Day 15: this is my first day of a third week without chemotherapy. The side effects were getting so bad that I have been given a week's respite this time. Yesterday was a bad day with no energy and I spent a lot of it sleeping, but today seems to be starting OK. The neuropathy is no better. It is a strange phenomenon. Pain and temperature is preserved, as is deep touch, but fine touch has gone. I think also there has been a loss of propriaception though this is harder to self measure. It is of characteristic 'glove and stocking' distribution, extending up my legs to halfway up my calves. It also involves the front two thirds of my tongue. It has affected my taste too. I have really gone off sweet things, especially strawberry, which I now loathe. However, some milk chocolates are very helpful, both for calories and for soothing my stomach, though very sweet chocolate is not welcome. I have a craving for savories, especially bitter things. Apricot, rhubarb, gooseberries all find favor. I dare say that a pint of bitter would go down well, though I am off alcohol.
We were promised a scorching summer, but July has been rather wet after Wimbledon. What has characterized this summer has been the wind. Living on the coast we normally experience cooling breezes to ameliorate the heat in summer, but this year it has mostly been too cold to sit out in the garden. Today is another overcast, showery day.
I have been reading John Le Carre's "A Most Wanted Man". It is a despairing look at modern life. Set in Germany, it explores the modern world of espionage directed against the Islamist threat. Germany is depicted as weak and ineffectual with one half of the Intelligence services in thrall to the Americans, and the other half part of the Human Rights mafia. America is clearly the villain; they do terrible things including extraordinary rendition, but are excused as being ignorant as Johnny-come-latelies to the spying game. The British are the worst, as they not only do terrible things, but they know what they are doing.
The reader is obviously meant to sympathize with the oppressed half Chechnyen/half Russian who has been tortured and imprisoned by both Russians and Turks, and with the rather naive British banker and German lawyer, but I am not sure whether I do. It seems probable that the Chechnyen was involved in terrorism albeit against the Russian beast, the Brit was a failure as a banker, husband and father and what is more acquiesced to his own father's money laundering. The young female German lawyer sees good in bad people and turns a blind eye to their crimes. In the end a man responsible for funding atrocities and assassinations is scooped up by the Americans to the disgust of one German group that wanted to turn him and use him to destroy Islamist terror from within.
Overall, the story presents a picture of how complex the 'War on Terror' is. Nothing is black and white and people have different opinions on shades of grey.
I spent some of the time reading the book in the garden on our swing chair. When the sun shines the garden looks very well with the hydrangeas all in full bloom as well as the lavender and potentillas. Buddleias are attracting bees and butterflies and the large tubs are overflowing with red, pink and white begonias. Smaller pots house white, red and orange double begonias. The fuchsias have been poor this year but patches of orange montbretia liven up the green, for green is everywhere. There is no sign of brown on the lawn, which is more meadow than grass, having seen a crop of daisies, then clover and now a yellow vetch.
I have had to take out one of the yew trees in our front hedge as it had died on us. I hope that the two adjacent trees will bridge the gap in time. Still, we have a new gardener who will, I hope, know about these things.
Wednesday, July 29, 2009
Sunday, July 26, 2009
Hope and Holiness; 1 Peter 1:13-16.
We are back in 1 Peter. Chris Kelly has returned from his Sabbatical and picked up the thread from where he left off.
We begin at 1 Peter ch 1 v 13: Therefore, prepare your minds for action; be self-controlled; set your hope fully on the grace to be given you when Jesus Christ is revealed. As obedient children, do not conform to the evil desires you had when you lived in ignorance. But just as he who called you is holy, so be holy in all you do; for it is written: "Be holy because I am holy."
These two verses give us two instructions about the Christian life: Hope and be Holy.
So many Christians major on Christian love. God is love, they say and their whole life is devoted to good works. I read this from a character in John Le Carre's latest novel, an earnest young lawyer doing pro-bono work for asylum seekers/illegal immigrants: "We'd rather be fooled than be cynical." But it can hardly be good stewardship to be the dupes of cynical crooks. Many people have scrimped to fund those doing the supposed good works.
