Toxic effects and mechanisms of nanoplastics on embryonic brain development using brain organoids model

Revealing the neurodevelopmental toxicity of face mask-derived microplastics to humans based on neural organoids

The massive use of face masks during and after the COVID-19 pandemic has raised global concerns about environmental issues. Microplastics released from face masks pose great threats to ecosystems and human health. However, the potentially hazardous effects of face mask-derived microplastics (FMMs) on humans remain poorly understood. Using neural organoid models aims to reveal the toxicity of FMMs to human early neural development. Retinal organoids derived from human embryonic stem cells were exposed to FMMs for 21 days during early retinogenesis. FMMs were internalized by retinal organoids. Exposure to FMMs disrupted the growth and development of retinal organoids in dose- and time-dependent manners, as evidenced by abnormal morphologies. Aberrant cell events, such as cell proliferation, apoptosis, and differentiation contributed to the disarrangement of the neural retina. Transcriptome data proved that the neurotoxicity of FMMs was closely related to disordered neurogenesis, anatomical structure morphogenesis, and axon guidance. Co-exposure to triphenyl phosphate (a common organophosphate flame retardant) and FMMs exhibited more pronounced neurotoxicity than FMM exposure alone. These findings are expected to uncover the potential threats of FMMs to human neurodevelopment and emphasize the importance of optimizing the management and safe disposal of used face masks.

Developing a feasible fast-track testing method for developmental neurotoxicity studies: alternative model for risk assessment of micro- and nanoplastics

Micro- and nanoplastics (MNPs) are widespread environmental pollutants that pose significant health risks. They originate from industrial processes, consumer products, and environmental degradation, inducing oxidative stress through cellular dysfunctions such as membrane interaction, internalization, mitochondrial damage, inflammation, metal ion leaching, and impaired antioxidant defense. Despite increasing evidence of their toxicity-particularly developmental neurotoxicity (DNT) and mitochondrial impairment-our understanding remains limited due to the high costs of animal studies, which reduce the overall size of experimental data. This underscores the urgent need for alternative test methods that are cost-effective, rapid, and translational. This review examines new approach methodologies (NAMs) for DNT assessment, addressing the ethical, financial, and translational limitations of animal models. NAMs integrate three complementary non-animal models that enhance conventional testing. First, zebrafish models provide organismal insights into behavioral and neurodevelopmental outcomes at minimal cost. Second, neuronal organoids replicate human-specific neurodevelopmental processes in a 3D system, offering mechanistic insights. Lastly, human cell lines enable high-throughput screening, integrating findings from zebrafish and organoid studies. Establishing a new paradigm for DNT testing is crucial for faster and more efficient toxicity and risk assessments, ultimately protecting public health. Standardizing and gaining regulatory acceptance for NAMs will improve predictive accuracy and broaden their application in environmental toxicology. Advancing these methodologies is essential to addressing the risks of MNP exposure while promoting ethical and sustainable research practices.

Life cycle exposure to differentially charged polystyrene nanoplastics leads to gender-specific particle accumulation and neurotoxicity in zebrafish (Danio rerio)

Nanoplastics (NPs) have been widely detected in freshwater environments and photodegradation, as well as physical and chemical breakdown, lead to different surface charges on the plastics. Although evidence in the literature highlights the importance of NPs surface charge to neurotoxicity, substantial gaps in mechanistic understanding remain. In the current study, zebrafish (Danio rerio) were exposed to differentially charged NPs (PS, PS-NH2, PS-COOH) at environmentally relevant concentration (10 μg/L). After full life cycle exposure, the potential neurotoxicity, brain damage, and the altered brain metabolism was investigated through light sheet microscopy 3-dimensional imaging, histopathology, Evans blue dye (EBD) extravasation, gene expression, and untargeted and targeted metabolomics of brain tissue in zebrafish. Exposure to PS, PS-NH2, PS-COOH caused adverse effects on the performance of neurobehaviors, blood-brain-barrier (BBB) permeability, amino acid metabolism, damage to the BBB and mitochondria, and overt inflammatory response. PS-NH2 (4.56-fold) and PS-COOH (3.59-fold) accumulated in the reticular formation (RF) of the male brain, while only PS-NH2 was detected in the RF (6.57-fold) and ventral hypothalamus (Hv) (3.08-fold) of female brains. Several important biological pathways were negatively impacted in a charge- and gender-specific fashion. This study provides novel insights into the underlying toxicity mechanisms of differentially charged NPs in a model aquatic species, as well as the associated environmental risks of this important group of emerging contaminants.

