Personal and Professional factors scale means: a comparison between respondents aged less than 50 years and those aged 50 plus years.
\r\n\tHowever, many questions concerning the shape and stability properties of lattice solitons remain open. For instance, do other types of lattice solitons in different geometrical structures exist as well? How does the lattice shape effect the solitons’ shape and soliton stability?
\r\n\tIn this book, we aim to present the recent developments in optical lattice soliton theory and applications.
\r\n\tTopics that will be included, but are not limited to:
\r\n\tOne-dimensional and two-dimensional lattice solitons in Kerr and saturable media
\r\n\tSolitons in Bose-Einstein condensates (BEC’s)
\r\n\tLinear, nonlinear and mixed linear-nonlinear optical lattice solitons
\r\n\tNonlocal nonlinear lattices
\r\n\tLattices with defects
\r\n\tSolitons in lattices with quadratic nonlinearities
\r\n\tSolitons in photonic-crystals and photonic-crystal fibers
\r\n\tSimilariton generation in optical lattices
\r\n\tPulse shaping in mode-locked lasers
\r\n\tLattice soliton interactions
Wiener in a seminal book (Wiener, 1948) associated the ancient Greek word ‘κυβερνητικος’ to the control of physiological systems. “Thus, as far back as four years ago, the group of scientists about Dr. Rosenblueth and myself had already become aware of the essential unity of the set of problems centering about communication, control and statistical mechanics, whether in the machine or in the living tissue. [...] We have decided to call the entire field [...] by the name Cybernetics, which we form from the Greek κυβερνητης or steersman. In choosing this term, we wish to recognize that the first significant paper on feed-back mechanisms is an article on governors, which was published by Clerk Maxwell in 1868 and that governor is derived from a Latin corruption of κυβερνητης. We also wish to refer to the fact that the steering engines of a ship are indeed one of the earliest and best developed forms of feed-back mechanisms.”
Norbert Wiener (1894-1964) and his book on cybernetics
The increasing knowledge in each sector of science led to a huge diversification of scientific research, especially in a borderline sector like cybernetics applied to physiological systems. A first problem to solve was the following: let’s suppose that two groups, one with a control engineering experience and the other one with a medical background (e.g., physicians), decide to cooperate, because they strongly believe that a joined research could be useful for developing mathematical and statistical models. Usually physicians do not have enough time to study and apply advanced modelling.
Wiener approached the communication between scientists belonging to different disciplines: “If a physiologist, who knows no mathematics, works together with a mathematician, who knows no physiology, the one will be unable to state his problem in terms that the other can manipulate, and the second will be unable to put the answers in any form that the first can understand. [...] The mathematician need not have the skill to conduct a physiological experiment, but he must have the skill to understand one, to criticize one, and to suggest one. The physiologist need not be able to prove a certain mathematical theorem, but he must be able to grasp its physiological significance and to tell the mathematician for what he should look.”
A correct interaction in terms of a clear communication and reciprocal comprehension of the objectives of the research activity between groups with different competences is a crucial aspect in any interdisciplinary research.
In 2003 at the University of Pisa it was decided to introduce a new course for undergraduate students in biomedical engineering, based on the Wiener ‘utopia’, in order to teach a novel discipline useful for helping biomedical students to communicate and cooperate effectively with physicians. We named this new course as Physiological Cybernetics, remembering the old Wiener definition.
The organization of this course was a difficult task, and it required to gain experience in order to integrate so different disciplines and to produce a common language between students in biomedical engineer and physicians. At a first glance this attempt seemed to be too ambitious, because the different approaches of biomedical engineers with respect to physicians seemed incompatible and even the languages of the two groups were so different to remember the Babel tower…
Tower of Babel (1563) Pieter Bruegel the Elder, Oil on Wood Panel - Kunsthistorisches Museum, Vienna, Austria.
A great deal of effort and attention was required to produce appealing and stimulating lectures, but after many years we can affirm that this challenge is successful, especially for the enthusiastic answers of the students: their number was increasing year after year (about seventy students per year are now attending the course).
A strict and trusted cooperation between different groups of physicians is growing up and several groups of physicians belonging to different medical fields are going to join us for new interactions.
The aim of this chapter is to describe how the approach to physiological cybernetics has led to integrate academic lessons with research activities. To be more specific, the basic idea of Physiological Cybernetics was to search for models able to emulate physiological systems based on the feedback theory and/or the system theory.
In fact, recently, the widespread use of friendly software packages for modelling, along with the development of powerful identification and control techniques has led to a renewed interest in control (Khoo, 2011; Hoppensteadt & Peskin, 2002; Cobelli & Carson, 2008) and identification (Westwick & Kearney, 2003) of physiological systems. Unfortunately physiological systems are intrinsically time variant and highly non linear. Moreover, an effective balance of the model complexity is a difficult task: low order models are usually too simple to be useful, on the other hand high order models are too complex for simulation purposes and they have too many unknown parameters to be identified.
Each model selected for investigation was studied by a group of biomedical students supervised by physicians. Each model required several iterations and reformulations, due to the continuous adjustment of the research objectives, changing their final horizon, because of the gap between experimental data and theoretical models, so that the answers to the doubts and questions were continuously moving with the obtained partial results.
A final goal of the research was to apply a mathematical framework for helping medical diagnostic techniques and for testing new therapeutic protocols.
The procedure of model extraction followed two main pathways: the first one (pathway A) led to a formulation of a mathematical model usually based on differential equations and on an as deep as possible insight into physiological mechanisms (Marmarelis, 2004; Ottesen et al., 2004; Edelstein-Keshet, 2005; Jones et al., 2009) via a physical description of the system.
The second one (pathway B) was founded on a model description based on a black-box and data-driven identification (Westwick & Kearney, 2003; Cobelli & Carson, 2008), usually leaving to stochastic models with a parametric or non-parametric structure (Ljung, 1987), depending on the a-priori knowledge of constitutive laws governing the observed system.
In this paper we will describe two examples of research activity based on the Physiological Cybernetics, both of them addressed to produce a biomedical framework for predicting the effects of therapeutic actions, but following the two different pathways. The first example follows a statistical non parametric approach, the second one a mathematical model based on differential equations
In 2004, some lessons of the Physiological Cybernetics course were addressed to describe metabolic dynamics of thyroid hormones T3 and T4.
It was an emblematical example regarding physiological feedback theory, intrinsically embedded inside human body.
We decided to focus some lessons on the model presented by Di Stefano et al. (1975), in an interesting paper, showing how this hormonal regulatory system could be described in terms of differential equations. This item was so intriguing for students, to require the support of physicians belonging to the Department of Endocrinology and Metabolism of the University of Pisa, in order to gain a better understanding of the physiology related to the feedback regulation of thyroid hormones. It was a representative example of pathway A, typical of classic physiological feedback, with a controller -the thyroid gland- embedded in the human body.
One of the physicians proposed a different challenging test to students: how to model another pathology with growing interest in endocrinology, i.e. the obesity?
This challenge was very complex and unsolved from a mathematical viewpoint. It was a classical example of Babel tower, because what physicians expected from us was impossible to be fulfilled in a deterministic framework, similar to the approach leading to the thyroid model.
First, we tried to consider differential equations for modelling dynamics of hormones, like leptin and ghrelin, playing an important role in controlling our weight, but the results obtained were too qualitative, simple and poor to mimic the multi-factorial aspects of obesity. It seemed to be a failed attempt, because it produced a useless model.
Hence we decided to change our approach to the challenge: if a deterministic model was inadequate, a data-driven black box model could be an alternative solution and we decided to follow pathway B. We came to the conclusion that the first and reachable step for coping with obesity was to build an interactive, user-friendly and graphically oriented toolbox for classifying obese patients. Therefore a SW tool, named Obefix, was developed for helping physicians in the classification of obese patients from physiological and psychological data.
Obefix program (Landi et al., 2007) was designed in order to produce an easy-to-use software tool for capturing all essential information on the patients using a reduced data set, solving the problem related to the high data dimensionality.
Obefix window for a classification of obese patients: the interface
An interesting outcome was that this software tool was able to classify patients in a limited and user-selected number of clusters.
Consider to analyze a numerous group of patients. First Obefix’s user may use the toolbox for searching a blind unsupervised partition of the treated data in different clusters, using a reduced set of variables, valuable for a correct classification of the patients.
After this first step, a supervised action is possible: physicians, after an evaluation of the unsupervised classification, can ask Obefix to repeat the analysis on a restricted subset of the initial individuals, in order to eventually exclude out-of-range patients (the outliers).
