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    <title>SJWEH - Online-first articles</title>
    <description>List of Online-first articles on the SJWEH website</description>
    <link>http://www.sjweh.fi/list_onlinefirst_rss.php</link>
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    <language>en-US</language>

    <copyright>SJWEH</copyright>
    <ttl>1</ttl>
    <managingEditor>lodo@ttl.fi (Lisa O\'Donoghue-Lindy)</managingEditor>
    <webMaster>risto@toivonen.biz (Risto Toivonen)</webMaster>

   <item>
      <title>The impact of cumulative years of biomechanical and psychosocial exposures on competing exit routes from paid employment among older workers in Norway: A life course perspective</title>
      <link>http://www.sjweh.fi/show_abstract.php?abstract_id=4330</link>
      <guid>http://www.sjweh.fi/show_abstract.php?abstract_id=4330</guid>
      <pubDate>Thu, 24 Sep 2026 14:03:24 +0200</pubDate>
      <category>Original article</category>
      <description><![CDATA[Objective   This study aimed to examine associations between cumulative years of biomechanical and psychosocial job exposures and premature labor market exit among older workers within a competing risks framework.

Methods   Using linked registry data and gender-specific job-exposure matrices, we constructed measures of cumulative years of biomechanical and psychosocial job exposures over the 30 years preceding baseline. A cohort of Norwegian workers (N=339 227) was followed from age 50 for up to 17 years, until statutory retirement age of 67 years. Fine & Gray competing risk models estimated subdistribution hazard ratios (SHR) for health-related exit, early retirement, and unemployment, stratified by gender.

Results   Several exposures were positively associated with the cumulative incidence of specific exit routes. Among men, the highest SHR per additional year of exposure were observed for standing/walking for health-related exit [SHR 1.013, 95% confidence interval (CI) 1.011–1.015], low decision authority for early retirement (SHR 1.008, 95% CI 1.006–1.008), and forward bending for unemployment (SHR 1.009, 95% CI 1.005–1.013). Among women, the highest SHR were observed for standing/walking for health-related exit (SHR 1.012, 95% CI 1.010–1.015), conflicting work methods for early retirement (SHR 1.017, 95% CI 1.014–1.019), and monotonous work for unemployment (SHR 1.034, 95% CI 1.027–1.041). Several biomechanical and psychosocial exposures showed inverse associations, which could be attributable to the higher cumulative incidence of competing exit routes in the Fine & Gray framework.

Conclusion   Within a competing-risks framework, cumulative years of biomechanical and psychosocial exposures were associated with distinct labor market exit patterns among older workers, highlighting the importance of incorporating work histories and competing routes into intervention design.
      <strong>by</strong> <i>Ulstein J, Undem K, Sundstrup E, Nielsen MB, Hasting RL</i>. doi:10.5271/sjweh.4329]]></description>
         </item>   <item>
      <title>Shift work schedule patterns and sleep outcomes: results from the SHIFT2HEALTH survey across eight European countries</title>
      <link>http://www.sjweh.fi/show_abstract.php?abstract_id=4329</link>
      <guid>http://www.sjweh.fi/show_abstract.php?abstract_id=4329</guid>
      <pubDate>Wed, 23 Sep 2026 16:29:18 +0200</pubDate>
      <category>Original article</category>
      <description><![CDATA[Objectives   This study aimed to describe shift work patterns in Europe using a data-driven approach and evaluate their impact on adverse sleep outcomes.

Methods   We analyzed 6245 participants from the SHIFT2HEALTH survey across eight European countries, who provided information on work schedules, shift work metrics, sleep quality and timing (MCTQshift) across different shifts, and chronic insomnia (Insomnia Severity Index). We used mixtures of von Mises-Fisher models to identify shift clusters based on shift start and end times and evaluated differences in shift-specific sleep duration and quality using Bayesian multilevel models. Associations of shift metrics with short average sleep duration and chronic insomnia, adjusting for confounders, were evaluated using Bayesian logistic regression.

Results   We identified five shift clusters: day, evening and night (mean shift lengths: 7.8, 7.9 and 9.5 hours, respectively), long day and long evening (mean lengths: 10.5 and 12.8 hours, respectively). Sleep duration and quality varied between clusters, with the shortest duration [mean 6.00, 95% credible interval (CI) 5.95–6.06 hours] and poorest quality (29.3% “poor”/“very poor”) sleep reported between night shifts. Compared to day workers, greater chronic insomnia odd ratios (OR) were observed among participants with >90% night shifts (OR 1.26, 95% CI 1.01–1.58), rotating shifts (OR 1.42, 95% CI 1.22–1.65) and with longer night work history (OR<sub>≥16 years</sub> 1.28, 95% CI 1.08–1.52). These variables and longer weekly working hours [OR <sub>6.10h increase</sub> 1.13, 95% CI 1.04–1.22) were associated with short sleep.

