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1.  Development and standardization of Mysore Tridosha scale 
Ayu  2011;32(3):308-314.
The authors have developed a personality scale to assess Tridoshas i.e. Vata, Pitta, and Kapha from psychological perspective in human beings. The Tridoshas are composed of the Pancha Mahabhutas, but one or the other Dosha is dominant singularly or in combination. There can never be a state when one or the other Pancha Mahabhutas and consequently the Tridoshas are absent totally. All five are essential to sustain life. Vata Dosha is composed of Akasa and Vayu Mahabhuta. Pitta Dosha is composed of Tejas or Agni and Ap Mahabhuta. Kapha Dosha is composed of Ap and Prithvi Mahabhuta. Although Tridosha is studied, understood, and applied in Ayurveda, the present authors have tried to validate the same from the domain of psychology. Since the authors are not from the domain of Ayurveda but of Psychology, there are some constructs that are not amenable for psychological testing which have been ignored. Only those constructs that can be used by psychologists to assess the psychological aspects of the Dosha Prakriti have been used to build items for the assessment of personality. In this process, the psychometric properties of the scale are established. The scale assesses the psychological manifestation of the Tridoshas, which was the basic objective. The standardization procedure involved in the development of the Mysore Psychological Tridosha Scale is herewith delineated.
PMCID: PMC3326873  PMID: 22529642
Ayurveda; Kapha; Pitta; personality assessment; psychometric scale; Tridosha; Vata
2.  PA01.17. A clinical study to evaluate the effect of extract based herbal formulation on hypertension- a single blinded standard controlled randomized study 
Ancient Science of Life  2012;32(Suppl 1):S66-S67.
In Ayurveda although there is no such terminology like hypertension but still this work is an approach to establish relationship between Hypertension & vitiated functioning of three governing forces of our body i.e. Tridosha and to treat Hypertension on Ayurvedic principles. The logic behind such correlation is based on the fact that, like other physiological processes, B.P. too is normal phenomenon of our body which is governed by Tridosha. After going through modern pathogenesis of primary hypertension and its symptomology, in present study it has been correlated with Vata Kaphaja Vikara with Rasavaha, Raktavaha and Manovahi Srotas as the seat of disease. Looking at its pathogenesis, the term Uccha Vyan Bala (exaggerated physiological functioning of Vyan Vayu leading to increase contractility of heart & blood vessels) can be coined for hypertension.
Subjective criteria Headache, Palpitation, Vertigo, Dyspnoea on walks and Fatigue. Objective criteria BP value recorded by sphygmomanometer in supine position. Final assessment of results; Subjective assessment 75 to 100% disappearance of symptoms effectively cured. 50 to 74% disappearance of symptoms well cured. 25 to 49% disappearance of symptoms fairly cured. 0 to 24% disappearance of symptoms poorly cured. Objective assessment Patient showing reduction in BP by 10mmHg Poorly cured; Patient showing reduction in BP between 11 to 20mmHg Fairly cured; Patient showing reduction in BP between 21 to 30 mmHg Well cured; Patient showing reduction in BP by more than 30 mmHg Effectively cured. Research methodology Type of study-Single blinded comparative study. Study site IPD and OPD department of Shubhdeep ayurved medical college, Indore (MP). Sample size 50 patients divided randomly into two equal groups. Group A given trial drug whereas Group B given control drug. Drug dosage and vehicle 1 capsule twice daily with lukewarm water after meals. Duration of treatment one month (examined at weekly intervals.) Dietary advice to strictly restrict the daily intake of Amla, Lavana, Guru & Vidahi diet.
70% Patients found to be hypertensive were above 40 years of age. 60% Patients were fond of salty & spicy diet. Out of 50 patients 30 patients (60%) belongs to service class. Out of 50 patients 35 patients (70%) were male. Regarding prevalence of symptoms, Dyspnoea on routine work was found in 82%, Headache & palpitation in 80%, Vertigo in 78% & Fatigue in 66% patients.
As per classical texts, Vata predominant diseases are caused due to vitiation of Vata due to emaciation (Dhatu Kshaya) & obstruction (Marg avarodha). Hypertension seems to be Vata predominant disease due to obstruction. Reason being that, Lavana is Vata Shamak, & should therefore decrease Blood pressure but on contrary it increases B.P. Similarly increase in weight leads to greater chances of High Blood pressure. Above discussion favours that Hypertension can be considered Vata predominant disease due to Marg avarodha by Kapha Dosha and Pitta Dosha in Anubandh. Finally it can be concluded that the drug under study has shown enthusiastic results in reducing the overall value of blood pressure. 64% patients got effectively cured, 24% got well cured and 12% got fairly cured. Regarding symptomatic relief, out of 25 patients 8 showed more than 75% relief, 9 showed more than 50% relief, 7 showed more than 25% relief and only 1 patient showed less than 25% relief in overall symptoms. No significant side effects have been reported in any subject.
PMCID: PMC3800947
3.  Dyslexia: A solution through Ayurveda evidences from Ayurveda for the management of dyslexia in children: A review 
Ayu  2012;33(4):486-490.
Dyslexia is one of the commonest learning disability. It is defined as a disorder where a child, in spite of all the classroom teaching, is not able to attain the language skills of reading, writing and spelling according to their level of intelligence. Dyslexia individuals often have difficulty in relating to the association between sound and their respective letters. Reversing or transposing the letters while writing is characteristic with letters such as b and d, P and q, etc., The prevalence among school children is reported as 9.87% and in the selected families, it is 28.32%. Dyslexia significantly interferes with academic achievement or activities of daily life and are not primarily due to sensory, motor or mentally handicaps. About 40% of dyslexic children and adolescents dropout of schools. According to Ayurveda, learning is a result of successive and complex interaction of Indriyas (cognitive and motor organs), Indriyartha (sense organs), Mana (psyche), Atma and Buddhi (intellect). Above all, the functioning of these factors is governed by Tridosha (vata, pitta and kapha) and Triguna (Sattva, Raja and Tama) in a specific coordination and balance Any disturbance in these Tridosha and Triguna will cause disordered functioning of Indriya, Mana and Buddhi leading to impaired learning or Dyslexia Ayurvedic drugs can help in the management of dyslexia by making these Tridosha and Triguna in well-balanced state and also by providing Medhya (intellect promoting) drugs to improve the learning ability in these children.
