Five-year outcomes of fractionated stereotactic body radiotherapy for oligometastatic prostate cancer from the TRANSFORM phase II trial.

Metastasis-directed therapy (MDT) for oligometastatic prostate cancer (PCa), including stereotactic body radiotherapy (SBRT), has shown promise but is still considered investigational. This is the 5-year analysis of the TRANSFORM trial, the largest prospective cohort of men with oligometastatic PCa treated with SBRT-based MDT. The primary endpoint was 5-year treatment escalation-free survival (TE-FS), defined as freedom from any new cancer therapy other than further SBRT. In total, 199 men received SBRT; 76.4% were hormone-naïve at baseline. The rate of 5-year TE-FS was 21.7% (95% confidence interval [CI]: 15.7%-28.7%) overall and 25.4% (95% CI: 18.1%-33.9%) in the hormone-naïve subgroup. The subgroups with International Society of Urological Pathology Grade Groups 4-5 disease (hazard ratio [HR] = 1.48, 95% CI: 1.05-2.01, p = .026), a higher baseline prostate-specific antigen (PSA) (HR = 1.06, 95% CI: 1.03-1.09, p < .001) and those who received prior androgen deprivation therapy (ADT) (HR = 2.13, 95% CI: 1.40-3.26, p < .001), were at greater risk of treatment escalation. Outcomes for participants with four or five initial lesions were comparable to those with one to three lesions. At last follow-up, 18.9% (95% CI: 13.2%-25.7%) of participants were free from treatment escalation (median follow-up of 67.9 months) and two participants had an undetectable PSA level. No treatment-related grade three or higher adverse events were reported. The findings of this study demonstrate that SBRT-based MDT is an effective option for delaying systemic treatment escalation in the context of oligometastatic PCa. Future randomised trials comparing SBRT-based MDT to standard-of-care ADT-based approaches are required to evaluate the impact of delaying ADT on survival.

American Board of Internal Medicine Nephrology Procedure Requirements for Initial Certification: Time for a Change and Pursuing Consensus in the Nephrology Community.

In 1988, the American Board of Internal Medicine (ABIM) defined essential procedural skills in nephrology, and candidates for ABIM certification were required to present evidence of possessing the skills necessary for placement of temporary dialysis vascular access, hemodialysis, peritoneal dialysis, and percutaneous renal biopsy. In 1996, continuous renal replacement therapy was added to the list of nephrology requirements. These procedure requirements have not been modified since 1996 while the practice of nephrology has changed dramatically. In March 2021, the ABIM Nephrology Board embarked on a policy journey to revise the procedure requirements for nephrology certification. With the guidance of nephrology diplomates, training program directors, professional and patient organizations, and other stakeholders, the ABIM Nephrology Board revised the procedure requirements to reflect current practice and national priorities. The approved changes include the Opportunity to Train standard for placement of temporary dialysis catheters, percutaneous kidney biopsies, and home hemodialysis which better reflects the current state of training in most training programs, and the new requirements for home dialysis therapies training will align with the national priority to address the underuse of home dialysis therapies. This perspective details the ABIM process for considering changes to the certification procedure requirements and how ABIM collaborated with the larger nephrology community in considering revisions and additions to these requirements.

The European Kidney Health Alliance (EKHA) and the Decade of the KidneyTM.

The European Kidney Health Alliance (EKHA) is an advocacy organization that defends the case of the kidney patients and the nephrological community at the level of the European Union (EU), and from there, top to bottom, also at the national level of the EU member states and the EU-associated countries. The Decade of the KidneyTM is a global initiative launched by the American Association of Kidney Patients (AAKP) to create greater awareness and organize patient demands for long overdue innovation in kidney care. This article describes the medical and patient burden of kidney disease, the history of EKHA, its major activities and tools for policy action, and the need for innovation of kidney care. We then describe the Decade of the KidneyTM initiative, the rationale behind why EKHA joined this activity to emanate parallel action at the European side, the novel professionalized structure of EKHA, and its immediate targets. The final aim is to align all major stakeholders for an action plan on kidney disease comparable to Europe's successful Beating Cancer Plan, with the additional intent that the EKHA model is applied also by the respective national kidney-related societies to create a broad mobilization at all levels. The ultimate aims are that the EU considers chronic kidney disease (CKD) as a major health and health-economic problem, to consequently have CKD included as a key health research target by the European Commission, and to improve quality of life and outcomes for all kidney patients.

