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Yang W, Ma K, Yin S, Wang W, An H, Huang Y, Guo H, Ao L, Yang Z, Zhang F. Multiomic Landscape of Primary Hypothyroidism Induced by Subchronic Exposure to Low-Dose Novel PFOS Substitute OBS in Human and Murine Models. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2025; 59:8329-8344. [PMID: 40178189 DOI: 10.1021/acs.est.4c10565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/05/2025]
Abstract
Sodium p-perfluorous nonenoxybenzenesulfonate (OBS) as a novel surrogate for perfluorooctanesulfonate (PFOS) has been extensively utilized in industrial manufacturing and daily life. However, studies on OBS-induced environmental health risks of obstructive biosynthesis (OBS) are currently limited, particularly the risk for thyroid diseases. Following the construction of in vivo (mouse) and in vitro (normal human primary thyrocytes) models of subchronic low-dose OBS exposure, we explored the thyroid-disrupting effects of OBS through multiomics approaches and experimental validations. Our results showed that subchronic exposure to low doses of OBS led to primary hypothyroidism in mice, presenting with reduced number and functional abnormalities of thyrocytes. Further in vitro assays confirmed that low-dose OBS-induced disulfidptosis, a newly discovered form of programmed cell death, in human primary thyrocytes. Meanwhile, exposure to low-dose OBS remarkably suppressed thyroid hormone synthesis pathways in mouse and human thyrocytes. The charted multiomic landscape of OBS-induced primary hypothyroidism in mammals revealed the thyroid toxicity and endocrine-disrupting properties of OBS, suggesting that it is not a safe alternative to PFOS.
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Affiliation(s)
- Wang Yang
- Chongqing Specialized Center for Diagnosis and Treatment of Thyroid Nodules and Thyroid Cancer, Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
- Department of Gastroenterology, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
- Key Laboratory of Medical Protection for Electromagnetic Radiation, Ministry of Education of China, Institute of Toxicology, College of Preventive Medicine, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Ke Ma
- Chongqing Specialized Center for Diagnosis and Treatment of Thyroid Nodules and Thyroid Cancer, Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
- Clinical Medical College, North Sichuan Medical College, Nanchong 637000, Sichuan, China
| | - Supeng Yin
- Chongqing Specialized Center for Diagnosis and Treatment of Thyroid Nodules and Thyroid Cancer, Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
| | - Weihua Wang
- Chongqing Specialized Center for Diagnosis and Treatment of Thyroid Nodules and Thyroid Cancer, Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
| | - Huihui An
- Medical Research Center, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
| | - Yinde Huang
- Chongqing Specialized Center for Diagnosis and Treatment of Thyroid Nodules and Thyroid Cancer, Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
| | - Hong Guo
- Department of Gastroenterology, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
| | - Lin Ao
- Key Laboratory of Medical Protection for Electromagnetic Radiation, Ministry of Education of China, Institute of Toxicology, College of Preventive Medicine, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Zeyu Yang
- Chongqing Specialized Center for Diagnosis and Treatment of Thyroid Nodules and Thyroid Cancer, Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
| | - Fan Zhang
- Chongqing Specialized Center for Diagnosis and Treatment of Thyroid Nodules and Thyroid Cancer, Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
- Clinical Medical College, North Sichuan Medical College, Nanchong 637000, Sichuan, China
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Sun M, Wu C, Jiang J, He Y, Zhu S, Yu Y. Hypertensive disorders of pregnancy affected thyroid hormone synthesis via endoplasmic reticulum stress in preterm infant rats. Heliyon 2025; 11:e41021. [PMID: 39790871 PMCID: PMC11714400 DOI: 10.1016/j.heliyon.2024.e41021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 11/14/2024] [Accepted: 12/05/2024] [Indexed: 01/12/2025] Open
Abstract
