Reading Conditions Research Articles

Assessing acute effects of two motor-cognitive training modalities on cognitive functions, postural control, and gait stability in older adults: a randomized crossover study.

The process of aging often accompanies a decline in cognitive function, postural control, and gait stability, consequently increasing the susceptibility to falls among older individuals. In response to these challenges, motor-cognitive training has emerged as a potential intervention to mitigate age-related declines. This study aims to assess the acute effects of two distinct motor-cognitive training modalities, treadmill dual-task training (TMDT) and interactive motor-cognitive training (IMCT), on cognitive function, postural control, walking ability, and dual-task performance in the elderly population. In this randomized crossover study, 35 healthy elderly individuals (aged 60-75) participated in three acute training sessions involving TMDT, IMCT, and a control reading condition. Assessments of executive function, postural control, gait performance, and cognitive accuracy were conducted both before and after each session. Both TMDT and IMCT improved executive functions. Notably, IMCT resulted in a significant enhancement in correct response rates and a reduction in reaction times in the Stroop task (p < 0.05) compared to TMDT and the control condition. IMCT also led to an increase in dual-task gait speed (p < 0.001) and showed a trend towards improved cognitive accuracy (p = 0.07). Conversely, TMDT increased postural sway with eyes open (p = 0.013), indicating a potential detriment to postural control. The findings suggest that IMCT holds greater immediate efficacy in enhancing cognitive function and gait stability among older adults compared to TMDT, with a lesser adverse impact on postural control. This underscores the potential of IMCT as a preferred approach for mitigating fall risk and enhancing both cognitive and physical functions in the elderly population.

Comparative Analysis of Blink Rates During Printed and On-Screen Reading Across Varying Screen Sizes

Objective: To compare the blink rates during resting periods and while engaging in printed and on-screen reading across different digital screen dimensions.Material and Methods: This study involved thirty-two university students with normal vision, who were recorded during a 3-minute conversation to establish baseline blink rates and subsequently during four reading conditions. Participants read four passages under different conditions: printed text, smartphone, tablet, and computer screens. Video recordings were then analysed to quantify blink rates (blinks per minute, bpm) for each condition.Results: Blink rates significantly decreased in all reading scenarios compared to the baseline resting condition (p-value&lt;0.05). Analysis via repeated measures ANOVA demonstrated significant differences in blink rates across all reading conditions (p-value&lt;0.01). Pairwise comparisons revealed that blink rates during smartphone reading were notably lower than printed text, tablets, and computers (p-value&lt;0.05). Conversely, blink rates exhibited no significant differences between printed text and tablet, printed text and computer, and computer and tablet readings (p-value&gt;0.05).Conclusion: The study reveals a consistent decrease in blink rates during various reading conditions with different digital screens compared to resting states, highlighting the influence of visual engagement on ocular behaviour. Reading with a smartphone has decreased blink rates, which may affect eye health and device use. Understanding these dynamicscan guide ergonomic design to reduce visual discomfort from digital screen use, supporting healthy reading habits in the digital age.

Investigation of the influence of 45-minute pre-sleep social media use on sleep quality and memory consolidation in adolescents

Adolescents devote a significant portion of their time to smartphone usage, often engaging in social media activities. Social media use has previously been linked to diminished sleep quality and reduced sleep durations in correlational studies. In this experimental study, we aimed to investigate the influence of pre-sleep social media use on memory consolidation, subjective arousal and objectively assessed sleep quality in adolescents. We compared the social media condition to two reading conditions, one involving reading a book on a smartphone and the other reading from a physical book in a within-subjects design. Twenty participants between 12 and 14 years engaged in these activities for 45 min before bedtime. Contrary to our expectations, the results indicated that pre-sleep social media use did not have a discernible impact on sleep quality, pre-sleep arousal or memory consolidation. All assessed sleep measures remained consistent across the three conditions. Subjectively, the social media condition was rated less thrilling than the reading conditions. This suggests that, within the confines of this experiment, pre-sleep social media exposure did not significantly disrupt adolescents' sleep or their ability to consolidate memories during sleep. This deviation from previous correlational studies might be explained by a possible impact of mental health factors on media consumption and sleep or the fact that contrary to their daily routines participants had to sleep after our intervention and could not continue to engage in their activities. This highlights the need for further investigations into the complexities of this interaction.