Biotransport and toxic effects of micro- and nanoplastics in fish model and their potential risk to humans: A review

The growing body of scientific evidence suggests that micro- and nanoplastics (MPs/NPs) pose a significant threat to aquatic ecosystems and human health. These particles can enter organisms through ingestion, inhalation, dermal contact, and trophic transfer. Exposure can directly affect multiple organs and systems (respiratory, digestive, neurological, reproductive, urinary, cardiovascular) and activate extensive intracellular signaling, inducing cytotoxicity involving mechanisms such as membrane disruption, extracellular polymer degradation, reactive oxygen species (ROS) production, DNA damage, cellular pore blockage, lysosomal instability, and mitochondrial depolarization. This review focuses on current research examining the in vivo and in vitro toxic effects of MPs/NPs on aquatic organisms, particularly fish, in relation to particulate toxicity aspects (such as particle transport mechanisms and structural modifications). Meanwhile, from the perspectives of the food chain and environmental factors, it emphasizes the comprehensive threats of MPs/NPs to human health in terms of both direct and indirect toxicity. Additionally, future research needs and strategies are discussed to aid in mitigating the potential risks of particulate plastics as carriers of toxic trace elements to human health.

Microplastics/nanoplastics and neurological health: An overview of neurological defects and mechanisms

The widespread use of plastic products worldwide has brought about serious environmental issues. In natural environments, it's difficult for plastic products to degrade completely, and so they exist in the form of micro/nanoplastics (M/NPs), which have become a new type of pollutant. Prolonged exposure to M/NPs can lead to a series of health problems in humans, particularly toxicity to the nervous system, with consequences including neurodevelopmental abnormalities, neuronal death, neurological inflammation, and neurodegenerative diseases. Although direct evidence from humans is still limited, model organisms and organoids serve as powerful tools to provide important insights. This article summarizes the effects of M/NPs on the nervous system, focusing on cognitive function, neural development, and neuronal death. Mechanisms such as neurotransmitter synthesis and release, inflammatory responses, oxidative stress, the gut-brain axis, and the liver-brain axis are covered. The neurotoxicity induced by M/NPs may exacerbate or directly trigger neurodegenerative diseases and neurodevelopmental disorders. We particularly emphasize potential therapeutic agents that may counteract the neurotoxic effects induced by M/NPs, highlighting a novel future research direction. In summary, this paper cites evidence and provides mechanistic perspectives on the effects of M/NPs on neurological health, providing clues for eliminating M/NP hazards to human health in the future.

Lead exposure leads to premature neural differentiation via inhibiting Wnt signaling

Heavy metals, such as Lead (Pb), are ubiquitous environmental pollutants that is a considerable problem worldwide. Increasing evidences suggest that Pb exposure negatively impact central nervous system. However, the exact toxic mechanism of Pb on early human brain development remain unclear due to the limitations of animal models and 2D cell models. In this study, we used human cortical organoids to reveal that Pb had specific early neurodevelopmental toxicity during the neural differentiation stage. We observed that short-term Pb exposure (10 days) is sufficient to induce premature neuronal differentiation. Mechanistically, Pb exposure downregulates the Wnt signaling in cortical organoids, and the activation of Wnt signaling reverses the neurodevelopmental phenotype. In support, Pb exposure during pregnancy lead to premature neuronal differentiation and reduced neurogenesis in mice. In conclusion, our study reveals the neuropathogenesis of Pb exposure and uncovers the potential intervention role of Wnt activation.

