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Dermitzakis I, Theotokis P, Axarloglou E, Delilampou E, Manthou ME, Meditskou S. Effects of hazardous chemicals on secondary sex ratio: A comprehensive review. CHEMOSPHERE 2024; 361:142467. [PMID: 38810798 DOI: 10.1016/j.chemosphere.2024.142467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 04/15/2024] [Accepted: 05/26/2024] [Indexed: 05/31/2024]
Abstract
The secondary sex ratio (SSR), defined as the ratio of male to female offspring at birth, has garnered significant scientific interest due to its potential impact on population dynamics and evolution. In recent years, there has been a growing concern regarding the potential consequences of environmental chemicals on the SSR, given their widespread exposure and potential enduring ramifications on the reproductive system. While SSR serves as an indicator of health, ongoing research and scientific inquiry are being conducted to explore the potential relationship between chemicals and offspring ratio. Although some studies have suggested a possible correlation, others have yielded inconclusive results, indicating that the topic is intricate and still needs to be elucidated. The precise mechanism by which chemical agents exert their influence on the SSR remains ambiguous, with disruption of the endocrine system being a prominent justification. In light of the complex interplay between chemical exposure and SSR, the present review aims to comprehensively examine and synthesize existing scientific literature to gain a deeper understanding of how specific chemical exposures may impact SSR. Insights into chemical hazards that shift SSR patterns or trends could guide prevention strategies, including legislative bans of certain chemicals, to minimize environmental and public health risks.
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Affiliation(s)
- Iasonas Dermitzakis
- Department of Histology-Embryology, School of Medicine, Aristotle University of Thessaloniki, 54124, Thessaloniki, Greece
| | - Paschalis Theotokis
- Department of Histology-Embryology, School of Medicine, Aristotle University of Thessaloniki, 54124, Thessaloniki, Greece
| | - Evangelos Axarloglou
- Department of Histology-Embryology, School of Medicine, Aristotle University of Thessaloniki, 54124, Thessaloniki, Greece
| | - Efthymia Delilampou
- Department of Histology-Embryology, School of Medicine, Aristotle University of Thessaloniki, 54124, Thessaloniki, Greece
| | - Maria Eleni Manthou
- Department of Histology-Embryology, School of Medicine, Aristotle University of Thessaloniki, 54124, Thessaloniki, Greece
| | - Soultana Meditskou
- Department of Histology-Embryology, School of Medicine, Aristotle University of Thessaloniki, 54124, Thessaloniki, Greece.
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Placental Transfer and Composition of Perfluoroalkyl Substances (PFASs): A Korean Birth Panel of Parent-Infant Triads. TOXICS 2021; 9:toxics9070168. [PMID: 34357911 PMCID: PMC8309930 DOI: 10.3390/toxics9070168] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 01/09/2023]
Abstract
Exposure to perfluoroalkyl substances (PFASs) is of public concern due to their persistent exposure and adverse health effects. Placental transfer of PFASs is an important excretion pathway of these chemicals in pregnant women and exposure route in fetuses. We measured PFAS concentrations in maternal, paternal, and umbilical cord serum collected from 62 pregnant Korean women and matched biological fathers of the fetuses. Placental transfer rates (cord to maternal serum ratio) of PFASs were also calculated. Demographics and pregnancy-related factors determining the placental transfer rates were identified using linear regression models. Maternal, paternal, and cord serum showed different PFASs compositions. Among the PFASs, perfluorooctane sulfonate (PFOS) showed the highest concentrations in maternal and paternal serum, while perfluorooctanoic acid (PFOA) showed the highest concentration in cord serum. There was a higher proportion of perfluoroalkyl carboxylic acids (PFCAs) with 9–12 carbon chains than those with 13–14 carbon chains in maternal and paternal serum, but this proportion was in the opposite direction in cord serum. PFOA and perfluorohexane sulfonate (PFHxS) had higher placental transfer rates (means of 0.32 and 0.36, respectively) than PFOS (mean of 0.12), which is in line with the results of previous studies. Gestational age and birth weight were positively associated with placental transfer rate of PFOA, PFHxS, and PFOS, while pre-pregnant BMI and weight were inversely associated with PFOS. This study showed that placental transfer of PFASs differs by compounds and is associated with pregnancy-related factors. Further studies on novel PFASs are warranted for Korean pregnant women.
