Maternal exposure to titanium dioxide nanoparticles during pregnancy and lactation alters offspring hippocampal mRNA BAX and Bcl-2 levels, induces apoptosis and decreases neurogenesis

Nervous system exposure of different classes of nanoparticles: A review on potential toxicity and mechanistic studies

Nanoparticles (NPs) are generally defined as very small particles in the size range of 1-100 nm. Due to the rapid development of modern society, many new materials have been developed. The widespread use of NPs in medical applications, the food industry and the textile industry has led to an increase in NPs in the environment and the possibility of human contact, which poses a serious threat to human health. The nervous system plays a leading role in maintaining the integrity and unity of the body and maintaining a harmonious balance with the external environment. Therefore, based on two categories of organic and inorganic NPs, this paper systematically summarizes the toxic effects and mechanisms of NPs released into the nervous system. The results showed that exposure to NPs may damage the nervous system, decrease learning and cognitive ability, and affect embryonic development. Finally, a remediation scheme for NPs entering the body via the environment is also introduced. This scheme aims to reduce the neurotoxicity caused by NPs by supplementing NPs with a combination of antioxidant and anti-inflammatory compounds. The results provide a valuable reference for future research in this field.

Titanium Dioxide Nanoparticles Induce Maternal Preeclampsia-like Syndrome and Adverse Birth Outcomes via Disrupting Placental Function in SD Rats

The escalating utilization of titanium dioxide nanoparticles (TiO2 NPs) in everyday products has sparked concerns regarding their potential hazards to pregnant females and their offspring. To address these concerns and shed light on their undetermined adverse effects and mechanisms, we established a pregnant rat model to investigate the impacts of TiO2 NPs on both maternal and offspring health and to explore the underlying mechanisms of those impacts. Pregnant rats were orally administered TiO2 NPs at a dose of 5 mg/kg body weight per day from GD5 to GD18 during pregnancy. Maternal body weight, organ weight, and birth outcomes were monitored and recorded. Maternal pathological changes were examined by HE staining and TEM observation. Maternal blood pressure was assessed using a non-invasive blood analyzer, and the urinary protein level was determined using spot urine samples. Our findings revealed that TiO2 NPs triggered various pathological alterations in maternal liver, kidney, and spleen, and induced maternal preeclampsia-like syndrome, as well as leading to growth restriction in the offspring. Further examination unveiled that TiO2 NPs hindered trophoblastic cell invasion into the endometrium via the promotion of autophagy. Consistent hypertension and proteinuria resulted from the destroyed the kidney GBM. In total, an exposure to TiO2 NPs during pregnancy might increase the risk of human preeclampsia through increased maternal arterial pressure and urinary albumin levels, as well as causing fetal growth restriction in the offspring.

Titanium dioxide nanoparticles oral exposure induce osteoblast apoptosis, inhibit osteogenic ability and increase lipogenesis in mouse

Titanium dioxide nanoparticles (TiO2-NPs) are widely used in food, paint, coating, cosmetic, and composite orthodontic material. As a common food additive, TiO2-NPs can accumulate in various organs of human body, but the effect and underlying mechanism of bone remain unclear. Here mice were exposed to TiO2-NPs by oral gavage, and histological staining of femoral sections showed that TiO2-NPs reduced bone formation and enhanced osteoclast activity and lipogenesis, contributing to decreased trabecula bone. Transmission electron microscope (TEM) as well as biochemical and flow cytometry analysis of osteoblast exhibited that TiO2-NPs accumulated in osteoblast cytoplasm and impaired mitochondria ultrastructure with increased reactive oxygen species (ROS) and lipid hyperoxide, resulting in osteoblast apoptosis. In terms of mechanism, TiO2-NPs treatment inhibited expression of AKT and then increased pro-apoptotic protein Bax expression which was failure to form heterodimers with decreased anti-apoptotic Bcl-2, activating downstream Caspase-9 and Caspase-3 and inducing apoptosis. Additionally, TiO2-NPs suppressed Wnt3a level and then activated anti-Glycogen synthesis kinase (GSK-3β) phosphorylation, and ultimately resulted in degradation of β-catenin which down-regulated Runt-related transcription factor 2 (Runx2) and Osterix, inhibiting expression of osteogenic related proteins. Together, these results revealed that exposure of TiO2-NPs induced apoptosis and inhibited osteoblast differentiation through suppressing PI3K/AKT and Wnt/β-catenin signaling pathways, resulting in reduction of trabecula bone.

Multigenerational inheritance of breathing deficits following perinatal exposure to titanium dioxide nanoparticles in the offspring of mice

BACKGROUND

The utilization of titanium dioxide nanoparticles (TIO2NPs) has experienced a significant surge in recent decades, and these particles are now commonly found in various everyday consumer products. Due to their small size, TIO2NPs can penetrate biological barriers and elicit adverse interactions with biological tissues. Notably, exposure of pregnant females to TIO2NPs during the perinatal period has been shown to disrupt the growth of offspring. Furthermore, this exposure induces epigenetic modifications in the DNA of newborns, suggesting the possibility of multigenerational effects. Thus, perinatal exposure to TIO2NPs may induce immediate metabolic impairments in neonates, which could be transmitted to subsequent generations in the long term.

RESULTS

In this study, we utilized perinatal exposure of female mice to TIO2NPs through voluntary food intake and observed impaired metabolism in newborn male and female F1 offspring. The exposed newborn mice exhibited reduced body weight gain and a slower breathing rate compared to non-exposed animals. Additionally, a higher proportion of exposed F1 newborns experienced apneas. Similar observations were made when the exposure was limited to the postnatal period, highlighting lactation as a critical period for the adverse effects of TIO2NPs on postnatal metabolism. Importantly, the breathing deficits induced by TIO2NPs were transmitted from F1 females to the subsequent F2 generation. Moreover, re-exposure of adult F1 females to TIO2NPs exacerbated the breathing deficits in newborn F2 males.

CONCLUSIONS

Our findings demonstrate that perinatal exposure to TIO2NPs disrupts postnatal body weight gain and respiration in the offspring, and these deficits are transmissible to future generations.

