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Spontaneously fermented millet product as a natural probiotic treatment for diarrhoea in young children: an intervention study in Northern Ghana.

Indigenous lactic acid fermented foods may have potential as probiotic treatment for diarrhoea, due to high levels of lactic acid bacteria. In this study the effect of a millet drink, spontaneously fermented by lactic acid bacteria, as a therapeutic agent among Ghanaian children with diarrhoea, was assessed. Children below 5 years of age coming to Northern Ghana health clinics for treatment of diarrhoea were randomised to two groups. Children of both groups received treatment for diarrhoea given at the local clinic. The intervention group in addition received up to 300 ml fermented millet drink (KSW) daily for 5 days after enrolment. The clinical outcome of diarrhoea and reported well-being were registered every day for the 5-day intervention and again 14 days after diagnosis. Among 184 children (mean age 17.4, standard deviation 11.3 months) included, no effects of the intervention were found with respect to stool frequency, stool consistency and duration of diarrhoea. However, KSW was associated with greater reported well-being 14 days after the start of the intervention (P=0.02). The fact that no effect of KSW on diarrhoea was observed could be because many children had a mild form of diarrhoea, and many were treated with antibiotics. Either this could have affected the lactic acid bacteria, or the lactic acid bacteria in KSW had no probiotic effects. It is speculated that the effect after two weeks could be due to a preventing effect of KSW on antibiotic-associated diarrhoea which could help reducing persistent diarrhoea.

Anti-Bacterial Agents↗

Consumption of Lactobacillus acidophilus and Bifidobacterium longum does not alter phytoestrogen metabolism and plasma hormones in men: a pilot study.

OBJECTIVE: The aim of this study was to determine whether equol excretion status and plasma hormone and leptin concentrations can be influenced by consumption of a probiotic supplement. A secondary focus was to investigate whether male equol excretors have a hormone profile consistent with reduced prostate cancer risk. DESIGN: The design was a randomized, single-blinded, placebo-controlled, parallel-arm trial. SUBJECTS: Thirty-one (31) of the initially enrolled 39 subjects, 18 to 37 years old, completed all study requirements. INTERVENTION: Subjects consumed either probiotic capsules (containing Lactobacillus acidophilus and Bifidobacterium longum) or placebo capsules for 2 months. Fasting plasma concentrations of testosterone (T), dihydrotestosterone (DHT), androstanediol glucuronide (AAG), androstenedione (A), dehydroepiandrosterone sulfate (DHEAS), sex hormone-binding globulin (SHBG), and leptin were measured on days 1 and 57. Urinary excretion of genistein, glycitein, daidzein, O-desmethylangolensin (O-Dma), and equol was measured on days 4 and 61 following a 4-day soy challenge. RESULTS: Probiotic consumption did not significantly alter equol excretor status, plasma hormone, or leptin concentrations in these subjects. At baseline, there were no differences in plasma hormone concentrations between equol excretors and nonexcretors; however, the low number of equol excretors included in this study limits the strength of this finding. CONCLUSIONS: The 2-month intervention with probiotic capsules did not significantly alter equol excretion, plasma hormone, or leptin concentrations in these subjects. A secondary finding was that male equol excretors in this study did not exhibit a hormone profile consistent with reduced prostate cancer risk, although this result should be interpreted with caution.

Adrenal Cortex Hormones↗

Immunomodulating potential of supplementation with probiotics: a dose-response study in healthy young adults.

Certain probiotic microorganisms have been found beneficial in the treatment of immune-related diseases and may also affect immune function in healthy people. Intervention studies of probiotics in healthy humans are urgently required. Here, the immunomodulating potential of Bifidobacterium animalis ssp. lactis (BB-12) and Lactobacillus paracasei ssp. paracasei (CRL-431) was studied in a double-blind placebo-controlled parallel dose-response trial (n=71) based on five randomly assigned groups of young healthy adults supplemented for 3 weeks with 0, 10(8), 10(9), 10(10) and 10(11) CFU day(-1), respectively, of a mixture of BB-12 and CRL-431. No statistically significant dose-dependent effect was found for phagocytic activity in blood leukocytes, fecal immunoglobulin A (IgA) concentrations or production of interferon-gamma and interleukin-10 in blood cells. When evaluating data according to the amount of viable BB-12 recovered from faeces, the interferon-gamma production in blood cells was significantly reduced. In conclusion, no solid effect on the immune function of young healthy adults supplemented with even high doses of B. animalis ssp. lactis BB-12 and L. paracasei ssp. paracasei CRL-431 was demonstrated in this study.