PMCID: PMC3665203  PMID: 23723664
Ayurveda; dyslexia; Medhya; Tridosha; Triguna
The medical and philosophical system of Asclepiades of Bithynia (fl. later second century BC)1 has been the subject of considerable controversy.2 His physical theory of anarmoi onkoi in particular has seen intense debate, and although many of its broader features appear to be fairly well established, many of its most fundamental details remain obscure. Perhaps somewhat paradoxically, some of the most important work carried out on Asclepiades has been explicitly focused instead on Heraclides of Pontus,3 the reconstruction of whose physical theory has often proceeded on the assumption that this was largely replicated by Asclepiades some two centuries later. But to a great extent the Asclepiadean debate has been framed in terms of the question of his intellectual debts to ancient atomism, and Epicureanism in particular, and in this respect the present study will be no different.4 The most recent scholarship has been sharply divided over this question. Vallance has emphasized the principally medical context of Asclepiades' system, and made the case that the frangibility of the onkoi marks such a fundamental divergence from Epicurus' atomism that any influence from Epicurean physics should be rejected, and that we should look instead especially to Erasistratus.5 Casadei, however, following on to a certain extent from the work of Pigeaud, has rightly drawn attention to the tendency in Vallance's exposition to suppress a number of fundamental elements of Asclepiades' doctrine which are undeniably also distinguishing features of Epicurean philosophy.6 The most significant of these include his particulate theory of matter, his antiteleological conception of nature, and his rejection of any theory of qualitative change. But these correspondences would certainly not be sufficient to qualify Asclepiades' system simply as a reproduction of Epicureanism, and there is clear evidence that Asclepiades stood in opposition to Epicurus in certain fundamental respects. In a recent study which has done much to establish Asclepiades' credentials as a philosopher, focusing especially on his philosophy of mind, Polito has underlined certain distinctly non-Epicurean elements in his system, such as his radical determinism and his denial of a localized ruling-part-of-the-soul.7 It thus seems clear that, despite some important parallels between their systems, Asclepiades cannot be regarded as an Epicurean physician. The evidence we have for his doctrine, and the authority which was accorded him by later writers, clearly attests to his status as an independent and innovative thinker in his own right. While Asclepiades' theory must, in my view, be analysed within the context of the Epicurean atomistic tradition, it must equally be acknowledged that any identifiable relationship between Epicurus and Asclepiades is likely to be one of considerable complexity.
In this paper I shall attempt to explore further the nature of the relationship between Epicurus and Asclepiades by examining some aspects of the latter's theory of matter. Given the widespread disagreement about his theory in general, I propose to focus on a fundamental question which I believe the extant evidence allows us to answer with a satisfactory degree of certainty, namely what Asclepiades' position was on the qualitative status of his onkoi. In Section I I shall analyse four passages which have a direct bearing on this question, from Caelius Aurelianus, Galen, Sextus Empiricus, and Calcidius respectively. I shall argue here that this position was in its details substantially the same as Epicurus' with regard to his atoms. It must be stressed that it is only in details that we can make such comparisons, since we have no surviving testimony which recounts Asclepiades' arguments or broader reasons for holding such a position. Nevertheless, in Section II I shall argue that these identifiable similarities in their respective doctrines on the qualities of their elements were more than superficial or incidental, and strongly suggest that Asclepiades and Epicurus shared certain premisses which were fundamental to their physics, which might then be used to contextualize and elucidate some of the more idiosyncratic and apparently unique parts of Asclepiades' system. This will lead me to suggest an interpretation of an important piece of evidence which may confirm that Asclepiades was reacting in a direct and critical way to certain aspects of Epicurus' physical doctrine.
PMCID: PMC2977080  PMID: 21076682
5.  Are Eyes Windows to a Deceiver's Soul? Children's Use of Another's Eye Gaze Cues in a Deceptive Situation 
Developmental psychology  2004;40(6):1093-1104.
Three experiments examined 3- to 5-year-olds' use of eye gaze cues to infer truth in a deceptive situation. Children watched a video of an actor who hid a toy in 1 of 3 cups. In Experiments 1 and 2, the actor claimed ignorance about the toy's location but looked toward 1 of the cups, without (Experiment 1) and with (Experiment 2) head movement. In Experiment 3, the actor provided contradictory verbal and eye gaze clues about the location of the toy. Four- and 5-year-olds correctly used the actor's gaze cues to locate the toy, whereas 3-year-olds failed to do so. Results suggest that by 4 years of age, children begin to understand that eye gaze cues displayed by a deceiver can be informative about the true state of affairs.
PMCID: PMC2567061  PMID: 15535759
6.  Self-Efficacy as a Marker of Cardiac Function and Predictor of Heart Failure Hospitalization and Mortality in Patients With Stable Coronary Heart Disease: Findings From the Heart and Soul Study 
The authors sought to evaluate the association of self-efficacy with objective measures of cardiac function, subsequent hospitalization for heart failure (HF), and all-cause mortality.
Observational cohort of ambulatory patients with stable CHD. The authors measured self-efficacy using a published, validated, 5-item summative scale, the Sullivan Self-Efficacy to Maintain Function Scale. The authors also performed a cardiac assessment, including an exercise treadmill test with stress echocardiography.
Main Outcome Measures
Hospitalizations for HF, as determined by blinded review of medical records, and all-cause mortality, with adjustment for demographics, medical history, medication use, depressive symptoms, and social support.
Of the 1,024 predominately male, older CHD patients, 1013 (99%) were available for follow-up, 124 (12%) were hospitalized for HF, and 235 (23%) died during 4.3 years of follow-up. Mean cardiac self-efficacy score was 9.7 (SD 4.5, range 0–20), corresponding to responses between “not at all confident” and “somewhat confident” for ability to maintain function. Lower self-efficacy predicted subsequent HF hospitalization (OR per SD decrease = 1.4, p = 0006), and all-cause mortality (OR per SD decrease = 1.4, p < .0001). After adjustment, the association of cardiac self-efficacy with both HF hospitalization and mortality was explained by worse baseline cardiac function.
Among patients with CHD, self-efficacy was a reasonable proxy for predicting HF hospitalizations. The increased risk of HF associated with lower baseline self-efficacy was explained by worse cardiac function. These findings indicate that measuring cardiac self-efficacy provides a rapid and potentially useful assessment of cardiac function among outpatients with CHD.
PMCID: PMC2764522  PMID: 19290708
self-efficacy; heart failure; epidemiology
Ancient Science of Life  1988;8(2):113-116.
In this paper the author discusses five souls viz, prana, Apana, Udana, Samana and vyana of Indian physiology. Also aims to show that the last named two souls were unknown to Galen.