How disruptive are monocular reading conditions really?

Purpose. Based on the fact that reading with both eyes shows a binocular advantage of about 10 % (shorter reading and fixation times compared to monocular reading) with good binocular coordination, the present study aims to investigate the influence of the quality of binocular vision on the effectiveness of reading. Material and Methods. The binocular eye movements (Eyelink II) of 260 test subjects were reevaluated. All subjects read 60 sentences in German containing a target word occurring either frequently or rarely in this language. Additionally, the reading condition was changed from monocular to binocular for 30 sentences. Furthermore the objective heterophoria and MCH heterophoria for all participants were determined. Results. In the case of monocular reading conditions, there was only a weak general word-frequency effect (b = 7.21; t = 1.91; p = 0.06) but fixation times for frequent words shortened slightly when objective heterophoria increased (b = −4.24; t = −3.82; p &lt; 0.001). For binocular reading conditions, on the other hand, there was a clear word-frequency effect (b = −48.77; t = −6.03; p &lt; 0.001) and, at the same time, an interaction with individual heterophoria (objective: b = 8.19; t = 14.57; p &lt; 0.001; MCH: b = 3.27; t = 4.40; p &lt; 0.001). Conclusion. Monocular reading conditions can be proven to be disruptive when investigating people with good binocular coordination. However, this effect turns out to be much smaller than what is assumed by many optometrists. People with good binocular coordination clearly show greater benefits when reading with both eyes. Keywords: BINOCULAR COORDINATION, BINOCULAR ADVANTAGE, READING

Electroencephalographic Classification Reveals Atypical Speech Motor Planning in Stuttering Adults.

This study explores speech motor planning in adults who stutter (AWS) and adults who do not stutter (ANS) by applying machine learning algorithms to electroencephalographic (EEG) signals. In this study, we developed a technique to holistically examine neural activity differences in speaking and silent reading conditions across the entire cortical surface. This approach allows us to test the hypothesis that AWS will exhibit lower separability of the speech motor planning condition. We used the silent reading condition as a control condition to isolate speech motor planning activity. We classified EEG signals from AWS and ANS individuals into speaking and silent reading categories using kernel support vector machines. We used relative complexities of the learned classifiers to compare speech motor planning discernibility for both classes. AWS group classifiers require a more complex decision boundary to separate speech motor planning and silent reading classes. These findings indicate that the EEG signals associated with speech motor planning are less discernible in AWS, which may result from altered neuronal dynamics in AWS. Our results support the hypothesis that AWS exhibit lower inherent separability of the silent reading and speech motor planning conditions. Further investigation may identify and compare the features leveraged for speech motor classification in AWS and ANS. These observations may have clinical value for developing novel speech therapies or assistive devices for AWS.

Implementation of binarized neural networks immune to device variation and voltage drop employing resistive random access memory bridges and capacitive neurons

Resistive Random Access Memories (ReRAM) arrays provides a promising basement to deploy neural network accelerators based on near or in memory computing. However most popular accelerators rely on Ohm’s and Kirchhoff’s laws to achieve multiply and accumulate, and thus are prone to ReRAM variability and voltage drop in the memory array, and thus need sophisticated readout circuits. Here we propose a robust binary neural network, based on fully differential capacitive neurons and ReRAM synapses, used in a resistive bridge fashion. We fabricated a network layer with up to 23 inputs that we extrapolated to large numbers of inputs through simulation. Defining proper programming and reading conditions, we demonstrate the high resilience of this solution with a minimal accuracy drop, compared to a software baseline, on image classification tasks. Moreover, our solution can achieve a peak energy efficiency, comparable with the state of the art, when projected to a 22 nanometer technology.