Associations between depressive symptoms and 5-year subsequent work nonparticipation due to long-term sickness absence, unemployment and early retirement in a cohort of 2,413 employees in Germany.

BACKGROUND: We examined the association of depressive symptoms with subsequent events - and duration thereof - of work nonparticipation (long-term sickness absence, unemployment and early retirement). METHODS: We employed a 5-year cohort from the Study on Mental Health at Work (S-MGA), based on a random sample of employees subject to social contributions aged 31-60 years in 2012 (N = 2413). Depressive symptoms were assessed at baseline through questionnaires, while work nonparticipation was recorded in follow-up interviews. Associations of depressive symptoms with subsequent events of work nonparticipation were examined in two-part models, with events analysed by logistic regressions and their duration by generalized linear models. RESULTS: Medium to severe depressive symptoms were associated with events of work nonparticipation (males Odds Ratio [OR] = 3.22; 95% CI = 1.90-5.45; females OR = 1.92; 95% CI = 1.29-2.87), especially with events of long-term sickness absence in both genders and events of unemployment in males. Mild depressive symptoms were also associated with events of work nonparticipation (males OR = 1.59; 95% CI = 1.19-2.11; females OR = 1.42; 95% CI = 1.10-1.84). Among those experiencing one or more events, the duration of total work nonparticipation was twice as high among males [Exp(ß) = 2.06; 95% CI = 1.53-2.78] and about one third higher [Exp(ß) = 1.38; 95% CI = 1.05-1.83] among females with medium to severe depressive symptoms. CONCLUSIONS: The present study focuses on both events and duration of work nonparticipation, which are both critical for examining societal consequences of depressive symptoms. It is key to regard also mild depressive symptoms as a possible risk factor and to include different types of work nonparticipation.

Long-term associations of psychosocial working conditions with depressive symptoms and work-related emotional exhaustion: comparing effects in a 5-year prospective study of 1949 workers in Germany.

OBJECTIVE: To test the hypothesis that psychosocial working conditions are more strongly associated with subsequent work-related emotional exhaustion (core component of burnout) than with depressive symptoms at follow-up. METHODS: A 5-year cohort study (2011/2012-2017), based on a random sample of persons in employment subject to payment of social contributions aged 31-60 years (Study on Mental Health at Work; S-MGA; N = 1949), included self-reported measures of organisational demands (organisational layoffs and restructuring), task-level demands (work pace and amount of work) and job resources (influence at work, possibilities for development, control over working time, role clarity), all taken from the COPSOQ, except the organisational demands that were single-item measures. Work-related emotional exhaustion and depressive symptoms were measured with the Oldenburg Burnout Inventory and the Patient Health Questionnaire-9, respectively. RESULTS: Cochrane Q tests revealed stronger associations between psychosocial working conditions and work-related emotional exhaustion only for the amount of work (p = 0.013) and control over working time (p = 0.027). No differences were observed for the Demands and Resources Indexes, capturing overall exposure to psychosocial working conditions. The same differences were observed in a subsample including only participants who remained at the same employer from baseline to follow-up, although more psychosocial working conditions were associated with work-related emotional exhaustion than with depressive symptoms. Supplementary analyses employing dichotomous measures of work-related emotional exhaustion and depressive symptoms confirmed these results. CONCLUSIONS: Overall, the findings provide limited evidence supporting the hypothesis that psychosocial working conditions are more strongly associated with work-related emotional exhaustion than with depressive symptoms.

Physical and psychosocial working conditions as predictors of 5-year changes in work ability among 2078 employees in Germany.

OBJECTIVE: To examine 5-year prospective associations between working conditions and work ability among employees in Germany. METHODS: A cohort study (2011/2012-2017), based on a random sample of employees in employments subject to payment of social contributions aged 31-60 years (Study on Mental Health at Work; S-MGA; N = 2,078), included data on physical and quantitative demands, control (influence, possibilities for development, control over working time), relations (role clarity and leadership quality) and work ability (Work Ability Index, WAI; subscale 'subjective work ability and resources'). Data were analysed using linear regression. RESULTS: Physical demands and control were associated with small 5-year changes in work ability (ΔR2 = 1%). Among the subgroup of employees with ≥ 25 sickness days, possibilities for development, control and quality of leadership were associated with changes in work ability (ΔR2 = 8%). CONCLUSIONS: The impact of working conditions on long term changes in work ability seems to be negligible. However, in vulnerable subpopulations experiencing poor health, working conditions may be associated to a larger extent to work ability over this time span.

