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Calvo MJ, Parra H, Santeliz R, Bautista J, Luzardo E, Villasmil N, Martínez MS, Chacín M, Cano C, Checa-Ros A, D'Marco L, Bermúdez V, De Sanctis JB. The Placental Role in Gestational Diabetes Mellitus: A Molecular Perspective. TOUCHREVIEWS IN ENDOCRINOLOGY 2024; 20:10-18. [PMID: 38812661 PMCID: PMC11132656 DOI: 10.17925/ee.2024.20.1.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/01/2023] [Indexed: 05/31/2024]
Abstract
During pregnancy, women undergo several metabolic changes to guarantee an adequate supply of glucose to the foetus. These metabolic modifications develop what is known as physiological insulin resistance. When this process is altered, however, gestational diabetes mellitus (GDM) occurs. GDM is a multifactorial disease, and genetic and environmental factors play a crucial role in its aetiopathogenesis. GDM has been linked to both macroscopic and molecular alterations in placental tissues that affect placental physiology. This review summarizes the role of the placenta in the development of GDM from a molecular perspective, including hormonal and pro-inflammatory changes. Inflammation and hormonal imbalance, the characteristics dominating the GDM microenvironment, are responsible for placental changes in size and vascularity, leading to dysregulation in maternal and foetal circulations and to complications in the newborn. In conclusion, since the hormonal mechanisms operating in GDM have not been fully elucidated, more research should be done to improve the quality of life of patients with GDM and their future children.
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Affiliation(s)
- María José Calvo
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo, Venezuela
| | - Heliana Parra
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo, Venezuela
| | - Raquel Santeliz
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo, Venezuela
| | - Jordan Bautista
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo, Venezuela
| | - Eliana Luzardo
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo, Venezuela
| | - Nelson Villasmil
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo, Venezuela
| | - María Sofía Martínez
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo, Venezuela
| | - Maricamen Chacín
- Facultad de Ciencias de la Salud, Barranquilla, Universidad Simón Bolívar, Barranquilla, Colombia
| | - Clímaco Cano
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo, Venezuela
| | - Ana Checa-Ros
- Research Group on Cardiorenal and Metabolic Diseases, Departamento de Medicina y Cirugía, Facultad de Ciencias de la Salud, Universidad Cardenal Herrera-CEU, CEU Universities, Valencia, Spain
- School of Life and Health Sciences, Aston University, Birmingham, United Kingdom
| | - Luis D'Marco
- Research Group on Cardiorenal and Metabolic Diseases, Departamento de Medicina y Cirugía, Facultad de Ciencias de la Salud, Universidad Cardenal Herrera-CEU, CEU Universities, Valencia, Spain
| | - Valmore Bermúdez
- Facultad de Ciencias de la Salud, Barranquilla, Universidad Simón Bolívar, Barranquilla, Colombia
| | - Juan Bautista De Sanctis
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
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Zheng Y, Zheng G, Li YY, Gong X, Chen Z, Zhu L, Xu Y, Xie X, Wu S, Jiang L. Implantable magnetically-actuated capsule for on-demand delivery. J Control Release 2023; 364:576-588. [PMID: 37951475 DOI: 10.1016/j.jconrel.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 10/08/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
Many implantable drug delivery systems (IDDS) have been developed for long-term, pulsatile drug release. However, they are often limited by bulky size, complex electronic components, unpredictable drug delivery, as well as the need for battery replacement and consequent replacement surgery. Here, we develop an implantable magnetically-actuated capsule (IMAC) and its portable magnetic actuator (MA) for on-demand and robust drug delivery in a tether-free and battery-free manner. IMAC utilizes the bistable mechanism of two magnetic balls inside IMAC to trigger drug delivery under a strong magnetic field (|Ba| > 90 mT), ensuring precise and reproducible drug delivery (9.9 ± 0.17 μg per actuation, maximum actuation number: 180) and excellent anti-magnetic capability (critical trigger field intensity: ∼90 mT). IMAC as a tetherless robot can navigate to and anchor at the lesion sites driven by a gradient magnetic field (∇ Bg = 3 T/m, |Bg| < 60 mT), and on-demand release drug actuated by a uniform magnetic field (|Ba| = ∼100 mT) within the gastrointestinal tract. During a 15-day insulin administration in vivo, the diabetic rats treated with IMAC exhibited highly similar pharmacokinetic and pharmacodynamic profiles to those administrated via subcutaneous injection, demonstrating its robust and on-demand drug release performance. Moreover, IMAC is biocompatible, batter-free, refillable, miniature (only Φ 6.3 × 12.3 mm3), and lightweight (just 0.8 g), making it an ideal alternative for precise implantable drug delivery and friendly patient-centered drug administration.