Other Christians major on faith. By faith are you saved, they say and they are especially concerned with whether so-and-so is really saved. Is his faith saving faith? Is he trusting only in the blood of Christ? Or is he adding something of his own? In my opinion that is a question the God only knows the answer to. It's not my responsibility to question who are who is not a Christian. I shall certainly guard the pulpit against heresy, but I have no window on men's souls. Such an overemphasis can lead to a bitter, twisted life that displays a meanness that is nothing to do with Christ.
So why neglect hope? I know that Paul says that of faith, hope and love, the greatest of these is love (1 Corinthians 13:13), but a life without hope is hopeless. Paul also says, If it is only for this life we have hope in Christ, we are to be pitied more than all men (1 Corinthians 15:19).
Have you ever flown first class? I did once. Not of choice, I hasten to add. I was due to fly from London to Philadelphia to stay with a Pastor friend in Wilmington, Delaware. The flight was delayed for 8 hours, so I looked for alternatives. After consulting a map I hit upon a a flight to Washington/Baltimore followed by the Amtrak to Wilmington. the airline agreed to the switch, but made me upgrade to Business Class. In those days this was an extra couple of hundred pounds and was just about affordable. However, when I checked in, there were no seats in Business so they bumped me up to First Class. I have travelled several times in Business since, but First Class is a revelation.
There were only two of us in First; the other was an Ambassador who didn't want conversation. The seats were sumptuous and the food... We were served a claret that must have been more than £100 a bottle (and this was in the Eighties!). We had fillet steak with all the trimmings and creme brulee to follow and a single steward between the two of us. It was like staying in the President's suite in a grand hotel (something else that once happened to me - two bedrooms, two bathrooms, a drawing room/dining room, five televisions - yes that's right, one in each bathroom - and a grand piano!).
I was thinking about the difference between those poor souls in steerage (economy, cattle class - name it how you like). A ten hour flight overnight, cramped in a hard seat with too little leg room, trying to sleep but waking every hour with cramp in one set of muscles or other, being woken every time the fat Texan with a large prostate on your left decides to visit the bathroom - at least you have twenty minutes when he's not overflowing his seat into yours - being woken by a tired flight attendant to serve you an overcooked, pre-frozen concoction of rice and dead chicken, while in the back of the seat in front of you an old movie is playing on a tiny screen, but you can't follow it because the hiss from the cheap headphones is drowned out by the noise of the engines.
And in my seat at the front of the airplane I pity you as I chew on my luscious steak that has been cooked on the plane and sip at my Mouton Rothschild, then don my airline-provided pyjamas while the steward transforms my seat into a flat bed with wonderfully deep pillows, real sheets and a duvet, and I think how the Lord as blessed me in this life compared to those miserable sinners at the back.
The thing is the airplane I am thinking about is Air France Flight AF 447 and it is doomed to come down in the South Atlantic with no survivors, and it doesn't matter whether you are sitting in the front or back of the airplane, your fate is the same.
If your hope is only for blessings in this life then we are indeed of all men most miserable. But our hope is in the return of Christ. His second coming is very close, like a bird skimming over the surface of a lake, He is very near. I am not sure when He will make His touch down, but I am certain He will. Soon and very soon we are going to see the King. This world is not my home, I'm just a-passing through. Who cares if the roof needs fixing or the carpets are thin, we are in transit. At the airport you notice that the bathrooms need cleaning - so what! You'll be gone in a couple of hours. Fix your eyes upon Jesus, Look full in His wonderful face and the things of earth will grow strangely dim in the light of his glory and grace.
But His demand of us is that we be Holy. Holiness means separating ourselves from sin. But it also means separating ourselves for God and to Him. Sometimes Christians in the past have concentrated on the first and neglected the second. No lipstick, no movies, no nylons. Always wear a hat in church. Walk on Sundays, but never run or skate or ride your bike. No TV, but listen to the hymn singing on the wireless then tune off when the comedy program comes on in case you fail to repress that sinful snigger. Closed orders of monks and nuns tried to separate themselves from the world but in shutting themselves in they did not the light of God to escape. Holiness means being like Christ, who healed the sick, succoured the poor, fed the hungry and preached to the needy. I remember in my youth being stunned to see a Salvation Army Major in a pub. Most Christians thought alcohol the Devil's brew, but here he was with his War Cry witnessing to those without hope. Now is the time to show the love that is the greatest of the three; now is the time to testify to the faith that saves.