Leadership behaviours and health-related early exit from employment: a prospective cohort study of 55 364 employees.

BACKGROUND: Absence of certain leadership behaviours, such as lack of feedback, recognition and involvement in employee development, has been associated with long-term sickness absence. We tested the hypothesis that absence of eight specific behaviours predicts health-related early exit from employment, and investigated differential effects in subgroups to guide future preventive initiatives. METHODS: Using Cox-proportional hazard modelling, we examined the prospective association between absence of leadership behaviours and health-related early exit from employment in a sample of 55 364 employees during 4.3 years follow-up. Leadership behaviours were measured by employee ratings in national surveys from 2012 to 2016. Exit from employment included disability pension and related measures of health-related early exit, retrieved from a national registry. RESULTS: We identified 510 cases of health-related early exit from employment during follow-up. A high level of absence of leadership behaviours, was associated with an increased risk of exit from employment (hazard ratio: 1.57, 95% CI: 1.31; 1.89). Subgroup analyses showed that the association between absence of leadership behaviours and exit from employment was similar for women and men and across age groups. The association was stronger for employees with high level of education than for employees with medium/low education, and the association was not observed among employees with a prevalent depressive disorder. CONCLUSIONS: Absence of the eight leadership behaviours is a risk factor for health-related early exit from employment in the Danish workforce. More studies are needed to confirm the results.

Testosterone and cortisol do not predict rejecting harm or maximizing outcomes in sacrificial moral dilemmas: A preregistered analysis.

Contemporary moral psychology explores the biological underpinnings of morality, including how neuromodulators influence moral judgment and decision making. Some studies suggest that higher circulating testosterone is associated with increased acceptance of sacrificial harm, such as killing one person to save five lives, consistent with utilitarian ethics and inconsistent with deontological ethics. However, most studies employ conventional analytic techniques that conflate concern about outcomes with reduced concern about sacrificial harm, many are statistically underpowered, and none examine potential regulating effects of cortisol. Therefore, we examined whether salivary concentrations of testosterone and cortisol jointly predict sacrificial dilemma judgments among a large sample of undergraduates (n = 199). We utilized an advanced cognitive modeling technique (process dissociation) to independently assess sensitivity to causing harm and maximizing outcomes, preregistering the prediction that higher testosterone would predict reduced harm-rejection rather than increased concern for outcomes, especially among people low in cortisol. However, neither testosterone, nor cortisol, nor their interaction predicted sacrificial dilemma response tendencies. Such findings raise questions about the robustness of past evidence suggesting links between testosterone and sacrificial dilemma judgments.

Determinants of kidney transplant candidates' decision to accept organ donor intervention transplants and participate in post-transplant research: A conjoint analysis.

Deceased organ donor intervention research aims to increase organ quality and quantity for transplantation. We assessed the proportion of kidney transplant candidates who would accept "intervention organs," participate in organ intervention research, and factors influencing acceptance. Kidney transplant candidates were presented 12 hypothetical scenarios, which varied three attributes, donor age, predicted waiting time to receive another organ offer, and research risk to the organ. Candidates were also randomly assigned to one of two conditions varying recipient risk. For each scenario, candidates agreed to accept the intervention organ or remain waitlisted. We fit a multivariable logit model to determine the association between scenario attributes and the acceptance decision. Of 249 participants, most (96%) accepted intervention organs under some or all conditions. Factors independently associated with candidates' greater likelihood of accepting an intervention organ included: low risk to the kidney from the intervention (OR 20.53 [95% Confidence Interval (CI), 13.91-30.29]); younger donor age (OR 3.72 [95% CI, 2.83-4.89]), longer time until the next organ offer (OR 3.48 [95% CI, 2.65-4.57]), and greater trust in their transplant physician (OR 1.03 [95% CI, 1.00-1.06]). Candidates with a lower likelihood of acceptance had been waitlisted longer (OR 0.97 per month [95% CI, 0.96-0.99]) and were Black (OR 0.21 [95% CI, 0.08-0.55]). Most candidates would accept an intervention organ, which should encourage transplant leaders to conduct deceased donor organ intervention trials.

Drug Development in Kidney Disease: Proceedings From a Multistakeholder Conference.

