scholarly journals The Impact of Ubiquitous Face Masks and Filtering Face Piece Application During Rest, Work and Exercise on Gas Exchange, Pulmonary Function and Physical Performance: A Systematic Review with Meta-analysis

2021 ◽  
Vol 7 (1) ◽  
Author(s):  
Tobias Engeroff ◽  
David A. Groneberg ◽  
Daniel Niederer
Keyword(s):  
Carbon Dioxide ◽  
Systematic Review ◽  
Gas Exchange ◽  
Pulmonary Function ◽  
Oxygen Saturation ◽  
Physical Performance ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Effect Sizes ◽  
The Impact

Abstract Background Protection against airborne infection is currently, due to the COVID-19-associated restrictions, ubiquitously applied during public transport use, work and leisure time. Increased carbon dioxide re-inhalation and breathing resistance may result thereof and, in turn, may negatively impact metabolism and performance. Objectives To deduce the impact of the surgical mask and filtering face piece type 2 (FFP2) or N95 respirator application on gas exchange (pulse-derived oxygen saturation (SpO2), carbon dioxide partial pressure (PCO2), carbon dioxide exhalation (VCO2) and oxygen uptake (VO2)), pulmonary function (respiratory rate and ventilation) and physical performance (heart rate HR, peak power output Wpeak). Methods Systematic review with meta-analysis. Literature available in Medline/Pubmed, the Cochrane Library and the Web of Knowledge with the last search on the 6th of May 2021. Eligibility criteria: Randomised controlled parallel group or crossover trials (RCT), full-text availability, comparison of the acute effects of ≥ 1 intervention (surgical mask or FFP2/N95 application) to a control/comparator condition (i.e. no mask wearing). Participants were required to be healthy humans and > 16 years of age without conditions or illnesses influencing pulmonary function or metabolism. Risk of bias was rated using the crossover extension of the Cochrane risk of bias assessment tool II. Standardised mean differences (SMD, Hedges' g) with 95% confidence intervals (CI) were calculated, overall and for subgroups based on mask and exercise type, as pooled effect size estimators in our random-effects meta-analysis. Results Of the 1499 records retrieved, 14 RCTs (all crossover trials, high risk of bias) with 25 independent intervention arms (effect sizes per outcome) on 246 participants were included. Masks led to a decrease in SpO2 during vigorous intensity exercise (6 effect sizes; SMD = − 0.40 [95% CI: − 0.70, − 0.09], mostly attributed to FFP2/N95) and to a SpO2-increase during rest (5 effect sizes; SMD = 0.34 [95% CI: 0.04, 0.64]); no general effect of mask wearing on SpO2 occurred (21 effect sizes, SMD = 0.34 [95% CI: 0.04, 0.64]). Wearing a mask led to a general oxygen uptake decrease (5 effect sizes, SMD = − 0.44 [95% CI: − 0.75, − 0.14]), to slower respiratory rates (15 effect sizes, SMD = − 0.25 [95% CI: − 0.44, − 0.06]) and to a decreased ventilation (11 effect sizes, SMD = − 0.43 [95% CI: − 0.74, − 0.12]). Heart rate (25 effect sizes; SMD = 0.05 [95% CI: − 0.09, 0.19]), Wpeak (9 effect sizes; SMD = − 0.12 [95% CI: − 0.39, 0.15]), PCO2 (11 effect sizes; SMD = 0.07 [95% CI: − 0.14, 0.29]) and VCO2 (4 effect sizes, SMD = − 0.30 [95% CI: − 0.71, 0.10]) were not different to the control, either in total or dependent on mask type or physical activity status. Conclusion The number of crossover-RCT studies was low and the designs displayed a high risk of bias. The within-mask- and -intensity-homogeneous effects on gas exchange kinetics indicated larger detrimental effects during exhausting physical activities. Pulse-derived oxygen saturation was increased during rest when a mask was applied, whereas wearing a mask during exhausting exercise led to decreased oxygen saturation. Breathing frequency and ventilation adaptations were not related to exercise intensity. FFP2/N95 and, to a lesser extent, surgical mask application negatively impacted the capacity for gas exchange and pulmonary function but not the peak physical performance. Registration: Prospero registration number: CRD42021244634

scholarly journals Compensatory Interventions for Cognitive Impairments in Psychosis: A Systematic Review and Meta-Analysis

