Maternal exposure to an environmentally relevant dose of triclocarban results in perinatal exposure and potential alterations in offspring development in the mouse model

A large-scale survey of urinary parabens and triclocarban in the Chinese population as well as the influencing factors and health risks

Parabens and triclocarban are widely applied as antimicrobial preservatives in foodstuffs, pharmaceuticals, cosmetics, and personal care products. However, few studies have been conducted on large-scale biomonitoring of parabens and triclocarban in the Chinese general population. In the present study, there were 1157 urine samples collected from 26 Chinese provincial capitals for parabens and triclocarban measurement to evaluate the exposure levels, spatial distribution, and influencing factors, as well as associated health risks in the Chinese population. The median concentrations of Σparabens and triclocarban were 14.0 and 0.03 μg/L, respectively. Methyl paraben was the predominant compound. Subjects in western China were more exposed to parabens, possibly due to climate differences resulting in higher consumption of personal care products. Subjects who were female, aged 18-44 years, or had a higher education level were found to have higher paraben concentrations. The frequency of drinking bottled water was positively associated with paraben exposure. The assessment of health risk based on urinary paraben concentrations indicated that 0.8 % of the subjects had a hazard index exceeding one unit, while Monte Carlo analysis suggested that 3.6 % of the Chinese population exposure to parabens had a potential non-carcinogenic risk. This large-scale biomonitoring study will help to understand the exposure levels of parabens and triclocarban in the Chinese general population and provide supporting information for government decision-making.

Triclocarban induces lipid droplet accumulation and oxidative stress responses by inhibiting mitochondrial fatty acid oxidation in HepaRG cells

Mitochondrial fatty acid oxidation (mtFAO) plays an important role in hepatic energy metabolism. Severe mtFAO injury leads to nonalcoholic fatty liver disease (NAFLD) and liver failure. Several drugs have been withdrawn owing to safety issues, such as induction of fatty liver disease through mtFAO disruption. For instance, the antimicrobial triclocarban (TCC), an environmental contaminant that was removed from the market due to its unknown safety in humans, induces NAFLD in rats and promotes hepatic FAO in mice. Therefore, there are no consistent conclusions regarding the effects of TCC on FAO and lipid droplet accumulation. We hypothesized that TCC induces lipid droplet accumulation by inhibiting mtFAO in human hepatocytes. Here, we evaluated mitochondrial respiration in HepaRG cells to investigate the effects of TCC on fatty acid-driven oxidation in cells, electron transport chain parameters, lipid droplet accumulation, and antioxidant genes. The results suggest that TCC increases oxidative stress gene expression (GCLM, p62, HO-1, and NRF2) through lipid droplet accumulation via mtFAO inhibition in HepaRG cells. The results of the present study provide further insights into the effect of TCC on human NAFLD through mtFAO inhibition, and further in vivo studies could be used to validate the mechanisms.

Advances in understanding the reproductive toxicity of endocrine-disrupting chemicals in women

Recently, there has been a noticeable increase in disorders of the female reproductive system, accompanied by a rise in adverse pregnancy outcomes. This trend is increasingly being linked to environmental pollution, particularly through the lens of Endocrine Disrupting Chemicals (EDCs). These external agents disrupt natural processes of hormones, including synthesis, metabolism, secretion, transport, binding, as well as elimination. These disruptions can significantly impair human reproductive functions. A wealth of animal studies and epidemiological research indicates that exposure to toxic environmental factors can interfere with the endocrine system's normal functioning, resulting in negative reproductive outcomes. However, the mechanisms of these adverse effects are largely unknown. This work reviews the reproductive toxicity of five major environmental EDCs-Bisphenol A (BPA), Phthalates (PAEs), Triclocarban Triclosan and Disinfection Byproducts (DBPs)-to lay a foundational theoretical basis for further toxicological study of EDCs. Additionally, it aims to spark advancements in the prevention and treatment of female reproductive toxicity caused by these chemicals.