Neurotoxicity of Titanium Dioxide Nanoparticles: A Comprehensive Review

The increasing use of titanium dioxide nanoparticles (TiO2 NPs) across various fields has led to a growing concern regarding their environmental contamination and inevitable human exposure. Consequently, significant research efforts have been directed toward understanding the effects of TiO2 NPs on both humans and the environment. Notably, TiO2 NPs exposure has been associated with multiple impairments of the nervous system. This review aims to provide an overview of the documented neurotoxic effects of TiO2 NPs in different species and in vitro models. Following exposure, TiO2 NPs can reach the brain, although the specific mechanism and quantity of particles that cross the blood-brain barrier (BBB) remain unclear. Exposure to TiO2 NPs has been shown to induce oxidative stress, promote neuroinflammation, disrupt brain biochemistry, and ultimately impair neuronal function and structure. Subsequent neuronal damage may contribute to various behavioral disorders and play a significant role in the onset and progression of neurodevelopmental or neurodegenerative diseases. Moreover, the neurotoxic potential of TiO2 NPs can be influenced by various factors, including exposure characteristics and the physicochemical properties of the TiO2 NPs. However, a systematic comparison of the neurotoxic effects of TiO2 NPs with different characteristics under various exposure conditions is still lacking. Additionally, our understanding of the underlying neurotoxic mechanisms exerted by TiO2 NPs remains incomplete and fragmented. Given these knowledge gaps, it is imperative to further investigate the neurotoxic hazards and risks associated with exposure to TiO2 NPs.

Prenatal titanium exposure and child neurodevelopment at 1 year of age: A longitudinal prospective birth cohort study

Previous animal studies provided the evidence that prenatal titanium exposure can cause neurotoxicity in their offspring, while human data is vacant. Our aim was to identify the associations of prenatal titanium exposure with the child neurodevelopment. Participants in present study were recruited during early pregnancy between 2014 and 2017. Urinary concentrations of titanium at first trimester were determined. We assessed child neurodevelopment using the Chinese version of Gesell Developmental Schedules at first year follow-up. The multivariable linear regressions and the robust modified Poisson regressions were used to estimate the associations of specific gravity corrected urinary titanium concentrations with the child neurodevelopment. In adjusted models, children's developmental quotient scores in the language domain were 2.03 points (95% CI: -3.66, -0.40) lower in the highest tertile of prenatal urinary titanium than in the lowest tertile. Also, children with prenatal urinary titanium in the highest tertile had 1.42 times (95% CI: 1.17, 1.72) increased risk of language development delay compared to those in the lowest tertile. No statistically significant associations were observed between titanium exposure and child development delay in motor, adaptive and social areas. The findings indicated that prenatal higher titanium exposure was associated with impaired language development, suggesting that titanium might act as developmental neurotoxicants.

Melatonin Protects Against Titanium Oxide-Induced Neurotoxicity: Neurochemical, Neurobehavioral, and Histopathological Evidences

titania (titanium dioxide, TiO₂) is known to induce neurotoxicity and CNS dysfunctions. Numerous studies have explored the neuroprotective effects of melatonin against neurotoxicity. This study evaluates the potential of melatonin to protect against titania-induced neurotoxicity and the role of the Keap1/Nrf2/ARE signaling pathway. One group of animals were treated with Titania (0.045 and 0.075 g/rat) alone while the other with added melatonin (1 mg/kg and 3 mg/kg) and behavioral alterations were assessed using OFT (open field test). Neurochemical and histopathological changes were also studied in the hippocampus by analyzing kelch ECH associating protein 1 (Keap1), nuclear factor erythroid 2-related factor 2 (Nrf2), and antioxidant response element (ARE). It was seen that the animals with added Melatonin had improved behavioral scores in the OFT, like anxiety and motor dysfunction triggered by TiO₂. Melatonin also reduced lipid peroxidation, ROS, GSSG, IL1β, TNFα, Bax, and Keap1 levels, but boosted GSH, GPx, GR, SOD,IL10,IL4, Bcl2, Nrf2, and ARE levels and improved quadruple mitochondrial enzyme complex activity in titania-treated animals. Histopathological examination showed melatonin induced cytoprotection against vacuolization and necrosis in granular cells of DG and pyramidal cells of CA1 area of the hippocampus. In our study, pretreatment with melatonin reduced titania-induced neurotoxicity in the hippocampus through a mechanism potentially mediated by the Keap-1/Nrf2/ARE pathway.

A review on the impacts of nanomaterials on neuromodulation and neurological dysfunction using a zebrafish animal model

Nanomaterials have been widely employed from industrial to medical fields due to their small sizes and versatile characteristics. However, nanomaterials can also induce unexpected adverse effects on health. In particular, exposure of the nervous system to nanomaterials can cause serious neurological dysfunctions and neurodegenerative diseases. A number of studies have adopted various animal models to evaluate the neurotoxic effects of nanomaterials. Among them, zebrafish has become an attractive animal model for neurotoxicological studies due to several advantages, including the well-characterized nervous system, efficient genome editing, convenient generation of transgenic lines, high-resolution in vivo imaging, and an array of behavioral assays. In this review, we summarize recent studies on the neurotoxicological effects of nanomaterials, particularly engineered nanomaterials and nanoplastics, using zebrafish and discuss key findings with advantages and limitations of the zebrafish model in neurotoxicological studies.

Dietary Antioxidant Curcumin Mitigates CuO Nanoparticle-Induced Cytotoxicity through the Oxidative Stress Pathway in Human Placental Cells

The placenta is an important organ that maintains a healthy pregnancy by transporting nutrients to the fetus and removing waste from the fetus. It also acts as a barrier to protect the fetus from hazardous materials. Recent studies have indicated that nanoparticles (NPs) can cross the placental barrier and pose a health risk to the developing fetus. The high production and widespread application of copper oxide (CuO) NPs may lead to higher exposure to humans, raising concerns of health hazards, especially in vulnerable life stages, e.g., pregnancy. Oxidative stress plays a crucial role in the pathogenesis of adverse pregnancy outcomes. Due to its strong antioxidant activity, dietary curcumin can act as a therapeutic agent for adverse pregnancy. There is limited knowledge on the hazardous effects of CuO NPs during pregnancy and their mitigation by curcumin. This study aimed to investigate the preventive effect of curcumin against CuO NP-induced toxicity in human placental (BeWo) cells. CuO NPs were synthesized by a facile hydrothermal process and characterized by X-ray diffraction, scanning electron microscopy, transmission electron microscopy, and photoluminescence techniques. We observed that curcumin did not induce toxicity in BeWo cells (1-100 µg/mL for 24 h), whereas CuO NPs decreased the cell viability dose-dependently (5-200 µg/mL for 24 h). Interestingly, CuO NP-induced cytotoxicity was effectively mitigated by curcumin co-exposure. The apoptosis data also exhibited that CuO NPs modulate the expression of several genes (p53, bax, bcl-2, casp3, and casp9), the activity of enzymes (caspase-3 and -9), and mitochondrial membrane potential loss, which was successfully reverted by co-treatment with curcumin. The mechanistic study suggested that CuO-induced reactive oxygen species generation, lipid peroxidation, and higher levels of hydrogen peroxide were significantly alleviated by curcumin co-exposure. Moreover, glutathione depletion and the lower activity of antioxidant enzymes (superoxide dismutase, glutathione peroxidase, and catalase) were effectively mitigated by curcumin. We believe this is the first report exhibiting that CuO-induced toxicity in BeWo cells can be effectively alleviated by curcumin. The pharmacological potential of dietary curcumin in NP-induced toxicity during pregnancy warrants further investigation.