In this framework, physicians can easily load data, select variables of interest, run a fast analysis and visualize results. Clusters are represented in planes, the principal planes, and single patients can be followed, automatically classified as belonging to a cluster, and grouped in Excel spreadsheets.
Obefix employs PCA (Principal Component Analysis) (Jolliffe, 2002) as an engineering statistical tool for reducing data dimensionality: users can then select either hierarchical or k-means clustering methods, for classification of patients on selected principal planes.
A clinical example of Obefix application was presented in Landi et al., (2007) the case study was the a-posteriori analysis of a dataset of severe obese women, submitted to adjustable gastric banding surgery. Obese individuals were initially candidate for gastric bariatric surgery; a presurgical preparation included also psychological evaluation.
At first, Obefix toolbox was applied for a multiple regression analysis (Mardia et al., 1979) with delta BMI (variation of the Body Mass Index expressed in %) six months after the gastric banding surgery as a dependent variable, associated with changes in pre-operative psychological data tests as independent variables.
The administrated questionnaire included 567 statements and subjects had to answer ‘‘true’’ or ‘‘false’’ according to what was predominantly true or false for them. It must be remarked that these results have been obtained using only psychological data and that in the literature the quantitative extraction of effective similarities in groups of patients in the case of a so complex and multi-factorial pathology is considered a critical and unsolved problem.
Three main homogeneous clusters were identified, representing subgroups of patients with working problems, with antisocial personality disorder and with obsessive-compulsive disorder. A strict correlation was statistically verified between the variations of BMI six months after surgery with the patients belonging to each subgroup.
All conclusions regarding the similarities between individuals belonging to different clusters were in a good accordance with medical experience and with clinical literature. Since Obefix development was considered a winning experience, we proceeded toward a following step, more interesting for the aims of the physiological cybernetics, i.e., produce and use a model able not only to classify the patients, but also to predict individual therapeutic outcome in terms of Excess Weight Loss (EWL, another common index for evaluating the loss of weight) after two years from surgery, using a set of pre-surgical data.
To be clearer, the more interesting aspect of this research was to set up a software tool able to predict the effects of a therapy and to address clinical researchers in choosing the patients that will maximally benefit from surgery.
A success in this task could represent the demonstration that the novel vision of Wiener was not a utopia, but a first example of dream coming true.
The research was again addressed to the study of the loss of weight for patients submitted to adjustable gastric banding surgery, because it was intriguing to consider a case study characterized by a high level of uncertainty in the prediction of long term effects.
Nowadays, in the medical literature it is still debated which categories of patients are better suited to this type of bariatric procedure and the selection of candidates for gastric banding surgery doesn\'t follows standardized guidelines.
In order to create a predictive model, the use of Artificial Neural Networks (ANNs) (Bishop, 1995; Rojas, 1996) appeared to be the best solution for predicting the weight loss after bariatric surgery, with respect to more traditional and used mathematical tools, e.g., the multiple linear regression. Therefore, a particular ANN was developed (see Figure 4) to improve the predictability of the linear model using a multi-layer Perceptron (MLP) with non linear activation functions (Rumelhart et al., 1986).
Architecture of the MLP model for calculating non linear WL predictive score u
A preliminary study on the feasibility of the statistical approach for obese patients was presented in Landi et al., (2010) while, a paper considering the application of ANNs in the outcome prediction of adjustable gastric banding in obese women was published in Piaggi et al., (2010).
In the following, an outline on the engineering approach to this predictive tool is briefly sketched.
The first step was to select the most significant predictors of long term weight loss (the dependent variable) among the psychological scales, age and pre-surgical BMI (independent variables) (Van Hout et al., 2005).
In order to choose the most predictive inputs of a ANN with a limited data set and several potential predictors, a best-subset algorithm based on multiple linear regression (Neter, 1975) was employed. Namely, all combinations of the independent variables (subsets including from one to four variables, in order to avoid over-fitted solutions due to a large number of parameters, with respect to observations) were separately considered as models for computing the best linear fit of the dependent variable.
The best predictive subset was selected from all these models as that with the highest adjusted R2 and a p-value less than 0.05.
The result was that age and the three psychological scales Paranoia - Pa, Antisocial practices - Asp and type-A behaviour - TpA constituted the best subset, and a predicted weight loss (WL) score was estimated through the formula
based on the linear combination of their regression coefficients, i.e., regression coefficients of (1) were a measure of the linear relationship between each independent variable and WL.
A non linear model was then built upon the same variables: the aim was to increase the goodness of prediction, taking advantage of ANNs data fitting capability.
For doing this, the four selected variables were used as inputs of a standard MLP for obtaining a non linear predictive score named u (see Figure 5).
Figure shows predicted WL on x-axis versus actual WL on y-axis. A comparison between the non linear (green solid line) and linear (red solid line) regressions show the better fit in the non linear case
A non linear activation function (i.e., the hyperbolic tangent function) was employed at the hidden layer units of the MLP to obtain a non linear combination of the inputs, as following:
This ANN architecture extended the regression performance of the previous linear model, which can be still obtained by replacing the nonlinear activation functions with the identity functions in the MLP, removing the nonlinear capability of the model.
The u score was then obtained as:
The global cost function - minimized by the ANN training process - was based on the correlation between u and WL scores, including their standardization terms, as following:
In this way, the ANN found the optimal values of weights (Wxh and Whu) and bias (bxh and bhu), which accounted the maximum correlation between the two scores.
The non linear solution accounted for 36% of WL variance, significantly higher than 10% of the linear model using the same independent variables: this indicated a better fit for the non linear model.
Furthermore, subjects were assigned to different groups according to actual WL quartiles in order to evaluate the classification (ROC curves) and prediction (cross-validation) capabilities of the estimated models. In Figure 6, the sensitivity and specificity of both models in relation to WL outcome are plotted for each possible cut-off in the so-called ROC curves and the Area Under each ROC Curve (AUC) is estimated. AUC measures the discriminating accuracy of the model, i.e., the ability of the model to correctly classify patients in their actual quartile of WL.
As a result, the non linear model achieved better results in terms of accuracy and mis-classification rates (70% and 30% vs. 66% and 34%, respectively) than the linear model.
ROC curves for nonlinear and linear models
So far, both linear and nonlinear predictive models were built by considering all patients of the data set, i.e., each model was estimated from a database with known input and output data.
After this model-building step, the linear and nonlinear models were applied to new patients, with unknown output values, in order to have a quantitative check on the effectiveness of the proposed method on the correct selection of the therapeutic effects.
Two additional statistic tools were introduced: the cross-validation method and the confusion matrix.
Both in case of linear and nonlinear model, patients were randomly subdivided in two groups, used for building and testing the models. A training data set was considered for calculating linear regression coefficients in the case of linear model and for selecting the optimal weights and bias in the case of the MLP. A test data set was used to make a prediction of the WL two years after the bariatric surgery.
Confusion matrix was the tool used for the validation of the prediction. The cross-validation method was repeated 100 times, changing the subsets of patients for training and test sets. It was surprising to verify that after this blind test on the whole dataset, it was possible to establish with over 70% of reliability if the patients will either maximally or minimally benefit from the intervention after two years, in the case of the nonlinear model. Conversely, the reliability was reduced of about 30% in the case of the linear model (Piaggi et al., 2010). Considering that the analysis was restricted to psychological presurgical tests and to age, this result seems to be a surprising success of a research derived from the physiological cybernetics course.
The second example shows the application of model predictive control (MPC) for an optimization of the therapy in HIV disease. It applies the subject of a group of lessons held during the physiological cybernetics course, in which the predictive control theory was presented to students as an effective tool for helping (and emulating) physicians in the selection of an optimal therapy, based on the patients\' responses.
The origin of this activity was born when some students asked to study a mathematical model for HIV.
It was easy to find HIV models existing in literature: many of them are well known and accepted from mathematical and from biomedical engineers as gold standards for studies in viral models.
In the literature, (Wodarz & Nowak, 1999) the simplest model presented for mathematical modelling of HIV considers only three state variables and it is mathematically described by:
System (5) consists of three differential equations. The state variables are: x, the concentration of healthy CD4+ T-cells; y, the concentration of HIV-infected CD4+ cells; v, the concentration of free HIV copies.