PMCID: PMC3331365  PMID: 22557641
8.  mHealth: A Strategic Field without a Solid Scientific Soul. A Systematic Review of Pain-Related Apps 
PLoS ONE  2014;9(7):e101312.
Mobile health (mHealth) has undergone exponential growth in recent years. Patients and healthcare professionals are increasingly using health-related applications, at the same time as concerns about ethical issues, bias, conflicts of interest and privacy are emerging. The general aim of this paper is to provide an overview of the current state of development of mHealth.
Methods and Findings
To exemplify the issues, we made a systematic review of the pain-related apps available in scientific databases (Medline, Web of Science, Gale, Psycinfo, etc.) and the main application shops (App Store, Blackberry App World, Google Play, Nokia Store and Windows Phone Store). Only applications (designed for both patients and clinicians) focused on pain education, assessment and treatment were included. Of the 47 papers published on 34 apps in scientific databases, none were available in the app shops. A total of 283 pain-related apps were found in the five shops searched, but no articles have been published on these apps. The main limitation of this review is that we did not look at all stores in all countries.
There is a huge gap between the scientific and commercial faces of mHealth. Specific efforts are needed to facilitate knowledge translation and regulate commercial health-related apps.
PMCID: PMC4085095  PMID: 24999983
9.  The Soul and the Body in the Philosophy of the Rambam 
Among the wide-spectrum contribution of the Rambam – the Maimonides – in philosophy to the word and to Judaism are his ideas on the body and on the soul and on the relations between them. His major approaches in these subjects are the following: 1) The body is the home of the soul, and the soul guides the body. That means the body and the soul are one unit. 2) The soul has five virtual parts. Each part is responsible for another activity in the human being. 3) Except for the treatment of diseases of the body and the soul with drugs, foods, physical exercise, etc., the Rambam believes that maintaining the health – of the body and of the soul – lies first of all, and probably exclusively, in observing the commandments and improving one’s ways, morals and conduct up to their highest levels, toward all of the world’s creatures. 4) The Rambam is of the opinion that one needs to persist in learning the Torah. One should worship God with awe and love and observe good values and virtues. All of these build the frameworks that maintain mental health and strengthen man’s abilities to develop skills for maintaining bodily health. This is so because body and soul are one – which is the basis of the Rambam’s philosophy of health and medicine.
PMCID: PMC3678934  PMID: 23908798
Maimonides; Rambam; soul; body; soul-body
10.  First-degree atrioventricular block is associated with heart failure and death in persons with stable coronary artery disease: data from the Heart and Soul Study 
European Heart Journal  2011;32(15):1875-1880.
First-degree atrioventricular block (AVB) has traditionally been considered a benign electrocardiographic finding in healthy individuals. However, the clinical significance of first-degree AVB has not been evaluated in patients with stable coronary heart disease. We investigated whether first-degree AVB is associated with heart failure (HF) and mortality in a prospective cohort study of outpatients with stable coronary artery disease (CAD).
Methods and results
We measured the P–R interval in 938 patients with stable CAD and classified them into those with (P–R interval ≥220 ms) and without (P–R interval <220 ms) first-degree AVB. Hazard ratios (HRs) and 95% confidence intervals were calculated for HF hospitalization and all-cause mortality. During 5 years of follow-up, there were 123 hospitalizations for HF and 285 deaths. Compared with patients who had normal atrioventricular conduction, those with first-degree AVB were at increased risk for HF hospitalization (age-adjusted HR 2.33: 95% CI 1.49–3.65; P= 0.0002), mortality [age-adjusted HR 1.58; 95% CI (1.13–2.20); P = 0.008], cardiovascular (CV) mortality [age-adjusted HR 2.33; 95% CI (1.28–4.22); P= 0.005], and the combined endpoint of HF hospitalization or CV mortality (age-adjusted HR 2.43: 95% CI 1.64–3.61; P ≤ 0.0001). These associations persisted after multivariable adjustment for heart rate, medication use, ischaemic burden, and QRS duration. Adjustment for left ventricular systolic and diastolic function partially attenuated the effect, but first-degree AVB remained associated with the combined endpoint of HF or CV death (HR 1.61, CI 1.02–2.54; P= 0.04).
In a large cohort of patients with stable coronary artery disease, first-degree AVB is associated with HF and death.
PMCID: PMC3202329  PMID: 21606074
Stable coronary artery disease; Atrioventricular block; Heart failure
11.  Understanding Brain, Mind and Soul: Contributions from Neurology and Neurosurgery 
Mens Sana Monographs  2011;9(1):129-149.
Treatment of diseases of the brain by drugs or surgery necessitates an understanding of its structure and functions. The philosophical neurosurgeon soon encounters difficulties when localising the abstract concepts of mind and soul within the tangible 1300-gram organ containing 100 billion neurones. Hippocrates had focused attention on the brain as the seat of the mind. The tabula rasa postulated by Aristotle cannot be localised to a particular part of the brain with the confidence that we can localise spoken speech to Broca’s area or the movement of limbs to the contralateral motor cortex. Galen’s localisation of imagination, reasoning, judgement and memory in the cerebral ventricles collapsed once it was evident that the functional units–neurones–lay in the parenchyma of the brain. Experiences gained from accidental injuries (Phineas Gage) or temporal lobe resection (William Beecher Scoville); studies on how we see and hear and more recent data from functional magnetic resonance studies have made us aware of the extensive network of neurones in the cerebral hemispheres that subserve the functions of the mind. The soul or atman, credited with the ability to enliven the body, was located by ancient anatomists and philosophers in the lungs or heart, in the pineal gland (Descartes), and generally in the brain. When the deeper parts of the brain came within the reach of neurosurgeons, the brainstem proved exceptionally delicate and vulnerable. The concept of brain death after irreversible damage to it has made all of us aware of ‘the cocktail of brain soup and spark’ in the brainstem so necessary for life. If there be a soul in each of us, surely, it is enshrined here.
PMCID: PMC3115284  PMID: 21694966
Brain; Brainstem; Mind; Soul; Neurology; Neurosurgery; Philosophy
12.  Depressive Symptoms and Perceived Doctor-Patient Communication in the Heart and Soul Study 
Doctor-patient communication is an important marker of health-care quality. Little is known about the extent to which medical comorbidities, disease severity and depressive symptoms influence perceptions of doctor-patient communication in patients with chronic disease.