Background Maternal hypertensive disorders of pregnancy (HDP) was associated with increased risk of congenital hypothyroidism in preterm infants, but its underlying mechanisms remain unclear. Objective To investigate the possible mechanisms by which intrauterine exposure to HDP affects thyroid hormone synthesis in preterm infant rats. Methods preterm infant rats were obtained by Caesarean section delivery from the L-NAME group and Control groups which was induced by L-NAME and saline, respectively. Thyroid hormone levels of preterm infant rats were detected by ELISA, and morphology structure were observed by H&E staining and electron microscopy, and the expression of key factors of thyroid hormone synthesis and endoplasmic reticulum stress indicators were analyzed by RT-qPCR and Western blotting. Results Compared with the Control group, significantly higher serum TSH concentration was observed in the L-NAME group (p < 0.05), while T3 and T4 levels showed no noticeable change. The L-NAME group revealed a reduction in the size and number of thyroid follicles, with the emergence of thyroid follicular epithelial hyperplasia. While electron microscopy revealed that the endoplasmic reticulum of thyroid follicular epithelial cells was marked swollen within L-NAME group. Additionally, the mRNA expression of Ttf1, Pax8 and Tshr was down-regulated in thyroid tissues of L-NAME group. Furthermore, the protein levels of Tg, NIS and TSHR were reduced, while the protein level of p-IRE1α, ATF6α, XBP1s and Bip were increased in the L-NAME group. Conclusion The results indicated that HDP may reduce the expression of key molecules involved in thyroid synthesis through endoplasmic reticulum stress which could ultimately result in the development of congenital hypothyroidism.
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Affiliation(s)
- Maomao Sun
- Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Congrong Wu
- Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Jie Jiang
- Departments of Neonatology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Yue He
- W. F. Maternal and Health Hospital, Weifang, China
| | - Sha Zhu
- Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yonghui Yu
- Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Departments of Neonatology, Shandong Provincial Hospital, Shandong University, Jinan, China
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Makkonen K, Jännäri M, Crisóstomo L, Kuusi M, Patyra K, Melnyk V, Linnossuo V, Ojala J, Ravi R, Löf C, Mäkelä JA, Miettinen P, Laakso S, Ojaniemi M, Jääskeläinen J, Laakso M, Bossowski F, Sawicka B, Stożek K, Bossowski A, Kleinau G, Scheerer P, FinnGen F, Reeve MP, Kero J. Mechanisms of thyrotropin receptor-mediated phenotype variability deciphered by gene mutations and M453T-knockin model. JCI Insight 2024; 9:e167092. [PMID: 38194289 PMCID: PMC11143923 DOI: 10.1172/jci.insight.167092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/05/2024] [Indexed: 01/10/2024] Open
Abstract
The clinical spectrum of thyrotropin receptor-mediated (TSHR-mediated) diseases varies from loss-of-function mutations causing congenital hypothyroidism to constitutively active mutations (CAMs) leading to nonautoimmune hyperthyroidism (NAH). Variation at the TSHR locus has also been associated with altered lipid and bone metabolism and autoimmune thyroid diseases. However, the extrathyroidal roles of TSHR and the mechanisms underlying phenotypic variability among TSHR-mediated diseases remain unclear. Here we identified and characterized TSHR variants and factors involved in phenotypic variability in different patient cohorts, the FinnGen database, and a mouse model. TSHR CAMs were found in all 16 patients with NAH, with 1 CAM in an unexpected location in the extracellular leucine-rich repeat domain (p.S237N) and another in the transmembrane domain (p.I640V) in 2 families with distinct hyperthyroid phenotypes. In addition, screening of the FinnGen database revealed rare functional variants as well as distinct common noncoding TSHR SNPs significantly associated with thyroid phenotypes, but there was no other significant association between TSHR variants and more than 2,000 nonthyroid disease endpoints. Finally, our TSHR M453T-knockin model revealed that the phenotype was dependent on the mutation's signaling properties and was ameliorated by increased iodine intake. In summary, our data show that TSHR-mediated disease risk can be modified by variants at the TSHR locus both inside and outside the coding region as well as by altered TSHR-signaling and dietary iodine, supporting the need for personalized treatment strategies.