Song and poetic text Bella ciao in a mosaic of languages, cultures and arts

The development of textology and intertextuality opens up new perspectives in the interpretation of famous texts, including the song of the Italian Resistance participants Bella ciao . Its numerous polymodal representations in different languages and arts account for the need to systematize them on uniform methodological grounds. The material of the article is the song and poetic text in Italian dialects and in the common Italian neo-standard, its translations into Romance languages, interpretations in Russian, Caucasian and other languages, as well as multimedia and polychannel versions. The goal of the article is to discuss intertextual, semantic and semiotic parameters of the text; to establish the parameters of internal and external intertextuality of the versions of the original text; and to characterize the precedent phenomena serving as the basis for the development and transformation of their aesthetics. The study aims to build and interpret the precedent links and associations of the song Bella ciao in its intertextual transformations; to determine its specificity in the semiocultural conditions of reading and interpretation and at the same time to evaluate its place in the context of Italian and world culture. The methodology is based on a set of methods at the intersection of linguosemiotic, functional and semantic approaches focusing on such parameters of the text as precedence, variation, correlation of linguistic and non-linguistic codes, comparison of the original and translations, polycode, polymodal and translation transformations. The study has established that, as a result of numerous intertextual transformations, the original text expressing unique Italian cultural meanings acquires new interpretations acting as a starting point or the development of both precedent and new plots. It is used as a polycoded intersemiotic model for the creation of new interpretations and, in the long term, becomes a tool for the preservation and reproduction of cultural memory.

The Archive as a World-Making Apparatus in the Anthropocene

This text aims to explore the archive as a powerful force that shapes life. Consequently, it seeks to develop an ethical framework for the archive from a feminist perspective. De-extinction can be linked to the archive as a stabilizing apparatus and a scene of responsibility (Wolfe 2018) that entails our ethical commitment to acknowledge the radical passivity of those who no longer exist in this world, both as individuals and species. This scene of responsibility is intertwined with the agency of the archive. In other words, the archive acts as a life-creating apparatus by shaping the conditions for reading, the future, and, to some extent, reality itself. By establishing the foundations for an ethics of the archive as a practice that creates life, this text aims to reframe the discourse surrounding extinction and de-extinction.

Remediation of Learning Difficulty Utilizing School-Based Cognitive Behavioral Intervention Measured by EEG Theta-Alpha and Theta-Beta Ratio During Resting and Cognitive Task Performance Conditions.

Background. EEG is an effective tool due to its ability to capture and interpret the changes in brain activity under different situations. Quantitative EEG (qEEG) can be essential in evaluating and treating children's learning problems. Methods and procedure. Fifty school-going children with difficulty in learning were studied. Analysis of the difference between pre-intervention and postintervention EEG power ratio of frequency bands, including Theta to Beta and Theta to Alpha, while eyes-closed, eyes-open, hyperventilation, writing, and reading conditions and the values for relative powers were calculated. The study correlated postintervention theta/beta ratio (TBR) and theta/alpha ratio (TAR) values with behavioral measures. Results. The findings suggested that there was a significant difference in pre-intervention and postintervention relative TAR and TBR power values. A significant increase of TAR and TBR power values was observed in eyes-closed (resting), hyperventilation, writing, and reading task conditions, indicative of a state of arousal at FP1FP2, T3T4, and O1O2 scalp locations. During eye open conditions, the TAR and TBR were significantly low at all 3 scalp locations, indicating a relaxed, conscious, and aware state of mind. Postintervention TAR and TBR values were significantly correlated with behavioral measures during 5 task conditions on several scalp locations. Conclusion. These quantitative electroencephalogram findings in children with learning problems indicate that with the increased complexity of the cognitive tasks, TAR and TBR increase, while postintervention, children could attain a relaxed and conscious state of mind during eyes-open condition.

Which reading comprehension is better? A meta-analysis of the effect of paper versus digital reading in recent 20 years

The development of digital technology has changed the audience's reading behavior and reading habits, and the difference between digital reading and paper reading has become a research hot spot. However, the academic circle has not reached an agreement on the reading effect of digital reading and paper reading. This study included 37 experimental studies for meta-analysis and analyzed the influence of moderating variables such as audience characteristics, text characteristics, and reading conditions. This study deepens the understanding of the reading effect and provides a reference for improving it. The study shows no significant difference in overall reading comprehension between digital reading and paper reading, and there are differences under moderating variables. The study has revealed that digital reading and paper reading have advantages and disadvantages and complement each other. The publishing industry should develop corresponding knowledge service products based on the characteristics of reading effects to promote the healthy development of the reading industry.