Adolescent↗

Probiotic immunomodulation in health and disease.

Probiotics, microorganisms that have a favorable influence on physiologic and pathological processes of the host by their effect on the intestinal flora, may play a role in improving human health. One of the putative effects is the modulation of immune function. Thus, the mucosal immune system and methods to assess its function are reviewed briefly. Probiotic modulation of humoral, cellular and nonspecific immunity is reviewed, with emphasis placed on immune response in disease models. There are very few reports of human intervention studies with probiotics. However, some of the possible future directions for research with respect to probiotics, immunity, and human health are discussed. Although the application of probiotics has demonstrated trends with respect to altered aspects of immune response, the underlying mechanisms by which that occurs are unclear.

Animals↗

What are we doing about Escherichia coli O157:H7 in cattle?

Many human foodborne illnesses can be caused by consumption of foodstuffs (including meat products) contaminated with pathogenic bacteria from animal intestinal contents or hides. Steps that have been taken in the slaughter plant to decrease the spread of foodborne pathogenic bacteria (e.g., hazard analysis and critical control point methods) have been very effective; however, meat products are still the source of foodborne bacterial human illnesses. Increasing numbers of human Escherichia coli O157:H7 illnesses have also been related to contact with animals or to water supplies contaminated by run-off from cattle farms. Thus, strategies that specifically target foodborne pathogenic bacteria in the animal at the farm or feedlot level have great potential to improve food safety and decrease human illnesses. In this review, we describe a broad range of live-animal intervention strategies, both probiotic and antipathogen. Additionally, we examine some of the effects of diet and management strategies on foodborne pathogenic bacterial populations. The use of antibiotics in food animals to decrease foodborne pathogens also will be briefly examined. Overall, the concurrent use of several of these preslaughter intervention strategies could synergistically decrease human illnesses by providing for additional barriers in a multiple-hurdle approach to improving food safety.

Abattoirs↗

Short-term consumption of probiotic-containing cheese and its effect on dental caries risk factors.

Cheese is known to contain compounds that reduce the risk of dental caries. The long-term consumption of milk containing Lactobacillus rhamnosus GG, ATCC 53103 (LGG), has been shown to reduce caries risk in children. The aim of the present study was to examine whether short-term consumption of cheese containing LGG and Lactobacillus rhamnosus LC 705 would diminish caries-associated salivary microbial counts in young adults. Altogether, 74 18-35 year-old subjects completed this double-blinded, randomised, placebo-controlled study. During the 3 week intervention, the subjects ate 5 x 15 g cheese per day. Oral examinations were made before and after the study. Stimulated salivary secretion rates, buffer capacity and counts of salivary Streptococcus mutans, yeast and lactobacilli were evaluated before and after the intervention and after a 3 week post-treatment period. The results showed no statistically significant difference between the groups in Streptococcus mutans counts after the intervention, but during the post-treatment period there was a significantly greater reduction in these counts in the intervention group compared to the control group (P=0.05). However, Streptococcus mutans counts decreased in 20% (P=0.01) and yeast counts in 27% (P=0.005) of all the subjects, regardless of the intervention group. Results from logistic regression showed a trend indicating that probiotic intervention might reduce the risk of the highest level of Streptococcus mutans (OR=0.37, 95% CI 0.08-1.75, P=0.21) and salivary yeasts (OR=0.40, 0.09-1.71, P=0.22).

Adolescent↗

Plasma metabolites mediate the causal relationship between gut microbiota and erectile dysfunction: insights from Mendelian randomization study.