Adverse Outcome Pathways Associated with the Ingestion of Titanium Dioxide Nanoparticles-A Systematic Review

Titanium dioxide nanoparticles (TiO₂-NPs) are widely used, and humans are exposed through food (E171), cosmetics (e.g., toothpaste), and pharmaceuticals. The oral and gastrointestinal (GIT) tract are the first contact sites, but it may be systemically distributed. However, a robust adverse outcome pathway (AOP) has not been developed upon GIT exposure to TiO₂-NPs. The aim of this review was to provide an integrative analysis of the published data on cellular and molecular mechanisms triggered after the ingestion of TiO₂-NPs, proposing plausible AOPs that may drive policy decisions. A systematic review according to Prisma Methodology was performed in three databases of peer-reviewed literature: Pubmed, Scopus, and Web of Science. A total of 787 records were identified, screened in title/abstract, being 185 used for data extraction. The main endpoints identified were oxidative stress, cytotoxicity/apoptosis/cell death, inflammation, cellular and systemic uptake, genotoxicity, and carcinogenicity. From the results, AOPs were proposed where colorectal cancer, liver injury, reproductive toxicity, cardiac and kidney damage, as well as hematological effects stand out as possible adverse outcomes. The recent transgenerational studies also point to concerns with regard to population effects. Overall, the findings further support a limitation of the use of TiO₂-NPs in food, announced by the European Food Safety Authority (EFSA).

Chronic maternal exposure to titanium dioxide nanoparticles alters breathing in newborn offspring

Background

Over the last two decades, nanotechnologies and the use of nanoparticles represent one of the greatest technological advances in many fields of human activity. Particles of titanium dioxide (TiO₂) are one of the nanomaterials most frequently found in everyday consumer products. But, due in particular to their extremely small size, TiO₂ nanoparticles (NPs) are prone to cross biological barriers and potentially lead to adverse health effects. The presence of TiO₂ NPs found in human placentae and in the infant meconium has indicated unequivocally the capacity for a materno-fetal transfer of this nanomaterial. Although chronic exposure to TiO₂ NPs during pregnancy is known to induce offspring cognitive deficits associated with neurotoxicity, the impact of a gestational exposure on a vital motor function such as respiration, whose functional emergence occurs during fetal development, remains unknown.

Results

Using in vivo whole-body plethysmographic recordings from neonatal mice, we show that a chronic exposure to TiO₂ NPs during pregnancy alters the respiratory activity of offspring, characterized by an abnormally elevated rate of breathing. Correspondingly, using ex vivo electrophysiological recordings performed on isolated brainstem-spinal cord preparations of newborn mice and medullary slice preparations containing specific nuclei controlling breathing frequency, we show that the spontaneously generated respiratory-related rhythm is significantly and abnormally accelerated in animals prenatally exposed to TiO₂ NPs. Moreover, such a chronic prenatal exposure was found to impair the capacity of respiratory neural circuitry to effectively adjust breathing rates in response to excitatory environmental stimuli such as an increase in ambient temperature.

Conclusions

Our findings thus demonstrate that a maternal exposure to TiO₂ NPs during pregnancy affects the normal development and operation of the respiratory centers in progeny.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12989-022-00497-4.

Safety and Toxicity Implications of Multifunctional Drug Delivery Nanocarriers on Reproductive Systems In Vitro and In Vivo

In the recent past, nanotechnological advancements in engineered nanomaterials have demonstrated diverse and versatile applications in different arenas, including bio-imaging, drug delivery, bio-sensing, detection and analysis of biological macromolecules, bio-catalysis, nanomedicine, and other biomedical applications. However, public interests and concerns in the context of human exposure to these nanomaterials and their consequential well-being may hamper the wider applicability of these nanomaterial-based platforms. Furthermore, human exposure to these nanosized and engineered particulate materials has also increased drastically in the last 2 decades due to enormous research and development and anthropocentric applications of nanoparticles. Their widespread use in nanomaterial-based industries, viz., nanomedicine, cosmetics, and consumer goods has also raised questions regarding the potential of nanotoxicity in general and reproductive nanotoxicology in particular. In this review, we have summarized diverse aspects of nanoparticle safety and their toxicological outcomes on reproduction and developmental systems. Various research databases, including PubMed and Google Scholar, were searched for the last 20 years up to the date of inception, and nano toxicological aspects of these materials on male and female reproductive systems have been described in detail. Furthermore, a discussion has also been dedicated to the placental interaction of these nanoparticles and how these can cross the blood–placental barrier and precipitate nanotoxicity in the developing offspring. Fetal abnormalities as a consequence of the administration of nanoparticles and pathophysiological deviations and aberrations in the developing fetus have also been touched upon. A section has also been dedicated to the regulatory requirements and guidelines for the testing of nanoparticles for their safety and toxicity in reproductive systems. It is anticipated that this review will incite a considerable interest in the research community functioning in the domains of pharmaceutical formulations and development in nanomedicine-based designing of therapeutic paradigms.

Hippocampal toxicity of metal base nanoparticles. Is there a relationship between nanoparticles and psychiatric disorders?