Particulate matter induces depression-like behavior through systemic inflammation and brain-derived neurotrophic factors

Particulate matter (PM) has always received widespread attention, PM2.5 pollution is associated with many adverse effects, including cardiovascular, respiratory and metabolic diseases and mood disorders. However, the underlying mechanisms are not yet clear. In this study, the small animal whole body inhalation exposure system collected real-time PM2.5 in the real environment, which can truly reflect the presence status of PM2.5 in the atmospheric environment. This study investigated the depressive like behavior of mice exposed to PM2.5 for a long time and proved its molecular mechanism through RNA-seq. C57BL/6 male mice were exposed to ambient air together with control mice, who breathed air filtered through high-efficiency air particulate filters. Depression like behavior was observed in mice exposed to PM for 4, 6, and 8 weeks through behavioral experiments, EEG signals, and pathological sections. RNA-seq results indicated that the depressive like behavior of mice exposed to PM2.5 might be related to pro-inflammatory and anti-inflammatory cytokines, as well as the BDNF pathways in the hippocampus and olfactory bulb. This study suggests that PM2.5 may induce depression in mice through the MAPK/CREB/BDNF pathway. ENVIRONMENTAL IMPLICATION: Atmospheric particulate matter has been classified as Class 1 pollutant by the International Agency for Research on Cancer. Current research mainly believed that PM2.5 seriously affected lung health, but there was little research on the effects of PM2.5 on other organs. With the improvement of quality of life, people were paying more attention to mental health, while there is little research on the effects of PM2.5 on brain. This study simulated a real PM2.5 exposure environment and explored the effects of PM2.5 on the brain of mice, provided a solid scientific basis for inducing depression after PM2.5 exposure.

Eco-corona enhanced the interactive effects of nanoplastics and 6:2 chlorinated polyfluorinated ether sulfonate in zebrafish embryos

Nanoplastics (NPs, < 1000 nm) interact with chemicals and biomolecules to produce chemical-/eco-corona, altering the environmental destiny, bioavailability, and toxicity of plastic particles and co-occurring chemicals. This study employs exogenous (humic acid, HA) and endogenous (bovine serum albumin, BSA) natural organic matter (NOM) to investigate the eco-corona formation on NPs and explore the interfacial effects of eco-corona and 6:2 chlorinated polyfluorinated ether sulfonate (Cl-PFESA, commonly named as F-53B) on zebrafish (Danio rerio) after 7 days of exposure. Our results indicated significant changes in growth and developmental indices of zebrafish embryos among all eco-corona groups (p < 0.05). Additionally, NFB (BSA-corona, 1 mg/L NPs + 200 μg/L F-53B + 10 mg/L BSA), NFH (HA-corona, 1 mg/L NPs + 200 μg/L F-53B + 10 mg/L HA) and NFHB (BSA-HA-corona, 1 mg/L NPs + 200 μg/L F-53B + 10 mg/L BSA + 10 mg/L HA) showed elevated bioaccumulation of NPs, ROS generation and induction of apoptosis. Transcriptomic analysis showed the number of differentially expressed genes (DEGs) in the following order: BSA-HA-corona (NFHB (2953) > HA-corona (NFH (2797) > NH (2721) > F-53B (2292) > NF (2033) > BSA-corona (NFB (687) > NB (450)), and no DEGs were detected in the single NP compared to the control. Further, the PI3K-AKT, immune system, endocrine system, digestive system, infectious diseases, and neurovegetative disease pathways showed sensitive responses in the NFH/NFHB groups compared to those in the NFB group. Therefore, the interactive effects of NPs and F-53B on zebrafish embryos were lower in the presence of BSA-corona than those in HA- or HA-BSA-coronas, indicating a relationship between the formation of diverse eco-coronas on NPs by multiple NOM and an associated increase in the interfacial toxicological effects of plastic particles and F-35B in freshwater organisms.

Engineering human midbrain organoid microphysiological systems to model prenatal PFOS exposure

Perfluorooctane sulfonate (PFOS), a class of synthetic chemicals detected in various environmental compartments, has been associated with dysfunctions of the human central nervous system (CNS). However, the underlying neurotoxicology of PFOS exposure is largely understudied due to the lack of relevant human models. Here, we report bioengineered human midbrain organoid microphysiological systems (hMO-MPSs) to recapitulate the response of a fetal human brain to multiple concurrent PFOS exposure conditions. Each hMO-MPS consists of an hMO on a fully 3D printed holder device with a perfusable organoid adhesion layer for enhancing air-liquid interface culturing. Leveraging the unique, simply-fabricated holder devices, hMO-MPSs are scalable, easy to use, and compatible with conventional well-plates, and allow easy transfer onto a multiple-electrode array (MEA) system for plug-and-play measurement of neural activity. Interestingly, the neural activity of hMO-MPSs initially increased and subsequently decreased by exposure to a concentration range of 0, 30, 100, to 300 μM of PFOS. Furthermore, PFOS exposure impaired neural development and promoted neuroinflammation in the engineered hMO-MPSs. Along with PFOS, our platform is broadly applicable for studies toxicology of various other environmental pollutants.