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Affiliation(s)
- Kristiina Makkonen
- Department of Clinical Sciences, Faculty of Medicine, and
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Meeri Jännäri
- Department of Clinical Sciences, Faculty of Medicine, and
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Luís Crisóstomo
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Matilda Kuusi
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Konrad Patyra
- Department of Clinical Sciences, Faculty of Medicine, and
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | | | - Veli Linnossuo
- Department of Clinical Sciences, Faculty of Medicine, and
| | - Johanna Ojala
- Department of Clinical Sciences, Faculty of Medicine, and
| | - Rowmika Ravi
- Department of Clinical Sciences, Faculty of Medicine, and
| | - Christoffer Löf
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Juho-Antti Mäkelä
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Päivi Miettinen
- New Children’s Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Saila Laakso
- New Children’s Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Marja Ojaniemi
- Department of Pediatrics and Adolescence, PEDEGO Research Unit and Medical Research Center, University and University Hospital of Oulu, Oulu, Finland
| | | | - Markku Laakso
- Institute of Clinical Medicine, Internal Medicine, University of Eastern Finland, Kuopio, Finland
| | - Filip Bossowski
- Department of Pediatrics, Endocrinology, Diabetes with a Cardiology Unit, Medical University in Białystok, Bialystok, Poland
| | - Beata Sawicka
- Department of Pediatrics, Endocrinology, Diabetes with a Cardiology Unit, Medical University in Białystok, Bialystok, Poland
| | - Karolina Stożek
- Department of Pediatrics, Endocrinology, Diabetes with a Cardiology Unit, Medical University in Białystok, Bialystok, Poland
| | - Artur Bossowski
- Department of Pediatrics, Endocrinology, Diabetes with a Cardiology Unit, Medical University in Białystok, Bialystok, Poland
| | - Gunnar Kleinau
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and
- Humboldt - Universität zu Berlin, Institute of Medical Physics, Biophysics, Group Structural Biology of Cellular Signaling, Berlin, Germany
| | - Patrick Scheerer
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and
- Humboldt - Universität zu Berlin, Institute of Medical Physics, Biophysics, Group Structural Biology of Cellular Signaling, Berlin, Germany
| | - FinnGen FinnGen
- Institute for Molecular Medicine Finland, HiLIFE, University of Helsinki, Helsinki, Finland
- FinnGen is detailed in Supplemental Acknowledgments
| | - Mary Pat Reeve
- Institute for Molecular Medicine Finland, HiLIFE, University of Helsinki, Helsinki, Finland
| | - Jukka Kero
- Department of Clinical Sciences, Faculty of Medicine, and
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
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Hypothyroidism Modeling in Wistar Rats: Comparison of Two Surgical Methods. Bull Exp Biol Med 2022; 173:794-800. [DOI: 10.1007/s10517-022-05634-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Indexed: 11/11/2022]
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Jang D, Eliseeva E, Klubo-Gwiezdzinska J, Neumann S, Gershengorn MC. TSH stimulation of human thyroglobulin and thyroid peroxidase gene transcription is partially dependent on internalization. Cell Signal 2022; 90:110212. [PMID: 34896620 PMCID: PMC8725617 DOI: 10.1016/j.cellsig.2021.110212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/29/2021] [Accepted: 12/05/2021] [Indexed: 02/03/2023]
Abstract
The TSH receptor (TSHR) is the major regulator of thyroid hormone biosynthesis in human thyrocytes by regulating the transcription of a number of genes including thyroglobulin (TG) and thyroperoxidase (TPO). Until recently, it was thought that TSHR initiated signal transduction pathways only at the cell-surface and that internalization was primarily involved in TSHR desensitization and downregulation. Studies primarily in mouse cells showed that TSHR internalization regulates gene transcription at an intracellular site also. However, this has not been shown for genes involved in thyroid hormone biosynthesis in human thyrocytes. We used human thyrocytes in primary culture. In these cells, the dose-response to TSH for gene expression is biphasic with low doses upregulating gene expression and higher doses decreasing gene expression. We used two approaches to inhibit internalization. In the first, we used inhibitors of dynamins, dynasore and dyngo-4a. Pretreatment with dynasore or dyngo-4a markedly inhibited TSH upregulation of TG and TPO mRNAs, as well as TG secretion. In the second, we used knockdown of dynamin 2, which is the most abundant dynamin in human thyrocytes. We showed that dynamin 2 knockdown inhibited TSHR internalization and decreased the TSH-stimulated levels of TG and TPO mRNAs and proteins. Lastly, we showed that the level of the activatory transcription factor phosphorylated cAMP response element binding protein (pCREB) in the cell nuclei was reduced by 68% when internalization was inhibited. We conclude that upregulation of genes involved in thyroid hormone synthesis in human thyrocytes is, in part, dependent on internalization leading to nuclear localization of an activated transcription factor(s).