2020 ◽  
Vol 46 (4) ◽  
pp. 869-883 ◽  
Author(s):  
Kelly Allott ◽  
Kristi van-der-EL ◽  
Shayden Bryce ◽  
Emma M Parrish ◽  
Susan R McGurk ◽  
...  
Keyword(s):  
Systematic Review ◽  
Psychiatric Symptoms ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Effect Sizes ◽  
Medium Effect ◽  
Post Intervention ◽  
Psychosocial Disability ◽  
The Impact

Abstract Objective Cognitive compensatory interventions aim to alleviate psychosocial disability by targeting functioning directly using aids and strategies, thereby minimizing the impact of cognitive impairment. The aim was to conduct a systematic review and meta-analysis of cognitive compensatory interventions for psychosis by examining the effects on functioning and symptoms, and exploring whether intervention factors, study design, and age influenced effect sizes. Methods Electronic databases (Ovid Medline, PsychINFO) were searched up to October 2018. Records obtained through electronic and manual searches were screened independently by two reviewers according to selection criteria. Data were extracted to calculate estimated effects (Hedge’s g) of treatment on functioning and symptoms at post-intervention and follow-up. Study quality was assessed using Cochrane Collaboration’s risk of bias tool. Results Twenty-six studies, from 25 independent randomized controlled trials (RCTs) were included in the meta-analysis (1654 participants, mean age = 38.9 years, 64% male). Meta-analysis revealed a medium effect of compensatory interventions on functioning compared to control conditions (Hedge’s g = 0.46, 95% CI = 0.33, 0.60, P < .001), with evidence of relative durability at follow-up (Hedge’s g = 0.36, 95% CI = 0.19, 0.54, P < .001). Analysis also revealed small significant effects of cognitive compensatory treatment on negative, positive, and general psychiatric symptoms, but not depressive symptoms. Estimated effects did not significantly vary according to treatment factors (ie, compensatory approach, dosage), delivery method (ie, individual/group), age, or risk of bias. Longer treatment length was associated with larger effect sizes for functioning outcomes. No evidence of publication bias was identified. Conclusion Cognitive compensatory interventions are associated with robust, durable improvements in functioning in people with psychotic illnesses.

scholarly journals A protocol for the systematic review and meta-analysis of thigmotactic behaviour in the open field test in rodent models associated with persistent pain

2021 ◽  
Vol 5 (1) ◽  
pp. e100135
Author(s):  
Xue Ying Zhang ◽  
Jan Vollert ◽  
Emily S Sena ◽  
Andrew SC Rice ◽  
Nadia Soliman
Keyword(s):  
Systematic Review ◽  
Outcome Measure ◽  
Meta Analysis ◽  
Persistent Pain ◽  
Effect Sizes ◽  
Bias Assessment ◽  
Animal Pain ◽  
Trim And Fill ◽  
Meta Analyses ◽  
The Impact

ObjectiveThigmotaxis is an innate predator avoidance behaviour of rodents and is enhanced when animals are under stress. It is characterised by the preference of a rodent to seek shelter, rather than expose itself to the aversive open area. The behaviour has been proposed to be a measurable construct that can address the impact of pain on rodent behaviour. This systematic review will assess whether thigmotaxis can be influenced by experimental persistent pain and attenuated by pharmacological interventions in rodents.Search strategyWe will conduct search on three electronic databases to identify studies in which thigmotaxis was used as an outcome measure contextualised to a rodent model associated with persistent pain. All studies published until the date of the search will be considered.Screening and annotationTwo independent reviewers will screen studies based on the order of (1) titles and abstracts, and (2) full texts.Data management and reportingFor meta-analysis, we will extract thigmotactic behavioural data and calculate effect sizes. Effect sizes will be combined using a random-effects model. We will assess heterogeneity and identify sources of heterogeneity. A risk-of-bias assessment will be conducted to evaluate study quality. Publication bias will be assessed using funnel plots, Egger’s regression and trim-and-fill analysis. We will also extract stimulus-evoked limb withdrawal data to assess its correlation with thigmotaxis in the same animals. The evidence obtained will provide a comprehensive understanding of the strengths and limitations of using thigmotactic outcome measure in animal pain research so that future experimental designs can be optimised. We will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines and disseminate the review findings through publication and conference presentation.