In a cross-sectional study of 703 outpatients with chronic coronary disease, we evaluated the extent to which patient reports of doctor-patient communication were influenced by medical comorbidities, disease severity and depressive symptoms. We assessed patient reports of doctor-patient communication using the Explanations of Condition and Responsiveness to Patient Preferences subscales from the “Interpersonal Processes of Care” instrument. Poor doctor-patient communication was defined as a score of <4 (range 1 to 5) on either subscale. All patients completed the nine-item Patient Health Questionnaire (PHQ) for measurement of depressive symptoms and underwent an extensive evaluation of medical comorbidities and cardiac function.
In univariate analyses, the following patient characteristics were associated with poor reported doctor-patient communication on one or both subscales: female sex, white or Asian race and depressive symptoms. After adjusting for demographic factors, medical comorbidities and disease severity, each standard deviation (5.4-point) increase in depressive symptom score was associated with a 50% greater odds of poor reported explanations of condition (OR 1.5, 95% CI, 1.2–1.8; p < 0.001) and a 30% greater odds of poor reported responsiveness to patient preferences (OR 1.3, 95% CI, 1.1–1.5; p = 0.01). In contrast, objective measures of disease severity (left ventricular ejection fraction, exercise capacity, inducible ischemia) and medical comorbidities (hypertension, diabetes, myocardial infarction) were not associated with reports of doctor-patient communication.
In outpatients with chronic coronary heart disease, depressive symptoms are associated with perceived deficits in doctor-patient communication, while medical comorbidities and disease severity are not. These findings suggest that patient reports of doctor-patient communication may partly reflect the psychological state of the patient.
PMCID: PMC2669866  PMID: 19274477
doctor-patient communication; depression; chronic disease
13.  The Soul-Sucking Wasp by Popular Acclaim – Museum Visitor Participation in Biodiversity Discovery and Taxonomy 
PLoS ONE  2014;9(4):e95068.
Taxonomy, the science of describing and naming of the living world, is recognized as an important and relevant field in modern biological science. While there is wide agreement on the importance of a complete inventory of all organisms on Earth, the public is partly unaware of the amount of known and unknown biodiversity. Out of the enormous number of undescribed (but already recognized) species in natural history museum collections, we selected an attractive example of a wasp, which was presented to museum visitors at a special museum event. We asked 300 visitors to vote on a name for the new species and out of four preselected options, Ampulex dementor Ohl n. sp. was selected. The name, derived from the ‘soul sucking’ dementors from the popular Harry Potter books is an allusion to the wasps' behavior to selectively paralyze its cockroach prey. In this example, public voting on a scientific name has been shown to be an appropriate way to link museum visitors emotionally to biodiversity and its discovery.
PMCID: PMC3995701  PMID: 24755672
14.  The role of religious leaders in promoting acceptance of vaccination within a minority group: a qualitative study 
BMC Public Health  2013;13:511.
Although childhood vaccination programs have been very successful, vaccination coverage in minority groups may be considerably lower than in the general population. In order to increase vaccination coverage in such minority groups involvement of faith-based organizations and religious leaders has been advocated. We assessed the role of religious leaders in promoting acceptance or refusal of vaccination within an orthodox Protestant minority group with low vaccination coverage in The Netherlands.
Semi-structured interviews were conducted with orthodox Protestant religious leaders from various denominations, who were selected via purposeful sampling. Transcripts of the interviews were thematically analyzed, and emerging concepts were assessed for consistency using the constant comparative method from grounded theory.
Data saturation was reached after 12 interviews. Three subgroups of religious leaders stood out: those who fully accepted vaccination and did not address the subject, those who had religious objections to vaccination but focused on a deliberate choice, and those who had religious objections to vaccination and preached against vaccination. The various approaches of the religious leaders seemed to be determined by the acceptance of vaccination in their congregation as well as by their personal point of view. All religious leaders emphasized the importance of voluntary vaccination programs and religious exemptions from vaccination requirements. In case of an epidemic of a vaccine preventable disease, they would appreciate a dialogue with the authorities. However, they were not willing to promote vaccination on behalf of authorities.
Religious leaders’ attitudes towards vaccination vary from full acceptance to clear refusal. According to orthodox Protestant church order, local congregation members appoint their religious leaders themselves. Obviously they choose leaders whose views are compatible with the views of the congregation members. Moreover, the positions of orthodox Protestant religious leaders on vaccination will not change easily, as their objections to vaccination are rooted in religious doctrine and they owe their authority to their interpretation and application of this doctrine. Although the dialogue with religious leaders that is pursued by the Dutch government may be helpful in controlling epidemics by other means than vaccination, it is unlikely to increase vaccination coverage.
PMCID: PMC3668146  PMID: 23711160
Vaccination; Minority groups; Orthodox Protestants; Religion; Religious leaders
15.  Establishing the Scientific Validity of Tridosha part 1: Doshas, Subdoshas and Dosha Prakritis 
Ancient Science of Life  2010;29(3):6-18.
In traditional Ayurdev, basic concepts such as Tridosa are introduced didactically. Students of Ayurdeva learn to appreciate their practical value through experience; their validity is empirical. In an age where validity of concepts is judged by their scientific relevance, establishing the scientific validity of Tridosha is a program of significance. It requires translating concept and practical application into the idiom of modern biology and medicine. Four different complementary approaches have been proposed to do so: factor analysis of human physiology; systems analysis of organism function; correlation of Dosha and genomic variations - Ayugenomics; and correlation of Dosha and cellular function. Together these four independent approaches present compelling evidence that the family of Dosha based, Ayurveda fundamental concepts - the three Doshas, their fifteen subdoshas, innate Dosha balance in the individual (prakriti), and Dosha imbalances (vikriti) are scientifically valid. This paper concerns the first three. (I) The systems approach shows how Tridosha applies to every living organism from the first cells, and how it is inherited and diversified in the history of life. (2) Ayugenomics confirms Dosha's inheritance. (3) Each Dosha is responsible for regulating an essential aspect of organism function, connected to a recognised definition of life: Vata, Input/Output (homeostasis); Pitta, Turnover (negative entropy production); Kapha, Storage (inheritable structure).
PMCID: PMC3336287  PMID: 22557353
16.  The Soul’s Wisdom: Stories of Living and Dying 
Current Oncology  2008;15(Suppl 2):s107.es48-s107.es52.
Cancer can lead to spiritual transformation, which can be seen as a form of alchemy. During this process, patients, family members, and even professional caregivers can find themselves having spiritual experiences that go beyond any they had previously encountered. This paper provides qualitative descriptions of the “Field” or “Soul Wisdom” experienced by patients and caregivers.
