Dilshad Manzar

Purpose of Review: Chronic circadian disruption, sleep impairment, and occupational stress in shift-working healthcare professionals can contribute to early cardiometabolic dysfunction before overt cardiovascular disease develops. This systematic review examines epidemiologic and physiologic evidence linking sleep and circadian disruption with autonomic, endocrine, metabolic, and vascular abnormalities in this population. Recent Findings: All the included studies revealed associations with poor sleep quality, reduced sleep duration, circadian misalignment, autonomic imbalance and poor metabolic profiles with night-shift or rotational schedules. A number of studies have shown abnormalities in heart rate variability, cortisol modulation, melatonin rhythmicity, endothelial function, risk of obesity, hypertension, and glucose dysregulation among shift-working health care workers. The feasibility of diagnosing early subclinical cardiometabolic risk is supported by emerging wearable-based and ambulatory physiologic monitoring methods such as actigraphy, digital sleep phenotyping, and biomarker testing. Furthermore, evidence indicates heterogeneity in physiologic susceptibility according to sex, chronotype, shift schedule, and stress-related behavioral factors. However, longitudinal multimodal physiologic studies remain limited. Summary: Current evidence supports a relationship between sleep and circadian disruption and early cardiometabolic vulnerability among healthcare shift workers. Integrating wearable-derived behavioral metrics with physiologic and biomarker-based phenotyping may improve the early identification of high-risk occupational profiles before irreversible cardiometabolic disease develops.

Muscular dystrophy (MD) is a progressive neuromuscular disorder characterized by muscle degeneration, leading to fatigue, reduced endurance, and impaired functional capacity. Evidence regarding the role of therapeutic exercises in late-onset muscular dystrophies (LOMD) remains limited and inconclusive. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted in accordance with PRISMA guidelines. Electronic databases including MEDLINE, Scopus, and Web of Science were searched from inception to September 2025. Eligible studies evaluated the effects of therapeutic exercises on fatigue, exercise tolerance, and aerobic capacity in individuals with LOMD. Data extraction and risk of bias assessment were performed independently by two reviewers. Meta-analysis was conducted using a random-effects model. Eight RCTs involving 501 participants were included. Meta-analysis demonstrated small, statistically non-significant effects of therapeutic exercises on fatigue (SMD = -0.20; 95% CI: -0.72 to 0.33; p = 0.46), exercise tolerance (SMD = 0.16, 95% CI: -0.06 to 0.38; p = 0.15), and aerobic power (SMD = 0.12; 95% CI: -0.24 to 0.48; p = 0.51). Heterogeneity ranged from low to high across outcomes. Therapeutic exercises appears to be a safe adjunct intervention and may provide small, although statistically non-significant, improvements in fatigue, exercise tolerance, and aerobic capacity in individuals with LOMD. While the findings suggest potential clinical benefits, the limited number of high-quality trials and heterogeneity warrant cautious interpretation. Further large-scale, well-designed RCTs are required to establish definitive evidence.

Post-menopausal women frequently exhibit balance and gait impairments associated with hormonal changes, increasing their risk of falls and reduced functional independence. This study investigated the effect of visual cue training on balance and gait in post-menopausal women. A total of 48 eligible participants were randomly allocated into two groups: group A received visual cue training combined with conventional exercises, and group B received conventional training only. Both groups underwent an 8-week intervention, and balance, gait performance, cognitive function, and depression were assessed before and after training. Significant improvements over time were observed in step length, cadence, center of pressure (COP) range, and Berg Balance Scale scores. Between-group differences favored the visual cue group for step length and COP range. Cadence demonstrated a significant time × group interaction, indicating a differential pattern of improvement between groups, without a significant overall group effect. Both groups showed significant improvements in P300 latency over time, with no significant time × group interaction (p=0.81). No significant between-group differences were found for gait speed, stride length, COP sway, or P300 amplitude. These findings suggest adding visual cues to conventional training enhances specific aspects of postural control and cognitive processing but does not provide additional benefits for all gait-related parameters. Visual cue-based training may therefore be a valuable adjunct to conventional rehabilitation programs aimed at improving functional mobility in post-menopausal women.