Healthy cells have a production constant rate λ and a death rate d. Infected cells have a death rate a, free virions are produced by the infected cells at a rate k and u is their death rate. In the case of active HIV infection the concentration of healthy cells decreases proportionally to the product xv, with a constant rate β representing a coefficient that depends on various factors, including the velocity of penetration of virus into cells and the frequency of encounters between uninfected cells and free virus.
A five-state model was developed in Wodarz & Nowak (1999). This model offers important theoretical insights into immune control of the virus based on treatment strategies, which can be viewed as a fast subsystem of the dynamics of HIV infection. It is mathematically described by:
Two states are added to (5) to describe the dynamics of w, the concentration of precursor cytotoxic T-lymphocytes (CTLp) responsible for the development of immune memory and z, the concentration of effector cytotoxic T-lymphocytes (CTLe) responsible for killing virus-infected cells cytotoxic T-lymphocyte precursors CTLp.
In the fourth and fifth differential equations c, q, b and h are relative production rate, conversion rate to effector CTLs, death rate of precursor CTLs, and of effector CTLs, respectively.
This model can discriminate the trend of infection as a function of the rate of viral replication: if the rate is high a successful immune memory cannot establish; conversely, if the replication rate is slow, the CTL-mediated immune memory helps the patient to successfully fight the infection.
In Landi & al. (2008) model (6) was modified as:
Model (7) differs from previous W-N in the new state variable r, an index of the aggressiveness of the virus, which substitutes the constant β.
An arbitrary assumption is that r increases linearly with time in untreated HIV-infected individuals, with a growth rate that depends on the constant r0 (a higher r0 value indicates a higher virulence growth rate). This hypothesis was verified consistent with the simulation results obtained in the case of infected people who do not show significant disease progression for many years without treatment (long-term non Progressors -LTNP).
Different typologies of patients may require to change the law describing the aggressiveness dynamics. We evaluated the possibility to adapt the model (7) to patients with different clinical progressions, changing the values of some parameters. In particular, we supposed to vary the coefficients b and h, which represent the death rate of immune defensive cells (effector CTLs and precursor CTLs). We considered the two extreme cases for HIV progression (see Figure 7): the lower values correspond to the model dynamics of LTNP patients; the higher values model the dynamics of fast progressor patients (FP).
The coefficients μT and μP represent the drug effectiveness weights for specific external inputs fT and fP, which represent the drug uptakes in case of Highly Active Antiretroviral Therapy (HAART).
HAART is a combination therapy that includes:
Reverse Transcriptase Inhibitors (RTI), to prevent cell-to-cell transmission, inhibiting reverse transcriptase activity.
Protease Inhibitors (PI), to prevent the production of virions by infected cells, inhibiting the production of viral protein precursors.
Dynamic behaviour of the state variables x, v, w and z vs. time in the case of untreated LTNP (solid line) and FP (dashed line) patients.
In different models presented in literature, the effects of RTI and PI drugs have been aggregated, nevertheless we decided to mimic the effects of PI drugs reducing the rate of virus production, i.e., modifying the rate coefficient k of production of new infected cells in the dynamical equation. Instead the effect of RTI drugs is simulated by reducing the infection rate of CD4+ cells by free virus. So, in model (7) the RTI drugs act in virulence equation, because their main role is halting cellular infection.
Another important feature differentiating the proposed model from standard literature is that it does not admit stable steady states, since the model parameters are such that, i.e., the aggressiveness never becomes a constant, since a slow increase of r describes well a real progression of the HIV infection. This hypothesis originates from the observation that the possibility of eradicating completely the virus has not been demonstrated and the HIV disease cannot be long-term controlled.
The inclusion of aggressiveness as a new state variable represented the main outcome of the study: this simple extension to Wodarz & Nowak models allowed us to mirror the natural history of HIV infection and to introduce a new state equation useful for introducing in the model the effects of pharmacologic control.
In Fig. 8 are shown the time courses of CD4 cells and virions obtained in simulation with model (7); for a qualitative validation of the model, compare the results with the plotted experimental data shown in Fig. 9 (Abbas et al., 2000).
Simulated behaviour of untreated LTNP HIV-infected patients for ten years with model described in (4). The graph shows viral load (dashed line) and CD4+ cells (solid line)
Typical clinical behaviour of HIV infection for about ten years. Figure shows HIV copies (triangles) and CD4+ cells (squares), in case of untreated HIV-infected human
A straightforward application of the control theory to model (7) was proposed in Pannocchia et al., (2010), with the application of a MPC strategy in anti-HIV therapy.
MPC algorithms (Mayne et al., 2000) utilize a mathematical model of the system to be controlled, to generate the predicted values of the future response. Predicted values are then used to compute a control sequence over a finite prediction horizon, in order to optimize the future behaviour of the controlled system. The control sequence is chosen minimizing a suitable cost function, including a measure of the deviation of the future state variables from reference target values and a measure of the control effort, while respecting state and control constraints. In plain words, the core of the control algorithm is an optimization algorithm, keeping the controlled variables close to their targets and within suitable constraints. The first output in the optimal sequence of control actions is then injected into the system, and the computation is repeated at subsequent control intervals.
The problem was how to adapt MPC to determine the optimal drug scheduling in anti-HIV therapy.
Some examples of MPC applied to biomedical applications like control of the glucose–insulin system in diabetics (Parker et al., 1999), anaesthesia (Ionescu et al., 2008), and HIV (Zurakowski & Teel., 2006) have been presented in literature, but all applications were considered for models admitting a steady-state stable equilibrium. On the other hand, MPC emerged as the more suitable solution for solving the drug optimal administration problem in anti-HIV therapy, even if the model was unstable. MPC algorithm pursued the following logic:
future outputs of the control algorithm are generated by the HIV model; measurements on individual patient are considered and compared with the predictions of the model.
the cost function to be minimized keeps the controlled variables e.g., CD4+ cells and free virions concentration close to the targets and respecting suitable soft constraints on the manipulated variables.
the cost function of the future control movements is minimized using a sequence of future PI and RTI drugs over the chosen control horizon, but only the first element of the suggested control sequence is applied to the system.
at the successive decision time, the algorithm is solved again if measurements of CD4+ cells and free virions concentration are available and the drug sequence is updated, repeating step c)
Some practical issues were considered (see Pannocchia et al., (2010) for a detailed study), because MPC was applied considering the two different cases of continuous applications of drugs, or of a structured interruption of therapy (STI) for patients. STI is a treatment strategy in HIV-infected patients, involves interrupting HAART in controlled clinical settings, for a specified duration of time. The possible explanation of the effectiveness of this clinical protocol was an induced autovaccination in the patients. The use of STI is currently debated between clinical researchers and most studies agree that STI may be successful if therapy is initiated early in HIV infection, but unsuccessful for people who started therapy later.
Furthermore, a discrete dosage approach required to modify the control algorithm using a non linear MPC: this was due to the clinical request to maintain a maximum dosage of drugs, as in standard HAART protocol, in order to reduce the risks of virus mutations.
Some comments are mandatory to stress the results of this model based on a differential equation deterministic approach. From the viewpoint of a model builder, two different situations have to be usually considered: basal and pathological conditions. In the case of infections, like HIV, the mathematical model have to mirror the natural evolution of HIV infection, and the pathological model must be more accurate, because today it is the only one that can be validated by experimental data, since patients are all maintained under therapy. The impact of therapy into HIV models must be introduced in a way as simple as possible, if we have to satisfy the task to formulate a model suitable for use in feedback control.
Simulation results were coherent with the medical findings: the comments of clinical researchers expert in HIV therapies were essential in testing the model and for evaluating the effectiveness of the proposed control methods.
Obtaining reliable models is relevant from a diagnostic and prognostic point of view, because it allows the physician to prove the therapeutic action using the model for testing the treatment in terms of optimal dosage and administration of drugs.
In 2008, the FDA approved an in silico model of diabetes as a pre-clinical testing tool for closed loop research at the seven JDRF Artificial Pancreas Consortium sites. The overall goal of the Artificial Pancreas project was to accelerate the development, regulatory approval, health insurance coverage, and clinical acceptance of continuous glucose monitoring and artificial pancreas technology (Juvenile Diabetes Research Foundation, 2008).
We strongly believe that also a simple but reliable in silico model of HIV can lead to an acceleration of the experimental tests for a clinical acceptance of new drugs in HIV disease.
Future activity will be devoted to develop models of HIV infection, able to include the issues of drug resistance and viral mutation, key issues for the HIV studies, and the interest of many clinical researchers in our work is encouraging in the upcoming research.