Acute exposure of triclocarban affects early embryo development in mouse through disrupting maternal-to-zygotic transition and epigenetic modifications

Triclocarban (TCC) is a broad-spectrum antibacterial agent used globally, and high concentrations of this harmful chemical exist in the environment. The human body is directly exposed to TCC through skin contact. Moreover, TCC is also absorbed through diet and inhaled through breathing, which results in its accumulation in the body. The safety profile of TCC and its potential impact on human health are still not completely clear; therefore, it becomes imperative to evaluate the reproductive toxicity of TCC. Here, we explored the effect of TCC on the early embryonic development of mice and its associated mechanisms. We found that acute exposure of TCC affected the early embryonic development of mice in a dose-dependent manner. Approximately 7600 differentially expressed genes (DEGs) were obtained by sequencing the transcriptome of 2-cell mouse embryos; of these, 3157 genes were upregulated and 4443 genes were downregulated in the TCC-treated embryos. GO and KEGG analysis revealed that the enriched genes were mainly involved in redox processes, RNA synthesis, DNA damage, apoptosis, mitochondria, endoplasmic reticulum, Golgi apparatus, cytoskeleton, peroxisome, RNA polymerase, and other components or processes. Moreover, the Venn analysis showed that the zygotic genome activation (ZGA) was affected and the degradation of maternal effector genes was inhibited. TCC induced changes in the epigenetic modification of 2-cell embryos. The level of DNA methylation increased significantly. Further, the levels of H3K27ac, H3K9ac, and H3K27me3 histone modifications decreased significantly, whereas those of H3K4me3 and H3K9me3 modifications increased significantly. Additionally, TCC induced oxidative stress and DNA damage in the 2-cell embryos. In conclusion, acute exposure of TCC affected early embryo development, destroyed early embryo gene expression, interfered with ZGA and maternal gene degradation, induced changes in epigenetic modification of early embryos, and led to oxidative stress and DNA damage in mouse early embryos.

Oxysterols Profile in Zebrafish Embryos Exposed to Triclocarban and Propylparaben-A Preliminary Study

Oxysterols have long been considered as simple by-products of cholesterol metabolism, but they are now fully designed as bioactive lipids that exert their multiple effects through their binding to several receptors, representing endogenous mediators potentially involved in several metabolic diseases. There is also a growing concern that metabolic disorders may be linked with exposure to endocrine-disrupting chemicals (EDCs). To date, there are no studies aimed to link EDCs exposure to oxysterols perturbation-neither in vivo nor in vitro studies. The present research aimed to evaluate the differences in oxysterols levels following exposure to two metabolism disrupting chemicals (propylparaben (PP) and triclocarban (TCC)) in the zebrafish model using liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). Following exposure to PP and TCC, there were no significant changes in total and individual oxysterols compared with the control group; however, some interesting differences were noticed: 24-OH was detected only in treated zebrafish embryos, as well as the concentrations of 27-OH, which followed a different distribution, with an increase in TCC treated embryos and a reduction in zebrafish embryos exposed to PP at 24 h post-fertilization (hpf). The results of the present study prompt the hypothesis that EDCs can modulate the oxysterol profile in the zebrafish model and that these variations could be potentially involved in the toxicity mechanism of these emerging contaminants.

Potential long-term developmental toxicity of in utero and lactational exposure to Triclocarban (TCC) in hampering ovarian folliculogenesis in rat offspring

Triclocarban (TCC), an antimicrobial compound commonly added to a wide range of household and personal hygiene care products, is one of the most prevalent endocrine-disrupting substances (EDS). This study was conducted to elucidate whether in utero and lactational exposure to TCC could adversely affect folliculogenesis and the onset of puberty in female rat offspring. Twenty pregnant Sprague Dawley rats were equally divided into Control and TCC dam groups (supplemented daily with drinking water enriched with 0.5 mg/L of TCC) from gestational day5 to postnatal day21 (PND21). Female offspring, 20 from control and 20 from TCC dams, were subdivided into 4 subgroups (PND21, PND28, PND35 & PND42). The day of vaginal opening and first estrous cycle were determined. Ovarian sections of the offspring were processed for H&E staining and for immunohistochemical expression of Ki67, Caspase-3 and androgen receptors (AR) on the granulosa cells of ovarian follicles. Follicular count and atretic index were assessed besides, serum estradiol, progesterone, FSH and LH, C-reactive protein (CRP), malondialdehyde (MDA) and total antioxidant capacity (TAC) were measured. TCC offspring exhibited a significant delay in the onset of puberty and impedance of normal transition of the primordial follicles to more developed ones with altered cyctoarchitecture. Also, TCC decreased follicular count, proliferation and gonado-somatic index while it increased atretic index, apoptosis and AR of the granulosa cells along with disturbance of the feminine hormonal profile and oxidant/antioxidant balance. This study highlighted the potential long-term consequences of in utero and lactational exposure to TCC on the postnatal development of the ovary in rat offspring.