scholarly journals Effect of dose administration aids on adherence to self-administered medications: a systematic review protocol

BMJ Open ◽  
2019 ◽  
Vol 9 (10) ◽  
pp. e030536
Author(s):  
Kanika Chaudhri ◽  
Madeleine Kearney ◽  
Richard O Day ◽  
Anthony Rodgers ◽  
Emily Atkins
Keyword(s):  
Systematic Review ◽  
Health Outcomes ◽  
Meta Analysis ◽  
Study Participant ◽  
Risk Of Bias ◽  
Cochrane Library ◽  
Secondary Outcome ◽  
Dose Administration ◽  
Common Solution ◽  
The Impact

IntroductionForgetting to take a medication is the most common reason for non-adherence to self-administered medication. Dose administration aids (DAAs) are a simple and common solution to improve unintentional non-adherence for oral tablets. DAAs can be in the form of compartmentalised pill boxes, automated medication dispensing devices, blister packs and sachets packets. This protocol aims to outline the methods that will be used in a systematic review of the current literature to assess the impact of DAAs on adherence to medications and health outcomes.Methods and analysisRandomised controlled trials will be identified through electronic searches in databases including EMBASE, MEDLINE, CINAHL and the Cochrane Library, from the beginning of each database until January 2020. Two reviewers will independently screen studies and extract data using the standardised forms. Data extracted will include general study information, characteristics of the study, participant characteristics, intervention characteristics and outcomes. Primary outcome is to assess the effects of DAAs on medication adherence. Secondary outcome is to evaluate the changes in health outcomes. The risk of bias will be ascertained by two reviewers in parallel using The Cochrane Risk of Bias Tool. A meta-analysis will be performed if data are homogenous.Ethics and disseminationEthics approval will not be required for this study. The results of the review described within this protocol will be disseminated through publication in a peer-reviewed journal and relevant conference presentations.PROSPERO registration numberCRD42018096087

scholarly journals Considering the methodological limitations in the evidence base of antidepressants for depression: a reanalysis of a network meta-analysis

BMJ Open ◽  
2019 ◽  
Vol 9 (6) ◽  
pp. e024886 ◽  
Author(s):  
Klaus Munkholm ◽  
Asger Sand Paludan-Müller ◽  
Kim Boesen
Keyword(s):  
Systematic Review ◽  
Clinical Study ◽  
Effect Size ◽  
Meta Analysis ◽  
Evidence Base ◽  
Risk Of Bias ◽  
Depression Symptom ◽  
Meta Analyses ◽  
The Impact ◽  
Clinical Study Reports

ObjectivesTo investigate whether the conclusion of a recent systematic review and network meta-analysis (Ciprianiet al) that antidepressants are more efficacious than placebo for adult depression was supported by the evidence.DesignReanalysis of a systematic review, with meta-analyses.Data sources522 trials (116 477 participants) as reported in the systematic review by Ciprianiet aland clinical study reports for 19 of these trials.AnalysisWe used the Cochrane Handbook’s risk of bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the risk of bias and the certainty of evidence, respectively. The impact of several study characteristics and publication status was estimated using pairwise subgroup meta-analyses.ResultsSeveral methodological limitations in the evidence base of antidepressants were either unrecognised or underestimated in the systematic review by Ciprianiet al. The effect size for antidepressants versus placebo on investigator-rated depression symptom scales was higher in trials with a ‘placebo run-in’ study design compared with trials without a placebo run-in design (p=0.05). The effect size of antidepressants was higher in published trials compared with unpublished trials (p<0.0001). The outcome data reported by Ciprianiet aldiffered from the clinical study reports in 12 (63%) of 19 trials. The certainty of the evidence for the placebo-controlled comparisons should be very low according to GRADE due to a high risk of bias, indirectness of the evidence and publication bias. The mean difference between antidepressants and placebo on the 17-item Hamilton depression rating scale (range 0–52 points) was 1.97 points (95% CI 1.74 to 2.21).ConclusionsThe evidence does not support definitive conclusions regarding the benefits of antidepressants for depression in adults. It is unclear whether antidepressants are more efficacious than placebo.