The world is coming apart. The financial crash has left many unemployed, many homeless and many bankrupt. What hope do they have? Only the fear of catching swine 'flu confronts them. In America now, following Britain, we are losing faith in our elected leaders. Despite the need to set up free field hospitals to cater for the uninsured, Obama's heath plan is stuck in Congress where even the Democrats can't stomach it. Obama's approval rating has fallen below 50% in record time, while Gordon Brown's seems stuck on 16%. Where can they put their trust? The middle verse in the Bible tells them: "It is better to take refuge in the LORD than to trust in man."(Psalm 118 v8)
This is what we should shout from the rooftops. Jesus is safe! Jesus saves! Jesus has risen! Jesus reigns! Jesus is returning! Put your trust in Him!
We begin at 1 Peter ch 1 v 13: Therefore, prepare your minds for action; be self-controlled; set your hope fully on the grace to be given you when Jesus Christ is revealed. As obedient children, do not conform to the evil desires you had when you lived in ignorance. But just as he who called you is holy, so be holy in all you do; for it is written: "Be holy because I am holy."
These two verses give us two instructions about the Christian life: Hope and be Holy.
So many Christians major on Christian love. God is love, they say and their whole life is devoted to good works. I read this from a character in John Le Carre's latest novel, an earnest young lawyer doing pro-bono work for asylum seekers/illegal immigrants: "We'd rather be fooled than be cynical." But it can hardly be good stewardship to be the dupes of cynical crooks. Many people have scrimped to fund those doing the supposed good works.
Other Christians major on faith. By faith are you saved, they say and they are especially concerned with whether so-and-so is really saved. Is his faith saving faith? Is he trusting only in the blood of Christ? Or is he adding something of his own? In my opinion that is a question the God only knows the answer to. It's not my responsibility to question who are who is not a Christian. I shall certainly guard the pulpit against heresy, but I have no window on men's souls. Such an overemphasis can lead to a bitter, twisted life that displays a meanness that is nothing to do with Christ.
So why neglect hope? I know that Paul says that of faith, hope and love, the greatest of these is love (1 Corinthians 13:13), but a life without hope is hopeless. Paul also says, If it is only for this life we have hope in Christ, we are to be pitied more than all men (1 Corinthians 15:19).
Have you ever flown first class? I did once. Not of choice, I hasten to add. I was due to fly from London to Philadelphia to stay with a Pastor friend in Wilmington, Delaware. The flight was delayed for 8 hours, so I looked for alternatives. After consulting a map I hit upon a a flight to Washington/Baltimore followed by the Amtrak to Wilmington. the airline agreed to the switch, but made me upgrade to Business Class. In those days this was an extra couple of hundred pounds and was just about affordable. However, when I checked in, there were no seats in Business so they bumped me up to First Class. I have travelled several times in Business since, but First Class is a revelation.
There were only two of us in First; the other was an Ambassador who didn't want conversation. The seats were sumptuous and the food... We were served a claret that must have been more than £100 a bottle (and this was in the Eighties!). We had fillet steak with all the trimmings and creme brulee to follow and a single steward between the two of us. It was like staying in the President's suite in a grand hotel (something else that once happened to me - two bedrooms, two bathrooms, a drawing room/dining room, five televisions - yes that's right, one in each bathroom - and a grand piano!).
I was thinking about the difference between those poor souls in steerage (economy, cattle class - name it how you like). A ten hour flight overnight, cramped in a hard seat with too little leg room, trying to sleep but waking every hour with cramp in one set of muscles or other, being woken every time the fat Texan with a large prostate on your left decides to visit the bathroom - at least you have twenty minutes when he's not overflowing his seat into yours - being woken by a tired flight attendant to serve you an overcooked, pre-frozen concoction of rice and dead chicken, while in the back of the seat in front of you an old movie is playing on a tiny screen, but you can't follow it because the hiss from the cheap headphones is drowned out by the noise of the engines.
And in my seat at the front of the airplane I pity you as I chew on my luscious steak that has been cooked on the plane and sip at my Mouton Rothschild, then don my airline-provided pyjamas while the steward transforms my seat into a flat bed with wonderfully deep pillows, real sheets and a duvet, and I think how the Lord as blessed me in this life compared to those miserable sinners at the back.
The thing is the airplane I am thinking about is Air France Flight AF 447 and it is doomed to come down in the South Atlantic with no survivors, and it doesn't matter whether you are sitting in the front or back of the airplane, your fate is the same.
