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Venegas FC, Rosas D, Delgado N, Estay-Olmos C, Iturriaga-Vásquez P, Rivera-Meza M, Torres GE, Renard GM, Sotomayor-Zárate R. Early-life exposure to sex hormones promotes voluntary ethanol intake in adulthood. A vulnerability factor to drug addiction. Prog Neuropsychopharmacol Biol Psychiatry 2024; 133:111001. [PMID: 38565388 DOI: 10.1016/j.pnpbp.2024.111001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/29/2024] [Accepted: 03/30/2024] [Indexed: 04/04/2024]
Abstract
While there is extensive research on alcohol dependence, the factors that make an individual vulnerable to developing alcoholism haven't been explored much. In this study, we aim to investigate how neonatal exposure to sex hormones affects alcohol intake and the regulation of the mesolimbic pathway in adulthood. The study aimed to investigate the impact of neonatal exposure to a single dose of testosterone propionate (TP) or estradiol valerate (EV) on ethanol consumption in adult rats. The rats were subjected to a two-bottle free-choice paradigm, and the content of dopamine (DA) and 3,4-dihydroxyphenylacetic acid (DOPAC) in the nucleus accumbens (NAcc) was measured using HPLC-ED. The expression of critical DA-related proteins in the mesolimbic pathway was evaluated through RT-qPCR and western blot analysis. Supraphysiological neonatal exposure to EV or TP resulted in increased ethanol intake over four weeks in adulthood. In addition, the DA and DOPAC content was reduced and increased in the NAcc of EV and TP-treated rats, and β-endorphin content in the hypothalamus decreased in EV-treated rats. The VTA μ receptor and DA type 2 form short receptor (D2S) expression were significantly reduced in EV and TP male rats. Finally, in an extended 6-week protocol, the increase in ethanol consumption induced by EV was mitigated during the initial two hours post-naloxone injection. Neonatal exposure to sex hormones is a detrimental stimulus for the brain, which can facilitate the development of addictive behaviors, including alcohol use disorder.
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Affiliation(s)
- Francisca C Venegas
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valparaíso, Chile; Department of Biomedical Sciences, University of Padua, Italy
| | - Daniela Rosas
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valparaíso, Chile
| | - Nicol Delgado
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valparaíso, Chile
| | - Camila Estay-Olmos
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valparaíso, Chile
| | - Patricio Iturriaga-Vásquez
- Departamento de Ciencias Químicas y Recursos Naturales, Facultad de Ingeniería y Ciencias, Universidad de la Frontera, Temuco, Chile
| | - Mario Rivera-Meza
- Departamento de Química Farmacológica y Toxicológica, Facultad de Ciencias Químicas y Farmacéuticas, Universidad de Chile, Santiago, Chile
| | - Gonzalo E Torres
- Department of Molecular Pharmacology & Neuroscience, Stritch School of Medicine, Loyola University Chicago, USA
| | - Georgina M Renard
- Centro de Investigación Biomédica y Aplicada (CIBAP), Escuela de Medicina, Facultad de Ciencias Médicas, Universidad de Santiago de Chile (USACH), Santiago, Chile.
| | - Ramón Sotomayor-Zárate
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valparaíso, Chile.
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Lenz B, Gerhardt S, Boroumand-Jazi R, Eichler A, Buchholz VN, Fasching PA, Kornhuber J, Banaschewski T, Flor H, Guldner S, Prignitz M, Nees F. Sex-specific association between prenatal androgenization (second-to-fourth digit length ratio) and frontal brain volumes in adolescents. Eur Arch Psychiatry Clin Neurosci 2023; 273:1243-1254. [PMID: 36449103 PMCID: PMC10449726 DOI: 10.1007/s00406-022-01515-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/26/2022] [Indexed: 12/03/2022]
Abstract
Prenatal androgenization associates sex-dependently with behavior and mental health in adolescence and adulthood, including risk-taking, emotionality, substance use, and depression. However, still little is known on how it affects underlying neural correlates, like frontal brain control regions. Thus, we tested whether prenatal androgen load is sex-dependently related to frontal cortex volumes in a sex-balanced adolescent sample. In a cross-sectional magnetic resonance imaging study, we examined 61 adolescents (28 males, 33 females; aged 14 or 16 years) and analyzed associations of frontal brain region volumes with the second-to-fourth digit length ratio (2D:4D), an established marker for prenatal androgenization, using voxel-based morphometry in a region-of-interest approach. Lower 2D:4D (indicative of higher prenatal androgen load) correlated significantly with smaller volumes of the right anterior cingulate cortex (r-ACC; β = 0.45) in male adolescents and with larger volumes of the left inferior frontal gyrus orbital part (l-IFGorb; β = - 0.38) in female adolescents. The regression slopes of 2D:4D on the r-ACC also differed significantly between males and females. The study provides novel evidence that prenatal androgenization may influence the development of the frontal brain in a sex- and frontal brain region-specific manner. These effects might contribute to the well-known sex differences in risk-taking, emotionality, substance use, and depression. Future research is needed to elucidate the role of prenatal androgenization within the biopsychosocial model.