Metal base nanoparticles are widely produced all over the world and used in many fields and products such as medicine, electronics, cosmetics, paints, ceramics, toys, kitchen utensils and toothpastes. They are able to enter the body through digestive, respiratory, and alimentary systems. These nanoparticles can also cross the blood brain barrier, enter the brain and aggregate in the hippocampus. After entering the hippocampus, they induce oxidative stress, neuro-inflammation, mitochondrial dysfunction, and gene expression alteration in hippocampal cells, which finally lead to neuronal apoptosis. Metal base nanoparticles can also affect hippocampal neurogenesis and synaptic plasticity that both of them play crucial role in memory and learning. On the one hand, hippocampal cells are severely vulnerable due to their high metabolic activity, and on the other hand, metal base nanoparticles have high potential to damage hippocampus through variety of mechanisms and affect its functions. This review discusses, in detail, nanoparticles' detrimental effects on the hippocampus in cellular, molecular and functional levels to reveal that according to the present information, which types of nanoparticles have more potential to induce hippocampal toxicity and psychiatric disorders and which types should be more evaluated in the future studies.

Maternal exposure to silicon dioxide nanoparticles reduces hippocampal neurogenesis and synaptogenesis and induces neurodegeneration in rat offspring hippocampus

Silicon dioxide nanoparticles (SiO₂-NPs) are among the most widely used nanoparticles because of their chemical-physical properties. Since most brain maturation occurs in the neonatal period in humans and many mammals, it is important to understand how NPs may affect this process. This study tested the hypothesis that SiO2-NPs from treated dams could affect the hippocampus of neonatal rats during lactation. Twenty-four pregnant rats, after delivery, were divided into three groups of control, SiO₂-NPs (25 mg/kg) and SiO₂-NPs (100 mg/kg). The rats were treated from 2^nd to 21^st days post-delivery by gavage and the effects of these NPs were evaluated in the offspring's hippocampi to reveal the effects of maternal exposure to SiO₂-NPs during lactation on the offspring's hippocampi. The offspring in the SiO₂-NPs groups had higher malondialdehyde concentration and lower antioxidant activity in the hippocampi than the non-treated control group. The mean number of doublecortin positive (DCX⁺) cells and synaptophysin expression in the hippocampi of the SiO₂-NPs groups were significantly lower than the control group, whereas the mean number of dark neurons was significantly higher. Also, animals in the SiO₂-NPs groups had a weak cognitive performance in adulthood. In conclusion, maternal exposure to SiO₂-NPs via breastfeeding could affect offspring's hippocampal neurogenesis and synaptogenesis, leading to impaired cognitive performance.

Pregnancy exposure of titanium dioxide nanoparticles causes intestinal dysbiosis and neurobehavioral impairments that are not significant postnatally but emerge in adulthood of offspring

BACKGROUND

Pregnancy exposure to titanium dioxide nanoparticles (TiO2NPs) is a vital consideration due to their inadvertent ingestion from environmental contamination. The potential health effects of TiO2NPs on the neurodevelopmental process should be seriously concerned in health risk assessment, especially for the pregnant women who are susceptible to the neurodevelopmental toxicity of nano-sized particles. However, the available evidence of neurodevelopmental toxicity of TiO2NPs remains very limited.

METHODS

In the present study, the pregnant mice were intragastric administered with 150 mg/kg TiO2NPs from gestational day (GD) 8 to 21, the maternal behaviors and neurodevelopment-related indicators in offspring were all assessed at different time points after delivery. The gut microbial community in both dams and their offspring were detected by using 16S ribosomal RNA (rRNA) gene sequencing. The gut-brain axis related indicators were also determined in the offspring.

RESULTS

The results clearly demonstrated that exposure to TiO2NPs did not affect the maternal behaviors of pregnant mice, or cause the deficits on the developmental milestones and perturbations in the early postnatal development of offspring. Intriguingly, our data revealed that pregnancy exposure of TiO2NPs did not affect locomotor function, learning and memory ability and anxiety-like behavior in offspring at postnatal day (PD) 21, but resulted in obvious impairments on these neurobehaviors at PD49. Similar phenomena were obtained in the composition of gut microbial community, intestinal and brain pathological damage in offspring in adulthood. Moreover, the intestinal dysbiosis induced by TiO2NPs might be highly associated with the delayed appearance of neurobehavioral impairments in offspring, possibly occurring through disruption of gut-brain axis.

CONCLUSIONS

This is the first report elucidated that pregnancy exposure to TiO2NPs caused delayed appearance of neurobehavioral impairments in offspring when they reached adulthood, although these perturbations did not happen at early life after delivery. These findings will provide valuable insights about neurodevelopmental toxicity of TiO2NPs, and call for comprehensive health risk assessment of TiO2NPs on the susceptible population, such as pregnant women.

Grape seed extract effects on hippocampal neurogenesis, synaptogenesis and dark neurons production in old mice. Can this extract improve learning and memory in aged animals?

BACKGROUND

During the elderly, hippocampal neurogenesis and synaptogenesis reduce and dark neurons (DNs) increase, leading to cognitive impairment. It is believed that natural products can protect the neural cells and system by protecting from damages or promoting regeneration. Therefore, the effects of grape seed extract (GSE) on the hippocampus of aged mice were investigated in this study.

METHODS

twelve old mice were divided into two groups of control and GSE. Animals in the GSE group received 300 mg/kg of GSE for eight weeks via gavage. At the end of treatment, cognition performance was evaluated by Morris water maze (MWM) and passive avoidance tests. Hippocampal neurogenesis, synaptogenesis and DNs production were evaluated with immunohistochemistry and histological evaluations on 5-micron coronal tissue sections.

RESULTS

The hippocampal mean number of double cortin positive cells (DCX⁺) per unit area, as well as synaptophysin expression in the GSE group, were significantly higher than the control group (p < 0.01). The frequency of DNs in the GSE group was lower than the control group (p < 0.05). Behavioral tests showed that GSE improves memory and learning performance.

CONCLUSION

Consuming GSE in the elderly can potentially alleviate the age-related reduction of hippocampal neurogenesis and synaptogenesis. It is also able to decrease hippocampal DNs production and increase memory and learning.