Environmentally relevant concentrations of triclocarban affect morphological traits and melanogenesis in zebrafish larvae

Human activity is responsible for producing several chemical compounds, which contaminate the aquatic environment and adversely influence the survival of aquatic species and indirectly human health. Triclocarban (TCC) belongs to the category of emerging pollutants and its presence in aquatic environment is justified by its wide use as antimicrobial agent in personal care products. The concern about this chemical is due to the risk of persistence in water and soils and bioaccumulation, which contributes to human exposition through the contaminated food consumption. The present study evaluated the developmental toxicity of TCC in zebrafish early-life stages starting with the assessment of acute toxicity and then focusing on the integrative analyses of the observed phenotype on zebrafish development. For this purpose, lethal and sublethal alterations of zebrafish embryos were investigated by the Fish Embryo Acute Toxicity Tests (FET tests). Subsequently, two concentrations of TCC were used to investigate the morphometric features and defects in larvae developmental pigmentation: an environmentally relevant (5μg/L) and toxicological (50μg/L), derived from the No Observed Effect Concentration (NOEC) value concentration. Furthermore, the expression levels of a key transcription factor for melanocyte differentiation and melanin syntheses, such as mitfa (microphthalmia-associated transcription factor) and tyr (tyrosinase) and its activity, were evaluated.

Antiseptic drugs and disinfectants with special scrutiny of COVID-19 pandemic related side effects

This review covers publications during the period of January 2020 to December 2020 on adverse reactions to antiseptic drugs and disinfectants. Specific agents discussed are alcohols (ethanol, isopropanol), aldehydes (formaldehyde), guanidines (chlorhexidine, polyhexamethylene guanidine, and polyhexamethylene biguanidine), benzalkonium compounds, triclocarban, povidone-iodine, and sodium hypochlorite. No new data were identified for glutaraldehyde, cetrimide, ethylene oxide, tosylchloramide, triclosan, iodine, and phenolic compounds. The use of antiseptic drugs and disinfectants has been considerably increased during 2020 in a variety of medical and occupational settings, in commerce and gastronomy, as well as in the household, due to their antiviral properties against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the Coronavirus Disease 2019 (COVID-19) pandemic. Exposure was additionally increased by widespread misinformation on social media for non-evidence based disinfectant use, even including ingestion or injection, as well as by questionable practices such as environmental spraying or disinfectant gates. Irritant effects on the respiratory system, skin and eyes were the most common adverse reaction, while the widespread and sometimes excessive use led to increased reports of poisonings, as well as cases of disinfectant adulteration including dilution into ineffective concentrations or addition of toxic agents such as methanol.

Age, gender, and racial/ethnic differences in the association of triclocarban with adulthood obesity using NHANES 2013-2016

This study examined the association between triclocarban and obesity among US adults and compared the pattern of this association across age, gender, and racial/ethnic groups. Study found triclocarban to be associated with obesity (OR: OR:1.123 95% CI: 1.046, 1.205) and this association remained among women (OR:1.14 95% CI: 1.031, 1.261). Study participants aged 60 years and older were more likely to be overweight (OR:1.131 95% CI: 1.022 1.251) and obese (OR:1.192 95% CI: 1.079, 1.317) when compared to other age groups. Likewise, non-Hispanic whites (OR:1.126 95% CI: 1.003, 1.263) and "other race including multi-racial" (OR:1.431 95% CI: 1.219, 1.679) were more likely to be obese when compared to other racial/ethnic groups. In conclusion, triclocarban is associated with obesity among US adults and there is evidence of gender, age, and racial/ethnicity differences in the association.