Connecting the dots: Exploring brain connectivity during responsibility recognition in construction contract negotiations

Despite recent advancements in monitoring brain activity, causal relationships within the brain during responsibility identification in construction contracts remain unexplored. We aimed to understand the neural mechanisms involved in the cognitive components and their interactions related to contract text reading by delving into the brain mechanisms of contract responsibility identification. This study investigated students’ brain connectivity using electroencephalography (EEG) data during a text-based contract responsibility-identification task. It employed an adaptive directed transfer function based on Granger causality to simulate directed and time-varying information flow in observed brain activity. We evaluated the EEG records of 18 participants under two reading conditions (involving or not involving contractor responsibility). During responsibility identification, the most substantial information exchange occurs in the somatosensory area of the brain. The results revealed a “top-down” cortical mechanism for responsibility identification, with the left parietal-occipital area (PO3) as the central hub promoting connectivity structures. These findings indicate that the perceptual processing of contract responsibility texts is associated with higher visual learning and memory quality. Contracts without contractor-responsibility clauses resulted in more substantial information flow output in the frontal cortex and consumed more cognitive resources. Our findings advance the understanding of cognitive processes involved in contract responsibility identification, providing a framework for investigating causal relationships within the brain and novel insights into cortical mechanisms. By identifying the neural basis of responsibility identification, stakeholders can develop effective training programs for negotiators and enhance their ability to interpret and implement construction contracts.

Effects perceived by Vietnamese B1 EFL students of extensive reading on intercultural competence

Investigation of effective approaches for supporting students’ linguistic and intercultural competence in the process of learning English as an international lingua franca has generally been an issue of great concern for teachers and researchers in language education. The study considered how fiction reading and non-fiction reading supported students’ reading comprehension and fostered their self-perception of intercultural competence. The scaffolds were tested in a pretest-posttest design on 58 participants, and in a classroom-based setting. Two measurement instruments included a reading comprehension test and a questionnaire on students’ self-perception of their intercultural competence. Both groups made significant progress in reading comprehension. Fiction reading condition was also found to contribute to the higher self-perception of intercultural competence. Discussion of the pros and cons of the experimental design and suggestions for further research into extensive reading and speech act appropriateness are in the last part of the paper. The paper finally puts forward the suggestion that short literary texts of cultures around the world might be considered as one of the meaningful inputs in B1 EFL classrooms.

L2 Arabic learners' processing of Arabic garden-path sentences: a consistent reading pattern.

The main purpose of this study was to investigate to what extent the L2 Arabic learners' reading process is affected by the incomplete representation of speech (the absence of short vowels and diacritics) while reading ambiguous sentences (garden path sentences). With a self-paced reading software program, 41 non-native male students, aged from 22 to 26, enrolled in King Saud University, participated in reading 44 sentences (followed by reading comprehension questions) representing three reading conditions, plain, vowelized-discretized, and wrongly-vowelized. For the reading times data, the analysis revealed that the GP structure had a significant effect on the reading processes of L2 Arabic learners; it took them longer to read the GP sentences than their non-GP counterparts. For the reading comprehension, the analysis did not reveal any significant differences between the means for the percentages of correct responses. For the comparison between the three reading conditions, a significant difference was found: it took the participants on average less time to read the GP sentences when presented plain, and more time with the incorrect representation. However, their reading comprehension was not affected. In addition to the good-enough model and the nature of Arabic morphology, the reading experience, is a good candidate to start with as an important factor in the interpretation of the ineffectiveness of the GP structure on the reading comprehension process of Arabic readers, in which the segregability of Arabic writing system prepare the readers to emphasize some sensory inputs and ignore others based on their past reading experience.

Exploring silent, small-group and adult mediated reading with nonfiction picturebooks: children's responses and educational potential in elementary school.

Following the editorial rise of the nonfiction picturebook, a growing line of research has been initiated to analyze its educational potential and its place in children's reading. However, the number of empirical studies on children's responses to nonfiction picturebook reading remains limited. Therefore, this study focuses -from a qualitative analysis based on participant observation, involving 97 elementary school participants between 8 and 9 years old and covering 48 hours of recording- on the reading of nonfiction picturebooks from three different reading conditions: silent, shared in small groups, and adult-mediated. The results reveal differences among the three reading approaches, evidencing a greater positive response to nonfiction picturebooks during individual and adult-mediated silent reading, a greater ability to foster critical and personal responses when mediated, as well as the fundamental role of illustrations and visual composition in fostering curiosity and critical reflection. However, small-group reading generated a greater number of negative responses, indicating the need to investigate it independently to more effectively harness its formative potential for children's readers, given that it is questioned in this study. Therefore, this paper provides a detailed analysis of these different reading conditions with nonfiction picturebooks and their implications for educational practice.