Safety assessment of titanium dioxide (E171) as a food additive

The present opinion deals with an updated safety assessment of the food additive titanium dioxide (E 171) based on new relevant scientific evidence considered by the Panel to be reliable, including data obtained with TiO2 nanoparticles (NPs) and data from an extended one-generation reproductive toxicity (EOGRT) study. Less than 50% of constituent particles by number in E 171 have a minimum external dimension < 100 nm. In addition, the Panel noted that constituent particles < 30 nm amounted to less than 1% of particles by number. The Panel therefore considered that studies with TiO2 NPs < 30 nm were of limited relevance to the safety assessment of E 171. The Panel concluded that although gastrointestinal absorption of TiO2 particles is low, they may accumulate in the body. Studies on general and organ toxicity did not indicate adverse effects with either E 171 up to a dose of 1,000 mg/kg body weight (bw) per day or with TiO2 NPs (> 30 nm) up to the highest dose tested of 100 mg/kg bw per day. No effects on reproductive and developmental toxicity were observed up to a dose of 1,000 mg E 171/kg bw per day, the highest dose tested in the EOGRT study. However, observations of potential immunotoxicity and inflammation with E 171 and potential neurotoxicity with TiO2 NPs, together with the potential induction of aberrant crypt foci with E 171, may indicate adverse effects. With respect to genotoxicity, the Panel concluded that TiO2 particles have the potential to induce DNA strand breaks and chromosomal damage, but not gene mutations. No clear correlation was observed between the physico-chemical properties of TiO2 particles and the outcome of either in vitro or in vivo genotoxicity assays. A concern for genotoxicity of TiO2 particles that may be present in E 171 could therefore not be ruled out. Several modes of action for the genotoxicity may operate in parallel and the relative contributions of different molecular mechanisms elicited by TiO2 particles are not known. There was uncertainty as to whether a threshold mode of action could be assumed. In addition, a cut-off value for TiO2 particle size with respect to genotoxicity could not be identified. No appropriately designed study was available to investigate the potential carcinogenic effects of TiO2 NPs. Based on all the evidence available, a concern for genotoxicity could not be ruled out, and given the many uncertainties, the Panel concluded that E 171 can no longer be considered as safe when used as a food additive.

Fetotoxicity of Nanoparticles: Causes and Mechanisms

The application of nanoparticles in consumer products and nanomedicines has increased dramatically in the last decade. Concerns for the nano-safety of susceptible populations are growing. Due to the small size, nanoparticles have the potential to cross the placental barrier and cause toxicity in the fetus. This review aims to identify factors associated with nanoparticle-induced fetotoxicity and the mechanisms involved, providing a better understanding of nanotoxicity at the maternal–fetal interface. The contribution of the physicochemical properties of nanoparticles (NPs), maternal physiological, and pathological conditions to the fetotoxicity is highlighted. The underlying molecular mechanisms, including oxidative stress, DNA damage, apoptosis, and autophagy are summarized. Finally, perspectives and challenges related to nanoparticle-induced fetotoxicity are also discussed.

A link between nanoparticles and Parkinson's disease. Which nanoparticles are most harmful?

Nowadays, different kinds of nanoparticles (NPs) are produced around the world and used in many fields and products. NPs can enter the body and aggregate in the various organs including brain. They can damage neurons, in particular dopaminergic neurons in the substantia nigra (SN) and striatal neurons which their lesion is associated with Parkinson's disease (PD). So, NPs can have a role in PD induction along with other agents and factors. PD is the second most common neurodegenerative disease in the world, and in patients, its symptoms progressively worsen day by day through different pathways including oxidative stress, neuroinflammation, mitochondrial dysfunction, α-synuclein increasing and aggregation, apoptosis and reduction of tyrosine hydroxylase positive cells. Unfortunately, there is no effective treatment for PD. So, prevention of this disease is very important. On the other hand, without having sufficient information about PD inducers, prevention of this disease would not be possible. Therefore, we need to have sufficient information about things we contact with them in daily life. Since, NPs are widely used in different products especially in consumer products, and they can enter to the brain easily, in this review the toxicity effects of metal and metal oxide NPs have been evaluated in molecular and cellular levels to determine potential of different kinds of NPs in development of PD.

Are Titania Photocatalysts and Titanium Implants Safe? Review on the Toxicity of Titanium Compounds

Titanium and its compounds are broadly used in both industrial and domestic products, including jet engines, missiles, prostheses, implants, pigments, cosmetics, food, and photocatalysts for environmental purification and solar energy conversion. Although titanium/titania-containing materials are usually safe for human, animals and environment, increasing concerns on their negative impacts have been postulated. Accordingly, this review covers current knowledge on the toxicity of titania and titanium, in which the behaviour, bioavailability, mechanisms of action, and environmental impacts have been discussed in detail, considering both light and dark conditions. Consequently, the following conclusions have been drawn: (i) titania photocatalysts rarely cause health and environmental problems; (ii) despite the lack of proof, the possible carcinogenicity of titania powders to humans is considered by some authorities; (iii) titanium alloys, commonly applied as implant materials, possess a relatively low health risk; (iv) titania microparticles are less toxic than nanoparticles, independent of the means of exposure; (v) excessive accumulation of titanium in the environment cannot be ignored; (vi) titanium/titania-containing products should be clearly marked with health warning labels, especially for pregnant women and young children; (vi) a key knowledge gap is the lack of comprehensive data about the environmental content and the influence of titania/titanium on biodiversity and the ecological functioning of terrestrial and aquatic ecosystems.

Basal Ti level in the human placenta and meconium and evidence of a materno-foetal transfer of food-grade TiO2 nanoparticles in an ex vivo placental perfusion model

Background

Titanium dioxide (TiO₂) is broadly used in common consumer goods, including as a food additive (E171 in Europe) for colouring and opacifying properties. The E171 additive contains TiO₂ nanoparticles (NPs), part of them being absorbed in the intestine and accumulated in several systemic organs. Exposure to TiO₂-NPs in rodents during pregnancy resulted in alteration of placental functions and a materno-foetal transfer of NPs, both with toxic effects on the foetus. However, no human data are available for pregnant women exposed to food-grade TiO₂-NPs and their potential transfer to the foetus. In this study, human placentae collected at term from normal pregnancies and meconium (the first stool of newborns) from unpaired mothers/children were analysed using inductively coupled plasma mass spectrometry (ICP-MS) and scanning transmission electron microscopy (STEM) coupled to energy-dispersive X-ray (EDX) spectroscopy for their titanium (Ti) contents and for analysis of TiO₂ particle deposition, respectively. Using an ex vivo placenta perfusion model, we also assessed the transplacental passage of food-grade TiO₂ particles.