scholarly journals Drug treatments for covid-19: living systematic review and network meta-analysis

BMJ ◽  
2020 ◽  
pp. m2980 ◽  
Author(s):  
Reed AC Siemieniuk ◽  
Jessica J Bartoszko ◽  
Long Ge ◽  
Dena Zeraatkar ◽  
Ariel Izcovich ◽  
...  
Keyword(s):  
Systematic Review ◽  
Mechanical Ventilation ◽  
Standard Care ◽  
Interferon Beta ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Drug Discontinuation ◽  
Duration Of Symptoms ◽  
Risk Of Death ◽  
The Impact

Abstract Objective To compare the effects of treatments for coronavirus disease 2019 (covid-19). Design Living systematic review and network meta-analysis. Data sources WHO covid-19 database, a comprehensive multilingual source of global covid-19 literature, up to 3 December 2020 and six additional Chinese databases up to 12 November 2020. Study selection Randomised clinical trials in which people with suspected, probable, or confirmed covid-19 were randomised to drug treatment or to standard care or placebo. Pairs of reviewers independently screened potentially eligible articles. Methods After duplicate data abstraction, a bayesian network meta-analysis was conducted. Risk of bias of the included studies was assessed using a modification of the Cochrane risk of bias 2.0 tool, and the certainty of the evidence using the grading of recommendations assessment, development and evaluation (GRADE) approach. For each outcome, interventions were classified in groups from the most to the least beneficial or harmful following GRADE guidance. Results 85 trials enrolling 41 669 patients met inclusion criteria as of 21 October 2020; 50 (58.8%) trials and 25 081 (60.2%) patients are new from the previous iteration; 43 (50.6%) trials evaluating treatments with at least 100 patients or 20 events met the threshold for inclusion in the analyses. Compared with standard care, corticosteroids probably reduce death (risk difference 17 fewer per 1000 patients, 95% credible interval 34 fewer to 1 more, moderate certainty), mechanical ventilation (29 fewer per 1000 patients, 54 fewer to 1 more, moderate certainty), and days free from mechanical ventilation (2.6 fewer, 0.2 fewer to 5.0 fewer, moderate certainty). The impact of remdesivir on mortality, mechanical ventilation, length of hospital stay, and duration of symptoms is uncertain, but it probably does not substantially increase adverse effects leading to drug discontinuation (0 more per 1000, 9 fewer to 40 more, moderate certainty). Azithromycin, hydroxychloroquine, lopinavir/ritonavir, interferon-beta, and tocilizumab may not reduce risk of death or have an effect on any other patient-important outcome. The certainty in effects for all other interventions was low or very low. Conclusion Corticosteroids probably reduce mortality and mechanical ventilation in patients with covid-19 compared with standard care, whereas azithromycin, hydroxychloroquine, interferon-beta, and tocilizumab may not reduce either. Whether or not remdesivir confers any patient-important benefit remains uncertain. Systematic review registration This review was not registered. The protocol is included as a supplement. Readers’ note This article is a living systematic review that will be updated to reflect emerging evidence. Updates may occur for up to two years from the date of original publication. This version is the second update of the original article published on 30 July 2020 ( BMJ 2020;370:m2980), and previous versions can be found as data supplements. When citing this paper please consider adding the version number and date of access for clarity.

scholarly journals The Impact of Histopathological Features on the Prognosis of Oral Squamous Cell Carcinoma: A Comprehensive Review and Meta-Analysis

2021 ◽  
Vol 11 ◽  
Author(s):  
Eder da Silva Dolens ◽  
Mauricio Rocha Dourado ◽  
Alhadi Almangush ◽  
Tuula A. Salo ◽  
Clarissa Araujo Gurgel Rocha ◽  
...  
Keyword(s):  
Systematic Review ◽  
Squamous Cell Carcinoma ◽  
Oral Squamous Cell Carcinoma ◽  
Cell Carcinoma ◽  
Squamous Cell ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Histopathological Features ◽  
Increased Risk ◽  
The Impact