The Physiological Cybernetics course represents an example of integration between different disciplines, in order to produce a common language between students in biomedical engineer and physicians. It offers students an opportunity to verify in practice how to move theoretical lectures, based on the development of mathematical models, to a practical interaction with physicians. This fact seems obvious from an educational viewpoint, but it isn\'t so usual in practice, because it requires a preliminary long period for preparing a common language between researchers in different fields. Judging from the students’ excellent results, if compared to students attending under-graduated courses in previous years, the example proposed was very successful.
In this chapter we presented two examples of research applications, derived from this educational experience, demonstrating that the old-novel vision of Wiener was not a utopia, and that a synergic cooperation between biomedical engineers and physicians can lead to interesting results.
The authors wish to thank all people cooperating with the activities of the Physiological Cybernetics course over many years, the physicians for their support and clinical supervision and the undergraduate active students for their enthusiasm.
The global rise in the aging population means that older individuals account for increasing numbers in society. Coupled with the challenge of providing social services for an aging population with an increased life expectancy, comes the equally significant impact of aging citizens who historically now face more years in retirement than earlier generations [1]. Statistics from the Australian Bureau of Standards [2] indicate that of 9.4 million people who had registered employment in the age group 45 years and more, approximately 3.6 million individuals (38%) were retired. The average age for recent retirees in Australia is 61.4 years [2]. The importance of enhancing the wellbeing of such a significant portion of the population becomes a necessary consideration for society in general.
These considerations advance a forceful argument for identifying factors which will lessen the burden of an aging demographic on social services and potentially improve the wellbeing of people in the retirement phase of their lives. In order to do so, it is important to guard against a perception of retirees as a homogenous group. This has potential to construct stereo-typical profiles which may be useful for statistical purposes but limit the formation of a multi-focal lens essential for increased insight into a complex phenomenon.
To demonstrate the value of inquiry into specific groups with distinctive characteristics of culture and tradition, a sample of working faith-based ministers in Australia and New Zealand was surveyed to gauge their perception of retirement. By studying this sample, we were able to include lesser researched factors such as spirituality and the influence of a call to ministry. In addition, this sample ascribes to a culture of holistic well-being which regards fostering physical and mental health as part of their faith-based culture. Lifestyle programs such as the Complete Health Improvement Program (CHIP), are widely embraced and have demonstrated significant success in addressing age-related conditions. Results have been published in several international medical journals.
Traditionally, faith-based ministers did little or no planning for retirement and generally retired with no real estate. We were interested to know how these factors impacted on the way contemporary ministers viewed retirement. Consequently, this chapter will explore factors that influence the perception of the retirement season of faith-based ministers in a specific context in the hope it will spark conversation about other related contexts.
The discussion will start with a brief reference to theories on aging and the need for extending inquiry to address the lesser researched phenomenon of spirituality and its impact on retirement planning in order to increase insight into retirement patterns. This will be followed by a section on the methodology employed and an outline of the survey instrument. Results from the data analysis will then be considered with reference to demographics and an outline of the personal and professional factors which impact the retirement perceptions of this sample. We will find out just how prepared these individuals think they are for retirement; whether they view the prospect as positive; how satisfied they are with their planning and when they are thinking about retiring. The results will be collated and differences between younger and older cohorts highlighted. In the discussion section, there will be a focus on the significance of the findings of this study, its limitations and concluding remarks. The results of this study are delivered within the context of a definition of retirement which breaks with some traditional concepts of retirement as an end of career phase. The orientation of the study regards aging as a positive experience and offers valuable insights into contemporary retirement perception as a season of continued active contribution and growth.
As society begins to grapple with the burgeoning impact of aged citizens on many levels of contemporary living, research into aging and retirement grows across a wide spectrum of issues relating to the phenomenon. In fact, aging has been attributed to a growing impetus on the development of social gerontology [3]. Representations of aging are discussed in academic literature through the lens of various gerontological theories. Early theories include Erikson [4], the Disengagement Theory of Cumming and Henry [5], and subsequent theories such as the Activity Theory [6], Successful Aging [7], Schroots [8] and Atchley’s Continuity Theory [9]. Some criticism of theories such as those relating to Rowe and Kahn’s Successful Aging, question the lack of consideration given to aspects including historical and cultural context and social relationships. The current study is situated within a distinctive historical and cultural context with the aim of identifying factors relating to cohorts within a specific group with strong cultural and traditional values.
Previous studies have identified a diverse range of factors impacting on retirement timing [10]. Trends in relation to retirement in the literature are discussed by authors like Cahill et al. [11] who forecast an increase in bridge-jobs. For this purpose, issues generally identified in research as impacting on retirement, such as finance and health, will be incorporated but variables specific to context such as spirituality will also be included.
The current study adopts an orientation in which retirement is regarded as a continued phase of career and personal development. Although the value of traditional gerontological theories is acknowledged, there is agreement with the view of Lytle et al. [12] that most of these theories do not consider retirement as a career stage nor is account taken of the diversity of cultural and historical perspectives.
In its statistics on retirement, the ABS [2] rates financial security as a principal factor influencing decisions to retire. The financial context within which retirement decisions are made, however, has grown increasingly complex [1]. In fact, it is contended that the individual will be challenged to navigate a way through retirement financial planning without professional aid. It is not surprising then that results from research studies indicate financial resources as a primary consideration relative to retirement [13].
Considerations of health in relation to retirement receive significant focus in the literature. In Australia, health is rated as a primary factor in most aspects relating to retirement [2]. Health costs, however, are increasingly becoming a challenge, constituting increasing pressure on financial planning for retirement [1]. In addition to physical health, the literature also proposes factors relating to mental health such as the role of social connections which is suggested as a buffer to age-related degeneration [14].
This inquiry aims to demonstrate the need for caution when generalizing statistics in relation to age-related study. Although most of the literature on retirement considered in this study referred to retirees as homogenous groups, studies which do account for age difference found significant differences in anticipated reasons for retirement [13]. Respondents in the 55–64 years old cohort, for example, rated financial security higher than their peers in the younger age bracket. Other studies suggest that there are age-related differences in planning for retirement. Jimenez et al. [15] found that the age differences in their Spanish study, however, are representative of a relatively young cohort. The population of contemporary aging spans more than five decades but represents a confusing concept in that there is cultural non-consensus about labels and definition particularly pertaining to the last two decades of aging [16]. While cognizance is taken of this issue, the current study will identify two clearly designated groups as younger (less than 50 years of age) and older (more than 50 years of age). This may suggest a limitation of this study but also creates the opportunity for future study to investigate possible differences within sub-groups of these age brackets.
In recent decades there has been an increasing focus in the literature on aspects of the nature of spirituality. Despite this growing interest, however, there has been little work on spirituality and gerontology even though spirituality is not a marginal consideration but according to Atchley, “a vital context for understanding aging” [16]. Indeed, Pargament [17] proposes that spirituality is a distinctive motivation and process. Yet although spirituality and religiosity have been offered as distinct constructs [18], most research has been undertaken from a religion-orientated standpoint [16].
Diverse perceptions and definition of religion and spiritualty have led to ongoing conversation with some ambiguity still pervading academic texts. There are instances where the terms are used interchangeably or in other cases embedded in either concept with resulting definition at times so encompassing or so narrowly focused, as to become confusing. This makes for an intriguing issue which unfortunately falls outside the scope of this chapter. For the purposes of this discussion, the authors have taken the standpoint that religion and spirituality be understood in relation to the worldview of the participants. The concept of religion as a parasol of beliefs formed from a specific interpretation of theology has come under change in recent years. The participants in this study do not reject traditionally institutionalised religion. Spirituality as operated collectively (The Call) finds expression in individual response (A Call). Spirituality for the individual is perceived as a dynamic and on-going experience in which individuals grow and mature in their understanding of their faith journey and in relationship to a divine being. Definition, therefore, becomes context orientated. This is not to deny that “the nature of spiritual experience is complex and does not lend itself to simplistic concepts of measure” [16]. It is offered as a conceptual framework for understanding the response of the participants.
As such incorporation of spirituality within the concept of aging and retirement that reflects the perception of the participants becomes a necessary inquiry. In this study, the role of spirituality and particularly the impact of the concept of a Call, which is understood as a personal invocation to serve others, will be included in the conversation. Atchley [16] proposes that for many individuals service itself is regarded as a spiritual experience. The Call to service for individuals may transcend organizational commitment and is perceived as divinely derived [19]. These considerations point to a need indicated in the literature for new studies linking retirement planning with spirituality and the identification of specific differences in retirement planning [20].