PMCID: PMC2528551  PMID: 18769614
17.  A mask to modify inspired air temperature and humidity and its effect on exercise induced asthma. 
Thorax  1992;47(6):446-450.
BACKGROUND: Heat and moisture loss from the respiratory tract during exercise are important triggers of exercise induced asthma. METHODS: A new heat and moisture exchange mask has been developed which both recovers exhaled heat and water and has a sufficiently low resistance for use during exercise. The effect of the mask on inspired air temperature was studied in four normal subjects. Eight asthmatic subjects performed identical exercise protocols on three separate days, breathing room air through a conventional mouthpiece, a dummy mask, and the new heat and moisture exchange mask. Seven different asthmatic subjects exercised while breathing cold air at -13 degrees C through a dummy or active mask. RESULTS: All subjects found the new mask comfortable to wear. The mean inspired temperature when the mask was used rose to 32.5 (1.4) degrees C when normal subjects breathed room air at 24 degrees C and to 19.1 (2.7) degrees C when they inhaled subfreezing air at -13 degrees C. The heat and moisture exchange mask significantly reduced the median fall in forced expiratory volume in one second (FEV1) after exercise to 13% (range 0-49%) when asthmatic subjects breathed room air compared with 33% (10-65%) with the dummy mask and 28% (21-70%) with the mouthpiece. The fall in FEV1 when the asthmatic subjects breathed cold air was 10% (0-26%) with the heat and moisture exchange mask compared with 22% (13-51%) with the dummy mask. CONCLUSION: Use of a heat and moisture exchange mask can raise the inspired temperature and humidity and ameliorate the severity of exercise induced asthma. The mask may be of practical value in non-contact sport or for people working in subzero temperatures.
PMCID: PMC463810  PMID: 1496504
18.  Atoh1-dependent rhombic lip neurons are required for temporal delay between independent respiratory oscillators in embryonic mice 
eLife  2014;3:e02265.
All motor behaviors require precise temporal coordination of different muscle groups. Breathing, for example, involves the sequential activation of numerous muscles hypothesized to be driven by a primary respiratory oscillator, the preBötzinger Complex, and at least one other as-yet unidentified rhythmogenic population. We tested the roles of Atoh1-, Phox2b-, and Dbx1-derived neurons (three groups that have known roles in respiration) in the generation and coordination of respiratory output. We found that Dbx1-derived neurons are necessary for all respiratory behaviors, whereas independent but coupled respiratory rhythms persist from at least three different motor pools after eliminating or silencing Phox2b- or Atoh1-expressing hindbrain neurons. Without Atoh1 neurons, however, the motor pools become temporally disorganized and coupling between independent respiratory oscillators decreases. We propose Atoh1 neurons tune the sequential activation of independent oscillators essential for the fine control of different muscles during breathing.
eLife digest
A healthy adult at rest will breathe in and out around 20 times per minute. Each breath requires a complex series of coordinated muscle activity. Inhalation begins with the opening of the airway followed by the contraction of the diaphragm and the intercostal muscles between the ribs, causing the chest cavity to expand. As the lungs increase in volume, the pressure inside them drops and air is drawn in. Relaxation of the diaphragm and intercostal muscles compresses the lungs, causing us to exhale.
Breathing is driven by the brainstem and it cannot be suppressed indefinitely: holding your breath eventually triggers a reflex that forces breathing to resume. The region of the brainstem that controls breathing is called the preBötzinger Complex. However, there is increasing evidence that a second region in the brainstem is also involved. This region, which is called the retrotrapezoid nucleus/parafacial respiratory group, consists of three types of excitatory neurons—Dbx1 neurons, Phox2b neurons, and Atoh1 neurons—but their roles had not been clear. Now, using multiple lines of genetically modified mice, Tupal et al. have teased apart the roles of these three cell types.
These experiments showed that the Dbx1 neurons—which are also found in the preBötzinger Complex—have an essential role in sending the signals from the brain that drive the different muscle activities needed to breathe. The Phox2b neurons modulate breathing based on the level of carbon dioxide in the blood. Atoh1 neurons help control the sequence of respiratory muscle activity during a breath, probably by selectively inhibiting different populations of Dbx1 neurons.
The work of Tupal et al. indicates that distinct populations of neurons within the brainstem independently control two different aspects of breathing: the generation of breathing rhythms, and the coordination of these rhythms. Given that many other physiological processes involve rhythmic activity patterns, this model may help us to understand how the brain generates and controls complex behaviors more generally.
PMCID: PMC4060005  PMID: 24842997
breathing; central pattern generator; PreBötzinger Complex; oscillator; transcription; mouse
19.  Does the Supplementary Motor Area Keep Patients with Ondine's Curse Syndrome Breathing While Awake? 
PLoS ONE  2014;9(1):e84534.
Congenital central hypoventilation syndrome (CCHS) is a rare neuro-respiratory disorder associated with mutations of the PHOX2B gene. Patients with this disease experience severe hypoventilation during sleep and are consequently ventilator-dependent. However, they breathe almost normally while awake, indicating the existence of cortical mechanisms compensating for the deficient brainstem generation of automatic breathing. Current evidence indicates that the supplementary motor area plays an important role in modulating ventilation in awake normal humans. We hypothesized that the wake-related maintenance of spontaneous breathing in patients with CCHS could involve supplementary motor area.
We studied 7 CCHS patients (5 women; age: 20–30; BMI: 22.1±4 kg.m−2) during resting breathing and during exposure to carbon dioxide and inspiratory mechanical constraints. They were compared with 8 healthy individuals. Segments of electroencephalographic tracings were selected according to ventilatory flow signal, from 2.5 seconds to 1.5 seconds after the onset of inspiration. After artefact rejection, 80 or more such segments were ensemble averaged. A slow upward shift of the EEG signal starting between 2 and 0.5 s before inspiration (pre-inspiratory potential) was considered suggestive of supplementary motor area activation.
In the control group, pre-inspiratory potentials were generally absent during resting breathing and carbon dioxide stimulation, and consistently identified in the presence of inspiratory constraints (expected). In CCHS patients, pre-inspiratory potentials were systematically identified in all study conditions, including resting breathing. They were therefore significantly more frequent than in controls.
This study provides a neurophysiological substrate to the wakefulness drive to breathe that is characteristic of CCHS and suggests that the supplementary motor area contributes to this phenomenon. Whether or not this “cortical breathing” can be taken advantage of therapeutically, or has clinical consequences (like competition with attentional resources) remains to be determined.