Conclusions   Data-driven analyses of work schedules may provide a more comprehensive evaluation of the impact of real-world shift work patterns on sleep.
      <strong>by</strong> <i>Santonja I, Dros C, Haider S, Winzer E, Wakolbinger M, Scionti K, Schoissengeier V, Wrzesińska MA, Binder-Olibrowska KW, Rakoczy J, Aufschnaiter AL, Höfler C, Wallner M, Cuparencu C, Wagner K-H, Boshuizen HC, Vingerhoeds MH, Lammers-van der Holst H, Papantoniou K</i>. doi:10.5271/sjweh.4334]]></description>
         </item>   <item>
      <title>Re: Magnusson Hanson LL, Madsen IEH, Blomqvist S, Holmgren R, Sørensen K, Rugulies R. Employment and working conditions and risk of suicidal behaviors: a systematic review and meta-analysis of longitudinal studies. Scand J Work Environ Health. 2026;52(5):486–501.</title>
      <link>http://www.sjweh.fi/show_abstract.php?abstract_id=4334</link>
      <guid>http://www.sjweh.fi/show_abstract.php?abstract_id=4334</guid>
      <pubDate>Tue, 22 Sep 2026 14:45:24 +0200</pubDate>
      <category>Amendments and corrections</category>
      <description><![CDATA[
      <strong>by</strong> <i>Magnusson Hanson LL, Madsen IEH, Blomqvist S, Holmgren R, Sørensen K, Rugulies R</i>. doi:10.5271/sjweh.4321]]></description>
         </item>   <item>
      <title>A review of reviews exploring gender differences in sickness absence</title>
      <link>http://www.sjweh.fi/show_abstract.php?abstract_id=4321</link>
      <guid>http://www.sjweh.fi/show_abstract.php?abstract_id=4321</guid>
      <pubDate>Mon, 14 Sep 2026 17:42:18 +0200</pubDate>
      <category>Review</category>
      <description><![CDATA[Objectives   Long-term sickness absence is a risk factor for leaving the workforce, causing economic stress and deteriorating health. Women have higher rates of sickness absence compared to men in most, but not all, European countries. Reasons for apparent gender differences are currently poorly understood, but hypotheses include that women may have more health problems (particularly those associated with reproductive health). Other hypotheses for gender differences include gendered health beliefs, attitudes/norms to sickness absence, work factors, work–family conflict, or barriers to return-to-work. This umbrella review aimed to synthesize and critically appraise the empirical evidence underpinning these hypotheses.

Methods   Following PRISMA and Joanna Briggs Institute methodological guidelines, a systematic search of seven electronic databases was conducted for peer-reviewed reviews (eg, systematic reviews, scoping reviews, critical reviews) and meta-analyses reporting on gender and sickness absence. The review protocol was pre-registered on PROSPERO.

Results   In total, 133 reviews were eligible for inclusion, of which 12 directly focused on gender differences in sickness absence. Only three hypotheses were investigated frequently and, although there was strong face validity, there was limited and mixed-quality underpinning empirical evidence. There was a surprising lack of focus on men and sickness absence.

Conclusion   Despite much research, the underlying causes for a gender gap in sickness absence remain poorly understood. Our findings highlight the need for caution when interpreting proposed hypotheses as established explanatory evidence. Whatever the cause, any gender difference in sickness absence is a gender equality problem, regardless of the cause. Future research should aim beyond describing gender differences to critically evaluating risk factors to develop prevention strategies.
      <strong>by</strong> <i>McKenzie AR, Croak B, Brokjøb LG, Stevelink SAM, Madan I, Brinchmann B, Nilsen W, Walker-Bone K, Aars NA, Mykletun A</i>. doi:10.5271/sjweh.4328]]></description>
         </item>   <item>
      <title>Work as the missing link in Europe’s Climate and Health Strategic Research Agenda</title>
      <link>http://www.sjweh.fi/show_abstract.php?abstract_id=4328</link>
      <guid>http://www.sjweh.fi/show_abstract.php?abstract_id=4328</guid>
      <pubDate>Mon, 14 Sep 2026 14:20:52 +0200</pubDate>
      <category>Discussion paper</category>
      <description><![CDATA[Objective   The aim of this Discussion Paper is to examine the integration of occupational health within the European Strategic Research and Innovation Agenda on Health and Climate Change (SRIAHCC) and identify critical gaps relevant to worker health, equity, and the European Green Deal.