Results

By ICP-MS analysis, we evidenced the presence of Ti in all placentae (basal level ranging from 0.01 to 0.48 mg/kg of tissue) and in 50% of the meconium samples (0.02–1.50 mg/kg), suggesting a materno-foetal passage of Ti. STEM-EDX observation of the placental tissues confirmed the presence of TiO₂-NPs in addition to iron (Fe), tin (Sn), aluminium (Al) and silicon (Si) as mixed or isolated particle deposits. TiO₂ particles, as well as Si, Al, Fe and zinc (Zn) particles were also recovered in the meconium. In placenta perfusion experiments, confocal imaging and SEM-EDX analysis of foetal exudate confirmed a low transfer of food-grade TiO₂ particles to the foetal side, which was barely quantifiable by ICP-MS. Diameter measurements showed that 70 to 100% of the TiO₂ particles recovered in the foetal exudate were nanosized.

Conclusions

Altogether, these results show a materno-foetal transfer of TiO₂ particles during pregnancy, with food-grade TiO₂ as a potential source for foetal exposure to NPs. These data emphasize the need for risk assessment of chronic exposure to TiO₂-NPs during pregnancy.

A key moment for TiO2: Prenatal exposure to TiO2 nanoparticles may inhibit the development of offspring

Applications of TiO₂ nanoparticles (NPs) in food, personal care products and industries pose risks on human health, particularly on vulnerable populations including pregnant women and infants. Fetus, deficient in mature defense system, is more susceptible to NPs. Publications on the developmental toxicity of TiO₂ NPs on the maternal-exposed progeny have emerged. This review presents the main exposure routes of TiO₂ NPs during pregnancy, including skin penetration, ingestion and inhalation, followed by transport of TiO₂ NPs to the placenta. Accumulation of TiO₂ NPs in placenta may cause dysfunction in nutrient transfer. TiO₂ NPs can be even transported to the fetus and generate toxicities, such as impairments of nervous and reproductive system, and failure in lung and cardiovascular development. The toxicities rely on the crystalline phase and concentrations, and the main mechanisms include the accumulation of excessive reactive oxygen species, DNA damage, and over-activation of signaling pathways such as MAPK which impairs neurotransmission. Finally, this review remarks on the significance for identifying TiO₂ NPs dosage safe for both mother and fetus, and particular attention should be paid at TiO₂ NPs concentrations safe for mother but toxic to fetus. Importantly, research on the epigenetic trans-generational inheritance of TiO₂ NPs is urgently needed to provide insights for deciding the prospects of TiO₂ NPs applications.

Engineered magnetic nanoparticles enhance chlorophyll content and growth of barley through the induction of photosystem genes

This study investigates the impact of an engineered magnetic nanoparticle (MNP) on a crop plant. For this purpose, a sonochemical synthetic approach was utilized in order to dope magnetic elements (Co and Nd) into technologically important iron oxide NPs. After being characterized by using TEM, SEM, and XRD instruments, the MNPs were hydroponically applied to barley plants with varying doses (from 125 to 1000 mg/L) both in germination (4 days) and early growing stages (3 weeks). Physiological responses, as well as expression of photosystem marker genes, were assessed. Compared to the untreated control, MNP treatment enhanced germination rate (~ 31%), tissue growth (8% in roots, 16% in shoots), biomass (~ 21%), and chlorophyll (a, b) (~ 20%), and carotenoids (~ 22%) pigments. In general, plants showed the highest growth enhancement at 125 or 250 mg/L treatment. However, higher doses diminished the growth indices. Compared to the control, the catalase activity was significantly reduced in the leaves (~ 33%, p < 0.005) but stimulated in the roots (~ 46%, p < 0.005). All tested photosystem marker genes (BCA, psbA, and psaA) were overexpressed in MNP-treated leaves than non-treated control. Moreover, the gene expressions were found to be proportionally increased with increasing MNP doses, indicating a positive correlation between MNPs and the photosynthetic machinery, which could contribute to the enhancement of plant growth.

Neuroprotective and long term potentiation improving effects of vitamin E in juvenile hypothyroid rats

Abstract. Protective effects of vitamin E (Vit E) on long term potentiation (LTP) impairment, neuronal apoptosis and increase of nitric oxide (NO) metabolites in the hippocampus of juvenile rats were examined. The rats were grouped (n=13) as: (1) control; (2) hypothyroid (Hypo) and (3) Hypo-Vit E. Propylthiouracil (PTU) was given in drinking water (0.05%) during 6 weeks. Vit E (20 mg/ kg) was daily injected (IP). To evaluate synaptic plasticity, LTP from the CA1 area of the hippocampus followed by high frequency stimulation to the ipsilateral Schafer collateral pathway was carried out. The cortical and hippocampal tissues were then removed to measure NO metabolites. The brains of 5 animals in each group were removed for apoptosis study. The hypothyroidism status decreased the slope, 10–90% slope and amplitude of field excitatory post synaptic potential (fEPSP) compared to the control group (P<0.01–P<0.001). Injection of Vit E increased the slope, 10–90% slope and amplitude of the fEPSP in the Hypo-Vit E group in comparison to the Hypo group (P<0.05–P<0.01). TUNEL positive neurons and NO metabolites were higher in the hippocampus of the Hypo rats, as compared to those in the hippocampus of the control ones (P<0.001). Treatment of the Hypo rats by Vit E decreased apoptotic neurons (P<0.01–P<0.001) and NO metabolites (P<0.001) in the hippocampus compared to the Hypo rats. The results of the present study showed that Vit E prevented the LTP impairment and neuronal apoptosis in the hippocampus of juvenile hypothyroid rats.

The effect of titanium dioxide nanoparticles on mice midbrain substantia nigra

OBJECTIVES

Widely used Titanium dioxide nanoparticles (TiO2) enter into the body and cause various organ damages. Therefore, we aimed to study the effect of TiO2 on the substantia nigra of midbrain.

MATERIALS AND METHODS

40 male BALB/c mice were randomly divided into five groups: three groups received TiO2 at doses of 10, 25, and 50 mg/kg, the fourth group received normal saline for 45 days by gavage, and control group (without intervention). Then, Motor tests including pole and hanging tests were done to investigate motor disorders. The animal brain was removed for histological purposes. Accordingly, immunohistochemistry was performed to detect tyrosine hydroxylase positive cells, and then toluidine blue staining was done to identify dark neurons in the substantia nigra. Eventually, the total number of these neurons were counted using stereological methods in different groups.