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Affiliation(s)
- Daesong Jang
- Laboratory of Endocrinology and Receptor Biology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Elena Eliseeva
- Laboratory of Endocrinology and Receptor Biology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Joanna Klubo-Gwiezdzinska
- Metabolic Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Susanne Neumann
- Laboratory of Endocrinology and Receptor Biology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Marvin C. Gershengorn
- Laboratory of Endocrinology and Receptor Biology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
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Xiao X, Liang J, Yang H, Wan X, Wang Z. Vitamin A deficiency or critical excess has negative effects on the growth performance, slaughter performance, and meat quality of goslings. Anim Feed Sci Technol 2021. [DOI: 10.1016/j.anifeedsci.2021.115064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Chaulin AM, Grigorieva JV, Suvorova GN, Duplyakov DV. Experimental Modeling Of Hypothyroidism: Principles, Methods, Several Advanced Research Directions In Cardiology. RUSSIAN OPEN MEDICAL JOURNAL 2021. [DOI: 10.15275/rusomj.2021.0311] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Hypothyroidism is one of the most common pathological conditions in modern clinical practice. Due to the fact that the targets of thyroid hormones are virtually all organs and tissues, the morphological and clinical manifestations arising with a deficiency of thyroid hormones are quite diverse. Experimental models of hypothyroidism in laboratory animals are widely used for preclinical study of the fundamental pathophysiological mechanisms underlying hypothyroidism, as well as for assessing the effectiveness of treatment-and-prophylactic effects. Currently, several groups of effective models of hypothyroidism have been developed: dietary, surgical, medicamentous, genetic, radioactive and immunological. Each of the specified models is based on different principles, has advantages and disadvantages, and can be used depending on the goals and objectives of the experiment. In this review, we will consistently consider hypothyroidism modeling methods and indicate some promising areas of their use in cardiology.