Background: The influence of severity of migraine-like symptoms on different levels of executive functions is not well established. In this study, we investigate the impact of severity of migraine-like symptoms on the relationship between core-level executive functions (attention and memory) and fluid intelligence. Methods: A cross-sectional study was conducted on university students (n = 427, age = 20.7 + 1.8 years). Participants completed self-report measures of Migraine Screen Questionnaire (MS-Q), single-item visual analogue scales (VASs) each for the subjective accounts of problems in core-level executive functions (attention and memory), and a single-item VAS for problems in fluid intelligence (PFI), and sociodemographics tool. The mediation effect model was used to determine the relationship. Results: The study found a correlation between i) attention problems and severity of migraine-like symptoms (b = 0.109, standard error (SE) = 0.026, p < 0.001), ii) severity of migraine-like symptoms and memory problems (b = 0.318, SE = 0.076, p < 0.001), and iii) severity of migraine-like symptoms – PFI (b = 0.243, SE = 0.083, p < 0.003), with an indirect effect of attention problems on memory problems and PFI and no correlation between severity of migraine-like symptoms and PFI. Conclusions: Self-reported accounts of problems in core-level executive functions and fluid intelligence are correlated. Severity of migraine-like symptoms may mediate the inter-relationship between some core-level and higher-level executive functions.

Background: Shift work is a well-established disruptor of sleep, yet the biological mechanisms driving sleep disturbances remain poorly understood. Salivary cortisol (HPA axis), α-amylase (sympathetic–adrenomedullary output), and DHEA-S (adrenal androgen with anti-glucocorticoid/resilience properties) are candidate indicators of stress-related sleep disruption. We therefore examined whether changes in these biomarkers were associated with 6-month sleep trajectories in health professionals. Methods: In a prospective 6-month repeated-measures design, 52 healthcare professionals (daytime vs rotating shifts; mean age 31.4 ± 9.4 years; 57% female) completed validated sleep assessments, PROMIS Sleep Disturbance, PROMIS Sleep Impairment, the Sleep-Wake Disorder Index (SWDI), and the NIH 7-day Sleep Diary, at baseline and six-month follow-up. Salivary cortisol, Dehydroepiandrosterone Sulfate (DHEA-S), and alpha-amylase were collected on the morning of Day 7 of each diary period. Change scores (Δ = follow-up – baseline) were computed. Repeated-measures ANOVA, Pearson correlations, and multivariable regressions assessed group differences and biomarker–sleep associations. Results: Compared with daytime workers, rotating shift workers reported significantly greater increases in sleep disturbance, impairment, and reduced sleep efficiency over time (all p < 0.05). Reductions in cortisol and alpha-amylase were significantly associated with worsening PROMIS Sleep Disturbance and SWDI scores (r = – 0.65 and – 0.53, respectively; p < 0.05). Multivariable regression showed that decreased cortisol (β = − 41.845, p = 0.0064) and increased DHEA-S (β = 0.001, p = 0.0405) associated with worsening PROMIS Sleep Impairment. A combined model including reduced cortisol, and increased DHEA-S associated with greater PROMIS Sleep Disturbance (adjusted R² = 0.698). Conclusion: In this pilot, changes in salivary cortisol and DHEA-S were associated with longitudinal changes in sleep. These results suggest potential utility for biomarker-informed risk stratification, warranting confirmation in larger, controlled studies. Plain Language Summary: People working rotating shifts often experience disrupted sleep and chronic stress due to irregular work hours. This study followed a group of rotating shift workers over six months to explore how stress levels, measured through saliva samples, and sleep quality changed over time. Researchers collected data on key stress hormones, including cortisol, alpha-amylase, and DHEA-S, and compared them with both subjective sleep surveys and daily sleep diaries. The results showed that as stress biomarkers declined, participants reported worse sleep quality and greater impairment in daily functioning. This suggests that when the body’s stress response system becomes weakened, what scientists call “lower cortisol levels” it may be a sign of long-term health strain. These physiological changes mirrored growing sleep disturbances over time. The findings highlight the importance of monitoring both sleep and biological stress markers in shift workers. Interventions that target better sleep hygiene and stress management may help protect the health of these essential workers. Future studies with larger, more diverse groups are needed to confirm these results and develop personalized strategies to reduce the negative effects of shift work. Graphical Abstract