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Liu B, Zhang R, Zhang H, Yu Y, Yao D, Yin S. Levels of Perfluoroalkyl Acids (PFAAs) in Human Serum, Hair and Nails in Guangdong Province, China: Implications for Exploring the Ideal Bio-Indicator. ARCHIVES OF ENVIRONMENTAL CONTAMINATION AND TOXICOLOGY 2020; 79:184-194. [PMID: 32494886 DOI: 10.1007/s00244-020-00743-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/23/2020] [Indexed: 06/11/2023]
Abstract
The widespread human exposure to perfluoroalkyl acids (PFAAs) has led to increasing public concern. In this study, we present a comprehensive measurement of total fluorine (TF), extractable organic fluorine (EOF), identified organic fluorine (IOF, total concentration of identified PFAAs quantified as fluorine) and 11 target PFAAs in human serum (n = 60), hair (n = 49) and nails (n = 39) collected from non-occupation exposed volunteers in 10 cities of Guangdong Province, China. The results indicated that EOF was the major form of fluorine in serum, accounting for 70-80% of TF. The levels of IOF contributed less than 10% of EOF. Perfluorooctane sulfonic acid (PFOS) was found to be the dominant PFAA with mean concentration of 23 ng·mL-1 in serum, 35 ng·g-1 in hair and 33 ng·g-1 in nail, respectively. Short-chain PFAAs (C ≤ 10) were the predominant PFAAs in three matrices. Levels of PFOS, perfluorohexane sulfonic acid (PFHxS), perfluoroundecanoic acid (PFUdA) and perfluorotridecanoic acid (PFTrDA) in males are significantly higher than those in females (p < 0.01). Significant positive correlations were observed between nail and serum for PFOS (p < 0.01), perfluorooctanoic acid (PFOA) (p < 0.05) and PFHxS (p < 0.01), suggesting that human nails, a noninvasive sample, are a promising bio-indicator for PFAA risk assessment.
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Affiliation(s)
- Baolin Liu
- College of Physics and Optoelectronic Engineering, Shenzhen University, Shenzhen, 518060, China
- College of Chemistry, Changchun Normal University, Changchun, 130032, China
| | | | - Hong Zhang
- College of Physics and Optoelectronic Engineering, Shenzhen University, Shenzhen, 518060, China.
| | - Yong Yu
- Key Laboratory of Wetland Ecology and Environment, Northeast Institute of Geography and Agroecology, Chinese Academy of Sciences, Changchun, 130102, China
| | - Dan Yao
- College of Physics and Optoelectronic Engineering, Shenzhen University, Shenzhen, 518060, China
| | - Shaoqiang Yin
- College of Physics and Optoelectronic Engineering, Shenzhen University, Shenzhen, 518060, China
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Knutsen HK, Alexander J, Barregård L, Bignami M, Brüschweiler B, Ceccatelli S, Cottrill B, Dinovi M, Edler L, Grasl-Kraupp B, Hogstrand C, Hoogenboom LR, Nebbia CS, Oswald IP, Petersen A, Rose M, Roudot AC, Vleminckx C, Vollmer G, Wallace H, Bodin L, Cravedi JP, Halldorsson TI, Haug LS, Johansson N, van Loveren H, Gergelova P, Mackay K, Levorato S, van Manen M, Schwerdtle T. Risk to human health related to the presence of perfluorooctane sulfonic acid and perfluorooctanoic acid in food. EFSA J 2018. [PMID: 32625773 DOI: 10.2903/j.efsa.2018.5194">10.2903/j.efsa.2018.5194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [10.2903/j.efsa.2018.5194','32625773', '10.1016/j.chemosphere.2015.03.015')">Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
10.2903/j.efsa.2018.5194" />
Abstract
The European Commission asked EFSA for a scientific evaluation on the risks to human health related to the presence of perfluorooctane sulfonic acid (PFOS) and perfluorooctanoic acid (PFOA) in food. Regarding PFOS and PFOA occurrence, the final data set available for dietary exposure assessment contained a total of 20,019 analytical results (PFOS n = 10,191 and PFOA n = 9,828). There were large differences between upper and lower bound exposure due to analytical methods with insufficient sensitivity. The CONTAM Panel considered the lower bound estimates to be closer to true exposure levels. Important contributors to the lower bound mean chronic exposure were 'Fish and other seafood', 'Meat and meat products' and 'Eggs and egg products', for PFOS, and 'Milk and dairy products', 'Drinking water' and 'Fish and other seafood' for PFOA. PFOS and PFOA are readily absorbed in the gastrointestinal tract, excreted in urine and faeces, and do not undergo metabolism. Estimated human half-lives for PFOS and PFOA are about 5 years and 2-4 years, respectively. The derivation of a health-based guidance value was based on human epidemiological studies. For PFOS, the increase in serum total cholesterol in adults, and the decrease in antibody response at vaccination in children were identified as the critical effects. For PFOA, the increase in serum total cholesterol was the critical effect. Also reduced birth weight (for both compounds) and increased prevalence of high serum levels of the liver enzyme alanine aminotransferase (ALT) (for PFOA) were considered. After benchmark modelling of serum levels of PFOS and PFOA, and estimating the corresponding daily intakes, the CONTAM Panel established a tolerable weekly intake (TWI) of 13 ng/kg body weight (bw) per week for PFOS and 6 ng/kg bw per week for PFOA. For both compounds, exposure of a considerable proportion of the population exceeds the proposed TWIs.