Occasional bursts of discovery and innovation have appeared during the otherwise stagnant past several decades of drug development in nephrology. Among other recent drug discoveries, the unexpected kidney benefits observed with sodium/glucose cotransporter 2 inhibitors may herald a renaissance of drug development in kidney disease. This recent progress highlights the need to further promote and stimulate research and development of promising therapies that may ameliorate the morbidity and mortality associated with kidney disease. To help identify and address barriers to drug development in nephrology, the Duke Clinical Research Institute convened a conference in April 2019 that included stakeholders from academia, industry, government agencies, and patient advocacy. From these discussions, several opportunities were identified to improve every stage of drug development for kidney disease from early discovery to implementation into practice. Key topics reviewed in this article are the utility of interconnected data and site research networks, surrogate end points, pragmatic and adaptive trial designs, the promising uses of real-world data, and methods to improve the generalizability of trial results and uptake of approved drugs for kidney-related diseases.

Workplace bullying and depressive symptoms among employees in Germany: prospective associations regarding severity and the role of the perpetrator.

OBJECTIVES: The aim of this study was to investigate the effect of self-reported workplace bullying on depressive symptoms in a prospective study among a representative sample of employees from Germany. We focused specifically on the role of the perpetrator (co-workers and superiors), which was never done before in a longitudinal design. METHODS: We used data from a nation-wide representative panel study with a 5-year follow-up (N = 2172). Data on bullying exposure were obtained separately for different perpetrators (co-workers and superiors) and degree of severity (severe bullying, i.e., at least weekly). Depressive symptoms were assessed with the Patient Health Questionnaire (PHQ). We used logistic regression analyses to examine the effect of workplace bullying at baseline on depressive symptoms at follow-up. RESULTS: After adjusting for baseline depressive symptoms, severe bullying by co-workers significantly increased the 5-year risk of depressive symptoms (OR = 2.50). Severe bullying by superiors had a nonsignificant effect. CONCLUSIONS: Workplace bullying is a risk factor for depressive symptoms among employees in Germany. The type of perpetrator seems to be an important factor to consider, as indicated by the elevated risk of depressive symptoms when bullying is perpetrated by co-workers.

Workplace bullying among employees in Germany: prevalence estimates and the role of the perpetrator.

OBJECTIVES: The aim of this study was to examine the prevalence of workplace bullying in Germany while also taking the perpetrator and severity level (measured by frequency) into account and considering the role of gender, age and socio-economic status. METHODS: We used data from a large representative sample (N = 4143) of employees in Germany subject to social security contributions. Self-reported bullying was assessed for different combinations of perpetrators (co-workers, superiors) and according to severity, i.e., being exposed at all and to severe bullying (at least weekly). RESULTS: Prevalence estimates varied from 2.9% for severe bullying by co-workers to 17.1% for overall bullying (i.e., without distinguishing by perpetrator, less severe bullying also included). Unskilled workers reported more bullying by both perpetrators than academics/managers. We also observed an age trend for severe bullying by superiors (i.e., bossing), with younger employees being more affected from bossing than elder. No gender differences were detected. CONCLUSIONS: The findings indicate that it is crucial to consider type of perpetrator and severity of the behaviors when examining the prevalence of workplace bullying. The way bullying is defined and operationalized strongly contributes to the prevalence estimates. Differences between subgroups and associations or cause-effect relationships should be analyzed with these variations in mind.

Does leadership support buffer the effect of workplace bullying on the risk of disability pensioning? An analysis of register-based outcomes using pooled survey data from 24,538 employees.

PURPOSE: To investigate whether self-reported exposure to workplace bullying predicts the risk of disability pensioning among employees in two occupational groups-(1) employees working with clients or customers and (2) office workers and manual workers-and whether leadership support and occupational group moderates that association. METHODS: Survey data from 24,538 employees (112,889 person years) were fitted to a national register containing information on disability-pension payments. Using multi-adjusted Cox-regression analysis, observations were followed in the register to assess the risk of disability pensioning. The average follow-up time was 4.6 years (standard deviation [SD] = 1.5). RESULTS: Self-reported exposure to workplace bullying predicted an increased risk of disability pensioning (hazard ratio [HR] = 1.46; 95% confidence interval [CI]: 1.15-1.86). This association was moderated by leadership support: the association between workplace bullying and disability pensioning was significantly different for respondents who reported low leadership support (HR = 1.97; 95% CI: 1.38-2.80) compared to respondents who reported medium (HR = 1.03; 95% CI: 0.60-1.76) or high leadership support (HR = 1.08; 95% CI: 0.60-1.95). Further analyses showed similar associations between workplace bullying and the risk of disability pensioning among the two occupational groups. CONCLUSIONS: Self-reported workplace bullying increases the risk of disability pensioning, and this association is buffered by leadership support. Workplace bullying should be considered an important workplace stressor. This study indicates that workplaces may enhance worker retention by actively promoting measures to eliminate the occurrence of workplace bullying and to enhance leadership support.