RESULTS

The results showed that the time recorded for mice to turn completely downward on the pole in the TiO2-50 group increased and also the time recorded for animals to hang on the wire in the hanging test significantly decreased (P<0.05) in comparison with other groups. Also, the average number of tyrosine hydroxylase positive neurons in TiO2-25 and TiO2-50 groups significantly decreased as compared to the TiO2-10 and control groups (P<0.05). The total number of dark neurons in the TiO2-25 and TiO2-50 groups was substantially higher than the TiO2-10, control and normal saline groups (P<0.05).

CONCLUSION

Our findings indicated that TiO2, depending on dose, can cause the destruction of dopaminergic neurons and consequently increase the risk of Parkinson's disease.

Impact of manganese ferrite (MnFe2O4) nanoparticles on growth and magnetic character of barley (Hordeum vulgare L.)

The main objective of this study was to assess the uptake and translocation of MnFe₂O₄ magnetic nanoparticles (MNPs) in hydroponically grown barley (Hordeum vulgare L.). Hydrothermally synthesized and well characterized MNPs (average crystallite size of 14.5 ± 0.5 nm) with varied doses (62.5, 125, 250, 500, and 1000 mg L^-1) were subjected to the plants at germination and early growing stages (three weeks). The tissues analyzed by vibrating-sample magnetometer (VSM) and transmission electron microscopy (TEM) revealed the uptake and translocation of MNPs, as well as their internalization in the leaf cells. Also, elemental analysis proved that manganese (Mn) and iron (Fe) contents were ∼7-9 times and ∼4-7 times higher in the leaves of MNPs-treated plants than the ones for non-treated control, respectively. 250 mg L^-1 of MNPs significantly (at least p < 0.05) promoted the fresh weight (FW, %10.25). However, higher concentrations (500 and 1000 mg L^-1) remarkably reduced the increase to %8 and %5, respectively, possibly due to the restricted water uptake. Also, catalase activity was increased from 91 (μM H₂O₂ min^-1 mg^-1) to 138 in leaves, and decreased to 66 in roots upon 1000 mg L^-1 of MNPs application. Chlorophyll and carotenoid contents were not significantly changed, except chlorophyll a (%6 increase at 1000 mg L^-1, p < 0.05). Overall, MnFe₂O₄ NPs were up-taken from the roots and migrated to the leaves which promoted the growth parameters of barley. Hence, MNPs can be suggested for barley breeding programs and can be proposed as effective delivery system for agrochemicals. However, the possible negative effect of MNPs due to its potential horizontal transfer from plants to animals via the food chain must be also considered.

miR-96-5p and miR-101-3p as potential intervention targets to rescue TiO2 NP-induced autophagy and migration impairment of human trophoblastic cells

Autophagy induced by titanium dioxide nanoparticles (TiO2 NPs) has been realized nowadays, but the underlying mechanisms remain largely unknown. Animal studies have confirmed that autophagy might be an important mechanism to impair placenta development, but the reversal of damage is not clear. Here, we used human HTR-8/SVneo (HTR) cells as a proper model to explore how autophagy is regulated in TiO2 NP-exposed human placenta cells. Our studies showed that TiO2 NPs could enter HTR cells and locate in cytoplasm. Although they did not affect cell viability even under 100 μg ml-1, autophagy was observed and cell migration ability was severely impaired. Further study showed that TiO2 NPs increased the expressions of both miR-96-5p and miR-101-3p and then, they targeted mTOR and decreased the expression of mTOR proteins. In addition, miR-96-5p also targeted Bcl-2 to down-regulate Bcl-2 protein level, which is also a key regulator of autophagy. We proved that when two microRNA inhibitors were added, cell autophagy was, to a greater extent, reversed compared with the result when one inhibitor was added, and the cell migration ability was also reversed to a greater degree. Our studies revealed that TiO2 NPs might impair placenta development via autophagy. Moreover, miR-96-5p as well as miR-101-3p may act as potential targets to reverse TiO2 NP-induced autophagy and placenta dysfunction.

Titanium dioxide nanoparticles induce proteostasis disruption and autophagy in human trophoblast cells

Titanium dioxide nanoparticles (TiO₂ NPs) exist in many nano-products and concerns have been raised about their potential toxicity on human beings. One such issue is their potential effects on placental function, and the studies on this topic are limited and the mechanism remains unclear. Here we employed human trophoblast HTR-8/SVneo cells to investigate the effects of TiO₂ NPs on trophoblast. Results showed that TiO₂ NPs could enter cells and were mostly distributed in lysosomes, with some in the cytoplasm. TiO₂ NPs and protein aggregation were found in both fetal bovine serum (FBS) in culture medium and cytoplasm of HTR-8/SVneo cells. In consistence with that, proteostasis of HTR-8/SVneo cells was significantly disrupted and endoplasmic reticulum (ER) stress related markers including PERK, IRE1-α were increased. After high speed centrifugation, the proteins PERK and IRE1-α were dramatically decreased in the highest TiO₂ NPs treatment group, which indicated interactions between TiO₂ NPs and these two proteins. Meanwhile, the protein expressions of LC3-II/LC3-I and P62, the autophagy biomarkers, were increased and the autophagy flux was not blocked. Cellular ROS stress increased and mitophagy related genes including PINK and Parkin increased along with the increased co-localization of LC3 and mitochondria. Taken together, these results indicated that TiO₂ NPs interacted with intracellular proteins and activated ER stress and mitophagy in HTR-8/SVneo cells, which might do damage to placental function.

Inducible nitric oxide inhibitor aminoguanidine, ameliorated oxidative stress, interleukin-6 concentration and improved brain-derived neurotrophic factor in the brain tissues of neonates born from titanium dioxide nanoparticles exposed rats