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Affiliation(s)
- Ying Zheng
- Guangdong Provincial Key Laboratory of Sensor Technology and Biomedical Instrument, School of Biomedical Engineering, Shenzhen Campus of Sun Yat-Sen University, Shenzhen 518107, China
| | - Guizhou Zheng
- Guangdong Provincial Key Laboratory of Sensor Technology and Biomedical Instrument, School of Biomedical Engineering, Shenzhen Campus of Sun Yat-Sen University, Shenzhen 518107, China
| | - Yuan Yuan Li
- Guangdong Provincial Key Laboratory of Sensor Technology and Biomedical Instrument, School of Biomedical Engineering, Shenzhen Campus of Sun Yat-Sen University, Shenzhen 518107, China
| | - Xia Gong
- Guangdong Provincial Key Laboratory of Sensor Technology and Biomedical Instrument, School of Biomedical Engineering, Shenzhen Campus of Sun Yat-Sen University, Shenzhen 518107, China
| | - Zhipeng Chen
- School of Mechanical and Electrical Engineering, Guangzhou University, Guangzhou 510006, China
| | - Linyu Zhu
- The 7(th) Affiliated Hospital, Sun Yat-sen University, Shenzhen 518107, China
| | - Yunsheng Xu
- The 7(th) Affiliated Hospital, Sun Yat-sen University, Shenzhen 518107, China
| | - Xi Xie
- State Key Laboratory of Optoelectronic Materials and Technologies, School of Electronics and Information Technology, Sun Yat-sen University, Guangzhou 510006, China
| | - Shuo Wu
- Guangdong Provincial Key Laboratory of Sensor Technology and Biomedical Instrument, School of Biomedical Engineering, Shenzhen Campus of Sun Yat-Sen University, Shenzhen 518107, China; The 3(rd) Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510630, China..
| | - Lelun Jiang
- Guangdong Provincial Key Laboratory of Sensor Technology and Biomedical Instrument, School of Biomedical Engineering, Shenzhen Campus of Sun Yat-Sen University, Shenzhen 518107, China.
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Li GY, Wu QZ, Song TJ, Zhen XC, Yu X. Dynamic regulation of excitatory and inhibitory synaptic transmission by growth hormone in the developing mouse brain. Acta Pharmacol Sin 2023; 44:1109-1121. [PMID: 36476808 PMCID: PMC10202927 DOI: 10.1038/s41401-022-01027-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/06/2022] [Indexed: 12/13/2022] Open
Abstract
Normal sensory and cognitive function of the brain relies on its intricate and complex neural network. Synaptogenesis and synaptic plasticity are critical to neural circuit formation and maintenance, which are regulated by coordinated intracellular and extracellular signaling. Growth hormone (GH) is the most abundant anterior pituitary hormone. Its deficiencies could alter brain development and impair learning and memory, while GH replacement therapy in human patients and animal models has been shown to ameliorate cognitive deficits caused by GH deficiency. However, the underlying mechanism remains largely unknown. In this study, we investigated the neuromodulatory function of GH in young (pre-weaning) mice at two developmental time points and in two different brain regions. Neonatal mice were subcutaneously injected with recombinant human growth hormone (rhGH) on postnatal day (P) 14 or 21. Excitatory and inhibitory synaptic transmission was measured using whole-cell recordings in acute cortical slices 2 h after the injection. We showed that injection of rhGH (2 mg/kg) in P14 mice significantly increased the frequency of mEPSCs, but not that of mIPSCs, in both hippocampal CA1 pyramidal neurons and L2/3 pyramidal neurons of the barrel field of the primary somatosensory cortex (S1BF). Injection of rhGH (2 mg/kg) in P21 mice significantly increased the frequency of mEPSCs and mIPSCs in both brain regions. Perfusion of rhGH (1 μM) onto acute brain slices in P14 mice had similar effects. Consistent with the electrophysiological results, the dendritic spine density of CA1 pyramidal neurons and S1BF L2/3 pyramidal neurons increased following in vivo injection of rhGH. Furthermore, NMDA receptors and postsynaptic calcium-dependent signaling contributed to rhGH-dependent regulation of both excitatory and inhibitory synaptic transmission. Together, these results demonstrate that regulation of excitatory and inhibitory synaptic transmission by rhGH occurs in a developmentally dynamic manner, and have important implication for identifying GH treatment strategies without disturbing excitation/inhibition balance.
