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Sokołowska A, Świerzko AS, Szala-Poździej A, Augustynowicz-Kopeć E, Kozińska M, Niemiec T, Błachnio M, Borkowska-Tatar D, Jensenius JC, Thiel S, Dziadek J, Cedzyński M. Selected factors of the innate immunity in Polish patients suffering from pulmonary tuberculosis. Immunobiology 2020; 225:151905. [PMID: 32007302 DOI: 10.1016/j.imbio.2020.151905] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 02/01/2023]
Abstract
We conducted a prospective study of 453 Polish patients suffering from pulmonary tuberculosis and 267 healthy controls. Selected polymorphisms of the genes encoding for collectins, ficolins and MBL-associated serine protease 2 were investigated as were serum concentrations of mannose-binding lectin, surfactant protein D, ficolin-1 and ficolin-3. The number of MBL2 gene exon 1 variant allele carriers was significantly higher in patients, compared with controls. The homozygosity for SFTPA2 +26 C > A SNP variant allele occurred less commonly within TB, while homozygosity for the FCN1 -542 G > A major allele was less frequent within the control group. Two patients were found MASP-2-deficient. Serum concentrations of MBL, SP-D and ficolin-1 were higher amongst patients while the converse was found for ficolin-3. Ficolin-1 had high specificity to differentiate between individuals with tuberculosis and healthy persons and therefore may be considered potential disease marker.
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Affiliation(s)
- Anna Sokołowska
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Lodowa 106, 93-232, Łódź, Poland
| | - Anna S Świerzko
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Lodowa 106, 93-232, Łódź, Poland
| | - Agnieszka Szala-Poździej
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Lodowa 106, 93-232, Łódź, Poland
| | | | - Monika Kozińska
- Institute of Tuberculosis and Lung Diseases, Plocka 26, 01-138, Warsaw, Poland
| | - Tomasz Niemiec
- The Voivodeship Hospital of Lung Diseases in Jaroszowiec, Kolejowa 1a, 32-312, Jaroszowiec, Poland
| | - Maria Błachnio
- Masovian Center of Lung Diseases and Tuberculosis Treatment, Narutowicza 80, 05-400, Otwock, Poland
| | | | - Jens C Jensenius
- Department of Biomedicine, Aarhus University, Høegh-Guldbergs Gade 10, 8000, Aarhus, Denmark
| | - Steffen Thiel
- Department of Biomedicine, Aarhus University, Høegh-Guldbergs Gade 10, 8000, Aarhus, Denmark
| | - Jarosław Dziadek
- Laboratory of Mycobacterium Genetics and Physiology, Institute of Medical Biology, Polish Academy of Sciences, Lodowa 106, 93-232, Łódź, Poland
| | - Maciej Cedzyński
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Lodowa 106, 93-232, Łódź, Poland.
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García-Laorden MI, Hernández-Brito E, Muñoz-Almagro C, Pavlovic-Nesic S, Rúa-Figueroa I, Briones ML, Rajas O, Borderías L, Payeras A, Lorente L, Freixinet J, Ferreres J, Obando I, González-Quevedo N, Rodríguez de Castro F, Solé-Violán J, Rodríguez-Gallego C. Should MASP-2 Deficiency Be Considered a Primary Immunodeficiency? Relevance of the Lectin Pathway. J Clin Immunol 2020; 40:203-210. [PMID: 31828694 PMCID: PMC7223972 DOI: 10.1007/s10875-019-00714-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 10/29/2019] [Indexed: 01/19/2023]
Abstract
Mannose-binding lectin (MBL)-associated serine protease-2 (MASP-2) is an indispensable enzyme for the activation of the lectin pathway of complement. Its deficiency is classified as a primary immunodeficiency associated to pyogenic bacterial infections, inflammatory lung disease, and autoimmunity. In Europeans, MASP-2 deficiency, due to homozygosity for c.359A > G (p.D120G), occurs in 7 to 14/10,000 individuals. We analyzed the presence of the p.D120G mutation in adults (increasing the sample size of our previous studies) and children. Different groups of patients (1495 adults hospitalized with community-acquired pneumonia, 186 adults with systemic lupus erythematosus, 103 pediatric patients with invasive pneumococcal disease) and control individuals (1119 healthy adult volunteers, 520 adult patients without history of relevant infectious diseases, and a pediatric control group of 311 individuals) were studied. Besides our previously reported MASP-2-deficient healthy adults, we found a new p.D120G homozygous individual from the pediatric control group. We also reviewed p.D120G homozygous individuals reported so far: a total of eleven patients with a highly heterogeneous range of disorders and nine healthy controls (including our four MASP-2-deficient individuals) have been identified by chance in association studies. Individuals with complete deficiencies of several pattern recognition molecules of the lectin pathway (MBL, collectin-10 and collectin-11, and ficolin-3) as well as of MASP-1 and MASP-3 have also been reviewed. Cumulative evidence suggests that MASP-2, and even other components of the LP, are largely redundant in human defenses and that individuals with MASP-2 deficiency do not seem to be particularly prone to infectious or autoimmune diseases.