Background Shift work is a well-established disruptor of sleep, yet the biological mechanisms driving sleep disturbances remain poorly understood. Salivary cortisol (HPA axis), α-amylase (sympathetic– adrenomedullary output), and DHEA-S (adrenal androgen with anti-glucocorticoid/resilience properties) are candidate indicators of stress-related sleep disruption. We therefore examined whether changes in these biomarkers were associated with 6-month sleep trajectories in health professionals. Methods In a prospective 6-month repeated-measures design, 52 healthcare professionals (daytime vs. rotating shifts; mean age 31.4 ± 9.4 years; 57% female) completed validated sleep assessments, PROMIS Sleep Disturbance, PROMIS Sleep Impairment, the Sleep-Wake Disorder Index (SWDI), and the NIH 7-day Sleep Diary, at baseline and six-month follow-up. Salivary cortisol, DHEA-S, and alpha-amylase were collected on the morning of Day 7 of each diary period. Change scores (Δ = follow-up – baseline) were computed. Repeated-measures ANOVA, Pearson correlations, and multivariable regressions assessed group differences and biomarker–sleep associations. Results Compared with daytime workers, rotating shift workers reported significantly greater increases in sleep disturbance, impairment, and reduced sleep efficiency over time (all p < 0.05). Reductions in cortisol and alpha-amylase were significantly associated with worsening PROMIS Sleep Disturbance and SWDI scores (r = –0.65 and –0.53, respectively; p < 0.05). Multivariable regression showed that decreased cortisol (β = −41.845, p = 0.0064) and increased DHEA-S (β = 0.001, p = 0.0405) associated with worsening PROMIS Sleep Impairment. A combined model including reduced cortisol, and increased DHEA-S associated with greater PROMIS Sleep Disturbance (adjusted R² = 0.698). Conclusion In this pilot, changes in salivary cortisol and DHEA-S were associated with longitudinal changes in sleep. These results suggest potential utility for biomarker-informed risk stratification, warranting confirmation in larger, controlled studies. Plain Language Summary People working rotating shifts often experience disrupted sleep and chronic stress due to irregular work hours. This study followed a group of rotating shift workers over six months to explore how stress levels, measured through saliva samples, and sleep quality changed over time. Researchers collected data on key stress hormones, including cortisol, alpha-amylase, and DHEA-S, and compared them with both subjective sleep surveys and daily sleep diaries. The results showed that as stress biomarkers declined, participants reported worse sleep quality and greater impairment in daily functioning. This suggests that when the body’s stress response system becomes weakened, what scientists call “lower cortisol levels” it may be a sign of long-term health strain. These physiological changes mirrored growing sleep disturbances over time. The findings highlight the importance of monitoring both sleep and biological stress markers in shift workers. Interventions that target better sleep hygiene and stress management may help protect the health of these essential workers. Future studies with larger, more diverse groups are needed to confirm these results and develop personalized strategies to reduce the negative effects of shift work.

The psychological mechanisms through which occupational stress impacts quality of life remain underexplored in shift-working healthcare professionals, a population exposed to unique stressors such as circadian disruption, high cognitive demands, and irregular work schedules. This study examined whether executive self-regulation mediates the relationship between perceived stress and quality of life in a sample of 82 shift-working healthcare professionals. Participants completed validated self-report measures, including the Perceived Stress Scale (PSS-4), Executive Skills Questionnaire–Revised (ESQ-R), and Quality of Life Scale (QOLS). Mediation analysis using 5126 bias-corrected bootstrapped samples revealed that perceived stress significantly predicted self-regulation difficulties, which in turn were associated with diminished quality of life. Self-regulation demonstrated an indirect-only mediation effect in both directions, though the forward path (stress → self-regulation → QOL) showed a stronger effect (indirect effect = −0.79; 95% CI: −1.63, −0.17), compared to the reverse path (QOL → self-regulation → stress; indirect effect = −0.04; 95% CI: −0.08, −0.01). Unsupervised K-means clustering identified three distinct behavioral clusters: resilient, low-strain, and high-strain, providing further support for personalized targeted interventions. These findings highlight self-regulation as a central mechanism through which stress affects quality of life and underscore the need for interventions that strengthen executive functioning in shift-based healthcare settings.

Shift work is prevalent among healthcare professionals and associated with significant health risks, including stress, sleep disturbances, and mood disorders. Despite known sex differences in stress responses, their impact on shift workers, particularly student pharmacists, is understudied. The objective of this study was to explore sex-specific differences in psychological and physiological stress responses among pharmacy students engaged in shift work. Psychological stress was assessed using validated scales like the Perceived Stress Scale (PSS), Shift Work Disorder Index (SWDI), Ford Insomnia Response to Stress Test (FIRST), and Positive and Negative Affect Schedule (PANAS). Additionally physiological stress was assessed using salivary biomarkers like cortisol, DHEA-S, IL-6, and alpha-amylase. Females reported significantly higher perceived stress (p = 0.0004), SWDI (p = 0.0302), insomnia (p = 0.0111), and negative affect (p = 0.0171) compared to males. Rotating shift workers showed elevated scores across all measures (p = 0.0005–0.0381). Female rotating shift workers exhibited higher alpha-amylases (p = 0.0191) and lower DHEA-S levels (p = 0.0176) than males. Strong correlations emerged between perceived stress and insomnia (r = 0.40, p = 0.0001) and between insomnia and negative affect (r = 0.55, p < 0.0001). Findings highlight females’ vulnerability, underscoring the need for sex-specific interventions and the early identification of stress biomarkers.