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Affiliation(s)
- Aleksey M. Chaulin
- Samara State Medical University, Samara, Russia; Samara Regional Clinical Cardiological Dispensary, Samara, Russia
| | | | | | - Dmitry V. Duplyakov
- Samara State Medical University, Samara, Russia; Samara Regional Clinical Cardiological Dispensary, Samara, Russia
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Brix K, Szumska J, Weber J, Qatato M, Venugopalan V, Al-Hashimi A, Rehders M. Auto-Regulation of the Thyroid Gland Beyond Classical Pathways. Exp Clin Endocrinol Diabetes 2020; 128:437-445. [PMID: 32074633 DOI: 10.1055/a-1080-2969] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This mini-review asks how self-regulation of the thyroid gland is realized at the cellular and molecular levels by canonical and non-canonical means. Canonical pathways of thyroid regulation comprise thyroid stimulating hormone-triggered receptor signaling. As part of non-canonical regulation, we hypothesized an interplay between protease-mediated thyroglobulin processing and thyroid hormone release into the circulation by means of thyroid hormone transporters like Mct8. We proposed a sensing mechanism by different thyroid hormone transporters, present in specific subcellular locations of thyroid epithelial cells, selectively monitoring individual steps of thyroglobulin processing, and thus, the cellular thyroid hormone status. Indeed, we found that proteases and thyroid hormone transporters are functionally inter-connected, however, in a counter-intuitive manner fostering self-thyrotoxicity in particular in Mct8- and/or Mct10-deficient mice. Furthermore, the possible role of the G protein-coupled receptor Taar1 is discussed, because we detected Taar1 at cilia of the apical plasma membrane of thyrocytes in vitro and in situ. Eventually, through pheno-typing Taar1-deficient mice, we identified a co-regulatory role of Taar1 and the thyroid stimulating hormone receptors. Recently, we showed that inhibition of thyroglobulin-processing enzymes results in disappearance of cilia from the apical pole of thyrocytes, while Taar1 is re-located to the endoplasmic reticulum. This pathway features a connection between thyrotropin-stimulated secretion of proteases into the thyroid follicle lumen and substrate-mediated self-assisted control of initially peri-cellular thyroglobulin processing, before its reinternalization by endocytosis, followed by extensive endo-lysosomal liberation of thyroid hormones, which are then released from thyroid follicles by means of thyroid hormone transporters.
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Affiliation(s)
- Klaudia Brix
- Department of Life Sciences and Chemistry, Jacobs University Bremen, Bremen, Germany
| | - Joanna Szumska
- Department of Life Sciences and Chemistry, Jacobs University Bremen, Bremen, Germany.,Present address of JS is Department of Internal Medicine III, Cardiology, Angiology and Respiratory Medicine, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Jonas Weber
- Department of Life Sciences and Chemistry, Jacobs University Bremen, Bremen, Germany
| | - Maria Qatato
- Department of Life Sciences and Chemistry, Jacobs University Bremen, Bremen, Germany
| | - Vaishnavi Venugopalan
- Department of Life Sciences and Chemistry, Jacobs University Bremen, Bremen, Germany
| | - Alaa Al-Hashimi
- Department of Life Sciences and Chemistry, Jacobs University Bremen, Bremen, Germany
| | - Maren Rehders
- Department of Life Sciences and Chemistry, Jacobs University Bremen, Bremen, Germany
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Mio C, Grani G, Durante C, Damante G. Molecular defects in thyroid dysgenesis. Clin Genet 2019; 97:222-231. [PMID: 31432505 DOI: 10.1111/cge.13627] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/17/2019] [Accepted: 08/19/2019] [Indexed: 12/12/2022]
Abstract
Congenital hypothyroidism (CH) is a neonatal endocrine disorder that might occur as itself or be associated to congenital extra-thyroidal defects. About 85% of affected subjects experience thyroid dysgenesis (TD), characterized by defect in thyroid gland development. In vivo experiments on null mice paved the way for the identification of genes involved thyroid morphogenesis and development, whose mutation has been strongly associated to TD. Most of them are thyroid-specific transcription factors expressed during early thyroid development. Despite the arduous effort in unraveling the genetics of TD in animal models, up to now these data have been discontinuously confirmed in humans and only 5% of TD have associated with known null mice-related mutations (mainly PAX8 and TSHR). Notwithstanding, the advance in genetic testing represented by the next-generation sequencing (NGS) approach is steadily increasing the list of genes whose highly penetrant mutation predisposes to TD. In this review we intend to outline the molecular bases of TD, summarizing the current knowledge on thyroid development in both mice and humans and delineating the genetic features of its monogenetic forms. We will also highlight current strategies to enhance the insight into the non-Mendelian mechanisms of abnormal thyroid development.
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Affiliation(s)
- Catia Mio
- Department of Medicine, University of Udine, Udine, Italy
| | - Giorgio Grani
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Cosimo Durante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Damante
- Department of Medicine, University of Udine, Udine, Italy.,Institute of Medical Genetics, Academic Hospital "Azienda Sanitaria Universitaria Integrata di Udine", Udine, Italy
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