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Affiliation(s)
- M Isabel García-Laorden
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Elisa Hernández-Brito
- Department of Immunology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
- Department of Medical and Surgical Sciences, School of Medicine, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Carmen Muñoz-Almagro
- Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain
- CIBER en Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Svetlana Pavlovic-Nesic
- Department of Pediatrics, Complejo Hospitalario Universitario Insular Materno Infantil, Las Palmas de Gran Canaria, Spain
| | - Iñigo Rúa-Figueroa
- Rheumatology Service, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - M Luisa Briones
- Department of Respiratory Diseases, Hospital Clínico y Universitario de Valencia, Valencia, Spain
| | - Olga Rajas
- Department of Respiratory Diseases, Hospital Universitario de la Princesa, Madrid, Spain
| | - Luis Borderías
- Department of Respiratory Diseases, Hospital San Jorge, Huesca, Spain
| | - Antoni Payeras
- Department of Internal Medicine, Hospital Son Llatzer, Palma de Mallorca, Spain
| | - Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, La Laguna, Spain
| | - Jordi Freixinet
- Department of Thoracic Surgery, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Jose Ferreres
- Intensive Care Unit, Hospital Clínico y Universitario de Valencia, Valencia, Spain
| | - Ignacio Obando
- Department of Pediatrics, Hospital Virgen del Rocío, Sevilla, Spain
| | - Nereida González-Quevedo
- Department of Immunology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Felipe Rodríguez de Castro
- Department of Medical and Surgical Sciences, School of Medicine, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
- Department of Respiratory Diseases, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Jordi Solé-Violán
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Carlos Rodríguez-Gallego
- Department of Immunology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain.
- University Fernando Pessoa Canarias, Las Palmas de Gran Canaria, Spain.
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Fu J, Wang J, Luo Y, Zhang L, Zhang Y, Dong X, Yu H, Cao M, Ma X. Association between MASP-2 gene polymorphism and risk of infection diseases: A meta-analysis. Microb Pathog 2016; 100:221-228. [PMID: 27725284 DOI: 10.1016/j.micpath.2016.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 10/01/2016] [Accepted: 10/06/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND The role of MASP-2 is vital in the process of complement activation by the lectin pathway. It is generally considered that the functional activation of MASP-2 contribute to the infection disease development process. AIMS To analyze the association between MASP-2 functional gene (rs72550870) polymorphism and the infection disease risk by a meta-analysis. METHOD Relevant case-control studies were identified by searching Cochrane Library, PubMed, Emabase, DOAJ, CAB Abstracts, CSA, CINAHL, EBSCO, Scopus, Global Health, Index Copernicus, CA, China National Knowledge Infrastructure (CNKI) databases up to 10th January 2016. The data were extracted and the methodological quality of studies were evaluated. The STATA 12.0 software was used to perform statistical analysis. RESULTS 9 studies were included. There was no significant association between masp-2 gene (p.D120G, rs72550870) polymorphism and the risk of infection disease under the allele model (G vs. A: OR = 0.89, 95%CI = 0.66-1.21)(P = 0.445>0.05) and the recessive model (AG + GG vs.AA: OR = 0.88, 95%CI = 0.65-1.20) (P = 0.428>0.05). CONCLUSION This is the first comprehensive meta-analysis indicates that the MASP-2 functional gene (rs72550870) polymorphism is not associated with the infection diseases, and the key functional gene polymorphism of rs72550870 did not increase susceptibility to the infection diseases. Similarly, there were no obvious difference in subgroup analysis based on geographical areas and pathogenic microorganisms.
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Affiliation(s)
- Jie Fu
- Department of Immunology, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China; National Hospital of Linxia City, Linxia, 731100, China
| | - Jingqiu Wang
- Department of Immunology, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Yanping Luo
- Department of Immunology, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Lifeng Zhang
- Department of Immunology, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Yuan Zhang
- Department of Immunology, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Xinfang Dong
- Department of Immunology, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Hongjuan Yu
- Department of Immunology, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Mingqiang Cao
- Department of Immunology, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Xingming Ma
- Department of Immunology, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China; Gansu Key Lab of Evidence Based Medicine and Clinical Transfer Medicine, Lanzhou University, Lanzhou, 730000, China.