Introduction: An interaction between oxidative stress, neuroinflammation, and nitric oxide (NO) has been suggested to have a role neurotoxicity. The aim of current research was to investigate the effect of aminoguanidine (AG) as an inducible NO synthase (iNOS) inhibitor, on brain-derived neurotrophic factor (BDNF), oxidative stress, and interleukin-6 (IL-6) concentrations in the brain tissues of neonates born from the rats exposed to titanium dioxide nanoparticles (TiO2 NPs) during gestation. Methods: The pregnant rats were grouped into three and received: (1) saline, (2) TiO2 (200 mg/kg, gavage), and (3) TiO2-AG [200 mg/kg intraperitoneal (IP)]. The treatment was started since the second gestation day up to the delivery time. The neonates born from the rats were deeply anesthetized, sacrificed, and the brains were collected for biochemical evaluations. Results: The neonates born from the rats exposed to TiO₂ showed a lower BDNF (p < .001) but a higher IL-6 (p < .01) concentrations in their hippocampal tissue. TiO₂ exposure also increased malondialdehyde (MDA) (p < .001) and NO metabolites (p < .001), while diminished thiol (p < .001), superoxide (SOD) (p < .001), and catalase (CAT) (p < .001) in all hippocampal, cortical, and cerebellar tissues. Administration of AG improved BDNF (p < .01) but attenuated IL-6 (p < .01) concentrations in the hippocampal tissue. AG also decreased MDA (p < .001) and NO metabolites (p < .01-p < .001), while increased thiol (p < .01-p < .001), SOD (p < .001), and CAT (p < .05-p < .001) in all cerebellar, hippocampal, cortical, and tissues. Conclusion: The results of the current research revealed that iNOS inhibitor AG, ameliorated oxidative stress, IL-6 concentration, and improved BDNF in the brain tissues of neonates born from TiO₂ NPs exposed rats.

Quantitative Proteomics Study Reveals Changes in the Molecular Landscape of Human Embryonic Stem Cells with Impaired Stem Cell Differentiation upon Exposure to Titanium Dioxide Nanoparticles

The increasing number of nanoparticles (NPs) being used in various industries has led to growing concerns of potential hazards that NP exposure can incur on human health. However, its global effects on humans and the underlying mechanisms are not systemically studied. Human embryonic stem cells (hESCs), with the ability to differentiate to any cell types, provide a unique system to assess cellular, developmental, and functional toxicity in vitro within a single system highly relevant to human physiology. Here, the quantitative proteomics approach is adopted to evaluate the molecular consequences of titanium dioxide NPs (TiO₂ NPs) exposure in hESCs. The study identifies ≈328 unique proteins significantly affected by TiO₂ NPs exposure. Proteomics analysis highlights that TiO₂ NPs can induce DNA damage, elevated oxidative stress, apoptotic responses, and cellular differentiation. Furthermore, in vivo analysis demonstrates remarkable reduction in the ability of hESCs in teratoma formation after TiO₂ NPs exposure, suggesting impaired pluripotency. Subsequently, it is found that TiO₂ NPs can disrupt hESC mesoderm differentiation into cardiomyocytes. The study unveils comprehensive changes in the molecular landscape of hESCs by TiO₂ NPs and identifies the impact which TiO₂ NPs can have on the pluripotency and differentiation properties of human stem cells.

Current understanding of the toxicological risk posed to the fetus following maternal exposure to nanoparticles

INTRODUCTION

With the broad use of nanotechnology, the number and variety of nanoparticles that humans can be exposed to has further increased. Consequently, there is growing concern about the potential effect of maternal exposure to various nanoparticles during pregnancy on a fetus. However, the nature of this risk is not fully known. Areas covered: In this review, materno-fetal transfer of nanoparticles through the placenta is described. Both prenatal and postnatal adverse effects, such as fetal resorption, malformation and injury to various organs in mice exposed to nanoparticles are reviewed. The potential mechanisms of toxicity are also discussed. Expert opinion: The toxicology and safe application of recently developed nanoparticles has attracted much attention in the past few years. Although many studies have demonstrated the toxicology of nanoparticles in various species, only a small number of studies have examined the effect on a fetus after maternal exposure to nanoparticles. This is particularly important, because the developing fetus is especially vulnerable to the toxic effects of nanoparticles during fetal development due to the unique physical stage of the fetus. Nanoparticles may directly or indirectly impair fetal development and growth after maternal exposure to nanoparticles.

A20 enhances the radiosensitivity of hepatocellular carcinoma cells to 60Co-γ ionizing radiation

The radioresistance of hepatocellular carcinoma (HCC) cells is a critical obstacle for effectively applying radiotherapy (RT) in HCC treatment. NF-κB, an important transcription factor, can influence critical cell fate decisions by promoting cell survival or anti-apoptosis in response to cell-stress, e.g. chemotherapies or ionizing radiation (IR). A20, also named as tumor necrosis factor α induced protein 3 (TNFAIP3), is a dominant negative regulator of NF-κB pathway and its functions in HCC are largely unknown. The present work aimed to reveal the role of A20 plays in affecting the radiosensitivity of HCC cells. Higher expression of A20 was detected in hepatic non-tumor cell line or clinical specimens compared with HCC cell lines or clinical specimens. A20 decreased the expression of proteins mediating cellular stress/injury response or epithelial-mesenchymal transition (EMT) process. Overexpression of A20 via adenovirus enhanced the effect of ⁶⁰Co-γ ionizing radiation (IR) on HCC cells’ injury, e.g. G2/M arrest or DNA double strands break (DSB). Moreover, A20 also enhanced the in vitro or in vivo survival inhibiting of HCC cells induced by IR. These results reveal the roles of A20 in HCC radiosensitization and overexpression of A20 would be a novel strategy for HCC radiotherapy.

Nanoparticles and female reproductive system: how do nanoparticles affect oogenesis and embryonic development

Along with the increasing application of nanoparticles (NPs) in many walks of life, environmental exposure to NPs has raised considerable health concerns. When NPs enter a pregnant woman’s body through inhalation, venous injection, ingestion or skin permeation, maternal toxic stress reactions such as reactive oxygen species (ROS), inflammation, apoptosis and endocrine dyscrasia are induced in different organs, particularly in the reproductive organs. Recent studies have shown that NPs disturb the developing oocyte by invading the protective barrier of theca cells, granulosa cell layers and zona pellucida. NPs disrupt sex hormone levels through the hypothalamic–pituitary-gonadal axis or by direct stimulation of secretory cells, such as granule cells, follicle cells, thecal cells and the corpus luteum. Some NPs can cross the placenta into the fetus by passive diffusion or endocytosis, which can trigger fetal inflammation, apoptosis, genotoxicity, cytotoxicity, low weight, reproductive deficiency, nervous damage, and immunodeficiency, among others. The toxicity of these NPs depend on their size, dosage, shape, charge, material and surface-coating. We summarize new findings on the toxic effect of various NPs on the ovary and on oogenesis and embryonic development. Meanwhile, we highlight the problems that need to be studied in the future. This manuscript will also provide valuable guidelines for protecting the female reproductive system from the toxicity of NPs and provide a certain reference value for NP application in the area of ovarian diseases.