PMCID: PMC3901646  PMID: 24475031
20.  Efficacy and cost-effectiveness of the 13C-urea breath test as the primary diagnostic investigation for the detection of Helicobacter pylori infection compared to invasive and non-invasive diagnostic tests 
Helicobacter pylori (H. pylori) is one of the most common bacterial infections in humans. There is a risk factor for gastric or duodenal ulcers, gastric cancer and MALT (Mucosa Associated Lymphoid Tissue)-Lymphomas. There are several invasive and non-invasive methods available for the diagnosis of H. pylori. The 13C-urea breath test is a non-invasive method recommended for monitoring H. pylori eradication therapy. However, this test is not yet used for primary assessment of H. pylori in Germany.
What are the clinical and health economic benefits of the 13C-urea breath test in the primary assessment of H. pylori compared to other invasive and non-invasive methods?
A systematic literature search including a hand search was performed for studies investigating test criteria and cost-effectiveness of the 13C-urea breath test in comparison to other methods used in the primary assessment of H. pylori. Only studies that directly compared the 13C-urea breath test to other H. pylori-tests were included. For the medical part, biopsy-based tests were used as the gold standard.
30 medical studies are included. Compared to the immunoglobulin G (IgG) test, the sensitivity of the 13C-urea breath test is higher in twelve studies, lower in six studies and one study reports no differences. The specificity is higher in 13 studies, lower in three studies and two studies report no differences. Compared to the stool antigen test, the sensitivity of the 13C-urea breath test is higher in nine studies, lower in three studies and one study reports no difference. The specificity is higher in nine studies, lower in two studies and two studies report no differences. Compared to the urease test, the sensitivity of the 13C-urea breath test is higher in four studies, lower in three studies and four studies report no differences. The specificity is higher in five studies, lower in five studies and one study reports no difference. Compared to histology, the sensitivity of the 13C-urea breath test is higher in one study and lower in two studies. The specificity is higher in two studies and lower in one study. One study each compares the 13C-urea breath test to the 14C-urea breath test and the polymerase chain reaction (PCR) test, respectively, and reports no difference in sensitivity and specificity with the 14C-urea breath test, and lower sensitivity and higher specificity compared to PCR. The statistical significance of these differences is described for six of the 30 studies.
Nine health economic evaluations are included in the Health Technology Assessment (HTA) report. Among these studies, the test-and-treat strategy using the 13C-urea breath test is compared to test-and-treat using serology in six analyses and to test and treat using the stool antigen test in three analyses. Thereby, test-and-treat using the breath test is shown to be cost-effective over the serology based strategy in three models and is dominated by a test-and-treat strategy using the stool antigen test in one model. A cost-effectiveness comparison between the urea breath test approach and the empirical antisecretory therapy is carried out in four studies. Of these, two studies report that the strategy using the urea breath test is cost-effective over the empirical antisecretory therapy. In two studies, test-and-treat using the 13C-urea breath test is compared to the empirical eradication therapy and in five studies to endoscopy-based strategies. The breath test approach dominates endoscopy in two studies and is dominated by this strategy in one study.
All included medical and economic studies are limited to a greater or lesser extent. Additionally, the results of the studies are heterogeneous regarding medical and economic outcomes respectively. Thus, the majority of the medical studies do not report the statistical significance of the differences in sensitivity and specificity. In direct comparisons the 13C- urea breath test shows higher sensitivity and specificity than the IgG and stool antigen tests. In comparison to the urease test, results for sensitivity are inconsistent, and the specificity is slightly higher for the 13C-urea breath test. There are not enough results for comparisons between the 13C-urea breath test and the 14C-urea breath test, histology and PCR to describe tendencies.
The included economic studies suggest that the test-and-treat strategy using the 13C-urea breath test is cost-effective compared to test-and-treat using serology as well as empirical antisecretory therapies. Due to a lack of valid studies, it is not possible to assess the breath test approach in comparison to test-and-treat using the stool antigen test and the empirical eradication therapy respectively, regarding the cost-effectiveness. The results of economic analyses comparing test-and-treat using the breath test to endoscopy strategies are too heterogeneous to draw any conclusions. Overall, none of the included economic models is able to completely capture the complexity of managing patients with dyspeptic complaints.
Based on available medical and economic studies, there is no sufficient evidence to recommend test and-treat using 13C-urea breath testing for the detection of H. pylori infection as the standard procedure for the management of uninvestigated dyspepsia in the German health care system. In addition, it must be considered that the DVGS guidelines of the Deutsche Gesellschaft für Verdauungs- und Stoffwechselkrankheiten (DVGS) recommend endoscopy based methods for the management of patients with dyspeptic complaints.
PMCID: PMC3011289  PMID: 21289901
21.  Effect of water temperature on dermal exposure to chloroform. 
Environmental Health Perspectives  1998;106(6):337-345.
We have developed and applied a new measurement methodology to investigate dermal absorption of chloroform while bathing. Ten subjects bathed in chlorinated water while breathing pure air through a face mask. Their exhaled breath was delivered to a glow discharge source/ion trap mass spectrometer for continuous real-time measurement of chloroform in the breath. This new method provides abundant data compared to previous discrete time-integrated breath sampling methods. The method is particularly well suited to studying dermal exposure because the full face mask eliminates exposure to contaminated air. Seven of the 10 subjects bathed in water at two or three different temperatures between 30 degrees C and 40 degrees C. Subjects at the highest temperatures exhaled about 30 times more chloroform than the same subjects at the lowest temperatures. This probably results from a decline in blood flow to the skin at the lower temperatures as the body seeks to conserve heat forcing the chloroform to diffuse over a much greater path length before encountering the blood. These results suggest that pharmacokinetic models need to employ temperature-dependent parameters. Two existing models predict quite different times of about 12 min and 29 min for chloroform flux through the stratum corneum to reach equilibrium. At 40 degrees C, the time for the flux to reach a near steady-state value is 6-9 min. Although uptake and decay processes involve several body compartments, the complicating effect of the stratum corneum lag time made it difficult to fit multiexponential curves to the data; however, a single-compartment model gave a satisfactory fit.