Nanoplastics exposure-induced mitochondrial dysfunction contributes to disrupted stem cell differentiation in human cerebral organoids

Nanoplastics are ubiquitous in our daily lives, raising concerns about their potential impact on the human brain. Many studies reported that nanoplastics permeate the blood-brain barrier and influence cellular processes in mouse models. However, the neurotoxic effects of ingesting nanoplastics on human brain remain poorly understood. Here, we treated cerebral organoids with polystyrene nanoplastics to model the effects of nanoplastic exposure on human brain. Importantly, we found that mitochondria might be the significant organelles affected by polystyrene nanoplastics using immunostaing and RNA-seq analysis. Subsequently, we observed the increased cell death and decreased cell differentiation in our cerebral organoids. In conclusion, our findings shed insights on the mechanisms underlying the toxicity of nanoplastics on human brain organoids, providing an evaluation system in detection potential environmental toxicity on human brain.

Microplastics in the human body: A comprehensive review of exposure, distribution, migration mechanisms, and toxicity

Microplastics (MPs) are pervasive across ecosystems, presenting substantial risks to human health. Developing a comprehensive review of MPs is crucial due to the growing evidence of their widespread presence and potential harmful effects. Despite the growth in research, considerable uncertainties persist regarding their transport dynamics, prevalence, toxicological impacts, and the potential long-term health effects they may cause. This review thoroughly evaluates recent advancements in research on MPs and their implications for human health, including estimations of human exposure through ingestion, inhalation, and skin contact. It also quantifies the distribution and accumulation of MPs in various organs and tissues. The review discusses the mechanisms enabling MPs to cross biological barriers and the role of particle size in their translocation. To ensure methodological rigor, this review adheres to the PRISMA guidelines, explicitly detailing the literature search strategy, inclusion criteria, and the quality assessment of selected studies. The review concludes that MPs pose significant toxicological risks, identifies critical gaps in current knowledge, and recommends future research directions to elucidate the prolonged effects of MPs on human health. This work aims to offer a scientific framework for mitigating MP-related hazards and establishes a foundation for ongoing investigation.

High-quality models for assessing the effects of environmental pollutants on the nervous system: 3D brain organoids

The prevalence of environmental problems and the increasing risk of human exposure to environmental pollutants have become a global concern. The increasing environmental pollution is one of the main reasons for the rising incidence of most neurological-related diseases in recent years. However, the ethical constraints of direct human research and the racial limitations of animal models have slowed the progress of research in this area. The purpose of this study is to review the neurotoxicity of different environmental pollutants on the brain using brain organoids as a new model and to conclude that brain organoids may play a key role in assessing the mechanisms by which environmental pollutants affect neurogenesis and cause neurological pathogenesis. To accurately determine the negative effects of environmental pollutants on the nervous system, self-organizing brain organoids that are highly similar to the developing brain have become a new model system for studying the effects of environmental pollutants on human brain development and disease. This study uses brain organoids as a model to summarize the neurotoxicity of different environmental pollutants on the nervous system, including structural changes in brain organoids, inhibition of neuronal differentiation and migration, impairment of mitochondrial function, damage to cellular cilia, and influence on signaling pathways. In conclusion, exposure to environmental pollutants may cause different neurotoxicity to the nervous system. Therefore, it is crucial to understand how to use brain organoids to ameliorate neurological disorders caused by environmental pollution.

Effects of nanoplastic exposure during pregnancy and lactation on neurodevelopment of rat offspring