If your hope is only for blessings in this life then we are indeed of all men most miserable. But our hope is in the return of Christ. His second coming is very close, like a bird skimming over the surface of a lake, He is very near. I am not sure when He will make His touch down, but I am certain He will. Soon and very soon we are going to see the King. This world is not my home, I'm just a-passing through. Who cares if the roof needs fixing or the carpets are thin, we are in transit. At the airport you notice that the bathrooms need cleaning - so what! You'll be gone in a couple of hours. Fix your eyes upon Jesus, Look full in His wonderful face and the things of earth will grow strangely dim in the light of his glory and grace.
But His demand of us is that we be Holy. Holiness means separating ourselves from sin. But it also means separating ourselves for God and to Him. Sometimes Christians in the past have concentrated on the first and neglected the second. No lipstick, no movies, no nylons. Always wear a hat in church. Walk on Sundays, but never run or skate or ride your bike. No TV, but listen to the hymn singing on the wireless then tune off when the comedy program comes on in case you fail to repress that sinful snigger. Closed orders of monks and nuns tried to separate themselves from the world but in shutting themselves in they did not the light of God to escape. Holiness means being like Christ, who healed the sick, succoured the poor, fed the hungry and preached to the needy. I remember in my youth being stunned to see a Salvation Army Major in a pub. Most Christians thought alcohol the Devil's brew, but here he was with his War Cry witnessing to those without hope. Now is the time to show the love that is the greatest of the three; now is the time to testify to the faith that saves.
The world is coming apart. The financial crash has left many unemployed, many homeless and many bankrupt. What hope do they have? Only the fear of catching swine 'flu confronts them. In America now, following Britain, we are losing faith in our elected leaders. Despite the need to set up free field hospitals to cater for the uninsured, Obama's heath plan is stuck in Congress where even the Democrats can't stomach it. Obama's approval rating has fallen below 50% in record time, while Gordon Brown's seems stuck on 16%. Where can they put their trust? The middle verse in the Bible tells them: "It is better to take refuge in the LORD than to trust in man."(Psalm 118 v8)
This is what we should shout from the rooftops. Jesus is safe! Jesus saves! Jesus has risen! Jesus reigns! Jesus is returning! Put your trust in Him!
Visiting the sick
Would you like to be an Angel? Would you like to see an Angel?
The beginning of Hebrews ch 13 says: Keep on loving each other as brothers. Do not forget to entertain strangers, for by so doing some people have entertained angels without knowing it.
Since this is letter written to Jews we must look to Jewish history to find the meaning. It may refer to Abraham who entertained three strangers before the destruction of Sodom. It may refer to the story of Gideon or perhaps to the parents of Samson who both met the Angel of the Lord before his birth. Whatever the reference, and probably it refers to all three since it does say 'some' (plural) have entertained angels unawares, it is an exhortation to show hospitality. But let us turn it the other way around. In Matthew 25, in the parable of the sheep and the goats, the righteous one ask Jesus, when did we see you sick or in prison and go to visit you? Jesus' reply was whatever you did for one of the least of these brothers of mine, you did for me.
As one who is sick, I thank the Lord for the 'angels' who have visited me. What has been remarkable has been the unerring timing of it all. Whenever we have a particular downtime or worry, there is the ring of the bell and in comes someone with a word of comfort or encouragement, a time of refreshing prayer or just a squeeze of the hand. The Lord has his timing right.
If you are thinking of visiting the sick, it is often wise to phone first because too many visitors can be wearing, don't make your visit too long and don't expect a sumptuous feast when you get there. But anyone visiting me will receive a warm welcome. I have even had a visitor from America who drove a couple of hundred miles on the day to see me.
So anyone out there who would like to visit, please do. But do phone first. My wife tells me that when I am at my lowest a visit from an 'angel' buoys me up and lifts my spirits.
The beginning of Hebrews ch 13 says: Keep on loving each other as brothers. Do not forget to entertain strangers, for by so doing some people have entertained angels without knowing it.