BACKGROUND: While the relationship between gut microbiota and erectile dysfunction (ED) has been reported, the specific pathways involved remain unclear. AIM: This study aims to investigate the causal relationship between gut microbiota and ED, and to identify the potential role of plasma metabolites as mediators. METHODS: Utilizing aggregated genome-wide association study (GWAS) data, a comprehensive two-sample Mendelian randomization (MR) analysis was performed involving 196 gut microbiota taxa, 1400 plasma metabolites and ED. Causal relationships between gut microbiota, plasma metabolites and ED were explored. In addition, mediation analysis was applied to identify the pathway from gut microbiota to ED mediated by plasma metabolites. OUTCOMES: This study reveals that plasma metabolites act as mediators regulating the influence of gut microbiota on ED. RESULTS: MR analysis identified causal relationships between six gut microbial taxa and ED, with Butyrivibrio increasing the risk of ED, while Alistipes, Prevotella 9, Dialister, Marvinbryantia, and LachnospiraceaeUCG010 exhibited protective effects. Additionally, 45 plasma metabolites demonstrated causal associations with ED. Finally, mediation analysis revealed four mediation relationships. Sensitivity analysis indicated no heterogeneity or pleiotropy in this study. CLINICAL IMPLICATIONS: Modulating gut microbiota or targeting specific metabolites may offer new therapeutic approaches for ED, highlighting the potential for microbiome-based interventions. STRENGTHS AND LIMITATIONS: The MR approach and large-scale GWAS data provide robust causal evidence, but the findings are limited by their focus on European populations and lack of experimental validation. Further studies are needed to confirm these mechanisms in diverse cohorts and functional models. CONCLUSION: This study establishes a causal link between gut microbiota, plasma metabolites, and ED, identifying specific microbial taxa and metabolites as key contributors to ED risk. The mediating role of plasma metabolites highlights potential therapeutic strategies, such as probiotics or dietary interventions targeting harmful metabolites.

Mendelian randomization↗

Hepatic encephalopathy: a review of its pathophysiology and treatment.

Hepatic encephalopathy (HE) is a broad spectrum of neuropsychiatric manifestations usually affecting individuals with end-stage liver disease. The presence of HE is a poor prognostic sign, with 1-year mortality rates of almost 60%. There is much debate about the underlying mechanisms that result in this syndrome; however, elevated plasma and central nervous system ammonia levels are considered key factors in its pathogenesis. Initial evaluation of the patient presenting with overt HE should include a careful search for predisposing factors, including underlying infection, gastrointestinal (GI) bleeding, electrolyte disturbances, hepatocellular carcinoma, dehydration, hypotension, and excessive use of benzodiazepines, psychoactive drugs, or alcohol. The mainstay of treatment for many years has been nonabsorbable disaccharides, particularly lactulose. Alternative treatments, which usually are second line in patients who do not respond to lactulose, include zinc, antibiotics (neomycin, metronidazole, and rifaximin), ornithine aspartate, sodium benzoate, probiotics, and surgical intervention. Accepted treatments for HE are associated with significant unpleasant side effects, including diarrhea, renal failure, neuropathy, and other GI disturbance. Newer therapies are still in development, and most are awaiting human trials in order to confirm their benefit. These include manganese chelators, L-carnitine, N-methyl-d-aspartate receptor antagonists, blood purification dialysis system, and an intravenous combination of sodium benzoate and phenylacetate.

Journal Article↗

Model of the epidemic of childhood atopy.

The reasons for the steep rise in the prevalence of atopic diseases such as asthma, atopic eczema and allergic rhinitis are unexplained. Studies have shown that immune regulation in the intestinal mucosa-associated lymphoid tissue (MALT) plays an important role in atopic sensitization and is influenced by the intestinal microflora. The hypothesis presented here is based on the following assumptions: 1. Mothers transfer some of their intestinal microflora to their children at birth and by close contact. 2. The intestinal microflora has the properties of an ecosystem that may react unexpectedly to changing conditions. 3. Modern lifestyle and diets negatively influence the intestinal ecosystem during the lifespan. Thus, from one generation to the next, there may be cumulative degradation of the intestinal microflora. Children inherit a non-physiological gut flora that is further degraded in later life and contributes to atopic sensitization in the following generation. Linear changes in environmental conditions and lifestyle may lead to non-linear changes in the gut flora and, possibly, to an increasing susceptibility to atopic diseases. Clinical studies using probiotics and dietary intervention should be the focus of future research.

Child↗

Irritable bowel syndrome.