Microplastics have emerged as a prominent global environmental contaminant, and they have been found in both human placenta and breast milk. However, the potential effects and mechanisms of maternal exposure to microplastics at various gestational stages on offspring neurodevelopment remain poorly understood. This investigation delves into the potential neurodevelopmental ramifications of maternal exposure to polystyrene nanoplastics (PS-NPs) during distinct phases of pregnancy and lactation. Targeted metabolomics shows that co-exposure during both pregnancy and lactation primarily engendered alterations in monoamine neurotransmitters within the cortex and amino acid neurotransmitters within the hippocampus. After prenatal exposure to PS-NPs, fetal rats showed appreciably diminished cortical thickness and heightened cortical cell proliferation. However, this exposure did not affect the neurodifferentiation of radial glial cells and intermediate progenitor cells. In addition, offspring are accompanied by disordered neocortical migration, typified by escalated superficial layer neurons proliferation and reduced deep layer neurons populations. Moreover, the hippocampal synapses showed significantly widened synaptic clefts and diminished postsynaptic density. Consequently, PS-NPs culminated in deficits in anxiolytic-like behaviors and spatial memory in adolescent offspring, aligning with concurrent neurotransmitter and synaptic alterations. In conclusion, this study elucidates the sensitive windows of early-life nanoplastic exposure and the consequential impact on offspring neurodevelopment.

Cytotoxicity of amine-modified polystyrene MPs and NPs on neural stem cells cultured from mouse subventricular zone

Microplastics (MPs) and nanoplastics (NPs) are found in various environments such as aquatic, terrestrial, and aerial areas. Once ingested and inhaled, these tiny plastic debris damaged the digestive and respiratory organ systems in animals. In humans, the possible connection between MPs and various diseases such as lung diseases has been raised. Yet, the impact of MPs on the human nervous system has been unclear. Previous research using animals and cultured cells showed possible neurotoxicity of MPs and NPs. In this study, we used neural stem cells cultured from mouse subventricular zone to examine the effects of polystyrene (PS) NPs and MPs with sizes of 0.1 μm, 1 μm, and 2 μm on the cell proliferation and differentiation. We observed that only positively charged NPs and MPs, but not negatively charged ones, decreased cell viability and proliferation. These amine-modified NPs and MPs decreased both neurogenesis and oligodendrogenesis. Finally, fully differentiated neurons and oligodendrocytes were damaged and removed by the application of NPs and MPs. All these effects varied among different sizes of NPs and MPs, with the greatest effects from 1 μm and the least effects from 2 μm. These results clearly demonstrate the cytotoxicity and neurotoxicity of PS-NPs and MPs.

Application of organoid technology in the human health risk assessment of microplastics: A review of progresses and challenges

Microplastic (MP) pollution has become a global environmental issue, and increasing concern has been raised about its impact on human health. Current studies on the toxic effects and mechanisms of MPs have mostly been conducted in animal models or in vitro cell cultures, which have limitations regarding inter-species differences or stimulation of cellular functions. Organoid technology derived from human pluripotent or adult stem cells has broader prospects for predicting the potential health risks of MPs to humans. Herein, we reviewed the current application advancements and opportunities for different organoids, including brain, retinal, intestinal, liver, and lung organoids, to assess the human health risks of MPs. Organoid techniques accurately simulate the complex processes of MPs and reflect phenotypes related to diseases caused by MPs such as liver fibrosis, neurodegeneration, impaired intestinal barrier and cardiac hypertrophy. Future perspectives were also proposed for technological innovation in human risk assessment of MPs using organoids, including extending the lifespan of organoids to assess the chronic toxicity of MPs, and reconstructing multi-organ interactions to explore their potential in studying the microbiome-gut-brainaxis effect of MPs.

The possible impacts of nano and microplastics on human health: lessons from experimental models across multiple organs

The widespread production and use of plastics have resulted in accumulation of plastic debris in the environment, gradually breaking down into smaller particles over time. Nano-plastics (NPs) and microplastics (MPs), defined as particles smaller than 100 nanometers and 5 millimeters, respectively, raise concerns due to their ability to enter the human body through various pathways including ingestion, inhalation, and skin contact. Various investigators demonstrated that these particles may produce physical and chemical damage to human cells, tissues, and organs, disrupting cellular processes, triggering inflammation and oxidative stress, and impacting hormone and neurotransmitter balance. In addition, micro- and nano-plastics (MNPLs) may carry toxic chemicals and pathogens, exacerbating adverse effects on human health. The magnitude and nature of these effects are not yet fully understood, requiring further research for a comprehensive risk assessment. Nevertheless, evidence available suggests that accumulation of these particles in the environment and potential human uptake are causes for concern. Urgent measures to reduce plastic pollution and limit human exposure to MNPLs are necessary to safeguard human health and the environment. In this review, current knowledge regarding the influence of MNPLs on human health is summarized, including toxicity mechanisms, exposure pathways, and health outcomes across multiple organs. The critical need for additional research is also emphasized to comprehensively assess potential risks posed by degradation of MNPLs on human health and inform strategies for addressing this emerging environmental health challenge. Finally, new research directions are proposed including evaluation of gene regulation associated with MNPLs exposure.