PMCID: PMC1532999  PMID: 9618350
The work reported in the preceding sections justifies, we think, a number of definite conclusions. In addition to this, some of the experiments indicate a line of thought which may lead to considerable alteration in our conceptions, both of phenomena of bacterial hypersensitiveness and of infection. 1. In guinea pigs two fundamentally different types of intradermal reactions may be observed. One of these is the immediate, transitory reaction which develops in animals sensitized against proteins (horse serum, etc.) and may be regarded as one of the manifestations of general protein hypersensitiveness, or anaphylaxis; the other is the tuberculin type of skin reaction which develops more slowly, leads to a more profound injury of the tissues and is independent of anaphylaxis as ordinarily conceived. 2. The tuberculin type of hypersensitiveness (as well as probably the typhoidin, mallein, abortin reactions, etc.) does not develop at all in guinea pigs sensitized with proteins, like horse serum, etc. While this form of hypersensitiveness may eventually be induced with materials not bacterial in origin, it has been observed up to date only as a reaction of bacterial infection. 3. Methods of treatment with protein material from bacterial cultures which sensitize guinea pigs to anaphylactic reactions with the bacterial extracts, do not sensitize them to the tuberculin type of reaction. Such sensitization is easily accomplished only by infecting the animals with living organisms. No reliable method of sensitizing guinea pigs to such reactions with dead bacterial material has as yet been worked out, though a few hopeful experiments have been obtained with massive injections of large amounts of the acid-precipitable substances (nucleoproteins?) from bacterial extracts. 4. In animals made hypersensitive to the tuberculin type of reaction by infection with living bacteria, the reaction may be elicited by intradermal injections of bacterial extracts from which all coagulable proteins, nucleoproteins, and Bence-Jones proteins have been removed, as well as this can be done by boiling with acid, etc. This proteose residue alone suffices to elicit such reactions. The exact chemical nature of the so called proteose residue must be further studied and analyzed when we have had opportunity to produce bacterial extracts in large quantity. These points seem incontrovertible on the basis of our own experiments, as well as those of other workers. There thus seem to develop two definite forms of hypersensitiveness in guinea pigs infected with bacteria, typical anaphylaxis in which the protein material of the bacterial cells is concerned, which develops late and which can be induced by repeated injections of dead bacterial material, and a hypersensitiveness to non-protein constituents which differs from the former, both in the laws that govern sensitization and in the manifestations which follow injections into the sensitized animals. While there is virtual agreement among immunologists concerning the essential mechanism of protein anaphylaxis, its dependence upon an antigen-antibody reaction, and the dominating rôle played by the sessile antibodies, the mechanism of hypersensitiveness to tuberculin and similar bacterial substances is still a problem of much uncertainty. The most striking difference between the two phenomena lies, as we have seen, in the criteria of sensitization, in that hypersensitiveness to the tuberculin type of reaction can hardly ever be induced by any of the ordinary methods of preparation with the constituents of dead bacteria, but develops promptly (7 to 10 days) in the course of actual infection with living organisms. The considerable specificity of such reactions forces the conclusion that the sensitizing substance must, in some way, be derived from the infecting microorganisms. The idea that the failure of sensitization with dead culture materials is perhaps due to the elaboration in the body of infected animals of bacterial products not represented in extracts of test-tube cultures is rendered unlikely by the fact that in the tuberculin-sensitive, infected animals, we can produce the reactions by the application of such dead extracts. It is neither logical nor in keeping with biological experience to assume that one substance will sensitize to reaction with another. This mistake was made early in the study of anaphylaxis in another connection and caused considerable delay of progress. Krause has shown that tuberculin sensitiveness may be blunted in infected animals by massive, but sublethal injections of tuberculin, and we have obtained some indications of the same thing. Moreover, others as well as ourselves have seen tuberculin reactivity decline in guinea pigs and in man in the stages of very severe infection. These facts would eliminate any assumption of mere cumulative injury as explaining this type of reaction, and stamp it as a mechanism at least analogous to ordinary anaphylaxis. The only remaining possibility to explain the difference between infected animals and those treated with dead bacterial constituents would be to assume that the difference must lie in the manner in which the sensitizing substance is administered to the animals, and that sensitization with the proteose residue materials depends upon criteria of sensitization differing in regard to the time and quantity factors from those governing protein sensitization. If one considers the relatively simpler chemical structure and perhaps physically greater diffusibility of the materials concerned in this reaction, one might readily expect such differences in the methods needed for sensitization. In keeping with such a line of reasoning our experiments have shown that the tuberculin active materials are constantly and rapidly being diffused out into the culture fluid from growing organisms, in quantities greater than can be extracted from similar amounts of the dead bacteria. It seems reasonable to assume from this that the same thing may happen in the animal body harboring a growing focus. And it would seem quite likely that the association of the tuberculin type of reaction with actual infection may depend upon the fact that sensitization to these non-protein substances depends upon a constant steady absorption of large amounts of the material. Moreover, the only hopeful experiments on the artificial production of tuberculin sensitiveness in guinea pigs obtained by us were those in which massive doses of the nucleoprotein material injected into guinea pigs gave rise to a moderate skin sensitiveness. Does the so called proteose residue form antibodies, and, if so, are substances analogous to antibodies involved in the tuberculin type of hypersensitiveness? The failure to transfer passively this form of hypersensitiveness to normal animals with the blood and tissues of tuberculin-sensitive ones would suggest that no antibodies are involved. But this is not conclusive on the basis of available experimental facts. We are inclined to believe that antibodies of a sort are involved, for the following reasons: (a) In our experiments with the uteri of highly sensitive extract-treated guinea pigs and of tuberculous guinea pigs, we have occasionally had positive reactions when the proteose residue alone was used. (b) We believe that these proteose substances are entirely analogous to the substances studied by Avery and Dochez (22) in the urine and blood of typhoid and pneumonia patients. They obtained precipitin reactions against homologous immune sera with the urine of infected cases concentrated by evaporation after boiling with acetic acid to remove coagulable proteins. (c) Petroff, with whom we discussed this proteose residue early in our work, has produced it, and tells us that he has obtained precipitin reactions with it by titrating it against the serum of a sheep treated for a long time with tubercle bacillus products. In suggesting an antibody response to a non-protein antigen we are aware that we are opposing what has been regarded as a well established doctrine in immunity; this is justified, or at least mitigated, we believe, by the consideration that reactions of the antigen-antibody type are the only explanation of specificity; and tuberculin, mallein, and typhoidin reactions are to a considerable degree specific. If such reaction bodies cannot be produced by precisely the same methods of administration as to time and quantity which are successful in