An in vitro study using confocal laser scanning microscopy to evaluate the marginal misfits of different implant-supported frameworks.

This study aimed to develop and evaluate a simple, non-destructive method for assessing the misfit and passivity of implant-retained prostheses frameworks. To simulate the rehabilitation of a mandible posterior partially edentulous area using 3-unit screw-retained frameworks supported by two implants were fabricated and divided into the following five groups (n = 10 in each group): OP = one-piece framework cast in Co-Cr with the conventional method (control-group); Co-Cr frameworks sectioned and welded by laser (=LAS) or tungsten inert gas (=TIG); Co-Cr CAD-CAM = milled Co-Cr framework; Zir CAD-CAM = milled zirconia framework. The horizontal |X| and vertical |Y| misfits were measured using confocal laser scanning microscopy with one or both screws tightened. Data were analyzed by a two-way ANOVA with repeated measures and Bonferroni correction (α = 0.05). The greatest |X| misfit was observed in the OP group with both screws tightened (290µm) and one screw tightened (388 and 340µm). The conventional casting groups sectioned and welded by laser or TIG had lower mean values (235.35µm, both screws tightened; and 275µm, one screw tightened) than the OP framework. However, these values still exceeded those of the milled Co-Cr and zirconia frameworks (190 and 216µm with both screws tightened). Across all reading conditions, every framework subjected to testing consistently maintained vertical |Y| misfit levels below the threshold of 53µm; however, the milled frameworks exhibited higher vertical misfits than the frameworks obtained by the conventional cast method. The frameworks, whether cast and sectioned with laser welding or milled from Co-Cr, exhibit improved marginal misfit and enhanced passive fit when compared to other fabrication methods. Additionally, the use of confocal laser scanning microscopy is highly effective for passivity and misfit analysis.

Literarno branje

Literary reading is the most important kind of reading for literary science. It can enrich other kinds of reading, especially those that might, in the future, become shallow due to certain features of “electronic reading”. Crucial in determining literary reading is its division into first-level and second-level reading, taking into account the general characteristics of literary interpretation, the reading conditions, the familiarity of the reader with the literary contract, his or her reading competence, empathy, intent and evaluation; in fact, division into reading levels is a division according to how the reader can or wishes to shape the meaning of what he or she has read. Whereas first-level reading involves filling out the referential framework, second level is concerned with filling out “the empty spaces” or the realisation of the work of art. As literary reading is form- and content-oriented, impressions are created and reinforced in the process of reading by the reader’s knowledge of literary theory, literary history and literary interpretation, as well as by all of the supporting literary sciences and the projection of non-literary knowledge onto the literary text. In short, literary reading is a complex process of giving meaning to the literary text, a process that, through various kinds and forms of reading, is performed by a literary competent reader.

Exploring the Utility of Narrative Comprehension and Production Tasks to Identify Vocabulary Delay Using Eye-Tracker

Objectives: The purpose of this study was to identify group differences in various aspects of narrative tasks performance (comprehension, production, and eye-tracking variables) and finally to explore whether narrative tasks can be used to detect vocabulary delay.Methods: Children in the 1st and 2nd grades (TD= 101, VD= 22) of elementary school participated in this study. All children participated in story comprehension and production tasks, and eye-tracking variables were extracted from two reading conditions (‘listening+reading’, and ‘reading’) in the story comprehension task.Results: There was a significant difference between the two groups in the ‘listening+reading’ condition in the story comprehension task, the ‘construction’ condition in the story production task, and the ‘total fixation duration (TFD)’ in the eye-tracking variables. We examined the ability of the story performances to discriminate vocabulary delays, and found that a total of 79.6% of the original cases based on the standardized vocabulary test could be correctly classified by the story performance variables. The ROC curve also showed that 84.6% of the children could be validly identified by a combination of narrative comprehension scores in the ‘listening+reading’ condition, narrative production scores in the ‘structure’ condition, and TFD in the ‘listening+reading’ condition of comprehension task.Conclusion: The significance of this study is that it explored the possibility of using narrative tasks as a useful tool for identifying micro-level vocabulary delays.

The effect on blink frequency of a selective blue-filtering photochromic lens in patients with benign essential blepharospasm.