Innovative explorations: unveiling the potential of organoids for investigating environmental pollutant exposure

As the economy rapidly develops, chemicals are widely produced and used. This has exacerbated the problems associated with environmental pollution, raising the need for efficient toxicological evaluation techniques to investigate the toxic effects and mechanisms of toxicity of environmental pollutants. The progress in the techniques of cell culture in three dimensions has resulted in the creation of models that are more relevant in terms of biology and physiology. This enables researchers to study organ development, toxicology, and drug screening. Adult stem cells (ASCs) and induced pluripotent stem cells (iPSCs) can be obtained from various mammalian tissues, including cancerous and healthy tissues. Such stem cells exhibit a significant level of tissue memory and ability to self-assemble. When cultivated in 3D in vitro environments, the resulting organoids demonstrate a remarkable capacity to recapitulate the cellular composition and function of organs in vivo. Recently, many tumors' tissue-derived organoids have been widely used in research on tumor pathogenesis, drug development, precision medicine, and other fields, including those derived from colon cancer, cholangiocarcinoma, liver cancer, and gastric cancer. However, the application of organoid models for evaluating the toxicity of environmental pollutants is still in its infancy. This review introduces the characteristics of the toxicity responses of organoid models upon exposure to pollutants from the perspectives of organoid characteristics, tissue types, and their applications in toxicology; discusses the feasibility of using organoid models in evaluating the toxicity of pollutants; and provides a reference for future toxicological studies on environmental pollutants based on organoid models.

Airborne Nanoplastics Exposure Inducing Irreversible Glucose Increase and Complete Hepatic Insulin Resistance

As an emerging type of pollutant, microplastics have become a global environmental problem. Approximately, a fifth of the global burden of type 2 diabetes can be attributed to air particulate pollution. However, scientific knowledge remains limited about the effects of airborne nanoplastics (NPs) exposure on metabolic diseases. In this experiment, a whole-body exposure system was used to simulate the real atmospheric environment, and three exposure concentrations combined with the actual environmental concentration were selected to explore the effects of airborne NPs on metabolic diseases. Based on histological analyses, metabolic studies, gene expression, metabolites, and molecular signaling analyses, mice exposed to airborne NPs were observed to show a phenotype of systemic inflammation and complete insulin resistance featuring excessive drinking and eating, weight loss, elevated blood glucose, and decreased triglyceride levels. After airborne NPs exposure, mice were intolerant to glucose and tolerant to insulin. In addition, airborne NPs exposure could result in long-term irreversible hyperglycemia. Together, the research findings provide a strong basis for understanding the hazards of airborne nanopollution on metabolic disorders.

Detection and quantification of various microplastics in human endometrium based on laser direct infrared spectroscopy

The pollution of microplastics (MPs) has received widespread attention with the increasing usage of plastics in recent years. MPs could enter the human body and exist in the circulatory system. Endometrium, with rich blood vessels, acts as an essential role in human health and female fertility. However, there is no study reporting the MPs exposure in human endometrium. We collected the endometrium samples to detect the presence of MPs qualitatively and quantitatively via laser direct infrared. We found that there was a total of 13 types of MPs existing in the collected samples, among which 6 special types of MPs were with both high abundance and high detection rate. The abundance of these MPs ranged from 0 to 117 particles/100 mg, with a median abundance of 21 particles/100 mg. Most detected MPs, accounting for 88.35 %, were in small size (20-100 μm). Among small-size MPs, ethylene-acrylic acid copolymer ranked first while polyethylene accounted for the largest proportion among large-size MPs (100-500 μm). Correlation analysis indicated there was no significant relationship between age and MP abundance or BMI and MP abundance. We also designed a questionnaire to investigate lifestyle and daily habits, aiming at revealing the potential relationship between MP exposure and living habits. We discovered that some drinking habits and chewing gum were significantly correlated with a higher level of MP exposure. For the first time, we identified the presence of MPs in human endometrium and clarified the potential connections between MP exposure and lifestyle. Further studies are still necessary to explore more underlying information.