BACKGROUND: Irritable bowel syndrome (IBS) a common worldwide problem, particularly women, and presents from the teenage years onward. OBJECTIVE: This article discusses the causes, diagnosis and management of IBS. DISCUSSION: Disturbed motility and sensory function underlie much of the disturbance in function that, not infrequently, begins following an episode of gastroenteritis. There is an intimate role for the brain-gut axis in modulating symptoms relating to underlying causes of small bowel bacterial overgrowth, food intolerance and sensitivity, and abnormalities of corticotropin releasing factors. Management requires long term involvement with the patient as there is no single therapeutic strategy that is predictably effective. However, diet, bulking agents, antispasmodics and a variety of alternative therapies including herbs, probiotics, and psychological intervention are important in individual patients.

Abdominal Pain↗

Systemic immunity-enhancing effects in healthy subjects following dietary consumption of the lactic acid bacterium Lactobacillus rhamnosus HN001.

OBJECTIVE: To determine the effects of the probiotic lactic acid bacterium, Lactobacillus rhamnosus HN001, on natural cellular immunity when delivered orally in normal low-fat milk (LFM) or lactose-hydrolyzed low-fat milk (LFM-LH). DESIGN: A three stage, pre-post intervention trial, spanning nine weeks. SETTING: Taipei Medical College Hospital, Taipei, Taiwan. SUBJECTS: Fifty-two healthy middle-aged and elderly volunteers (17 males, 35 females; median age 63.5, range 44-80). INTERVENTIONS: Stage 1 (run-in diet): 25 g/200 mL reconstituted LFM powder, twice daily for 3 weeks. Stage 2 (probiotic intervention): LFM or LFM-LH, supplemented with 10(9) CFUs/g L. rhamnosus HN001 in each case, for 3 weeks. Stage 3 (wash-out): LFM for 3 weeks. MEASURES OF OUTCOME: In vitro phagocytic capacity of peripheral blood polymorphonuclear (PMN) leukocytes; in vitro tumoricidal activity of natural killer (NK) leukocytes. RESULTS: Immunological responses were unaffected by the run-in diet of LFM alone. In contrast, the relative proportion of PMN cells showing phagocytic activity increased by 19% and 15%, respectively, following consumption of HN001 in either LFM or LFM-LH; the relative level of NK cell tumor killing activity increased by 71% and 147%. In most cases these levels declined following cessation, but remained above baseline. CONCLUSIONS: Dietary consumption of L. rhamnosus HN001, in a base of low-fat milk or lactose-hydrolyzed low-fat milk, appears to enhance systemic cellular immune responses and may be useful as a dietary supplement to boost natural immunity.

Adult↗

Enhancing immunity by dietary consumption of a probiotic lactic acid bacterium (Bifidobacterium lactis HN019): optimization and definition of cellular immune responses.

OBJECTIVE: To define the cellular basis for immune enhancement by a probiotic lactic acid bacteria strain (Bifidobacterium lactis HN019); and to determine whether immune enhancement can be optimized by delivery in oligosaccharide-enriched low-fat milk. DESIGN: A double-blind, three-stage before-and-after intervention trial. SETTING: Taipei Medical College Hospital, Taipei, Taiwan. SUBJECTS: Fifty healthy Taiwanese citizens (age range 41-81; median 60) randomly allocated to two groups. INTERVENTIONS: In stage 1 (run-in control stage) all subjects consumed reconstituted low-fat milk (LFM) for 3 weeks; in stage 2 (probiotic intervention) subjects consumed B. lactis in LFM (group A) or B. lactis in lactose-hydrolysed LFM (group B) for 3 weeks; in stage 3 all subjects returned to non-supplemented LFM for a further 3 weeks (washout stage). The innate immune functions of two different leucocyte types (polymorphonuclear (PMN) cells and natural killer (NK) cells) were assessed at four time points via in vitro analyses on peripheral blood samples. RESULTS: While consumption of LFM alone had no significant effect on immune responses, stage 2 results indicated significantly enhanced PMN cell phagocytosis and NK cell tumour killing activity following consumption of milk containing B. lactis. These increases levelled off following cessation of B. lactis consumption, but remained above the pre-treatment values. Increases in PMN and NK cell activity were greatest among subjects who consumed B. lactis in lactose-hydrolysed LFM. CONCLUSIONS: Dietary consumption of the probiotic bacterium B. lactis HN019 enhanced immune function of two different types of leucocytes; the degree of enhancement was increased by consuming B. lactis in an oligosaccharide-rich substrate. SPONSORSHIP: Financial support was provided by the New Zealand Dairy Board.