Methods   We analyze the SRIAHCC in relation to related EU policy documents on occupational safety and health, climate change and the green transition, and other current scientific evidence. In addition, we performed an original survey and workshop consultations with key stakeholders in the field and conducted a Delphi-inspired consultation round within the EU INTERCAMBIO project.

Results   While the SRIAHCC appropriately frames climate change as a public health emergency, occupational health is not systematically addressed either as a structural determinant of climate vulnerability or as a core domain of adaptation and mitigation research. Direct and indirect occupational exposures including heat stress, extreme weather events, air pollution, and emerging risks in relevant sectors, eg, decarbonization and circular economy, receive limited attention beyond the healthcare sector. Psychosocial impacts, inequalities affecting migrant and precarious workers, and productivity and income consequences are insufficiently addressed. Furthermore, the agenda lacks a clear implementation framework for workplace adaptation and harmonized occupational-climate monitoring systems.

Conclusions   Without explicit integration of work and working conditions into the SRIAHCC, Europe’s climate and health strategy likely underestimates the true health costs of climate change and the green transition. Embedding occupational health as a core pillar of the SRIAHCC is essential to ensure coherent EU governance, equitable worker protection, and a resilient, sustainable transition.
      <strong>by</strong> <i>Albin M, Turner MC, Svensson S, Njoroge M, Viegas S, Mathieu C, Pearce N, Burdorf A, Straif K, Broberg K, Kogevinas M</i>. doi:10.5271/sjweh.4327]]></description>
         </item>   <item>
      <title>Shift work and prescriptions of anxiolytic and antidepressant drugs among healthcare workers in Region Stockholm: a prospective cohort study</title>
      <link>http://www.sjweh.fi/show_abstract.php?abstract_id=4327</link>
      <guid>http://www.sjweh.fi/show_abstract.php?abstract_id=4327</guid>
      <pubDate>Tue, 08 Sep 2026 23:08:18 +0200</pubDate>
      <category>Original article</category>
      <description><![CDATA[Objective   The aim of this study was to investigate the associations between shift work (including night work) and multiple prescriptions of anxiolytic and antidepressant drugs (PAD) among nursing staff in Region Stockholm, Stockholm County’s healthcare authority.

Methods   Using register-based data, 32 375 nurses and nursing assistants employed at Region Stockholm for ≥1 year between 2008 and 2019 were included. Exposures were obtained from an employee register, while PAD were obtained from a national pharmaceutical register. With a one-year follow-up, discrete-time proportional hazards models were used to estimate hazard ratios (HR) after adjusting for covariates, in a final analytical sample of 17 834.

Results   Increased hazards of PAD were recorded among those who were on permanent night shifts [HR 1.39, 95% confidence interval (CI) 1.32–1.47] compared to those who worked days only. We observed a dose–response association between the number of night shifts and PAD. Among night workers, increased hazards were observed for those who worked ≥3 consecutive nights >21 times (HR 1.11, 95% CI 1.03–1.20) compared with those with none. Lastly, among non-night workers, decreased hazards were observed for quick returns from afternoon shifts (<11 hours) compared with those with no quick returns.

Conclusion   Exclusive night work is associated with increased risks of multiple PAD compared to day work, implying an increase in risk of mental disorders among nurses and nurse assistants.
      <strong>by</strong> <i>Addo S, Nilsson T, Gustavsson P, Bodin T, Bigert C, Lashari A, Härmä M, Brulin E</i>. doi:10.5271/sjweh.4325]]></description>
         </item>   <item>
      <title>Job strain and cardiovascular mortality over long-term follow-up: a harmonized multicohort individual participant data meta-analysis</title>
      <link>http://www.sjweh.fi/show_abstract.php?abstract_id=4325</link>
      <guid>http://www.sjweh.fi/show_abstract.php?abstract_id=4325</guid>
      <pubDate>Mon, 07 Sep 2026 14:04:48 +0200</pubDate>
      <category>Original article</category>
      <description><![CDATA[Objective   We aimed to assess the long-term association between high job strain (JS) and cardiovascular disease (CVD) mortality in cohorts from Italy, Germany, and the United States.

