cells (EPCs), was fixed onto the copolymer chain. Finally, it is proved by in vitro blood tests that the coronary stent decorated with VE-Cad loaded-amphoteric copolymer displayed good platelet anti-adhesion characteristic. This anti-adhesion characteristic was attributed to the zwitterionic structure and the biofunctionality of specifically capturing EPCs confirmed by the results that the antibody-decorated coronary stent was trapped with EPCs. Finally, the in vivo implantation experiments of the antibody-decorated coronary stent in rabbit for 4 weeks were carried out. Results indicated that the endothelium and smooth surface of the antibody-loaded stent was found to be due to the covered effect of EPCs, without obvious intimal hyperplasia. The strategy we proposed has great potential in the design and preparation of blood-contact biomedical materials and devices.
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Affiliation(s)
- Huan Chen
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University , Nanjing, 210023, P.R. China
| | - Xiaobo Wang
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University , Nanjing, 210023, P.R. China
| | - Qian Zhou
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University , Nanjing, 210023, P.R. China
| | - Ping Xu
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University , Nanjing, 210023, P.R. China
| | - Yang Liu
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University , Nanjing, 210023, P.R. China
| | - Mimi Wan
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University , Nanjing, 210023, P.R. China
| | - Min Zhou
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affliated Hospital of Nanjing University Medical School , Nanjing, 210008, P.R. China
| | - Chun Mao
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University , Nanjing, 210023, P.R. China
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7
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Fazioli F, Colella G, Miceli R, Di Salvatore MG, Gallo M, Boccella S, De Chiara A, Ruosi C, de Nigris F. Post-surgery fluids promote transition of cancer stem cell-to-endothelial and AKT/mTOR activity, contributing to relapse of giant cell tumors of bone. Oncotarget 2017; 8:85040-85053. [PMID: 29156702 PMCID: PMC5689592 DOI: 10.18632/oncotarget.18783] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 05/29/2017] [Indexed: 12/21/2022] Open
Abstract
Giant cell tumors of bone (GCTB) are rare sarcomas with a high rate of unpredictable local relapse. Studies suggest that surgical methods affect recurrence, supporting the idea that local disease develops from re-growth of residual cancer cells. To identify early prognostic markers of individual risk of recurrence, we evaluated the effect of post-surgery fluids from a cohort of GCTB patients on growth of primary and established sarcoma cell lines, and mice xenograph. Post-surgery fluids increased cell growth and enhanced expression of CD44++, the principal receptor for the extracellular matrix component hyaluronan and the mesenchymal stem marker CD117+. Cancer cells became highly invasive and tumorigenic, acquiring stemness properties, and activated AKT/mTOR pathway. Prolonged stimulation with post-surgery fluids down-regulated the mesenchymal gene TWIST1 and Vimentin protein, and transdifferentiated cells into tubule-like structures positive to the endothelial markers VE-Cadherin and CD31+. In mice, post-surgery fluids gave rise to larger and more vascularized tumors than control, while in patients AKT/mTOR pathway activation was associated with recurrence by logistic regression (Kaplan-Meier; P<0.001). These findings indicate that post-surgery fluids are an adjuvant in mechanisms of tumor regrowth, increasing stem cell growth and AKT/mTOR activity.
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Affiliation(s)
- Flavio Fazioli
- Division of Musculoskeletal Oncology Surgery, National Cancer Institute G. Pascale, Naples, Italy
| | - Gianluca Colella
- Department of Human Health, Federico II University of Naples, Naples, Italy
| | - Roberta Miceli
- S.C. Cellular Biology and Biotherapy, National Cancer Institute G. Pascale, Naples, Italy
| | | | - Michele Gallo
- Division of Musculoskeletal Oncology Surgery, National Cancer Institute G. Pascale, Naples, Italy
| | - Serena Boccella
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples Italy
| | - Annarosaria De Chiara
- Division of Pathology, National Cancer Institute G. Pascale Foundation, Naples, Italy
| | - Carlo Ruosi
- Department of Human Health, Federico II University of Naples, Naples, Italy
| | - Filomena de Nigris
- Department of Biochemistry, Biophysics and General Pathology, University of Campania "Luigi Vanvitelli", Naples Italy
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