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Knutsen HK, Alexander J, Barregård L, Bignami M, Brüschweiler B, Ceccatelli S, Cottrill B, Dinovi M, Edler L, Grasl-Kraupp B, Hogstrand C, Hoogenboom LR, Nebbia CS, Oswald IP, Petersen A, Rose M, Roudot AC, Vleminckx C, Vollmer G, Wallace H, Bodin L, Cravedi JP, Halldorsson TI, Haug LS, Johansson N, van Loveren H, Gergelova P, Mackay K, Levorato S, van Manen M, Schwerdtle T. Risk to human health related to the presence of perfluorooctane sulfonic acid and perfluorooctanoic acid in food. EFSA J 2018; 16:e05194. [PMID: 32625773 PMCID: PMC7009575 DOI: 10.2903/j.efsa.2018.5194] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The European Commission asked EFSA for a scientific evaluation on the risks to human health related to the presence of perfluorooctane sulfonic acid (PFOS) and perfluorooctanoic acid (PFOA) in food. Regarding PFOS and PFOA occurrence, the final data set available for dietary exposure assessment contained a total of 20,019 analytical results (PFOS n = 10,191 and PFOA n = 9,828). There were large differences between upper and lower bound exposure due to analytical methods with insufficient sensitivity. The CONTAM Panel considered the lower bound estimates to be closer to true exposure levels. Important contributors to the lower bound mean chronic exposure were 'Fish and other seafood', 'Meat and meat products' and 'Eggs and egg products', for PFOS, and 'Milk and dairy products', 'Drinking water' and 'Fish and other seafood' for PFOA. PFOS and PFOA are readily absorbed in the gastrointestinal tract, excreted in urine and faeces, and do not undergo metabolism. Estimated human half-lives for PFOS and PFOA are about 5 years and 2-4 years, respectively. The derivation of a health-based guidance value was based on human epidemiological studies. For PFOS, the increase in serum total cholesterol in adults, and the decrease in antibody response at vaccination in children were identified as the critical effects. For PFOA, the increase in serum total cholesterol was the critical effect. Also reduced birth weight (for both compounds) and increased prevalence of high serum levels of the liver enzyme alanine aminotransferase (ALT) (for PFOA) were considered. After benchmark modelling of serum levels of PFOS and PFOA, and estimating the corresponding daily intakes, the CONTAM Panel established a tolerable weekly intake (TWI) of 13 ng/kg body weight (bw) per week for PFOS and 6 ng/kg bw per week for PFOA. For both compounds, exposure of a considerable proportion of the population exceeds the proposed TWIs.