The identification of factors influencing pre-retirement planning potentially illuminates patterns of adjustment to retirement [21]. Indeed, increased understanding of retirement and aging is significant in contributing to the response of organizations, government and society to the aging phenomenon [22]. The current inquiry will highlight the importance of considering retirement planning in specific context and of the need for differentiating between age cohorts. It is hoped that additional insight into lesser researched factors impacting aging, such as spirituality will add value to the conversation. These results will indicate the evolving trends for specific groups with strong cultural and traditional ties and suggest insights to enhance understanding for management strategies.
This study adopted an ex post facto cross-sectional self-reporting survey to collect data from working Seventh-day Adventist Ministers in Australia and New Zealand. Permission to access these ministers along with the ministers’ email addresses was provided from the respective regional employers. In 2018, emails were sent to these ministers outlining the purpose of the survey and inviting them to participate in the survey questionnaire via an online survey hosted by SurveyMonkey. This online link was left open for one month with three reminders sent to the potential respondents during this time. About 570 emails were sent to ministers and 228 interacted with the online survey, representing a 40% response rate.
Ethics approval for this research study was obtained from the Avondale Human Research Ethics Committee (Project number 2018.3).
The survey questionnaire included 11 democratic and professional work-related questions. These included items on training, length of service, type of ministry and location. This was followed by survey items relating to personal and professional factors from which 14 personal and professional scales were constructed. All items were rated on a 4-point Likert scale in which respondents were asked to rate their agreement with the positive stem statement from minimally to substantially.
Physical Health was measured by an overall physical health scale. Cognitive health was measured by the Cognitive Function scale [23] which measures the individual respondent’s perception of their cognitive ability.
Respondent’s perception of psychological stress and depression was measured using items adapted from the K10 [24] with two additional items specifically related to ministry. Items for the Wellbeing scale were adapted from the survey on Retirement Intentions for Australian Medical Practitioners [13] with the addition of one item relating specifically to the call to ministry. Items measuring the respondent’s perception about aging, were adapted from the Anxiety About Ageing Scale [25].
The items for the Work Centrality scale, measuring the importance of work, were sourced from the Work Centrality Questionnaire [26] which included additional questions relating specifically to the centrality of ministry and calling.
Four items from the Retirement Resource Inventory (RRI) Financial scale, measured the respondents’ view of their financial status in relation to retirement and their perception about current and future support. These items were adapted from the RRI [23]. Five items from the Retirement Resource Inventory Social scale, based on the RRI [23] measures a wide range of perceived social support.
The items from the Personal Resilience scale measure the individual’s response to their perception of their ability to deal with the challenges of life. The items are adapted from the RRI [23] with two additional items sourced from The Resilience Advantage [27]. The items from the Future Pathway subscale (FS), [28] were included to measure the respondents’ perception of their ability to plan and accomplish goals.
The survey also included four items relating to aspects of ministry as a career and the divine ‘calling’ of their work. It was anticipated that these items would generate a Calling scale. Factor and scale reliability analysis of these items indicated that these items do not generate a single scale. These separate items were, however, included in the analysis of the data.
The respondents were then asked to rate the following items on a 4-point Likert scale:
How prepared for retirement do you think you are?
How confident are you that retirement will be a positive season of your life?
How satisfied are you with your planning for retirement?
What factors will determine the timing of your retirement?
Of the 228 respondents, 93.36% were male, 92.11% were married, 68.58% completed their primary theological training in Australia and 76% of the respondents were presently serving in Australia and 24% in New Zealand. In terms of employment history, 35.96%, 29.39%, 18.86%, 11.84% and 3.95% had been employed as ministers for 0–10 years, 10–20 years, 20–30 years, 30–40 years and 40+ years respectively.
In terms of present service orientation, 52.86% serve in an urban church; 25.11% serve in a rural church; 16.30% have some type of administration role while the rest (5.72%) have other roles. For this cohort, 11.85% reported that they worked less than 40 hours per week, 39.47% reported they worked 40–49 h per week, 32.89% reported that they worked 50–59 h per week and 15.79% reported they worked 60+ h per week.
Of the respondents 7.46% were aged under 29 years, 15.35% were 30–39 years, 24.12% were 40–49 years, 28.07% were 50–59 years, 12.72% were 60–64% and 12.8% were 65+ years. This resulted in 46.93% of the respondents being less than 50 years of age and 53.70% being 50+ years of age. This two group age division was adopted in the univariate calculations. To facilitate reading, the two groups will be referred to as the younger set (less than 50 years of age) and the older set (fifty years and older).
All factor scales had a reliability coefficient (Cronbach’s alpha) greater than 0.75 (Table 1) which supported the use of these scales in this context. These factors were measured on a 4-point Likert scale signifying any reported mean greater than 2.5 indicates that the majority of the respondents agreed or strongly agreed with positive statements relating to the respective factors (Figure 1).
Personal and Professional factors scale means: a comparison between respondents aged less than 50 years and those aged 50 plus years.
Personal and professional factors impacting the retirement experience.
There were significant differences by age group for some of these factors (Table 1). As expected, those aged less than 50 years reported significantly higher values of physical health than those aged 50 plus years [(t) = 3.250, p = 0.001]. What is interesting, however, is the absolute values of the Physical Health scale means (2.752 and 2.324) appear relatively low which was not expected given the importance of living and promoting a healthy lifestyle within the mission of the Seventh-day Adventist church. In terms of psychological stress, despite the significant difference [(t) = 2.673, p = 0.008], the mean scale values (1.579 and 1.416) suggest the majority of both the younger and older age group were coping relatively well with the stress generated by their profession. In contrast to physical health, it was the younger set that was more likely to register greater levels of stress in their professional role than the older set.
There was also a significant difference between the younger and the older age group in terms of their perceived retirement finance resources [(t) = 2.665, p = 0.008]. Even though the older set reported higher mean RRI-Finance ratings than their younger colleagues, a mean of 2.334 compared to 2.060, their absolute values being below 2.500 would suggest that a large percentage of the ministers are still not comfortable with their present retirement financial resources.
This study focused on four aspects of current ministers’ perceptions of retirement: preparedness for retirement; viewing retirement as a positive season; satisfaction with planning for retirement; factors influencing timing of retirement. Most of the ministers were quite confident that retirement would be a positive season of their life (M = 3.067, SD = 0.762). They were, however, less confident that, at this point in time, they were prepared for retirement (M = 2.585, SD = 0.787) and were not satisfied with their planning for retirement (M = 2.380, SD = 0.904). There were significant age group differences in the perceptions of preparation aspects for retirement. The older set was significantly more confident that they were prepared [(t) = −3.322, p = 0.001] and satisfied with their planning for retirement [(t) = −3.067, p = 0.002] than their younger colleagues.
To explore the potential relationships between the outcome measures: How prepared for retirement do you think you are? How confident are you that retirement will be a positive season in your life? How satisfied are you with your planning for retirement? and the 14 personal and professional factors (Table 1), backward multiple regression was carried out(Tables 2–4). The resulting residual distributions were near normal. Further, the collinearity statistic ‘VIP’ was calculated to test for multicollinearity between the respective predictors. All VIP values were less than 10, indicating that multicollinearity does not appear problematic [29].
Predictors of ministers’ perception of how prepared they thought they were for retirement.
Predictors of ministers’ perception of how confident they are that retirement will be a positive season of their lives.
Predictors of ministers’ perception of how satisfied they were with their planning for retirement.
For the younger set, regression analysis generated a single significant factor model that explained 33.3% of the variance in ministers’ perception of how prepared they thought they were for retirement. The single predictor of this sample of ministers’ perception of their preparedness for retirement was their rating of the Retirement Resource Inventory: Finance (β = +0.459). The higher they rated their financial retirement resources, the more they felt they were prepared for retirement. For the older set, regression analysis generated a two significant factor model that explained 29.8% of the variance in ministers’ perception of how prepared they thought they were for retirement. The strongest predictor was their rating of the Retirement Resource Inventory: Finance (β = +0.394), followed by Psychological Stress (β = −0.216). The negative Beta values indicate that the higher they rated psychological stress, the less their perception of their preparedness for retirement (Table 2).