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Affiliation(s)
- Guang-Ying Li
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Soochow University, Suzhou, 215123, China.
- Institute of Neuroscience, State Key Laboratory of Neuroscience, Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China.
- School of Life Sciences, Peking-Tsinghua Center for Life Sciences, and Peking University McGovern Institute, Peking University, Beijing, 100871, China.
| | - Qiu-Zi Wu
- Institute of Neuroscience, State Key Laboratory of Neuroscience, Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China
- School of Life Sciences, Peking-Tsinghua Center for Life Sciences, and Peking University McGovern Institute, Peking University, Beijing, 100871, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Tian-Jia Song
- School of Life Sciences, Peking-Tsinghua Center for Life Sciences, and Peking University McGovern Institute, Peking University, Beijing, 100871, China
| | - Xue-Chu Zhen
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and College of Pharmaceutical Sciences, Soochow University, Suzhou, 215123, China
| | - Xiang Yu
- Institute of Neuroscience, State Key Laboratory of Neuroscience, Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China.
- School of Life Sciences, Peking-Tsinghua Center for Life Sciences, and Peking University McGovern Institute, Peking University, Beijing, 100871, China.
- University of Chinese Academy of Sciences, Beijing, 100049, China.
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Sferruzzi-Perri AN, Lopez-Tello J, Napso T, Yong HEJ. Exploring the causes and consequences of maternal metabolic maladaptations during pregnancy: Lessons from animal models. Placenta 2020; 98:43-51. [PMID: 33039031 DOI: 10.1016/j.placenta.2020.01.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/20/2020] [Accepted: 01/29/2020] [Indexed: 02/07/2023]
Abstract
Pregnancy is a remarkable physiological state, during which the metabolic system of the mother adapts to ensure that nutrients are made available for transfer to the fetus for growth and development. Adaptations of maternal metabolism during pregnancy are influenced by the metabolic and nutritional status of the mother and the production of endocrine factors by the placenta that exert metabolic effects. Insufficient or inappropriate adaptations in maternal metabolism during pregnancy may lead to pregnancy complications with important short- and long-term effects for both the health of the child and mother. This is very evident in gestational diabetes, which is marked by greater glucose intolerance and insulin resistance above that expected of a normal pregnancy. Gestational diabetes is associated with increased fetal weight and/or increased adiposity, higher instrumented delivery rates and greater risks for both mother and child of developing type 2 diabetes in the long-term. However, despite the negative health impacts of such metabolic imbalances during pregnancy, the precise mechanisms responsible for orchestrating these changes remain largely unknown. The present review describes the dynamic pregnancy-specific changes that occur in the metabolic system of the mother during pregnancy. It also discusses findings using surgical, pharmacological, genetic and dietary methods in experimental animals that highlight the role of pathways in maternal tissues that lead to metabolic dysfunction, with a particular focus on gestational diabetes. Finally, it summarises the work largely employing gene targeting and hormone administration in rodents that have illuminated the involvement of placental endocrine function in driving maternal metabolic adaptations. While current animal models may not fully replicate what is observed in humans, these have been instrumental in showing that there is a dynamic interplay between changes in maternal metabolic physiology and the placental production of endocrine factors that govern the availability of nutrients to the growing fetus. However, more work is required to specifically identify the placenta-driven changes in maternal metabolic physiology that ensure the appropriate level of insulin production and action during pregnancy. In doing so, these studies may pave the way to understanding the development of pregnancy complications like gestational diabetes, as well as further our understanding of type-2 diabetes and the control of metabolic physiology more broadly.