In utero and lactational exposure to triclocarban: Age-associated changes in reproductive parameters of male rat offspring

Triclocarban (TCC) is an antimicrobial compound, widely used in personal care products, such as soaps, toothpaste, and shampoo. This agent is incompletely removed by wastewater treatment and represents an environmental contaminant. Studies show that TCC has been associated with some endocrine disruptions. In vitro, TCC demonstrated potent androgen-augmenting activity and aromatase inhibition. In this sense, exposure during critical periods of development (gestation and lactation) could lead to some adverse health outcomes in offspring. Therefore, the present study evaluated if maternal exposure to three different doses of TCC could interfere in the reproductive parameters of male offspring. Pregnant female Wistar rats were separated into four groups: vehicle Control (CTR); TCC 0.3 mg/kg (TCC 0.3); TCC 1.5 mg/kg (TCC 1.5); TCC 3.0 mg/kg (TCC 3.0). Dams were treated daily by oral gavage from gestational day 0 to lactational day 21. The males were evaluated in different timepoint: infancy (PND 21), puberty (PND 50) and adult life (PND 90-120). The histomorphometric analysis of testis and testosterone level were assessed on PND 21, 50, 120; sexual behavior and sperm parameters at adulthood. In the TCC 3.0 group, a decrease in the testis interstitial volume and an increase in testosterone levels were observed on PND 21. Moreover, there was a decrease in the diameter of the seminiferous tubules on PND 50, and a decrease in sexual competency in adulthood. These results suggest that exposure to a human relevant dose of TCC may interfere with reproduction and could have implications for human health.

Association between triclocarban and triclosan exposures and the risks of type 2 diabetes mellitus and impaired glucose tolerance in the National Health and Nutrition Examination Survey (NHANES 2013-2014)

BACKGROUND

There has been increasing interest in the concept that exposure to environmental chemicals may be contributing factors to epidemics of diabetes mellitus (DM). Triclocarban and triclosan (TCs) are synthetic antibacterial chemicals that are widely used in personal care products. Studies have shown that TCs are endocrine disruptors that alter metabolic conditions. However, it remains unclear whether exposure to TCs is a risk factor for impaired glucose tolerance (IGT) and type 2 diabetes mellitus (T2DM).

OBJECTIVE

We explored the hypothesis that TCs exposure is associated with an increased risk of IGT and T2DM.

METHOD

To test our hypothesis, we analyzed the U.S. National Health and Nutrition Examination Survey (NHANES) cross-sectional data from 2013 to 2014. IGT and T2DM were diagnosed based on an oral glucose tolerance test (OGTT) and the WHO standards. The levels of urinary TCs were measured using an HPLC-MS/MS method that NHANES investigators developed. The association between urinary TCs status and IGT and T2DM was examined separately in men and women using multivariable logistic regression models adjusted for age, race, BMI, education, ratio of family income to poverty, smoking, exercise and hypertension.

RESULTS

Nine hundred US participants (429 men and 471 women) were included in the analysis, of whom 242 (26.89%) were diagnosed with T2DM and 117 (13.00%) had IGT. Among women, there was a significant positive association between triclocarban, but not triclosan exposure and T2DM (OR: 1.79, 95% CI: 1.05, 2.05) after adjusting for potential confounding factors. Among men, no significant association between TCs exposure and IGT or T2DM was observed.

CONCLUSIONS

Triclocarban exposure may increase the risk of T2DM in the women, although additional studies are needed to confirm the results of this study and to investigate the underlying mechanisms.

Genotoxicity assessment of triclocarban by comet and micronucleus assays and Ames test

The widespread usage and ubiquitous distribution of triclocarban (3,4,4'-trichlorocarbanilide, TCC) have raised public concerns about its health effects. At present, there is little information about the genotoxicity of TCC. In this study, we used a battery of genotoxicity testing methods including salmonella reverse mutation test (Ames test), comet assay and micronucleus assay to detect the effects of TCC on gene mutation, DNA breakage, and chromosome damage. The results of Ames test showed that TCC at 0.1-1000 μg/plate did not significantly increase the number of revertant colonies in the four standard Salmonella typhimurium strains, i.e., TA97, TA98, TA100, and TA102, when compared to the vehicle control. The results from comet assay demonstrated that exposure to 5, 10, or 15 μM TCC for 24 h did not significantly increase the percentage of comet cells, tail length (TL), DNA in tail (T DNA%), or olive tail moment (OTM) in keratinocyte HaCaT and hepatic L02 cells. Moreover, TCC did not markedly enhance the frequency of micronucleated cells or micronuclei in HaCaT and L02 cells in the micronucleus assay. Taken together, the results indicated that TCC did not exhibit any genotoxic effects. Our study provides additional information for the safety profile of TCC.