For those ministers aged 50 years and less, regression analysis generated a three significant factor model that explained 41.4% of the variance in ministers’ perception of how confident they are that retirement will be a positive season of their lives. The strongest predictor was their rating of their physical health (β = −0.350). The higher they rated their physical health, the less they felt that retirement would be a positive season of their life. The next strongest predictors were Wellbeing (β = 0.260), followed by their rating of “ministry is a calling which is divinely inspired and is directed to a specific purpose for a set time” (β = 0.211). This was followed by their rating of “ministry is a vocation which allows for personal fulfillment and development and contributes to the greater good” (β = 0.185). For those ministers aged 50+ years, regression analysis generated a two significant factor model that explained 42.6% of the variance in older ministers’ perception of how confident they are that retirement will be a positive season of their lives. The strongest predictor was their rating of the anxiety about aging (β = +0.362). Because of the reverse orientation of this factor, this result indicates that the less ministers are anxious about aging, the more they will see retirement as a positive season of their life. The next significant predictor was their rating of the Retirement Resource Inventory: Finance factor (β = +0.362) (Table 3).
For ministers aged 50 years and less, regression analysis generated a three significant factor model that explained 57.4% of the variance in younger ministers’ perception of how satisfied they were with their planning for retirement. The strongest predictor was their rating of the Retirement Resource Inventory: Finance (β = +0.586) factor, followed by their self-reported Physical Health rating (β = −0.238) and then their rating of “ministry is a vocation which allows for personal fulfillment and development and contributes to the greater good” (β = 0.177) factor. For the older set, regression analysis generated a two significant factor model that explained 47.5% of the variance in older ministers’ perception of how satisfied they were with their planning for retirement.
The strongest predictor was their rating of the Retirement Resource Inventory: Finance (β = +0.362), followed by their Future Scale—pathway rating (β = +0.294) (Table 4).
There were some differences between the age groups in terms of importance of some factors in timing of retirement (Figure 2). The less than 50 years group more often reported that impairment of cognitive function would be a significant factor in the timing of retirement than the 50+ group [t(196) = 2.013, p = 0.045]. The less than 50 years group also more often reported that an understanding they had completed the task God had called them to do, would be a significant factor in the timing of retirement than the 50+ group [t(194) = 2.492, p = 0.014].
Mean ratings of the respective factors influencing the timing of retirement across the two age groups.
The relative importance of the respective factors influencing the timing of retirement for the two age groups was strikingly similar (Table 5). The differences, when they occurred were minor. The pattern of the ranking of both age groups followed the same overall trend: The most important factor in terms of retirement timing was the response to God’ calling. The next important set of factors was: health assessment; both physical and psychological. This was followed by the need to retire to help others. Then with a ranking of 7/11 came ‘achieving sufficient financial security’. All the other factors were considered of lesser importance in determining timing of retirement.
Factors influencing timing of retirement: a comparison between respondents aged less than 50 years and those aged 50 plus years.
In terms of ranking differences across the age groups the less than 50 years group ranked cognitive impairment above physical illness whereas for the 50+ years the order was reversed; a difference that was not predicted. The timing of the retirement of their spouse had little impact on the retirement timing for most of the ministers. Ministers within the 50+ age group ranked timing of spouse retirement lower than the younger years age group. In fact, the older age group ranked timing of spouse retirement as the least important of the respective timing of retirement factors presented to them.
At the start of this chapter, we noted that an aging population now implies that a significant portion of society faces an historically increased number of years in retirement. Not only will an increasing percentage of citizens in developed countries live longer, but they will experience a more complex retirement dynamic as they come to realize. “Aging is not what it used to be…” [30].
This phenomenon has far-reaching implications for society in general and calls for an informed response at local and state level. A multidimensional approach to retirement necessitates a multi-focal lens in which it is recognized that retirees are not a homogenous group. This necessitates consideration of culture specific impacting factors and awareness of contextual influence in age-differentiated approaches in order to gain in-depth insight into the retirement phenomena.
We hoped to make a contribution to the conversation on retirement by selecting a specific group of participants with strong cultural and traditional ties to illustrate that in addition to the well-documented impacting factors of health and finance, additional influencers have significant impact on the way retirement is viewed. In addition, we sought the response of two age identified groups (50 years and younger, 50 years and older) to identify age related differences in perception to retirement. This group of working Seventh-day Adventist ministers in Australia and New Zealand presented an opportunity to address lesser researched areas such as the impact of spirituality and a calling as well as an opportunity to study a group with a culture of adherence to promoting a holistic lifestyle as part of their faith beliefs. In addition, it became clear from a reading of the literature that there is only limited research into perceptions of contemporary ministers of religion [31].
Response to the inquiry into personal and professional factors impacting retirement indicated that these ministers rated their cognitive health very highly. They also gave regard for wellbeing, personal resilience and their ability to plan for the future relatively high ratings. The centrality of their work was also highly rated, a result common to other careers where work is regarded to some degree as a ‘calling’ [13]. Anxiety about aging was rated in mid-range. In terms of financial and social resources for retirement, the social component was rated highly but in contrast, the financial component received a low rating.
Most of the minsters saw their career as a divine life-long calling which may be divided into periods of particular focus but always with a service orientation. Their retirement was not seen as an end of ministry but rather a time to move into a different ministry orientation. This view finds commonality with the central premise of Atchley’s Continuity Theory (1989) in which older adults seek to preserve and maintain previous lifestyle patterns, identities and values.
There were age group differences with the older set rating their psychological stress significantly lower and their financial retirement resources significantly higher than their younger colleagues. As predicted, the younger set rated their physical health significantly higher than their older colleagues.
The study focused on three principal aspects of retirement: How prepared participants thought they were for retirement?; Whether they thought retirement would be a positive season?; Whether they were satisfied with their planning for retirement? Most of the ministers were quite confident that retirement would be a positive season of their life but please see further discussion below. They were, however, less confident that they were prepared for retirement and were not satisfied with their planning for retirement. Even though both age groups ranked these elements of retirement in the same order, the younger set were less confident about each element than the older ministers.
For both age groups, financial resources were the strongest positive predictor of perceptions of preparedness for retirement. For the younger set, psychological stress was a negative predictor of preparedness; the greater the stress the less prepared for retirement they felt. Whether an increase in psychological stress was linked to a perception that retirement may come earlier than planned or that stressed ministers generated more negative assessments of their present situation, needs further exploration.
Predictors of retirement as a positive season of life were different for the two age groups; something that was not foreseen. For the 50+ years age group the two predictors were financial resources, as expected, and their anxiety about aging. The less anxious they were about aging, the more often they perceived that retirement would be a positive season of their life. In contrast, for the younger group, financial resources were not a predictor that retirement would be a positive season of their life. Rather the following factors were considered significant: wellbeing; a perception that calling to ministry was for a specified task and the view that ministry allowed for personal development and fulfillment. These are personal and professional factors that could be seen to enhance ministers’ ability to cope well with life changes in general, so it seems reasonable to have these factors associated with a positive view of retirement. For the younger set, physical health was a negative predictor of the retirement phase. Why? A possible explanation could be that younger ministers who felt physically healthy now, anticipated poorer health in the future and thus perceived that retirement will be less positive.
Associated with the ministers’ perception of their preparedness for retirement, is their perception of satisfaction with their planning. For both age groups perception of retirement finance resources, once again, consistently predicted their satisfaction with retirement planning. As predicted, the older set’s perception of their future orientation was a positive predictor of satisfaction with their retirement planning. What is interesting, however, is that this is not a predictor for the younger ministers, perhaps suggesting that retirement planning often does not become a focused activity until ministers reach the 50+ years age range. For the younger set, the perception that their career was a vocation which allows for personal fulfillment and development was also a predictor of satisfaction with their retirement planning. This may indicate that for these ministers, personal development orientation includes planning for the future. The awareness that a positive retirement experience necessitates taking personal responsibility for being prepared for this eventuality demonstrates an emerging trend for ministers. The weight given to personal development may also suggest that the younger group regard retirement as an opportunity to continue growing and contributing to the welfare of others.
Results from considering the responses of participants in terms of timing for retirement reiterate the importance of inquiry into specific context. The most significant factor influencing the timing of retirement was not finances but for both age groups, confidence that they had completed God’s calling. Results like this have important implications for management strategies. It is clear that it cannot be assumed that monetary considerations constitute the primary decider of when individuals in this study will retire. These participants have indicated that they will continue working until they feel certain they have accomplished the task for which they were called, irrespective of financial considerations but dependent on health status.
Although both age groups placed a high premium on health when it came to decisions about when to retire, the younger group gave pre-eminence to cognitive health, while the older group considered physical health as more important. Either way, the high ranking given to health is potentially further evidence that contemporary faith-based ministers are entering a new era where they are aware of the necessity of taking personal responsibility for their personal and professional wellbeing. This may be illustrated by the increasing enrollment and growth of Seventh-day Adventist holistic health programs in the USA, Australia and New Zealand.