Parasite stress and pathogen avoidance relate to distinct dimensions of political ideology across 30 nations.

People who are more avoidant of pathogens are more politically conservative, as are nations with greater parasite stress. In the current research, we test two prominent hypotheses that have been proposed as explanations for these relationships. The first, which is an intragroup account, holds that these relationships between pathogens and politics are based on motivations to adhere to local norms, which are sometimes shaped by cultural evolution to have pathogen-neutralizing properties. The second, which is an intergroup account, holds that these same relationships are based on motivations to avoid contact with outgroups, who might pose greater infectious disease threats than ingroup members. Results from a study surveying 11,501 participants across 30 nations are more consistent with the intragroup account than with the intergroup account. National parasite stress relates to traditionalism (an aspect of conservatism especially related to adherence to group norms) but not to social dominance orientation (SDO; an aspect of conservatism especially related to endorsements of intergroup barriers and negativity toward ethnic and racial outgroups). Further, individual differences in pathogen-avoidance motives (i.e., disgust sensitivity) relate more strongly to traditionalism than to SDO within the 30 nations.

Consequential differences in perspectives and practices concerning children with developmental language disorders: an integrative review.

BACKGROUND: Inter-professional collaboration (IPC) has been recommended for many years as a means by which the needs of children with developmental language disorders (DLD) can be met at school. However, effective IPC remains difficult to achieve and our knowledge of how to support it is limited. A shared understanding between those involved has been identified as critical to IPC. AIMS: To examine the literature, as one source of data, for evidence of a shared understanding between the fields of speech and language therapy (SLT) and education about children with DLD and how such needs can best be met at school. METHODS & PROCEDURES: An integrative review of the literature was undertaken. A systematic search of the published, peer-reviewed literature (between 2006 and 2016) was conducted for empirical and theoretical papers and a manual search was undertaken to obtain a representative sample of policy/professional guidelines. A total of 81 papers across SLT and education were included in the review. The papers were scrutinized using a qualitative content analysis. MAIN CONTRIBUTION: Although some commonality between perspectives in the literature was identified, differences between the fields dominated. These differences related to how DLD is conceptualized; how children's needs are assessed; which outcomes are prioritized and how best these outcomes can be achieved. We also found differences about what constitutes useful knowledge to guide practice. We suggest that the nature of the differences we identified in the literature may have negative implications for practitioners wishing to collaborate to meet the needs of children with DLD in school. The perspectives of practising SLTs and teachers need to be sought to determine whether the findings from the literature reflect dilemmas in practice. CONCLUSIONS: Effective IPC is essential to meet the needs of children with DLD in school; yet, it remains difficult to achieve. Our review of the literature across SLT and education indicates evidence of a lack of shared understanding about DLD. If these differences are also evident in practice, then a conceptual model to support IPC may be warranted.

Is organizational justice climate at the workplace associated with individual-level quality of care and organizational affective commitment? A multi-level, cross-sectional study on dentistry in Sweden.

PURPOSE: The aim of this study is to investigate whether organizational justice climate at the workplace level is associated with individual staff members' perceptions of care quality and affective commitment to the workplace. METHODS: The study adopts a cross-sectional multi-level design. Data were collected using an electronic survey and a response rate of 75% was obtained. Organizational justice climate and affective commitment to the workplace were measured by items from Copenhagen Psychosocial Questionnaire and quality of care by three self-developed items. Non-managerial staff working at dental clinics with at least five respondents (n = 900 from 68 units) was included in analyses. A set of Level-2 random intercept models were built to predict individual-level organizational affective commitment and perceived quality of care from unit-level organizational justice climate, controlling for potential confounding by group size, gender, age, and occupation. RESULTS: The results of the empty model showed substantial between-unit variation for both affective commitment (ICC-1 = 0.17) and quality of care (ICC-1 = 0.12). The overall results showed that the shared perception of organizational justice climate at the clinical unit level was significantly associated with perceived quality of care and affective commitment to the organization (p < 0.001). CONCLUSIONS: Organizational justice climate at work unit level explained all variation in affective commitment among dental clinics and was associated with both the individual staff members' affective commitment and perceived quality of care. These findings suggest a potential for that addressing organizational justice climate may be a way to promote quality of care and enhancing affective commitment. However, longitudinal studies are needed to support causality in the examined relationships. Intervention research is also recommended to probe the effectiveness of actions increasing unit-level organizational justice climate and test their impact on quality of care and affective commitment.