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Affiliation(s)
- Bernd Lenz
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Sarah Gerhardt
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Rafat Boroumand-Jazi
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Anna Eichler
- Department of Child and Adolescent Mental Health, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Verena Nadine Buchholz
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Peter A Fasching
- Department of Obstetrics and Gynecology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Herta Flor
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Stella Guldner
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Maren Prignitz
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Frauke Nees
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Institute of Medical Psychology and Medical Sociology, University Medical Center Schleswig Holstein, Kiel University, Kiel, Germany
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Eichler A, Kaufmann F, Titzmann A, Fasching PA, Beckmann MW, Gerlach J, Kratz O, Moll GH, Buchholz VN, Kornhuber J, Lenz B. 2D:4D biomarker reliability and validity in a within-subject pregnancy-childhood-adolescence cohort. Early Hum Dev 2023; 181:105776. [PMID: 37084692 DOI: 10.1016/j.earlhumdev.2023.105776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/11/2023] [Accepted: 04/11/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND A lot of studies use the second-to-fourth digit length ratio (2D:4D) as a biomarker for intrauterine androgen load to predict behavioral and mental health problems. Thus, knowledge of 2D:4D's metric properties, namely reliability and validity, is essential. METHOD 2D:4D handscans were available from 149 adolescents (M = 13.32 years, SD = 0.35) and their mothers. For 88 adolescents, there were also primary-school age handscans (M = 7.87 years, SD = 0.68). Prenatal risks for the 1st to 3rd trimesters were recorded during the 3rd trimester of pregnancy (alcohol exposition: meconium biomarker and maternal self-report; nicotine exposition: maternal self-report; maternal depressive symptoms and subjective stress: questionnaires). RESULTS The 2D:4D ratio was highly stable from childhood to early adolescence. However, both developmental and sex effects were present: The 2D:4D ratio increased with age and was higher in adolescent girls vs. boys. Significant 2D:4D mother-child associations were found for girls. Significant main effects could be found for the prenatal risk factors alcohol (self-report) and nicotine consumption. CONCLUSION In line with earlier studies, the 2D:4D biomarker proved to be an inter-individually stable measure with an intra-individual increase from childhood to early adolescence. Sex differences in adolescence and associations with maternal prenatal health behaviour underline the validity of the biomarker. Findings on heritability emphasize the importance of interpreting 2D:4D results in a sex-specific manner.