Limitations of this study include that it only accessed ministers from one faith-based community. Even so, it is expected that this career specific study could have application to other faith-based ministers but additional studies with different faith-based ministers are needed to test this expectation. The sample size though reasonable for the Australian and New Zealand Seventh-day Adventist faith–based community, comprise a relatively small number of ministers. This limited the ability of the study to explore differences within the sample in terms of such characteristics as ministry type, location, training, gender and a larger range of age groups. Finally, the data obtained was constrained by the researchers’ questionnaire framework. Factors that influence ministers’ perceptions of retirement outside this framework can and should be explored by studies adopting a qualitative research orientation.
The rising tide of baby boomers entering retirement, coupled with global challenges of the aging phenomena, has focused the spotlight on employee preparation for retirement. Faith-based ministers, who traditionally followed a line that God would take care of them in retirement, have entered a new era in which, while not negating their faith beliefs, are advocating for a more active role in preparing for the retirement phase. Insights gained from this study will make a valuable contribution to the general understanding of retirement as a ‘comma’ and no longer as a ‘full-stop’ in an individual’s life span. Results from this study show that individuals who envisage a retirement season in which, service for the greater good is continued in some form, are more likely to experience a positive retirement life phase. In particular, these results focus on the importance of understanding factors impacting retirement in specific context, strengthening the argument that retirees cannot be regarded as a homogeneous group. Results have indicated evolving patterns even within cohorts of the aging population. It is proposed that the adoption of a multifocal lens to view retirement has the potential to enhance organizational management strategies, interpersonal connectivity and intrapersonal growth and wellbeing. By increasing the wellbeing of retirees in the community, a potentially significant resource will be unleashed to augment ever-increasing social needs. This study presents an opportunity to incorporate insight from specific context into macro-evolving patterns; shifting perception of aging and retirement as an increasing burden on society to one of a potential positive contributory resource. This surely constitutes a step in the right direction.
The authors acknowledge the contribution of Dr Peter Williams and Dr Bruce Manning to the work of this research.
The authors declare that they are not aware of any conflict of interest in the course of conducting this research.
A note of thanks to Lynelle Waring for editorial assistance.
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\n'}]},successStories:{items:[]},authorsAndEditors:{filterParams:{sort:"featured,name"},profiles:[{id:"105746",title:"Dr.",name:"A.W.M.M.",middleName:null,surname:"Koopman-van Gemert",slug:"a.w.m.m.-koopman-van-gemert",fullName:"A.W.M.M. Koopman-van Gemert",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/105746/images/5803_n.jpg",biography:"Dr. Anna Wilhelmina Margaretha Maria Koopman-van Gemert MD, PhD, became anaesthesiologist-intensivist from the Radboud University Nijmegen (the Netherlands) in 1987. She worked for a couple of years also as a blood bank director in Nijmegen and introduced in the Netherlands the Cell Saver and blood transfusion alternatives. She performed research in perioperative autotransfusion and obtained the degree of PhD in 1993 publishing Peri-operative autotransfusion by means of a blood cell separator.\nBlood transfusion had her special interest being the president of the Haemovigilance Chamber TRIP and performing several tasks in local and national blood bank and anticoagulant-blood transfusion guidelines committees. Currently, she is working as an associate professor and up till recently was the dean at the Albert Schweitzer Hospital Dordrecht. She performed (inter)national tasks as vice-president of the Concilium Anaesthesia and related committees. \nShe performed research in several fields, with over 100 publications in (inter)national journals and numerous papers on scientific conferences. \nShe received several awards and is a member of Honour of the Dutch Society of Anaesthesia.",institutionString:null,institution:{name:"Albert Schweitzer Hospital",country:{name:"Gabon"}}},{id:"83089",title:"Prof.",name:"Aaron",middleName:null,surname:"Ojule",slug:"aaron-ojule",fullName:"Aaron Ojule",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Port Harcourt",country:{name:"Nigeria"}}},{id:"295748",title:"Mr.",name:"Abayomi",middleName:null,surname:"Modupe",slug:"abayomi-modupe",fullName:"Abayomi Modupe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"Landmark University",country:{name:"Nigeria"}}},{id:"94191",title:"Prof.",name:"Abbas",middleName:null,surname:"Moustafa",slug:"abbas-moustafa",fullName:"Abbas Moustafa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94191/images/96_n.jpg",biography:"Prof. Moustafa got his doctoral degree in earthquake engineering and structural safety from Indian Institute of Science in 2002. He is currently an associate professor at Department of Civil Engineering, Minia University, Egypt and the chairman of Department of Civil Engineering, High Institute of Engineering and Technology, Giza, Egypt. He is also a consultant engineer and head of structural group at Hamza Associates, Giza, Egypt. Dr. Moustafa was a senior research associate at Vanderbilt University and a JSPS fellow at Kyoto and Nagasaki Universities. He has more than 40 research papers published in international journals and conferences. He acts as an editorial board member and a reviewer for several regional and international journals. His research interest includes earthquake engineering, seismic design, nonlinear dynamics, random vibration, structural reliability, structural health monitoring and uncertainty modeling.",institutionString:null,institution:{name:"Minia University",country:{name:"Egypt"}}},{id:"84562",title:"Dr.",name:"Abbyssinia",middleName:null,surname:"Mushunje",slug:"abbyssinia-mushunje",fullName:"Abbyssinia Mushunje",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Fort Hare",country:{name:"South Africa"}}},{id:"202206",title:"Associate Prof.",name:"Abd Elmoniem",middleName:"Ahmed",surname:"Elzain",slug:"abd-elmoniem-elzain",fullName:"Abd Elmoniem Elzain",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Kassala University",country:{name:"Sudan"}}},{id:"98127",title:"Dr.",name:"Abdallah",middleName:null,surname:"Handoura",slug:"abdallah-handoura",fullName:"Abdallah Handoura",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Supérieure des Télécommunications",country:{name:"Morocco"}}},{id:"91404",title:"Prof.",name:"Abdecharif",middleName:null,surname:"Boumaza",slug:"abdecharif-boumaza",fullName:"Abdecharif Boumaza",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Abbès Laghrour University of Khenchela",country:{name:"Algeria"}}},{id:"105795",title:"Prof.",name:"Abdel Ghani",middleName:null,surname:"Aissaoui",slug:"abdel-ghani-aissaoui",fullName:"Abdel Ghani Aissaoui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/105795/images/system/105795.jpeg",biography:"Abdel Ghani AISSAOUI is a Full Professor of electrical engineering at University of Bechar (ALGERIA). He was born in 1969 in Naama, Algeria. He received his BS degree in 1993, the MS degree in 1997, the PhD degree in 2007 from the Electrical Engineering Institute of Djilali Liabes University of Sidi Bel Abbes (ALGERIA). He is an active member of IRECOM (Interaction Réseaux Electriques - COnvertisseurs Machines) Laboratory and IEEE senior member. He is an editor member for many international journals (IJET, RSE, MER, IJECE, etc.), he serves as a reviewer in international journals (IJAC, ECPS, COMPEL, etc.). He serves as member in technical committee (TPC) and reviewer in international conferences (CHUSER 2011, SHUSER 2012, PECON 2012, SAI 2013, SCSE2013, SDM2014, SEB2014, PEMC2014, PEAM2014, SEB (2014, 2015), ICRERA (2015, 2016, 2017, 2018,-2019), etc.). His current research interest includes power electronics, control of electrical machines, artificial intelligence and Renewable energies.",institutionString:"University of Béchar",institution:{name:"University of Béchar",country:{name:"Algeria"}}},{id:"99749",title:"Dr.",name:"Abdel Hafid",middleName:null,surname:"Essadki",slug:"abdel-hafid-essadki",fullName:"Abdel Hafid Essadki",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Nationale Supérieure de Technologie",country:{name:"Algeria"}}},{id:"101208",title:"Prof.",name:"Abdel Karim",middleName:"Mohamad",surname:"El Hemaly",slug:"abdel-karim-el-hemaly",fullName:"Abdel Karim El Hemaly",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/101208/images/733_n.jpg",biography:"OBGYN.net Editorial Advisor Urogynecology.