ObjectiveOver many decades, studies on histopathological features have not only presented high-level evidence of contribution for treatment directions and prognosis of oral squamous cell carcinoma (OSCC) but also provided inconsistencies, making clinical application difficult. The 8th TNM staging system of OSCC has acknowledged the importance of some histopathological features, by incorporating depth of invasion (DOI) to T category and extranodal extension (ENE) to N category. The aim of this systematic review with meta-analysis is to determine the most clinically relevant histopathological features for risk assessment and treatment planning of OSCC and to elucidate gaps in the literature.MethodsA systematic review was conducted using PRISMA guidelines, and the eligibility criteria were based on population, exposure, comparison, outcome, and study type (PECOS). PubMed, Cochrane, Scopus, and Web of Science were searched for articles exploring the impact of histopathological features on OSCC outcomes with Cox multivariate analysis. Pooled data were subjected to an inverse variance method with random effects or fixed effect model, and the risk of bias was evaluated using quality in prognosis studies (QUIPS). Quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.ResultsThe study included 172 articles published from 1999 to 2021. Meta-analyses confirmed the prognostic potential of DOI, ENE, perineural invasion, lymphovascular invasion, and involvement of the surgical margins and brought promising results for the association of bone invasion, tumor thickness, and pattern of invasion with increased risk for poor survival. Although with a small number of studies, the results also revealed a clinical significance of tumor budding and tumor-stroma ratio on predicted survival of patients with OSCC. Most of the studies were considered with low or moderate risk of bias, and the certainty in evidence varied from very low to high.ConclusionOur results confirm the potential prognostic usefulness of many histopathological features and highlight the promising results of others; however, further studies are advised to apply consistent designs, filling in the literature gaps to the pertinence of histopathological markers for OSCC prognosis.Systematic Review RegistrationInternational Prospective Register of Systematic Reviews (PROSPERO), identifier CRD42020219630.

scholarly journals Prevalence of multimorbid degenerative lumbar spinal stenosis with knee and/or hip osteoarthritis: protocol for a systematic review and meta-analysis

2020 ◽  
Author(s):  
James J. Young ◽  
Jan Hartvigsen ◽  
Rikke K. Jensen ◽  
Ewa M. Roos ◽  
Carlo Ammendolia ◽  
...  
Keyword(s):  
Systematic Review ◽  
Data Extraction ◽  
Meta Analysis ◽  
Hip Osteoarthritis ◽  
Healthcare Setting ◽  
Risk Of Bias ◽  
Sample Population ◽  
Case Definitions ◽  
Prevalence Estimates ◽  
The Impact

Abstract Background: Lumbar spinal stenosis (LSS) and knee and hip osteoarthritis (OA) are prevalent conditions in the aging population and published literature suggests they share many symptoms and often are present at the same time in patients. However, no prevalence estimates of multimorbid LSS and knee and/or hip OA are currently available. The primary objective of this systematic review is therefore to estimate the prevalence of multimorbid LSS with knee and/or hip OA using radiological, clinical, and combined case definitions. Methods: This systematic review protocol has been designed according to the guidelines from the Cochrane Collaboration and are reported according the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. A comprehensive search will be performed in the following databases: MEDLINE, EMBASE, CENTRAL, and CINAHL. Forward citation tracking will be performed in Web of Science. No restriction for publication data and language will be applied in the literature search, but only articles in English will be included. The search strategy will include the following domains: LSS, knee OA, and hip OA. Retrieved citations will be screened by two authors independently. Disagreements will be discussed until consensus, and a third reviewer will be consulted if consensus cannot be reached. Data extraction and assessment of methodological quality will be done by two authors independently, using a standardized data extraction form and a modified Risk of Bias Tool for Prevalence studies. Meta-analysis estimating prevalence with 95% CI will be performed using a random effects model. Meta-regression analyses will be performed to investigate the impact of the following covariates: LSS clinical presentations, sample population, healthcare setting, risk of bias, and other patient characteristics on prevalence estimates for multimorbid LSS and knee and/or hip OA.Discussion: The results of this review will provide the first estimates of the prevalence of multimorbid LSS and hip and knee OA based on various case definitions. The impact of covariates such as LSS clinical presentations, sample population, healthcare setting, risk of bias, and patient characteristics on prevalence estimates will also be presented. Systematic review registration: Submitted to PROSPERO, awaiting registration

scholarly journals The impact of eHealth group interventions on the mental, behavioural, and physical health of adults: A systematic review protocol