Methods   We harmonized data from four cohort studies (MONICA Brianza, SEMM, MONICA/KORA, MIDUS), selecting employed participants aged 30–60 years and CVD-free at baseline. High JS was operationalized as high job demands and low job control. CVD mortality was ascertained over a median follow-up of >23 years. We estimated Cox models within each cohort; the main model was adjusted for sex, age, education, and occupational class. Additional analyses examined JS categories (low JS, active, passive, high JS), subgroups by sex and occupational classes, and person-time < and ≥65 years. Results were pooled using random-effects meta-analysis. Relevant published studies were identified for synthesis with our results.

Results   Over 444 767 person-years, 842 CVD deaths occurred. High JS was associated with CVD mortality [hazard ratio (HR) 1.14, 95% confidence interval (CI) 1.01–1.27], with no evidence of heterogeneity. Results were consistent across JS categories, by sex (men: HR 1.15, 95% CI 1.07–1.23; women: HR 1.11, 95% CI 0.88–1.39), and across person-time <65 years (HR 1.24, 95% CI 0.91–1.67) and ≥65 years (HR 1.10, 95% CI 0.80–1.50). The association was stronger among manual workers (HR 1.25, 95% CI 0.84–1.86). Job demands appeared to contribute more than job control. Four published studies with comparable follow-up but heterogeneous study designs reported estimates consistent with our findings.

Conclusions   High JS is a long-term predictor of CVD mortality, consistently across sexes and during both working age and after retirement. Workplace redesign to reduce job demands, particularly among manual workers, is warranted within a comprehensive prevention strategy.
      <strong>by</strong> <i>Giusti EM, Li X, Veronesi G, Linkohr B, Peters A, Waldenberger M, Borchini R, Cesana G, Li J, Rückert-Eheberg I-M, Ferrario MM</i>. doi:10.5271/sjweh.4322]]></description>
         </item>   <item>
      <title>Long working hours and dental caries: A 12-year longitudinal study of 1.1 million workers</title>
      <link>http://www.sjweh.fi/show_abstract.php?abstract_id=4322</link>
      <guid>http://www.sjweh.fi/show_abstract.php?abstract_id=4322</guid>
      <pubDate>Wed, 19 Aug 2026 20:47:28 +0200</pubDate>
      <category>Original article</category>
      <description><![CDATA[Objectives   Dental caries is a leading noncommunicable disease worldwide; however, its association with occupational factors, particularly long working hours, has not been elucidated. This study examined the longitudinal association between long working hours and dental caries in a large Korean working-age cohort.

Methods   Using data from the Kangbuk Samsung Health Study (2013–2024), we analyzed 1 136 767 person-visits of workers aged 20–64 years. Long working hours were defined as >52 hours per week. Dental caries was identified from clinical oral examinations performed by licensed dentists. Associations were estimated using generalized estimating equations adjusted for age, gender, and educational level. Subgroup and sensitivity analyses were also performed.

Results   Long working hours were significantly associated with dental caries (odds ratio 1.024, 95% confidence interval 1.007–1.041). In the subgroup analyses, compared with their respective counterparts, the association between long working hours and dental caries was significantly stronger among women, individuals with a college-level education or higher, and those with proactive oral health behaviors such as dental visits and toothbrushing before sleep.

Conclusions   Long working hours were independently associated with the risk of dental caries; women and highly educated workers exhibited a stronger association with dental caries. These findings suggest the potential value of integrating oral health strategies into occupational health policies, particularly among more vulnerable subgroups.
      <strong>by</strong> <i>Park MY, Ahn J</i>. doi:10.5271/sjweh.4319]]></description>
         </item>   <item>
      <title>Precarious employment and its impact on chronic obstructive pulmonary disease in the Swedish working population – a longitudinal register-based study</title>
      <link>http://www.sjweh.fi/show_abstract.php?abstract_id=4319</link>
      <guid>http://www.sjweh.fi/show_abstract.php?abstract_id=4319</guid>
      <pubDate>Tue, 18 Aug 2026 16:22:32 +0200</pubDate>
      <category>Original article</category>
      <description><![CDATA[Objective   Chronic obstructive pulmonary disease (COPD) is a respiratory disorder, and – after tobacco smoking – occupational exposures are among the most important risk factors. Precarious employment (PE) has been linked to a range of adverse mental and physical health outcomes; however, evidence regarding its potential association with COPD remains limited. PE may contribute to COPD risk through both greater exposure to occupational hazards and health-related behaviors, particularly smoking. This study aimed to examine whether PE is associated with COPD in the Swedish working population and assess whether these associations differ by gender.