Adult↗

Probiotics for women's health.

GOALS: The goals of this research were 2-fold: (1) to determine whether a commercially available probiotic mixture (VSL-3) could survive and grow in a continuous culture system simulating the vaginal environment and (2) to determine whether the probiotic mixture was capable of suppressing the growth of a known vaginal vault pathogen, Gardnerella vaginalis. BACKGROUND: An abnormal vaginal microflora, such as that associated with bacterial vaginosis (BV) is an important health issue for women. In addition, the association of this condition with preterm labor and delivery suggests that control of BV may impact the number of preterm births. Interventional trials with antibiotics have received mixed reviews and other interventional options, including the use of probiotics, are being considered. STUDY: A well-documented continuous culture system has been used to determine whether VSL-3 can survive and grow in conditions simulating a vaginal environment. In addition, the ability of VSL-3 to inhibit the growth of a known vaginal vault pathogen, G. vaginalis, has been determined. RESULTS: The probiotic mixture was shown to survive and maintain itself within the fermentation vessel of the continuous culture system over an extended period of time. This mixture, when challenged with a known pathogen, was also shown to suppress the growth of G. vaginalis. CONCLUSIONS: It may be feasible to use probiotics as interventional therapy to suppress the growth of pathogens within the vaginal vault associated with BV.

Culture Techniques↗

A probiotic mixture alleviates symptoms in irritable bowel syndrome patients: a controlled 6-month intervention.

BACKGROUND: Irritable bowel syndrome is a gastrointestinal disorder of unknown aetiology. The effect of probiotics in this syndrome remains unclear. AIM: To investigate whether a probiotic mixture containing Lactobacillus rhamnosus GG, L. rhamnosus LC705, Bifidobacterium breve Bb99 and Propionibacterium freudenreichii ssp. shermanii JS is effective in alleviating irritable bowel syndrome symptoms. METHODS: A total of 103 patients fulfilling the Rome I or II criteria took part in this 6-month, randomized, double-blind placebo-controlled trial. The patients received a probiotic capsule or a placebo capsule daily. Gastrointestinal symptoms and bowel habits were recorded. RESULTS: At the end the total symptom score (abdominal pain + distension + flatulence + borborygmi) was 7.7 (95% CI: -13.9 to -1.6) points lower in the probiotic group (P = 0.015). This represents a median reduction of 42% in the symptom score of the probiotic group compared with 6% in the placebo group. In individual symptoms, borborygmi was milder in the probiotic group (P = 0.008), and for the rest of the symptoms there was a non-significant trend. CONCLUSIONS: The results indicate that this probiotic mixture is effective in alleviating irritable bowel syndrome symptoms. Considering the high prevalence of irritable bowel syndrome and the lack of effective therapies, even a slight reduction in symptoms could have positive public health consequences.

Adult↗

Impact of consuming a milk drink containing a probiotic on mood and cognition.

OBJECTIVE: The impact on mood and memory of consuming a probiotic containing milk drink, or a placebo, was examined as, previously, a poor mood has been found to correlate with the frequency of constipation. DESIGN: A double-blind placebo-controlled trial with random allocation of subjects. SETTING: Subjects went about their normal life in the community apart from three visits to the laboratory. SUBJECTS: One hundred and thirty-two healthy members of general population, mean age 61.8 years, volunteered in response to local media coverage. One hundred and twenty-four finished the trial. INTERVENTION: For a 3-week period, either a probiotic containing milk drink, or a placebo, were consumed daily. Mood and cognition were measured at baseline, and after 10 and 20 days of consumption. RESULTS: At baseline those who reported themselves to be less frequently constipated were more clearheaded, confident and elated. Although the taking of the probiotic did not generally change the mood, this appeared to be a reflection of the generally good mood in this sample. When those in the bottom third of the depressed/elated dimension at baseline were considered, they selectively responded by reporting themselves as happy rather than depressed after taking the probiotic. The intervention did not, however, influence the reported frequency of defaecation, probably a reflection of the initially low incidence of constipation. An unexpected and possibly chance finding was that the consumption of probiotics resulted in a slightly-poorer performance on two measures of memory. CONCLUSIONS: The consumption of a probiotic-containing yoghurt improved the mood of those whose mood was initially poor. This improvement in mood was not, however, associated with an increased frequency of defaecation.