\nAbdel Karim M. A. El-Hemaly, MRCOG, FRCS � Egypt.\n \nAbdel Karim M. A. El-Hemaly\nProfessor OB/GYN & Urogynecology\nFaculty of medicine, Al-Azhar University \nPersonal Information: \nMarried with two children\nWife: Professor Laila A. Moussa MD.\nSons: Mohamad A. M. El-Hemaly Jr. MD. Died March 25-2007\nMostafa A. M. El-Hemaly, Computer Scientist working at Microsoft Seatle, USA. \nQualifications: \n1.\tM.B.-Bch Cairo Univ. June 1963. \n2.\tDiploma Ob./Gyn. Cairo Univ. April 1966. \n3.\tDiploma Surgery Cairo Univ. Oct. 1966. \n4.\tMRCOG London Feb. 1975. \n5.\tF.R.C.S. Glasgow June 1976. \n6.\tPopulation Study Johns Hopkins 1981. \n7.\tGyn. Oncology Johns Hopkins 1983. \n8.\tAdvanced Laparoscopic Surgery, with Prof. Paulson, Alexandria, Virginia USA 1993. \nSocieties & Associations: \n1.\t Member of the Royal College of Ob./Gyn. London. \n2.\tFellow of the Royal College of Surgeons Glasgow UK. \n3.\tMember of the advisory board on urogyn. FIGO. \n4.\tMember of the New York Academy of Sciences. \n5.\tMember of the American Association for the Advancement of Science. \n6.\tFeatured in �Who is Who in the World� from the 16th edition to the 20th edition. \n7.\tFeatured in �Who is Who in Science and Engineering� in the 7th edition. \n8.\tMember of the Egyptian Fertility & Sterility Society. \n9.\tMember of the Egyptian Society of Ob./Gyn. \n10.\tMember of the Egyptian Society of Urogyn. \n\nScientific Publications & Communications:\n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Asim Kurjak, Ahmad G. Serour, Laila A. S. Mousa, Amr M. Zaied, Khalid Z. El Sheikha. \nImaging the Internal Urethral Sphincter and the Vagina in Normal Women and Women Suffering from Stress Urinary Incontinence and Vaginal Prolapse. Gynaecologia Et Perinatologia, Vol18, No 4; 169-286 October-December 2009.\n2- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nFecal Incontinence, A Novel Concept: The Role of the internal Anal sphincter (IAS) in defecation and fecal incontinence. Gynaecologia Et Perinatologia, Vol19, No 2; 79-85 April -June 2010.\n3- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nSurgical Treatment of Stress Urinary Incontinence, Fecal Incontinence and Vaginal Prolapse By A Novel Operation \n"Urethro-Ano-Vaginoplasty"\n Gynaecologia Et Perinatologia, Vol19, No 3; 129-188 July-September 2010.\n4- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n5- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n6- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n7-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n8-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n9-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n10-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n11-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n12- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n13-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n14- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n15-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n\n16-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n17- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis\n\n18-Maternal Mortality in Egypt, a cry for help and attention. The Second International Conference of the African Society of Organization & Gestosis, 1998, 3rd Annual International Conference of Ob/Gyn Department � Sohag Faculty of Medicine University. Feb. 11-13. Luxor, Egypt. \n19-Postmenopausal Osteprosis. The 2nd annual conference of Health Insurance Organization on Family Planning and its role in primary health care. Zagaziz, Egypt, February 26-27, 1997, Center of Complementary Services for Maternity and childhood care. \n20-Laparoscopic Assisted vaginal hysterectomy. 10th International Annual Congress Modern Trends in Reproductive Techniques 23-24 March 1995. Alexandria, Egypt. \n21-Immunological Studies in Pre-eclamptic Toxaemia. Proceedings of 10th Annual Ain Shams Medical Congress. Cairo, Egypt, March 6-10, 1987. \n22-Socio-demographic factorse affecting acceptability of the long-acting contraceptive injections in a rural Egyptian community. Journal of Biosocial Science 29:305, 1987. \n23-Plasma fibronectin levels hypertension during pregnancy. The Journal of the Egypt. Soc. of Ob./Gyn. 13:1, 17-21, Jan. 1987. \n24-Effect of smoking on pregnancy. Journal of Egypt. Soc. of Ob./Gyn. 12:3, 111-121, Sept 1986. \n25-Socio-demographic aspects of nausea and vomiting in early pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 35-42, Sept. 1986. \n26-Effect of intrapartum oxygen inhalation on maternofetal blood gases and pH. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 57-64, Sept. 1986. \n27-The effect of severe pre-eclampsia on serum transaminases. The Egypt. J. Med. Sci. 7(2): 479-485, 1986. \n28-A study of placental immunoreceptors in pre-eclampsia. The Egypt. J. Med. Sci. 7(2): 211-216, 1986. \n29-Serum human placental lactogen (hpl) in normal, toxaemic and diabetic pregnant women, during pregnancy and its relation to the outcome of pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:2, 11-23, May 1986. \n30-Pregnancy specific B1 Glycoprotein and free estriol in the serum of normal, toxaemic and diabetic pregnant women during pregnancy and after delivery. Journal of the Egypt. Soc. of Ob./Gyn. 12:1, 63-70, Jan. 1986. Also was accepted and presented at Xith World Congress of Gynecology and Obstetrics, Berlin (West), September 15-20, 1985. \n31-Pregnancy and labor in women over the age of forty years. Accepted and presented at Al-Azhar International Medical Conference, Cairo 28-31 Dec. 1985. \n32-Effect of Copper T intra-uterine device on cervico-vaginal flora. Int. J. Gynaecol. Obstet. 23:2, 153-156, April 1985. \n33-Factors affecting the occurrence of post-Caesarean section febrile morbidity. Population Sciences, 6, 139-149, 1985. \n34-Pre-eclamptic toxaemia and its relation to H.L.A. system. Population Sciences, 6, 131-139, 1985. \n35-The menstrual pattern and occurrence of pregnancy one year after discontinuation of Depo-medroxy progesterone acetate as a postpartum contraceptive. Population Sciences, 6, 105-111, 1985. \n36-The menstrual pattern and side effects of Depo-medroxy progesterone acetate as postpartum contraceptive. Population Sciences, 6, 97-105, 1985. \n37-Actinomyces in the vaginas of women with and without intrauterine contraceptive devices. Population Sciences, 6, 77-85, 1985. \n38-Comparative efficacy of ibuprofen and etamsylate in the treatment of I.U.D. menorrhagia. Population Sciences, 6, 63-77, 1985. \n39-Changes in cervical mucus copper and zinc in women using I.U.D.�s. Population Sciences, 6, 35-41, 1985. \n40-Histochemical study of the endometrium of infertile women. Egypt. J. Histol. 8(1) 63-66, 1985. \n41-Genital flora in pre- and post-menopausal women. Egypt. J. Med. Sci. 4(2), 165-172, 1983. \n42-Evaluation of the vaginal rugae and thickness in 8 different groups. Journal of the Egypt. Soc. of Ob./Gyn. 9:2, 101-114, May 1983. \n43-The effect of menopausal status and conjugated oestrogen therapy on serum cholesterol, triglycerides and electrophoretic lipoprotein patterns. Al-Azhar Medical Journal, 12:2, 113-119, April 1983. \n44-Laparoscopic ventrosuspension: A New Technique. Int. J. Gynaecol. Obstet., 20, 129-31, 1982. \n45-The laparoscope: A useful diagnostic tool in general surgery. Al-Azhar Medical Journal, 11:4, 397-401, Oct. 1982. \n46-The value of the laparoscope in the diagnosis of polycystic ovary. Al-Azhar Medical Journal, 11:2, 153-159, April 1982. \n47-An anaesthetic approach to the management of eclampsia. Ain Shams Medical Journal, accepted for publication 1981. \n48-Laparoscopy on patients with previous lower abdominal surgery. Fertility management edited by E. Osman and M. Wahba 1981. \n49-Heart diseases with pregnancy. Population Sciences, 11, 121-130, 1981. \n50-A study of the biosocial factors affecting perinatal mortality in an Egyptian maternity hospital. Population Sciences, 6, 71-90, 1981. \n51-Pregnancy Wastage. Journal of the Egypt. Soc. of Ob./Gyn. 11:3, 57-67, Sept. 1980. \n52-Analysis of maternal deaths in Egyptian maternity hospitals. Population Sciences, 1, 59-65, 1979. \nArticles published on OBGYN.net: \n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n2- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n3- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n4-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n5-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n6-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n7-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n8-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n9- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n10-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n11- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n12-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n13-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n14- Abdel Karim M. El Hemaly. 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