calling forth protein antibodies, this should not astonish us, since, after all, the substances that we are dealing with are simpler in chemical structure than are the proteins, and physically are probably of relatively greater diffusibility. It may be that the greater diffusibility of the proteose-like substances transfers much of the actual reaction phenomena to an intracellular location, and that this to some extent influences the presence of circulating antibodies. It may also be that these more diffusible non-protein antigens are more rapidly eliminated from the animal body than are the proteins. Indeed, the above mentioned observations of Avery and Dochez, and the recent work of Wildbolz (23), Lanz (24), Imhof (25), and Gibson and Carroll (26), who demonstrated tuberculin active antigens in the urine of active cases, would corroborate such a view. The evidence available at the present time, however, concerning antibody formation to these non-protein substances is, we recognize, largely indirect, at least as far as our own work is concerned, and we present it in the present connection purely as a working hypothesis. Finally, perhaps the most important theoretical consideration indicated by our experiments is the following. We have in the tuberculin reaction a form of hypersensitiveness which seems to be (in guinea pigs, at least) analogous entirely to the typhoidin reaction, the mallein reaction, and the abortin reaction. Whenever reactions of this type have been carefully studied, whatever the bacteria involved, they have been associated with infection as in tuberculosis, and have been followed by analogous clinical manifestations. It would seem perhaps that we are dealing with a law applicable to bacterial infection in general. It would appear that certain non-coagulable substances of uncertain chemical constitution are being constantly elaborated in the course of bacterial growth, and passed into the circulation of infected animals. As a result of this, infected animals become sensitized to these heat-and acid-resistant materials, in tuberculosis in the course of I to 2 weeks, in the case of more rapidly growing bacteria perhaps sooner. Early in the course of infection, the animal becomes sensitized and subsequently the further elaboration and distribution of these materials from the bacterial focus plays a fundamental part in the injury of the animal. These proteose-like substances, like tuberculin, possessing but slight toxicity for the normal animal, become highly toxic to the sensitized one. Thus, these substances, while not being true exotoxins in the ordinary sense, would still represent a highly toxic bacterial product comparable in its injurious effect to toxins when produced in the body of an animal thus sensitized. If there is any value in these deductions the attention of bacteriologists should be turned to the non-protein constituents of bacterial cells in their further immunological studies, as well as to the protein materials. It is obvious that the next step in our investigations must consist in producing the non-coagulable material from bacterial extracts in considerable quantity, to determine their antibody-forming properties in detail, and elucidate, if possible, the laws which govern sensitization with them. This work has been begun, but it has seemed advisable to publish this as far as we have gone because it will take a long time before it can be completed.
PMCID: PMC2128693  PMID: 19868574
23.  A double dose of double effect 
Journal of Medical Ethics  2000;26(3):204-205.
This paper presents a clinically orientated illustration of the doctrine of double effect. The case of an elderly gentleman with advanced cancer is discussed, with particular emphasis on two dilemmas encountered during the terminal phase of his illness. The author describes how the doctrine of double effect was applied to help the team make some complex management decisions.
Key Words: Doctrine of double effect • competence • ethics • beneficence
PMCID: PMC1733219  PMID: 10860214
24.  Continuous Distributions of Ventilation-Perfusion Ratios in Normal Subjects Breathing Air and 100% O2 
A new method has been developed for measuring virtually continuous distributions of ventilation-perfusion ratios (V̇A/Q̇) based on the steadystate elimination of six gases of different solubilities. The method is applied here to 12 normal subjects, aged 21—60. In nine, the distributions were compared breathing air and 100% oxygen, while in the remaining three, effects of changes in posture were examined. In four young semirecumbent subjects (ages 21—24) the distributions of blood flow and ventilation with respect to V̇A/Q̇ were virtually log-normal with little dispersion (mean log standard deviations 0.43 and 0.35, respectively). The 95.5% range of both blood flow and ventilation was from V̇A/Q̇ ratios of 0.3—2.1, and there was no intrapulmonary shunt (V̇A/Q̇ of 0). On breathing oxygen, a shunt developed in three of these subjects, the mean value being 0.5% of the cardiac output. The five older subjects (ages 39—60) had broader distributions (mean log standard deviations, 0.76 and 0.44) containing areas with V̇A/Q ratios in the range 0.01—0.1 in three subjects. As for the young subjects, there was no shunt breathing air, but all five developed a shunt breathing oxygen (mean value 3.2%), and in one the value was 10.7%. Postural changes were generally those expected from the known effects of gravity, with more ventilation to high VA/Q areas when the subjects were erect than supine. Measurements of the shunt while breathing oxygen, the Bohr CO2 dead space, and the alveolar-arterial oxygen difference were all consistent with the observed distributions. Since the method involves only a short infusion of dissolved inert gases, sampling of arterial blood and expired gas, and measurement of cardiac output and minute ventilation, we conclude that it is well suited to the investigation of pulmonary gas exchange in man.
PMCID: PMC301524  PMID: 4601004
25.  How is the New Public Management applied in the occupational health care system? - decision-makers' and OH personnel's views in Finland 
In many countries occupational health care system is in change. Occupational health studies are mainly focused on occupational health substance and content. This study offers new perspectives on municipal OHS and its operations from management perspective.
The aim of this study is to analyse how New Public Management (NPM) doctrines are applied in the Finnish occupational health care system (OHS). The main focus is to describe and compare the views of decision-makers' and OH workers within the framework of NPM.
The data were collected by semi-structured interviews from 17 municipal decision-makers' and 26 municipal OH workers. Data was analyzed by examining coded data in a theory-driven way according to Hood's doctrine of NPM.
The doctrines were not as compatible with the OH personnel view as with the decision-makers' view. Decision-makers and OH personnel highlighted the strict criteria required for operation evaluation. Moreover, decision-makers strongly accentuated professional management in the public sector and the reorganization of public sector units. These were not equally relevant in OH personnel views. In OH personnel views, other doctrines (more attention to performance and accomplishments, emphasizing and augmentation of the competition and better control of public expense and means test) were not similarly in evidence, only weak evidence was observed when their importance viewed as medium by decision-makers. Neither of the respondents group kept the doctrine of management models of the private sector relevant.
The NPM and Hoods doctrine fitted well with OH research. The doctrine brought out view differences and similarities between decision-makers and OH personnel. For example, policymakers highlighted more strongly the structural change by emphasizing professional management compared to OH personnel. The need for reorganization of municipal OH, regardless of different operational preconditions, was obvious for both decision-makers and OH personnel. The adaptation of more clarify management to a municipal context is not trouble-free. The municipality systemic structure, complex operational environment, and reconciliation of political and officer authority set challenges to management of municipalities.
PMCID: PMC3177899  PMID: 21880141

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