Background: Perceived stress and vulnerability to develop insomnia are closely linked, with negative mood affect playing a key role. Shift workers, particularly student pharmacists juggling academic demands and irregular work schedules, are at heightened risk for stress-related sleep disturbances. While previous studies have explored their direct relationships, limited evidence exists on the dual role of negative mood affect as both a mediator and a non-mediator in these pathways. This study investigates the mediating role of negative mood affect in the relationship between perceived stress and vulnerability to develop insomnia and assesses whether negative mood affect mediates the reverse relationship. Methods: A cross-sectional study was conducted on 86 student pharmacist shift workers at Notre Dame of Maryland University. Participants completed validated self-report measures, including the Perceived Stress Scale (PSS), the Ford Insomnia Response to Stress Test (FIRST), and the Positive and Negative Affect Schedule (PANAS). Mediation analysis using Hayes’ PROCESS macro (Model 4) examined the mediating role of negative mood affect in both pathways. Bias-corrected bootstrapping with 5000 iterations calculated confidence intervals for indirect effects, with significance set at p < 0.05. Results: Negative mood affect partially mediated the relationship between perceived stress and vulnerability to develop insomnia. Higher stress levels were associated with increased negative mood affect (b = 0.49, SE = 0.05, p < 0.01), which, in turn, was linked to greater insomnia vulnerability (b = 0.39, SE = 0.04, p < 0.01). The indirect effect was significant (b = 0.19, 95% CI [0.06, 0.33]). In contrast, negative mood affect did not mediate the reverse pathway (p = 0.15). Conclusion: Negative mood affect significantly mediates the relationship between perceived stress and insomnia vulnerability but not the reverse pathway. Interventions targeting emotional regulation may help reduce stress-related sleep disturbances. Longitudinal studies are needed to confirm these findings and refine interventions. Plain Language Summary: Student pharmacists who work irregular shifts often experience high levels of stress and disrupted sleep, which can negatively impact their health, academic performance, and overall well-being. This study explored how negative mood, including feelings of anxiety, irritability, and sadness, might explain the connection between perceived stress and vulnerability to insomnia. The findings revealed that higher stress levels were linked to increased negative mood, which in turn heightened vulnerability to insomnia. However, when examining the reverse pathway, whether insomnia influences stress through negative mood, the results showed no significant effect. This suggests that while negative mood plays a key role in how stress contributes to sleep problems, it does not explain how poor sleep might increase stress. These results highlight the importance of emotional regulation strategies, such as mindfulness or counseling, in managing stress and improving sleep health among student pharmacists. Addressing negative mood could break the cycle between stress and sleep disturbances. Future research should investigate these relationships over time and consider other factors, like coping mechanisms or cognitive arousal, to provide a more comprehensive understanding. Meanwhile, academic institutions and healthcare organizations can use these insights to create wellness programs that support both mental health and sleep quality for student pharmacists working demanding shifts.

Background: People with Parkinson’s disease present with both motor and non-motor symptoms. Tele rehabilitation (TR) is effective to maintain and improve different functional activities in people with neurological disorders. Virtual reality (VR)-based rehabilitation involves training movement and activities in a virtual setting. Objective: To systematically review the evidence and estimate the effect of virtual and tele-rehabilitation on motor and non-motor impairments in patients with PD. Methods: The databases MEDLINE, PEDro, Scopus, and Web of Science were searched from inception to January 2024 for randomized controlled trials (RCTs) and quasi-experimental studies. The methodological quality of the included studies and risk of bias was assessed using the PEDro scale and Cochrane risk of bias tool respectively. Studies providing sufficient data on either of the pre-established outcome measure were included in the meta-analysis. Results: Meta-analysis of the 18 studies showed that more improvement in balance function was seen with VR rehabilitation than with traditional exercise (TE) training. VR and TE were found to have similar effects on the (DGI) dynamic gait timed-up and go (TUG) test. Conclusions: The available evidence suggests a positive effect of VR exercise on balance function. TR is feasible and provides similar clinical benefits to that of in-person care. VR and TR compared to TE in physiotherapy have similar effects on gait.