Triclocarban impairs autophagy in neuronal cells and disrupts estrogen receptor signaling via hypermethylation of specific genes

Although an increasing body of evidence suggests that triclocarban, a phenyl ether classified as a contaminant of emerging concern, presents a risk to development, there is limited data available on the potential interplay of triclocarban with the developing mammalian nervous system. This study was aimed to investigate the impact of environmentally pervasive chemical triclocarban on autophagy and estrogen receptor-mediated signaling pathways in mouse neurons. The study showed that triclocarban impaired autophagy and disrupted estrogen receptor signaling in mouse embryonic neurons in primary culture. Triclocarban used at environmentally relevant concentrations inhibited the mRNA and protein expression of ESR1 and GPER1 but not ESR2. The triclocarban-induced decrease in the expression of estrogen receptors was supported by the colocalization of the receptors in mouse neurons and corresponded to hypermethylation of the Esr1 and Gper1 genes. Selective antagonists increased the effects of triclocarban, which suggests that the neurotoxic effects of triclocarban, in addition to decreasing estrogen receptor expression, are mediated via inhibition of the neuroprotective capacity of the receptors. Furthermore, Becn1 and Atg7 siRNAs potentiated the caspase-3-dependent effect of triclocarban, which points to triclocarban-induced impairment of autophagy. Indeed, triclocarban dysregulated the expression of autophagy-related genes, and caused a time-dependent inhibition of the mRNA expression of Becn1, Map1lc3a, Map1lc3b, Nup62, and Atg7, which was correlated with a decrease in the protein levels of MAP1LC3B, BECN1 and autophagosomes, but not NUP62 protein level which was increased. Intriguingly, the Esr1 and Gper1 siRNAs did not affect the level of autophagosomes, suggesting that the triclocarban-induced impairment of autophagy is independent of the triclocarban-induced disruption of estrogen receptor signaling in mammalian neurons. Because our data provided evidence that triclocarban has the capacity to impair autophagy and disrupt estrogen receptor signaling in brain neurons at an early developmental stage, we postulate to categorize the compound as a neurodevelopmental risk factor.

In utero and lactational exposure to triclocarban: reproductive effects on female rat offspring

Triclocarban (TCC) is an antimicrobial compound widely used in personal care products such as soaps, toothpaste, and shampoo. This agent is incompletely removed by wastewater treatment and represents an environmental contaminant. Recent studies have shown that TCC is associated with some endocrine disruptions. The aim of the present study was to evaluate if TCC exposure during critical periods of development (gestation and lactation) could lead to adverse effects on reproductive and behavior parameters of female offspring. Pregnant female Wistar rats were divided into four groups (n = 8-11/group): Control; TCC 0.3 mg/kg (TCC 0.3); TCC 1.5 mg/kg; TCC 3.0 mg/kg (TCC 3.0); and treated daily by oral gavage from gestational day 0 to lactational day 21. The female pups (F1 generation) were weaned on post-natal day 21 and included in the study. No litter-mates were used for the same group. There was a decrease in estradiol levels in the TCC 0.3 and TCC 3.0 groups. Moreover, there was a decrease in progesterone levels and an increase in pre-implantation loss in the TCC 3.0 group in adulthood. It is suggested, in this study, that the decrease in progesterone biosynthesis could interfere with implantation process. The exposure window to TCC is an important factor, as we found alterations only in the offspring.

Radiocarbon Tracers in Toxicology and Medicine: Recent Advances in Technology and Science

This review summarizes recent developments in radiocarbon tracer technology and applications. Technologies covered include accelerator mass spectrometry (AMS), including conversion of samples to graphite, and rapid combustion to carbon dioxide to enable direct liquid sample analysis, coupling to HPLC for real-time AMS analysis, and combined molecular mass spectrometry and AMS for analyte identification and quantitation. Laser-based alternatives, such as cavity ring down spectrometry, are emerging to enable lower cost, higher throughput measurements of biological samples. Applications covered include radiocarbon dating, use of environmental atomic bomb pulse radiocarbon content for cell and protein age determination and turnover studies, and carbon source identification. Low dose toxicology applications reviewed include studies of naphthalene-DNA adduct formation, benzo[a]pyrene pharmacokinetics in humans, and triclocarban exposure and risk assessment. Cancer-related studies covered include the use of radiocarbon-labeled cells for better defining mechanisms of metastasis and the use of drug-DNA adducts as predictive biomarkers of response to chemotherapy.