Methods   A nationwide register-based cohort of 1 984 081 working-age individuals in Sweden was followed for 14 years (2003–2017). PE was operationalized multidimensionally: contractual employment insecurity, temporariness, multiple jobholding, income level, and coverage by collective bargaining agreements. Cumulative incidence of COPD (2004–2017) was identified through register-based diagnoses. Risk ratios (RR) were estimated using generalized linear models with a log link function, adjusting for sociodemographic factors, occupational exposures, and smoking where available.

Results   PE was associated with a graded increase in COPD risk, ranging from substandard employment [adjusted RR (RR<sub>adj</sub>) 1.18, 95% confidence interval (CI) 1.14–1.22] to PE (RR<sub>adj</sub> 1.39, 95% CI 1.31–1.47). Among the dimensions of PE, low income was the strongest contributor (RR 1.44, 95% CI 1.39–1.50), while unstable employment had a modest effect (RR 1.16, 95% CI 1.12–1.20).

Conclusion   PE is associated with elevated risk of COPD in the Swedish workforce. These findings emphasize the role of employment conditions as a social determinant of respiratory health.
      <strong>by</strong> <i>Lundh F, Gunn V, Kreshpaj B, Kvart S, Bodin T, Albin M, Selander J, Ekström S, Wiebert P, Matilla-Santander N</i>. doi:10.5271/sjweh.4318]]></description>
         </item>   <item>
      <title>Night work, sleep disruption and long-COVID risk: a population-based cohort study</title>
      <link>http://www.sjweh.fi/show_abstract.php?abstract_id=4318</link>
      <guid>http://www.sjweh.fi/show_abstract.php?abstract_id=4318</guid>
      <pubDate>Tue, 04 Aug 2026 22:33:33 +0200</pubDate>
      <category>Original article</category>
      <description><![CDATA[Objective   Circadian and sleep disruption may increase the risk and severity of SARS-CoV-2 infections, but the role of night shift work and disturbed sleep in the development of long-COVID remains inadequately investigated. We prospectively examined the association of night work and sleep disturbances with risk of long-COVID.

Methods   We followed participants of the COVICAT study, a population-based cohort of adults in Catalonia, Spain between 2021 and 2023. Night shift work and sleep characteristics were assessed in 2021. Long-COVID was defined as the report of persistent symptoms (>3 months) after a SARS-CoV-2 infection. Poisson regression analysis was performed to evaluate the independent and joint effects of night shift work and sleep disturbances including chronic insomnia with risk of long-COVID. Analyses were stratified by sex, body mass index and chronotype.

Results   During the two-year follow-up, 284 of the 1899 newly infected participants reported long-COVID symptoms. Compared to day workers, night shift workers had 88% higher risk of developing long-COVID [95% confidence interval (CI) 1.29–2.72], after adjusting for potential confounders. The risk further increased among night workers with obesity. Chronic insomnia in the general population was associated with 42% increased risk of long-COVID (95% CI 1.12–1.78). Night workers with chronic insomnia had a 2.7 fold higher long-COVID risk (95% CI 1.60–4.51) compared to day workers without chronic insomnia. Associations persisted in various sensitivity analyses.

Conclusions   Our findings from a large prospective cohort indicate that night shift work and poor sleep are independently and jointly associated with a higher risk of long-COVID.
      <strong>by</strong> <i>Papantoniou K, Espinosa A, Karachaliou M, Lassale C, Castaño-Vinyals G, Harding BN, De Matteis S, Straif K, Alonso-Nogués E, Dobaño C, Moncunill G, Blay N, Iraola-Guzmán S, de Cid R, Garcia-Aymerich J, Kogevinas M</i>. doi:10.5271/sjweh.4317]]></description>
         </item>   <item>
      <title>Genomic insights into somatic mutations from occupational exposure to low-dose ionizing radiation</title>
      <link>http://www.sjweh.fi/show_abstract.php?abstract_id=4317</link>
      <guid>http://www.sjweh.fi/show_abstract.php?abstract_id=4317</guid>
      <pubDate>Thu, 02 Jul 2026 16:47:52 +0200</pubDate>
      <category>Original article</category>
      <description><![CDATA[Objective   Low-dose ionizing radiation (LDIR, ≤100 mGy) is a public health concern due to its extensive use in diagnostic and therapeutic imaging. This study examined somatic variants (SV) among Korean industrial radiographers exposed to LDIR using whole-genome sequencing (WGS).