A cohort study on self-reported role stressors at work and poor sleep: does sense of coherence moderate or mediate the associations?

AIM: The aim of the present study was to examine the bidirectional associations between subjective role ambiguity and role conflicts at work, respectively, and self-reported sleep 2 years later. In addition, we also examine whether sense of coherence (SOC) moderate or mediate the association between role stressors and poor sleep and between poor sleep and role stressors. METHODS: We used questionnaire data collected in 2006 and 2008 from the Workplace Bullying and Harassment cohort. In 2006, 3363 responded to the questionnaire and in 2008 1671 responded. In total, 1569 participants responded in both 2006 and 2008 to the questions on role stressors (in terms of role ambiguity and role conflicts at work) and sleep problems in both 2006 and 2008. Sleep problems were assessed with the awakening index (AWI) and the disturbed sleep index (DSI). Moderation and mediation analyses of the association were estimated using structural equation modelling. RESULTS: We found a prospective association between role stressors and sleep problems [beta values were 0.07 (95% CI 0.03-0.11) and 0.05 (CI 0.01-0.10) for DSI and AWI, respectively] when adjusting for sleep problems at baseline, age, sex, and life style factors (i.e. alcohol, smoking, and leisure time physical activity). SOC moderated the association showing that participants with lower SOC scores who reported higher role ambiguity reported sleep problems to a higher extent than participants with high SOC scores. SOC also mediated the association between role stressors and sleep problems. We also found support for sleep problems at baseline and role stressors 2 years later [DSI 0.04 (CI 0.00-0.08) and 0.15 (CI 0.09-0.21)] for role ambiguity and role conflicts, respectively. Similar results were observed for AWI. CONCLUSION: Subjective role stressors were prospectively associated with sleep problems. Yet, sleep problems could also prospectively predict subjective role stressors (i.e. reverse causation). The analyses also showed that SOC may be regarded as both a mediating and a moderating factor of the association between subjective role conflicts and poor sleep. We found that SOC moderated the prospective association so participants with low SOC report more sleep problems with subjective role conflicts compared to participants with high SOC. Finally, we also found SOC mediated the prospective association between subjective role stressors and sleep problems and the reverse association.

The associations between workplace bullying, salivary cortisol, and long-term sickness absence: a longitudinal study.

BACKGROUND: Workplace stressors, such as bullying, are strongly related to subsequent long-term sickness absence, but little is known of the possible physiological mechanisms linking workplace stressors and sickness absence. The primary aim of this study was to investigate to what extent cortisol levels were associated with subsequent sickness absence and if cortisol mediated the association between workplace bullying and sickness absence. We additionally investigated possible bidirectional associations between bullying, cortisol, and long-term sickness absence. METHODS: Participants came from two Danish cohort studies, the "Psychosocial RIsk factors for Stress and MEntal disease" (PRISME) cohort and the "Workplace Bullying and Harassment" (WBH) cohort (n = 5418). Information about exposure to workplace bullying and morning and evening salivary cortisol was collected at three time points with approximately two years in between. After each data collection, all participants were followed for two years in registers, and cases with long-term sickness absence lasting 30 or more consecutive days were identified. The association between cortisol levels and subsequent sickness absence was assessed by logistic regression, while the extent to which the association between bullying and sickness absence was mediated by cortisol was quantified through natural direct and indirect effects. RESULTS: High evening cortisol was associated with a decreased risk of sickness absence (OR = 0.82, 95% CI = 0.68-0.99), but we did not find that high morning cortisol levels (OR = 0.98, 95% CI = 0.81-1.18) or high morning-to-evening slope (OR = 0.99, 95% CI = 0.82-1.18) were associated with subsequent sickness absence. We also tested for reverse causation and found that long-term sickness absence, but not salivary cortisol, was a strong risk factor for subsequent workplace bullying. There was no indication that cortisol mediated the association between workplace bullying and sickness absence. CONCLUSION: We found no straightforward and simple association between cortisol and long-term sickness absence. Furthermore, the association between workplace bullying and long-term sickness absence was not mediated by cortisol.