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Affiliation(s)
- Amanda N Sferruzzi-Perri
- Centre for Trophoblast Research, Department of Physiology, Development and Neuroscience, Downing Street, University of Cambridge, Cambridge, CB2 3EG, UK.
| | - Jorge Lopez-Tello
- Centre for Trophoblast Research, Department of Physiology, Development and Neuroscience, Downing Street, University of Cambridge, Cambridge, CB2 3EG, UK
| | - Tina Napso
- Centre for Trophoblast Research, Department of Physiology, Development and Neuroscience, Downing Street, University of Cambridge, Cambridge, CB2 3EG, UK
| | - Hannah E J Yong
- Centre for Trophoblast Research, Department of Physiology, Development and Neuroscience, Downing Street, University of Cambridge, Cambridge, CB2 3EG, UK
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Furigo IC, de Souza GO, Teixeira PDS, Guadagnini D, Frazão R, List EO, Kopchick JJ, Prada PO, Donato J. Growth hormone enhances the recovery of hypoglycemia via ventromedial hypothalamic neurons. FASEB J 2019; 33:11909-11924. [PMID: 31366244 DOI: 10.1096/fj.201901315r] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Growth hormone (GH) is secreted during hypoglycemia, and GH-responsive neurons are found in brain areas containing glucose-sensing neurons that regulate the counter-regulatory response (CRR). However, whether GH modulates the CRR to hypoglycemia via specific neuronal populations is currently unknown. Mice carrying ablation of GH receptor (GHR) either in leptin receptor (LepR)- or steroidogenic factor-1 (SF1)-expressing cells were studied. We also investigated the importance of signal transducer and activator of transcription 5 (STAT5) signaling in SF1 cells for the CRR. GHR ablation in LepR cells led to impaired capacity to recover from insulin-induced hypoglycemia and to a blunted CRR caused by 2-deoxy-d-glucose (2DG) administration. GHR inactivation in SF1 cells, which include ventromedial hypothalamic neurons, also attenuated the CRR. The reduced CRR was prevented by parasympathetic blockers. Additionally, infusion of 2DG produced an abnormal hyperactivity of parasympathetic preganglionic neurons, whereas the 2DG-induced activation of anterior bed nucleus of the stria terminalis neurons was reduced in mice without GHR in SF1 cells. Mice carrying ablation of Stat5a/b genes in SF1 cells showed no defects in the CRR. In summary, GHR expression in SF1 cells is required for a normal CRR, and these effects are largely independent of STAT5 pathway.-Furigo, I. C., de Souza, G. O., Teixeira, P. D. S., Guadagnini, D., Frazão, R., List, E. O., Kopchick, J. J., Prada, P. O., Donato, J., Jr. Growth hormone enhances the recovery of hypoglycemia via ventromedial hypothalamic neurons.
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Affiliation(s)
- Isadora C Furigo
- Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Gabriel O de Souza
- Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Pryscila D S Teixeira
- Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Dioze Guadagnini
- School of Applied Sciences, State University of Campinas, Limeira, Brazil
| | - Renata Frazão
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Edward O List
- Edison Biotechnology Institute and Heritage College of Osteopathic Medicine, Ohio University, Athens, Ohio, USA
| | - John J Kopchick
- Edison Biotechnology Institute and Heritage College of Osteopathic Medicine, Ohio University, Athens, Ohio, USA
| | - Patricia O Prada
- School of Applied Sciences, State University of Campinas, Limeira, Brazil
| | - Jose Donato
- Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
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Lee SH, Kim BH, Park CG, Lee C, Lim BY, Choy YB. Implantable small device enabled with magnetic actuation for on-demand and pulsatile drug delivery. J Control Release 2018; 286:224-230. [DOI: 10.1016/j.jconrel.2018.07.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/17/2018] [Accepted: 07/23/2018] [Indexed: 11/25/2022]
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Napso T, Yong HEJ, Lopez-Tello J, Sferruzzi-Perri AN. The Role of Placental Hormones in Mediating Maternal Adaptations to Support Pregnancy and Lactation. Front Physiol 2018; 9:1091. [PMID: 30174608 PMCID: PMC6108594 DOI: 10.3389/fphys.2018.01091] [Citation(s) in RCA: 245] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 07/23/2018] [Indexed: 12/12/2022] Open
Abstract
During pregnancy, the mother must adapt her body systems to support nutrient and oxygen supply for growth of the baby in utero and during the subsequent lactation. These include changes in the cardiovascular, pulmonary, immune and metabolic systems of the mother. Failure to appropriately adjust maternal physiology to the pregnant state may result in pregnancy complications, including gestational diabetes and abnormal birth weight, which can further lead to a range of medically significant complications for the mother and baby. The placenta, which forms the functional interface separating the maternal and fetal circulations, is important for mediating adaptations in maternal physiology. It secretes a plethora of hormones into the maternal circulation which modulate her physiology and transfers the oxygen and nutrients available to the fetus for growth. Among these placental hormones, the prolactin-growth hormone family, steroids and neuropeptides play critical roles in driving maternal physiological adaptations during pregnancy. This review examines the changes that occur in maternal physiology in response to pregnancy and the significance of placental hormone production in mediating such changes.