Methods   WGS data from 65 workers (mean age 36.7 years) collected between 2016 and 2023 were analyzed. Participants had a mean employment duration of 12.7 years and an average cumulative radiation dose of 33.9 mSv from National Dose Registry records. SV were identified via the GATK Mutect2 single-sample workflow applied to peripheral blood-derived DNA and sequentially filtered using standard pipelines, including FilterMutectCalls, population frequency, recurrent artifacts, Funcotator annotation, and manual Integrative Genomics Viewer review.

Results   A total of 105 170 somatic variants were identified, with a median of 1744 variants per individual, approximately 98% of which were single nucleotide variants. Cumulative radiation dose showed a significant positive correlation with total SV burden (R=0.32, P=0.013), including both coding (R=0.34, P=0.008) and non-coding regions (R=0.31, P=0.015). Age, smoking, alcohol consumption, hypertension, and hyperlipidemia were not significantly associated with variant burden.

Conclusions   These WGS-based findings provide preliminary insight into blood-derived SV patterns among occupationally exposed radiation workers. Given the small sample size, blood-only design, and absence of matched unexposed controls, the findings should be interpreted as hypothesis-generating and require validation in larger longitudinal studies with comprehensive exposure assessment.
      <strong>by</strong> <i>Kim K, Kang J, Lim DM, Jang S, Lee Y, Lee YH, Yoon HJ, Yang S, Kim SH, Lee D, Jang WI, Sung H, Kim M-J, Son E, Kim H-S, Lee D, Park HR, Seo S, Kim YH</i>. doi:10.5271/sjweh.4294]]></description>
         </item>   <item>
      <title>Occupational heat stress and the role of wearable cooling interventions: A systematic review and meta-analysis of physiological and perceptual outcomes</title>
      <link>http://www.sjweh.fi/show_abstract.php?abstract_id=4294</link>
      <guid>http://www.sjweh.fi/show_abstract.php?abstract_id=4294</guid>
      <pubDate>Thu, 30 Apr 2026 01:52:12 +0200</pubDate>
      <category>Review</category>
      <description><![CDATA[Objective   Occupational heat stress, driven by high ambient temperatures, humidity, and radiant heat impairs health, safety, and productivity. Among the interventions for mitigating heat strain, wearable cooling technologies [eg, water/ice, phase-change materials (PCM), ventilated/evaporative garments] is increasingly used, but their comparative effectiveness remains unclear. This systematic review aimed to evaluate the effectiveness of wearable cooling intervention on physiological and perceptual outcomes during heat exposure.

Methods   Adhering to PRISMA guidelines (PROSPERO: CRD42025631559), we searched PubMed, Embase, and Scopus (February 2026) for randomized or non-randomized intervention trials among workers or acclimatized adults. Data were extracted as mean/standard deviation (or transformed equivalents) and pooled using random-effects meta-analysis. Heterogeneity (I2), small-study effects (Egger’s test) and sensitivity/subgroup analyses of cooling modalities were performed. Risk of bias (RoB 2, ROBINS-I) and certainty (GRADE) were assessed.

Results   Sixty-nine studies were included in our review. Post-exposure, wearable cooling significantly reduced rectal temperature [mean difference (MD) -0.24°C; 95% confidence interval (CI) -0.37– -0.1; I<sup>2</sup>=43.91%], gastrointestinal temperature (MD -0.26°C; -0.52– -0.001; I<sup>2</sup>=98.13%), skin temperature (MD -1.14°C; -1.85– -0.42; I<sup>2</sup>=96.56%), and heart rate (MD -7.69 bpm; -11.22– -4.15; I<sup>2</sup>=73.19%). Egger’s tests suggested possible small-study effects for skin temperature and heart rate but not for core temperatures. Subgroup analyses indicated more consistent benefits with water/ice and PCM garments. Overall certainty ranged from low to very low due to risk of bias, inconsistency, and imprecision.

Conclusions   Wearable cooling attenuates physiological heat strain and improves thermal comfort, particularly via water/ice and PCM systems. Given high heterogeneity and low certainty, adequately powered, standardized, head-to-head trials are needed.
      <strong>by</strong> <i>Sheth A, Viramgami A, Thakor M, Modi B, Bagepally B, Kar A, Ram E, Dave A, Balachandar R</i>]]></description>
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