Affect↗

Probiotics for treating infectious diarrhoea.

BACKGROUND: Probiotics are microbial cell preparations or components of microbial cells that have a beneficial effect on the health and well being of the host. Probiotics may offer a safe intervention in acute infectious diarrhoea to reduce the duration and severity of the illness. OBJECTIVES: To assess the effects of probiotics in proven or presumed infectious diarrhoea. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group's trials register (December 2002), the Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2002), MEDLINE (1966 to 2002), EMBASE (1988 to 2002), and reference lists from studies and reviews. We also contacted organizations and individuals working in the field, and pharmaceutical companies manufacturing probiotic agents. SELECTION CRITERIA: Randomized controlled trials comparing a specified probiotic agent with placebo or no probiotic in people with acute diarrhoea that is proven or presumed to be caused by an infectious agent. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial methodological quality and extracted data. MAIN RESULTS: Twenty-three studies met the inclusion criteria with a total of 1917 participants, mainly in countries with low overall mortality rates. Trials varied in relation to the probiotic(s) tested, dosage, methodological quality, and the diarrhoea definitions and outcomes. Probiotics reduced the risk of diarrhoea at 3 days (relative risk 0.66, 95% confidence interval 0.55 to 0.77, random effects model; 15 studies) and the mean duration of diarrhoea by 30.48 hours (95% confidence interval 18.51 to 42.46 hours, random effects model, 12 studies). Subgroup analysis by probiotic(s) tested, rotavirus diarrhoea, national mortality rates, and age of participants did not fully account for the heterogeneity. REVIEWERS' CONCLUSIONS: Probiotics appear to be a useful adjunct to rehydration therapy in treating acute, infectious diarrhoea in adults and children. More research is needed to inform the use of particular probiotic regimens in specific patient groups.

Adult↗

The effect of a probiotic milk product on plasma cholesterol: a meta-analysis of short-term intervention studies.

INTRODUCTION: Certain fermented dairy milk products may have beneficial effects on plasma cholesterol levels. However, a number of studies have produced conflicting results as to whether dietary supplementation by a probiotic dairy product containing the bacteria culture Causido(R) reduces plasma cholesterol. OBJECTIVE: To conduct a meta-analysis of intervention studies to evaluate the effect of the Causido(R) culture on plasma total cholesterol and low-density lipoprotein (LDL)-cholesterol. THE PROBIOTIC MILK PRODUCT: The yoghurt product Gaio(R) is fermented with Causido(R), composed of one strain of Enterococcus faecium (human species) with the proposed cholesterol-lowering effect, and two strains of Streptococcus thermophilus. STUDY INCLUSION AND DATA EXTRACTION: Six studies were identified from a literature search and from the yoghurt producer. All studies met the inclusion criteria. Summary data for plasma concentrations of total cholesterol and LDL-cholesterol were extracted from the original publications or by personal request to the authors. Data from 4-8 weeks of treatment duration was used. STATISTICAL ANALYSIS: We performed a traditional meta-analysis where mean differences between intervention and control of the pre-post changes in total cholesterol and LDL-cholesterol were calculated, as well as 95% confidence intervals (CIs). RESULTS: In the six studies included in the meta-analysis, the Gaio(R) interventions produced changes in total cholesterol above those of the control groups ranging from -0.02 to -1.02 mmol/l and in LDL-cholesterol ranging from -0.02 to -1.15 mmol/l. After inclusion of an open-label study, the meta-analysis of the double-blind studies showed that Gaio(R) as compared to the control group changed total cholesterol by -0.22 mmol/l (95% CI: -0.35 to -0.08, P<0.01) and LDL-cholesterol by -0.20 mmol/l (95% CI: -0.33 to -0.06, P<0.005). The outcome was essentially the same if all studies were included. CONCLUSIONS: The present meta-analysis of controlled short-term intervention studies shows that the fermented yoghurt product produced a 4% decrease in total cholesterol and a 5% decrease in LDL-cholesterol when the open-label study is excluded. To demonstrate sustained effects on blood lipids, long-term studies are required. SPONSORSHIP: MD Foods A/S, Denmark.

Adult↗