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Affiliation(s)
- Tina Napso
- Department of Physiology, Development and Neuroscience, Centre for Trophoblast Research, University of Cambridge, Cambridge, United Kingdom
| | - Hannah E J Yong
- Department of Physiology, Development and Neuroscience, Centre for Trophoblast Research, University of Cambridge, Cambridge, United Kingdom
| | - Jorge Lopez-Tello
- Department of Physiology, Development and Neuroscience, Centre for Trophoblast Research, University of Cambridge, Cambridge, United Kingdom
| | - Amanda N Sferruzzi-Perri
- Department of Physiology, Development and Neuroscience, Centre for Trophoblast Research, University of Cambridge, Cambridge, United Kingdom
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Dai G, Wang D, Dong H. Effects of recombinant human growth hormone on protein malnutrition and IGF-1 and IL-2 gene expression levels in chronic nephrotic syndrome. Exp Ther Med 2018; 15:4167-4172. [PMID: 29725365 PMCID: PMC5920232 DOI: 10.3892/etm.2018.5953] [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: 07/28/2017] [Accepted: 12/11/2017] [Indexed: 11/05/2022] Open
Abstract
The aim of the study was to investigate the effects of recombinant human growth hormone on protein malnutrition and insulin-like growth factor-1 (IGF-1) and interleukin-2 (IL-2) gene expressions in chronic nephrotic syndrome. Eighty patients with chronic nephrotic syndrome were admitted to our hospital. The patients were included in the study period from January 2015 to December 2016 and were divided into two groups (40 cases in each group) according to the random number method. All the patients enrolled received symptomatic and supportive treatment. The observation group was injected subcutaneously with recombinant human growth hormone, while the control group was treated with Shenyankangfu tablets. The recovery time of the clinical symptoms, change in serum protein, caloric intake and protein metabolism after intervention were compared between the two groups. Changes in serum cystatin C, IGF-1 and IL-2 before intervention, and at 1 week, 1 month and 3 months after intervention were detected, and the adverse reactions in the two groups were observed during the treatment. After intervention, the improvement time of proteinuria, hypoproteinemia, edema and hyperlipidemia in the observation group was significantly shorter than that in the control group (P<0.05). The expression of transferrin, pre-albumin, albumin and total protein in the observation group was significantly superior increased compared to those in the observation group prior to intervention and the control group after intervention (P<0.05). In addition the caloric intake, protein intake and urea nitrogen survival rate in the observation group were significantly superior to those in the observation group prior to intervention and the control group after intervention (P<0.05). At 1 week, 1 month and 3 months after intervention, the levels of serum cystatin C, IGF-1 and IL-2 in the observation group were markedly obviously lower than those in the control group during the same period (P<0.05). The total proportion of allergy, systemic pruritus, nausea and vomiting, abdominal distension and abdominal pain in the observation group was obviously lower than that in the control group (P<0.05). Compared with the traditional Chinese medicine Shenyankangfu tablets applied in the control group, the recombinant human growth hormone used for patients with chronic nephrotic syndrome can improve the clinical symptoms more quickly, regulate the protein metabolism and reduce the inflammatory response in the body, which also has fewer adverse reactions and higher safety.
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Affiliation(s)
- Guang Dai
- Department of Nephrology, Zhumadian Central Hospital, Zhumadian, Henan 463000, P.R. China
| | - Donghai Wang
- Department of Nephrology, Zhumadian Central Hospital, Zhumadian, Henan 463000, P.R. China
| | - Hua Dong
- Department of Nephrology, The Affiliated Hospital of Binzhou Medical College, Binzhou, Shandong 256603, P.R. China
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