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Bjarnadottir H, Arnardottir M, Ludviksson BR. Frequency and distribution of FCN2 and FCN3 functional variants among MBL2 genotypes. Immunogenetics 2016; 68:315-25. [PMID: 26795763 PMCID: PMC4842218 DOI: 10.1007/s00251-016-0903-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 01/08/2016] [Indexed: 12/14/2022]
Abstract
The six types of pattern recognition molecules (PRMs) that initiate complement via the lectin pathway (LP) comprise collectins and ficolins. The importance of having various PRMs to initiate the LP is currently unclear. Mannan-binding lectin (MBL) is a collectin member of the LP PRMs. MBL deficiency is common with mild clinical consequence. Thus, the lack of MBL may be compensated for by the other PRMs. We hypothesized that variants FCN2 + 6424 and FCN3 + 1637delC that cause gene-dose-dependent reduction in ficolin-2 and ficolin-3 levels, respectively, may be rare in MBL-deficient individuals due to the importance of compensation within the LP. The aim of this study was to investigate the distribution and frequency of these variants among MBL2 genotypes in healthy subjects. The allele frequency of FCN2 + 6424 and FCN3 + 1637delC was 0.099 and 0.015, respectively, in the cohort (n = 498). The frequency of FCN2 + 6424 tended to be lower among MBL-deficient subjects (n = 53) than among MBL-sufficient subjects (n = 445) (0.047 versus 0.106, P = 0.057). In addition, individuals who were homozygous for FCN2 + 6424 were sufficient MBL producers. The frequency of FCN3 + 1637delC did not differ between the groups. The frequency of FCN2 + 6424 was similar in FCN3 + 1637delC carriers (n = 15) versus wild type (n = 498). Furthermore, subjects that were heterozygote carriers of both FCN2 + 6424 and FCN3 + 1637delC were sufficient MBL producers. In conclusion, FCN2 + 6424 carriers with MBL deficiency tend to be rare among healthy individuals. MBL-deficient individuals with additional LP PRM defects may be at risk to morbidity.
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Affiliation(s)
- Helga Bjarnadottir
- Department of Immunology, Landspitali-The National University Hospital of Iceland, Hringbraut (Building 14 at Eiriksgata), 101, Reykjavik, Iceland.
| | - Margret Arnardottir
- Department of Immunology, Landspitali-The National University Hospital of Iceland, Hringbraut (Building 14 at Eiriksgata), 101, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Bjorn Runar Ludviksson
- Department of Immunology, Landspitali-The National University Hospital of Iceland, Hringbraut (Building 14 at Eiriksgata), 101, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Keizer MP, Wouters D, Schlapbach LJ, Kuijpers TW. Restoration of MBL-deficiency: redefining the safety, efficacy and viability of MBL-substitution therapy. Mol Immunol 2014; 61:174-84. [PMID: 25044097 DOI: 10.1016/j.molimm.2014.06.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 05/30/2014] [Accepted: 06/03/2014] [Indexed: 12/28/2022]
Abstract
MBL-deficiency is a commonly occurring deficiency of the innate immune system, affecting a substantial part of the population and has been extensively studied. MBL appears to function as a disease modifier. The role of MBL in different conditions is context-dependent. Many clinical studies show conflicting results, which can be partially explained by different definitions of MBL-deficiency, including phenotype- and genotype-based approaches. In this review we give an overview of literature of MBL, its role in different pathologies, diseases and patient populations. We review MBL replacement studies, and discuss the potential of MBL substitution therapy. We finally suggest that new MBL substitution trials should be conducted within a predefined patient population. MBL-deficiency should be based on serum levels and confirmed by genotyping.