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Bae J, Kim S, Barr DB, Buck Louis GM. Maternal and paternal serum concentrations of persistent organic pollutants and the secondary sex ratio: A population-based preconception cohort study. ENVIRONMENTAL RESEARCH 2018; 161:9-16. [PMID: 29096317 PMCID: PMC5747985 DOI: 10.1016/j.envres.2017.10.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/25/2017] [Accepted: 10/26/2017] [Indexed: 05/24/2023]
Abstract
Recent declines in the secondary sex ratio (SSR), defined as the ratio of males to females at birth, in some industrialized countries may be attributed to exposure to environmental toxicants such as persistent organic pollutants (POPs). This study aimed to evaluate the association of couples' preconception exposure to POPs with the SSR. The study cohort comprised 235 couples who were enrolled in the Longitudinal Investigation of Fertility and the Environment (LIFE) Study between 2005 and 2009 prior to conception and prospectively followed through delivery of a singleton birth. Upon enrollment, couples' serum concentrations (ng/g) were measured for 9 organochlorine pesticides, 1 polybrominated biphenyl, 10 polybrominated diphenyl ethers, and 36 polychlorinated biphenyls (PCBs). Birth outcome data including infant sex were collected upon delivery. Modified Poisson regression models were used to estimate the relative risks (RRs) and 95% confidence intervals (CIs) of a male birth for each chemical. Of the 56 POPs examined, maternal PCB 128 and paternal hexachlorobenzene were significantly associated with a female excess (RRs, 0.75 [95% CI, 0.60-0.94] and 0.81 [95% CI, 0.68-0.97] per 1SD increase in log-transformed serum chemical concentrations, respectively), whereas maternal mirex and paternal PCB 128 and p,p'-dichlorodiphenyldichloroethylene were significantly associated with a male excess (RR range, 1.10-1.22 per 1SD increase in log-transformed serum chemical concentrations). After adjusting for multiple comparisons, only maternal mirex remained significantly associated with the SSR. This exploratory study on multiple classes of POPs demonstrated no conclusive evidence on the association between parental preconception exposure to POPs and the SSR.
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Affiliation(s)
- Jisuk Bae
- Department of Preventive Medicine, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro 17-gil Nam-gu, Daegu 42472, Republic of Korea.
| | - Sungduk Kim
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6710B Rockledge Drive, Bethesda, MD 20817, USA; Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, 9609 Medical Center Drive, Bethesda, MD 20892, USA.
| | - Dana Boyd Barr
- Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322, USA.
| | - Germaine M Buck Louis
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6710B Rockledge Drive, Bethesda, MD 20817, USA.
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Wu H, Olmsted A, Cantonwine DE, Shahsavari S, Rahil T, Sites C, Pilsner JR. Urinary phthalate and phthalate alternative metabolites and isoprostane among couples undergoing fertility treatment. ENVIRONMENTAL RESEARCH 2017; 153:1-7. [PMID: 27875712 PMCID: PMC5222784 DOI: 10.1016/j.envres.2016.11.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 10/19/2016] [Accepted: 11/07/2016] [Indexed: 05/23/2023]
Abstract
BACKGROUND Epidemiological data suggest associations between phthalate exposures to a variety of adverse reproductive outcomes including reduced sperm quality and reproductive success. While mechanisms of these associations are not fully elucidated, oxidative stress has been implicated as a potential mediator. We examined associations of urinary metabolites of phthalates and phthalate alternative plasticizers with oxidative stress among couples seeking fertility treatment. METHODS Seventeen urinary plasticizer metabolites and 15-F2t isoprostane, a biomarker of oxidative stress, were quantified in spot samples from 50 couples seeking fertility treatment who enrolled in the Sperm Environmental Epigenetics and Development Study during 2014-2015. RESULTS In multivariable analyses, percent change in isoprostane was positively associated with interquartile range increases for the oxidative metabolites of di-2-ethylhexyl phthalate, [mono-2-ethyl-5-hydroxyhexyl phthalate (MEHHP; 20.0%, p=0.02), mono-2-ethyl-5-oxohexyl phthalate (MEOHP; 24.1%, p=0.01), and mono-2-ethyl-5-carboxypentyl phthalate (MECPP; 24.1%, p=0.004)], mono-isobutyl phthalate (MiBP; 17.8%, p=0.02), mono-hydroxyisobutyl phthalate (MHiBP; 27.5%, p=0.003), and cyclohexane-1,2-dicarboxylic acid mono-hydroxy-isononyl ester (MHINCH; 32.3%, p=0.002). Stratification of participants by sex revealed that isoprostane was positively associated with MHiBP (41.4%, p=0.01) and monocarboxy-isononyl phthalate (MCNP; 26.0%, p=0.02) among females and MEOHP (35.8%, p=0.03), MiBP (29.2%, p=0.01), MHiBP (34.7%, p=0.007) and MHINCH (49.0%, p=0.002) among males. CONCLUSIONS Our results suggest that exposure to phthalates and phthalate replacements are associated with higher levels of oxidative stress in a sex-specific manner. Additional studies are needed to replicate our findings and to examine the potential health implications of the use of phthalates and alternative phthalates in consumer end products.