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Affiliation(s)
- Anna Eichler
- Department of Child and Adolescent Mental Health, University Hospital Erlangen, Friedrich-Alexander-Univesität Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Franziska Kaufmann
- Department of Child and Adolescent Mental Health, University Hospital Erlangen, Friedrich-Alexander-Univesität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Adriana Titzmann
- Department of Obstetrics and Gynecology, University Hospital Erlangen, Friedrich-Alexander-Univesität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Peter A Fasching
- Department of Obstetrics and Gynecology, University Hospital Erlangen, Friedrich-Alexander-Univesität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Matthias W Beckmann
- Department of Obstetrics and Gynecology, University Hospital Erlangen, Friedrich-Alexander-Univesität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Jennifer Gerlach
- Department of Child and Adolescent Mental Health, University Hospital Erlangen, Friedrich-Alexander-Univesität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Oliver Kratz
- Department of Child and Adolescent Mental Health, University Hospital Erlangen, Friedrich-Alexander-Univesität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Gunther H Moll
- Department of Child and Adolescent Mental Health, University Hospital Erlangen, Friedrich-Alexander-Univesität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Verena N Buchholz
- Department of Psychiatry and Psychotherapy, University Hospital Erlangen, Friedrich-Alexander-Univesität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, University Hospital Erlangen, Friedrich-Alexander-Univesität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Bernd Lenz
- Department of Psychiatry and Psychotherapy, University Hospital Erlangen, Friedrich-Alexander-Univesität Erlangen-Nürnberg (FAU), Erlangen, Germany; Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Macrophage Migration Inhibitory Factor in Major Depressive Disorder: A Multilevel Pilot Study. Int J Mol Sci 2022; 23:ijms232415460. [PMID: 36555097 PMCID: PMC9779321 DOI: 10.3390/ijms232415460] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Macrophage migration inhibitory factor (MIF) is a controversially discussed inflammatory marker in major depressive disorder (MDD). While some studies show an association of high MIF protein levels with depression, animal models have yielded conflicting results. Thus, it remains elusive as to whether MIF plays an anti- or pro-depressive role. Therefore, we aimed to examine the potential of MIF at the genetic, expression and protein levels as a risk factor and biomarker to diagnose, monitor, or predict the course of MDD. Patients with a current major depressive episode (n = 66 with, and n = 63 without, prior medication) and remitted patients (n = 39) were compared with healthy controls (n = 61). Currently depressed patients provided a second blood sample after three weeks of therapy. Depression severity was assessed by self-evaluation and clinician rating scales. We genotyped for three MIF polymorphisms and analyzed peripheral MIF expression and serum levels. The absence of minor allele homozygous individuals in the large group of 96 female patients compared with 10-16% in female controls suggests a protective effect for MDD, which was not observed in the male group. There were no significant group differences of protein and expression levels, however, both showed predictive potential for the course of depression severity in some subgroups. While MIF protein levels, but not MIF expression, decreased during treatment, they were not associated with changes in depression severity. This project is the first to investigate three biological levels of MIF in depression. The data hint toward a genetic effect in women, but do not provide robust evidence for the utility of MIF as a biomarker for the diagnosis or monitoring of MDD. The observed predictive potential requires further analysis, emphasizing future attention to confounding factors such as sex and premedication.
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Pillerová M, Borbélyová V, Pastorek M, Riljak V, Hodosy J, Frick KM, Tóthová L. Molecular actions of sex hormones in the brain and their potential treatment use in anxiety disorders. Front Psychiatry 2022; 13:972158. [PMID: 36159923 PMCID: PMC9492942 DOI: 10.3389/fpsyt.2022.972158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/17/2022] [Indexed: 11/13/2022] Open
Abstract
Anxiety disorders are one of the most prevalent mood disorders that can lead to impaired quality of life. Current treatment of anxiety disorders has various adverse effects, safety concerns, or restricted efficacy; therefore, novel therapeutic targets need to be studied. Sex steroid hormones (SSHs) play a crucial role in the formation of brain structures, including regions of the limbic system and prefrontal cortex during perinatal development. In the brain, SSHs have activational and organizational effects mediated by either intracellular or transmembrane G-protein coupled receptors. During perinatal developmental periods, the physiological concentrations of SSHs lead to the normal development of the brain; however, the early hormonal dysregulation could result in various anxiety diorders later in life. Sex differences in the prevalence of anxiety disorders suggest that SSHs might be implicated in their development. In this review, we discuss preclinical and clinical studies regarding the role of dysregulated SSHs signaling during early brain development that modifies the risk for anxiety disorders in a sex-specific manner in adulthood. Moreover, our aim is to summarize potential molecular mechanisms by which the SSHs may affect anxiety disorders in preclinical research. Finally, the potential effects of SSHs in the treatment of anxiety disorders are discussed.