The aim of this clinical study was to assess the impact of a non-invasive selective blue-filtering photochromic lens coating Crizal Prevencia on the treatment and response of benign essential blepharospasm (BEB). Twenty-four patients were recruited in the outpatient clinic of the Medical University of Vienna in a randomized, double-blind, cross-over study design. Blink frequencies were assessed in patients with BEB before and 14 days after intervention with either a filtering ophthalmic lens or a placebo lens, respectively. Outcome parameters include sub-group analysis of a blink frequency under six different conditions: three photopic conditions, one resting condition, one reading condition, and one video game condition. From 24 recruited patients, 15 patients were available for final analysis. Comparing the optical blue filtering lens to placebo, showed a reduced blink frequency in specific subtests, but not compared to baseline. In conclusion, optical filtering glasses might have a beneficial effect on BEB and provide a non-invasive therapeutic add-on option, in addition to botulinum neurotoxin therapy, for patients with BEB and should necessarily be further investigated in a multicenter setting, resulting in larger sample sizes to gain valid information about the effect of photochromic blue filter glasses in BEB.Clinical trial registration: https://drks.de/search/en/trial/DRKS00032135, DRKS00032135.

Online Processing Shows Advantages of Bimodal Listening‐While‐Reading for Vocabulary Learning: An Eye‐Tracking Study

AbstractChildren can learn words incidentally from stories. This kind of learning is enhanced when stories are presented both aurally and in written format, compared to just a written presentation. However, we do not know why this bimodal presentation is beneficial. This study explores two possible explanations: whether the bimodal advantage manifests online during story exposure, or later, at word retrieval. We collected eye‐movement data from 34 8‐to 9‐year‐old children exposed to two stories, one presented in written format (reading condition), and the second presented aurally and written at the same time (bimodal condition). Each story included six unfamiliar words (non‐words) that were repeated three times, as well as definitions and clues to their meaning. Following exposure, the learning of the new words' meanings was assessed. Results showed that, during story presentation, children spent less time fixating the new words in the bimodal condition, compared to the reading condition, indicating that the bimodal advantage occurs online. Learning was greater in the bimodal condition than the reading condition, which may reflect either an online bimodal advantage during story presentation or an advantage at retrieval. The results also suggest that the bimodal condition was more conducive to learning than the reading condition when children looked at the new words for a shorter amount of time. This is in line with an online advantage of the bimodal condition, as it suggests that less effort is required to learn words in this condition. These results support educational strategies that routinely present new vocabulary in two modalities simultaneously.

Impact of Interruptions During Screening Mammography on Physician Well-Being and Patient Care

ObjectiveTo assess the impact of interruptions on radiologists’ efficiency, accuracy, and job satisfaction in interpreting screening mammograms. MethodsThis institutional review board–approved retrospective reader study recruited nine breast radiologists from a single academic institution [name withheld] to interpret 150 screening mammograms performed between December 1, 2008, and December 31, 2015 under two different reading conditions, as follows: (1) uninterrupted batch reading and (2) interrupted reading. The 150 cases consisted of 125 normal mammograms and 25 mammograms with subtle breast cancers. Cases were divided into two groups of 75 cases each (cohort 1 and cohort 2), with a comparable distribution of cancer cases. Four rounds of 75 cases each were conducted with a 6-week washout period between rounds 2 and 3. After completing each interpretation session, readers completed a seven-question survey, assessing perceptions of mental and physical effort, level of frustration, and performance satisfaction. Clinical performance metrics (reading time, recall rate, sensitivity, specificity, accuracy, and positive predictive value 1) were calculated. ResultsRecall rates were significantly (P = .04) higher during interrupted reading sessions (35.4%) than they were during uninterrupted batch reading sessions (31.4%). Accuracy was significantly (P = .049) worse in the interrupted reading sessions (69.5%), compared with uninterrupted sessions (73.6%). Differences in overall image interpretation times were not statistically significant (P = .065). Compared with uninterrupted batch reading sessions, readers during interrupted sessions reported feeling busier (P < .001), encountered higher levels of cognitive demand (P = .005), experienced elevated levels of physical fatigue (P = .004), and expressed lower levels of satisfaction with their performance (P = .041). ConclusionInterruptions during interpretation of screening mammography have deleterious effects on physician performance and their sense of well-being.