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Affiliation(s)
- Haotian Wu
- Department of Environmental Health Sciences, School of Public Health and Health Sciences, University of Massachusetts, 686 North Pleasant Street, Amherst, MA 01003, United States
| | - Alexandra Olmsted
- Department of Environmental Health Sciences, School of Public Health and Health Sciences, University of Massachusetts, 686 North Pleasant Street, Amherst, MA 01003, United States
| | - David E Cantonwine
- Department of Obstetrics Gynecology and Reproductive Biology, Division of Maternal Fetal Medicine Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States
| | - Shahin Shahsavari
- Department of Environmental Health Sciences, School of Public Health and Health Sciences, University of Massachusetts, 686 North Pleasant Street, Amherst, MA 01003, United States
| | - Tayyab Rahil
- Division of Reproductive Endocrinology and Infertility, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199, United States
| | - Cynthia Sites
- Division of Reproductive Endocrinology and Infertility, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199, United States
| | - J Richard Pilsner
- Department of Environmental Health Sciences, School of Public Health and Health Sciences, University of Massachusetts, 686 North Pleasant Street, Amherst, MA 01003, United States.
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The Current Epidemiologic Evidence on Exposures to Poly- and Perfluoroalkyl Substances (PFASs) and Male Reproductive Health. CURR EPIDEMIOL REP 2016. [DOI: 10.1007/s40471-016-0071-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Bae J, Kim S, Kannan K, Buck Louis GM. Couples' urinary concentrations of benzophenone-type ultraviolet filters and the secondary sex ratio. THE SCIENCE OF THE TOTAL ENVIRONMENT 2016; 543:28-36. [PMID: 26575635 PMCID: PMC4688162 DOI: 10.1016/j.scitotenv.2015.11.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 10/16/2015] [Accepted: 11/04/2015] [Indexed: 05/21/2023]
Abstract
The secondary sex ratio (SSR), defined as the ratio of males to females at birth, has been investigated in relation to endocrine disruptors to search for environmental toxicants perturbing human sex selection. Benzophenone (BP)-type ultraviolet (UV) filters, which are used in sunscreens and personal care products, have been reported to exert estrogenic and anti-androgenic activities. This study aimed to evaluate the association between maternal, paternal, and couple urinary concentrations of BP-type UV filters and the SSR, given the absence of previous investigation. The study cohort comprised 220 couples who were enrolled in the Longitudinal Investigation of Fertility and the Environment (LIFE) Study between 2005 and 2009 prior to conception and who had a singleton birth during the follow-up period. Couples' urinary concentrations of five BP-type UV filters (ng/mL) were measured using triple-quadrupole tandem mass spectrometry: 2,4-dihydroxybenzophenone (BP-1), 2,2',4,4'-tetrahydroxybenzophenone (BP-2), 2-hydroxy-4-methoxybenzophenone (BP-3), 2,2'-dihydroxy-4-methoxybenzophenone (BP-8), and 4-hydroxybenzophenone (4-OH-BP). Modified Poisson regression models were used to estimate the relative risks (RRs) of a male birth for each BP-type UV filter, after adjusting for potential confounders. When maternal and paternal urinary BP-type UV filter concentrations were modeled jointly, both maternal BP-2 (2nd vs 1st tertile, RR, 0.62, 95% confidence interval [CI], 0.43-0.91) and paternal BP-2 (3rd vs 1st tertile, RR, 0.67, 95% CI, 0.45-0.99; p-trend, 0.04) were significantly associated with an excess of female births. Contrarily, maternal 4-OH-BP was significantly associated with an excess of male births (2nd vs 1st tertile, RR, 1.87, 95% CI, 1.27-2.74; 3rd vs 1st tertile, RR, 1.80, 95% CI, 1.13-2.87; p-trend, 0.02). Our findings provide the first evidence suggesting that BP-type UV filters may affect the SSR. However, future corroboration is needed, given the exploratory design of this study.
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Affiliation(s)
- Jisuk Bae
- Department of Preventive Medicine, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Republic of Korea; Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6100 Executive Boulevard, Rockville, MD 20852, USA.
| | - Sungduk Kim
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6100 Executive Boulevard, Rockville, MD 20852, USA.
| | - Kurunthachalam Kannan
- Wadsworth Center, New York State Department of Health, Empire State Plaza, P.O. Box 509, Albany, NY 12201-0509, USA; Department of Environmental Health Sciences, School of Public Health, State University of New York at Albany, Empire State Plaza, P.O. Box 509, Albany, NY 12201-0509, USA.
| | - Germaine M Buck Louis
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6100 Executive Boulevard, Rockville, MD 20852, USA.
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