2020 ◽  
Author(s):  
Cheryl L Currie ◽  
Richard Larouche ◽  
M. L. Voss ◽  
Erin K. Higa ◽  
Rae Spiwak ◽  
...  
Keyword(s):  
Mental Health ◽  
Systematic Review ◽  
Physical Health ◽  
Meta Analysis ◽  
Primary Objective ◽  
Risk Of Bias ◽  
Community Dwelling ◽  
Controlled Trials ◽  
Sex And Gender ◽  
The Impact

Abstract Background: COVID-19 has resulted in an increased demand for mental health services globally. There is emerging evidence for the efficacy for group eHealth interventions that support population-based mental health and wellbeing, but a systematic review is lacking. The primary objective of this systematic review is to summarize the evidence for eHealth group counselling and coaching programs for adults. A second objective is to assess, within studies selected for our primary objective, the impact of programs that encourage PA on outcomes compared to those that do not.Methods and Design: Randomized controlled trials that assess the impact of eHealth group counselling or coaching programs on mental health, health behaviour, or physical health conditions or concerns among community dwelling adults will be searched in MEDLINE, PsycInfo, CINHAL, and the Central Register of Controlled Trials. The review will be structured using PRISMA guidelines. Studies will be synthesized using the Cochrane Handbook and Synthesis Without Meta-Analysis (SWiM) reporting guideline. Quality will be evaluated using GRADE. Risk of bias will be assessed using the Cochrane Risk of Bias tool with higher quality studies prioritized when drawing conclusions. The role of sex and gender will be considered as well as possible gender biases at all stages of the review.Discussion: This review will examine the effectiveness of eHealth counselling and coaching programs delivered to adults in a group format. Findings will inform the decisions of governments, communities, and health care organizations responding to the COVID-19 pandemic in Canada. Systematic review registration: The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO: CRD42020187551).

scholarly journals Insomnia Interventions in the Workplace: A Systematic Review and Meta-Analysis

2020 ◽  
Vol 17 (17) ◽  
pp. 6401
Author(s):  
Juan Vega-Escaño ◽  
Ana María Porcel-Gálvez ◽  
Rocío de Diego-Cordero ◽  
José Manuel Romero-Sánchez ◽  
Manuel Romero-Saldaña ◽  
...  
Keyword(s):  
Systematic Review ◽  
Randomized Clinical Trials ◽  
Behavioral Therapy ◽  
Meta Analysis ◽  
Sleep Onset ◽  
Cochrane Collaboration ◽  
Risk Of Bias ◽  
Publication Date ◽  
The Impact

The aim of this systematic review and meta-analysis was to identify and evaluate the impact of interventions to improve or reduce insomnia in the workforce through randomized clinical trials. Following the recommendations of the PRISMA and MARS statement, a systematic literature search was carried out on the PubMed, Web of Science, CINHAL, and PsycINFO databases, with no restrictions on the language or publication date. For the meta-analysis, a random-effects model and the Insomnia Severity Index were used as outcome measures. To assess the risk of bias and the quality of evidence, the Cochrane Collaboration tool and the GRADE method were used, respectively. Twenty-two studies were included in the systematic review and 12 studies in the meta-analysis, making a total of 14 intervention groups with a sample of 827 workers. Cognitive behavioral therapy was the most widely used intervention. According to the estimated difference between the means, a moderate effect for the reduction of insomnia symptoms after the intervention (MD −2.08, CI 95%: [−2.68, −1.47]) and a non-significant degree of heterogeneity were obtained (p = 0.64; I2 = 0%). The quality of the evidence and the risk of bias were moderate. The results suggest that interventions on insomnia in the workplace are effective for improving workers’ health, and that improvements in the quality of sleep and a decrease in the symptoms of insomnia are produced, thanks to an increase in weekly sleeping hours and a reduction in latency at sleep onset. As regards work, they also led to improvements in productivity, presenteeism, and job burnout.

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