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Affiliation(s)
- M P Keizer
- Department of Immunopathology, Sanquin Blood Supply, Division Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Pediatric Hematology, Immunology & Infectious Diseases, Emma Children's Hospital, AMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - D Wouters
- Department of Immunopathology, Sanquin Blood Supply, Division Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - L J Schlapbach
- Paediatric Critical Care Research Group, Mater Research, University of Queensland, Brisbane, Australia
| | - T W Kuijpers
- Department of Pediatric Hematology, Immunology & Infectious Diseases, Emma Children's Hospital, AMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Blood Cell Research, Sanquin Blood Supply, Division Research and Landsteiner Laboratory of the AMC, University of Amsterdam, Amsterdam, The Netherlands
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Sokolowska A, Szala A, St Swierzko A, Kozinska M, Niemiec T, Blachnio M, Augustynowicz-Kopec E, Dziadek J, Cedzynski M. Mannan-binding lectin-associated serine protease-2 (MASP-2) deficiency in two patients with pulmonary tuberculosis and one healthy control. Cell Mol Immunol 2014; 12:119-21. [PMID: 24658431 DOI: 10.1038/cmi.2014.19] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 02/24/2014] [Accepted: 02/24/2014] [Indexed: 11/09/2022] Open
Affiliation(s)
- Anna Sokolowska
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Lodz, Poland
| | - Agnieszka Szala
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Lodz, Poland
| | - Anna St Swierzko
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Lodz, Poland
| | | | - Tomasz Niemiec
- The Voivodeship Hospital of Lung Diseases in Jaroszowiec, Jaroszowiec, Poland
| | - Maria Blachnio
- Masovian Center of Lung Diseases and Tuberculosis Treatment, Otwock, Poland
| | | | - Jaroslaw Dziadek
- Laboratory of Mycobacterium Genetics and Physiology, Institute of Medical Biology, Polish Academy of Sciences, Lodz, Poland
| | - Maciej Cedzynski
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Lodz, Poland
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Olszowski T, Poziomkowska-Gęsicka I, Jensenius JC, Adler G. Lectin pathway of complement activation in a Polish woman with MASP-2 deficiency. Immunobiology 2014; 219:261-2. [PMID: 24332888 DOI: 10.1016/j.imbio.2013.10.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 10/28/2013] [Indexed: 11/23/2022]
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Thiel S. Complement activating soluble pattern recognition molecules with collagen-like regions, mannan-binding lectin, ficolins and associated proteins. Mol Immunol 2007; 44:3875-88. [PMID: 17768106 DOI: 10.1016/j.molimm.2007.06.005] [Citation(s) in RCA: 182] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Indexed: 01/31/2023]
Abstract
Mannan-binding lectin (MBL), L-ficolin, M-ficolin and H-ficolin are all complement activating soluble pattern recognition molecules with recognition domains linked to collagen-like regions. All four may form complexes with four structurally related proteins, the three MBL-associated serine proteases (MASPs), MASP-1, MASP-2 and MASP-3, and a smaller MBL-associated protein (MAp19). The four recognition molecules recognize patterns of carbohydrate or acetyl-group containing ligands. After binding to the relevant targets all four are able to activate the complement system. We thus have a system where four different and/or overlapping patterns of microbial origin or patterns of altered-self may be recognized, but in all cases the signalling molecules, the MASPs, are shared. MASP-1 and MASP-3 are formed from one gene, MASP1/3, by alternative splicing generating two different mRNAs from a single primary transcript. Similarly MASP-2 and MAp19 are both generated from one gene, MASP-2/MAp19, by alternative splicing. A number of non-synonymous polymorphisms of the four recognition molecules and of the MASPs are known, and the implications of these alterations are being studied. The clinical impact of deficiencies will be discussed.
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Affiliation(s)
- Steffen Thiel
- Department of Medical Microbiology and Immunology, University of Aarhus, Wilhelms Meyers Allé, 8000 Aarhus C, Denmark.
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Thiel S, Steffensen R, Christensen IJ, Ip WK, Lau YL, Reason IJM, Eiberg H, Gadjeva M, Ruseva M, Jensenius JC. Deficiency of mannan-binding lectin associated serine protease-2 due to missense polymorphisms. Genes Immun 2007; 8:154-63. [PMID: 17252003 DOI: 10.1038/sj.gene.6364373] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Mannan-binding lectin (MBL) and ficolins distinguish between self, non-self and altered-self by recognizing patterns of ligands on the surface of microorganisms or aberrant cells. When this happens MBL-associated serine protease-2 (MASP-2) is activated and cleaves complement factors to start inflammatory actions. We examined human populations for MASP-2 levels, MASP-2 function and for the presence of mutations in coding exons of MASP2. The MASP-2 levels were lowest in Africans from Zambia (median, 196 ng/ml) followed by Hong Kong Chinese (262 ng/ml), Brazilian Amerindians (290 ng/ml) and Danish Caucasians (416 ng/ml). In the Chinese population, we uncovered a novel four amino-acid tandem duplication (p.156_159dupCHNH) associated with low levels of MASP-2. The frequency of this mutation as well as the SNPs p.R99C, p.R118C, p.D120G, p.P126L and p.V377A were analyzed. The p.156_159dupCHNH was only found in Chinese (gene frequency 0.26%) and p.D120G was found only in Caucasians and Inuits from West-Greenland. The p.P126L and p.R99Q were present in Africans and Amerindians only, except for p.R99Q in one Caucasian. The MASP-2 levels were reduced in individuals with p.V377A present. The MASP-2 present in individuals homozygous for p.377A or p.99Q had a normal enzyme activity whereas MASP-2 in individuals homozygous for p.126L was non-functional.
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Affiliation(s)
- S Thiel
- Department of Medical Microbiology and Immunology, University of Aarhus, Aarhus, Denmark.
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