Effects of triclocarban on oxidative stress and innate immune response in zebrafish embryos

Triclocarban (TCC) is used in many household and personal hygiene products. TCC has been widely detected in wastewater around the world. The present study reveals that TCC can activate oxidative stress, induce total antioxidant capacity expression and lipid peroxidation, and increase the activities of superoxide dismutase and other antioxidant enzymes to resist oxidative damage. A significant induction of concentrations of proinflammatory mediator and nitric oxide (NO), accompanied by an upregulated expression of inducible NO synthase gene, was detected in zebrafish embryos exposed to TCC. The transcription of immune-response-related genes, including tnf-α, il-1β, il-4, il-8, and cxcl-clc, was significantly upregulated on exposure to TCC. Furthermore, we found that the exposure of zebrafish embryos to TCC decreased immune cell recruiting in the head. Expressions of nf-κb, trif, myd88, irak4, and traf6 were altered on exposure to TCC. These results demonstrated that exposure to TCC at environmental concentrations significantly affects the expression of immune-response-related genes in zebrafish embryos following oxidative stress and the release of proinflammatory mediators through Toll-like receptor signaling pathway. Thus, we assumed that the ecological risk of TCC on aquatic organisms could not be ignored.

Triclocarban Disrupts the Epigenetic Status of Neuronal Cells and Induces AHR/CAR-Mediated Apoptosis

Triclocarban is a phenyl ether that has recently been classified as a contaminant of emerging concern. Evidence shows that triclocarban is present in human tissues, but little is known about the impact of triclocarban on the nervous system, particularly at early developmental stages. This study demonstrated that triclocarban that was used at environmentally relevant concentrations induced apoptosis in mouse embryonic neurons, inhibited sumoylation, and changed the epigenetic status, as evidenced by impaired activities of HDAC, sirtuins, and DNMT, global DNA hypomethylation, and alterations of methylation levels of bax, bcl2, Ahr, and Car genes. The use of selective antagonists and specific siRNAs, which was followed by the co-localization of aryl hydrocarbon receptor (AHR) and constitutive androstane receptor (CAR) in mouse neurons, points to the involvement of AHR and CAR in triclocarban-induced neurotoxicity. A 24-h treatment with triclocarban enhanced protein levels of the receptors which was paralleled by Car hypomethylation and Ahr hypermethylation. Car hypomethylation is in line with global DNA hypomethylation and explains the increased mRNA and protein levels of CAR in response to triclocarban. Ahr hypermethylation could reflect reduced Ahr mRNA expression and corresponds to lowered protein levels after 3- and 6-h exposures to triclocarban that is likely related to proteasomal degradation of activated AHR. We hypothesize that the triclocarban-induced apoptosis in mouse neurons and the disruption of epigenetic status involve both AHR- and CAR-mediated effects, which may substantiate a fetal basis of the adult onset of neurological diseases; however, the expression of the receptors is regulated in different ways.

Potential Developmental and Reproductive Impacts of Triclocarban: A Scoping Review

Triclocarban (TCC) is an antimicrobial agent used in personal care products. Although frequently studied with another antimicrobial, triclosan, it is not as well researched, and there are very few reviews of the biological activity of TCC. TCC has been shown to be a possible endocrine disruptor, acting by enhancing the activity of endogenous hormones. TCC has been banned in the US for certain applications; however, many human populations, in and outside the US, exhibit exposure to TCC. Because of the concern of the health effects of TCC, we conducted a scoping review in order to map the current body of literature on the endocrine, reproductive, and developmental effects of TCC. The aim of this scoping review was to identify possible endpoints for future systematic review and to make recommendations for future research. A search of the literature until August 2017 yielded 32 relevant studies in humans, rodents, fish, invertebrates, and in vitro. Based on the robustness of the literature in all three evidence streams (human, animal, and in vitro), we identified three endpoints for possible systematic review: estrogenic activity, androgenic activity, and offspring growth. In this review, we describe the body of evidence and make recommendations for future research.