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Affiliation(s)
- Miriam Pillerová
- Faculty of Medicine, Institute of Molecular Biomedicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Veronika Borbélyová
- Faculty of Medicine, Institute of Molecular Biomedicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Michal Pastorek
- Faculty of Medicine, Institute of Molecular Biomedicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Vladimír Riljak
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
| | - Július Hodosy
- Faculty of Medicine, Institute of Molecular Biomedicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Karyn M Frick
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI, United States
| | - L'ubomíra Tóthová
- Faculty of Medicine, Institute of Molecular Biomedicine, Comenius University in Bratislava, Bratislava, Slovakia
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Buchholz VN, Mühle C, Kornhuber J, Lenz B. Markers of Prenatal Androgen Exposure Correlate With Online Sexual Compulsivity and Erectile Function in Young Men. Front Psychiatry 2021; 12:517411. [PMID: 33889090 PMCID: PMC8055940 DOI: 10.3389/fpsyt.2021.517411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/08/2021] [Indexed: 11/13/2022] Open
Abstract
Pornography addiction and sexual dysfunction are increasingly prevalent in young men. Previous studies suggest that prenatal androgen exposure plays a role in addiction and sexual functionality. Here, we tested whether lower second-to-fourth finger length ratio (2D:4D) and later age at spermarche, both putative indicators of higher androgen levels in utero, correlate with online sexual compulsivity (OSC scale of ISST), erectile function (IIEF-5), and ejaculatory control (PEPA) in 4,370 young men (age IQR: 25-26 years) of the Cohort Study on Substance Use Risk Factors. Statistical analyses revealed that lower 2D:4D correlated with higher scores on the OSC scale. Moreover, higher age at spermarche correlated with higher OSC scores and decreased erectile function. Interestingly, OSC severity, but not the frequency of pornography use, correlated negatively with erectile function and ejaculatory control. This is the first study to associate two independent proxies of prenatal testosterone level with OSC. These findings provide novel insight into intrauterine predisposition of sexual behavior and related sexual function in adulthood.
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Affiliation(s)
- Verena N Buchholz
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Christiane Mühle
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | | | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Bernd Lenz
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.,Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Siegmann EM, Müller T, Dziadeck I, Mühle C, Lenz B, Kornhuber J. Digit ratio (2D:4D) and transgender identity: new original data and a meta-analysis. Sci Rep 2020; 10:19326. [PMID: 33168880 PMCID: PMC7653965 DOI: 10.1038/s41598-020-72486-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 09/02/2020] [Indexed: 01/20/2023] Open
Abstract
Previously reported associations between second-to-fourth digit length ratio (2D:4D), a proxy for prenatal androgen load, and transgender identity have been inconsistent. The objectives of the present study were to provide additional original data and an updated meta-analysis concerning this association. In a study of 464 participants, we compared the 2D:4D of transgender individuals with age- and sex-matched controls. Patients were recruited at a specialized psychiatrist's medical office, whereas controls were hired via flyers, advertisements, and as convenience sample. A random-effects meta-analysis of the literature (17 samples, n = 3674) also quantifies the overall magnitude of the difference in 2D:4D between transgender individuals and controls. In our study providing new original data, we found a significantly higher (i.e. feminized) left-hand 2D:4D in the male-to-female transgender (MtF) identity [mean age: 32.3 (18; 61)] than in the male control group [mean age: 34.5 (18; 65)] with a Cohen's d = 0.271. Concordantly, the meta-analytic results suggest a significant difference in 2D:4D among MtF individuals compared to male controls [g = 0.153; 95% CI (0.063; 0.243)], which was even more pronounced when individuals had been diagnosed by a clinician instead of self-identified as transgender [g = 0.193; 95% CI (0.086; 0.300)]. In both studies, no significant results were revealed for female-to-male transgender individuals [mean age: 26.1 (18; 53)] versus female controls [mean age: 27.2 (18; 55)]. This original investigation and the updated meta-analysis clarify the association between transgender identity and 2D:4D indicating the influence of prenatal androgen on the development of gender identity in subjects born as males.
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Affiliation(s)
- Eva-Maria Siegmann
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Tobias Müller
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
- Psychiatric Practice, Treibberg 5, 90403, Nuremberg, Germany
| | - Isabelle Dziadeck
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Christiane Mühle
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Bernd Lenz
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
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