Since this is letter written to Jews we must look to Jewish history to find the meaning. It may refer to Abraham who entertained three strangers before the destruction of Sodom. It may refer to the story of Gideon or perhaps to the parents of Samson who both met the Angel of the Lord before his birth. Whatever the reference, and probably it refers to all three since it does say 'some' (plural) have entertained angels unawares, it is an exhortation to show hospitality. But let us turn it the other way around. In Matthew 25, in the parable of the sheep and the goats, the righteous one ask Jesus, when did we see you sick or in prison and go to visit you? Jesus' reply was whatever you did for one of the least of these brothers of mine, you did for me.
As one who is sick, I thank the Lord for the 'angels' who have visited me. What has been remarkable has been the unerring timing of it all. Whenever we have a particular downtime or worry, there is the ring of the bell and in comes someone with a word of comfort or encouragement, a time of refreshing prayer or just a squeeze of the hand. The Lord has his timing right.
If you are thinking of visiting the sick, it is often wise to phone first because too many visitors can be wearing, don't make your visit too long and don't expect a sumptuous feast when you get there. But anyone visiting me will receive a warm welcome. I have even had a visitor from America who drove a couple of hundred miles on the day to see me.
So anyone out there who would like to visit, please do. But do phone first. My wife tells me that when I am at my lowest a visit from an 'angel' buoys me up and lifts my spirits.
Saturday, July 25, 2009
My health again
It has been a difficult week. I have been just as slow to recover from the single drug as I was with the two drugs. The only thing that I have escaped is the cold-induced parasthesia. I'm glad I have an extra week to recover this time. The worst thing is the lethargy; after 7 pm I am a zombie. I have been trying to write a piece on TCL1, but some days I write no more than 20 words. I have also been preparing my accounts ready for the taxman, a tedious task at the best of times. However, with the future uncertain I thought it best to get them out of the way during this three week break.
I was asked if I would speak at the UK CLL Forum meeting in September, but the truth is I am so weak I would not even make the journey to London. Perhaps next year...
The postural hypotension has been bad enough for me to drop my usual blood-pressure pills, but even walking from bed to armchair sends my pulse rate up to 120 per minute. I have been doing exercises while lying down to try and strengthen my muscles which have wasted away with all this inactivity.
Course 9 starts on Wednesday week, so keep me in your thoughts and prayers, please.
I was asked if I would speak at the UK CLL Forum meeting in September, but the truth is I am so weak I would not even make the journey to London. Perhaps next year...
The postural hypotension has been bad enough for me to drop my usual blood-pressure pills, but even walking from bed to armchair sends my pulse rate up to 120 per minute. I have been doing exercises while lying down to try and strengthen my muscles which have wasted away with all this inactivity.
Course 9 starts on Wednesday week, so keep me in your thoughts and prayers, please.
Church Music
I have been listening to the new Stuart Townend combined CD and DVD. Only a few of the songs are new: Creations Sings, The Light of the World, There is an Everlasting Kindness, To See the King of Heaven Fall, and My Fault, plus a new version of Cowper's hymn, O for a Closer Walk with Thee. A couple of older hymns I hadn't previously heard: My Heart is Filled with Thankfulness from 2003 and Holy Spirit, Living Breath of God from 2005.
I was particular moved by the words of O Church Arise:
O Church arise and put your armour on;
Hear the call of Christ our captain.
For now the weak can say that they are strong
In the strength that God has given.
With shield of faith and belt of truth
We'll stand against the Devil's lies;
An Army bold, whose battle cry is love
Reaching out to those in darkness.
Our call to war, to love the captive soul,
But to rage against the captor;
And with the sword that makes the wounded whole,
We'll fight with faith and valour.
When faced with trials on every side
We know the outcome is secure,
And Christ will have the prize for which he died,
An inheritance of nations.
Come see the cross, where love and mercy meet,
As the son of God is stricken;
Then see his foes lie crushed beneath his feet,
For the conqueror has risen!
And as the stone is rolled away,
And Christ emerges from the grave,
this victory march continues 'til the day
Every eye and heart shall see him.
So Spirit, come, put strength in every stride,
give grace for every hurdle.
That we may run with faith to win the prize
Of a servant good and faithful.
As saints of all still line the way,
Retelling triumphs of his grace,
We hear their calls, and hunger for the day
When with Christ we'll stand in glory.
To demonstrate that my musical taste is catholic (not Catholic) I have also enjoyed a CD of Russian Orthodox Chant by Bulgarian choirs from Sofia. Scriabin, Tchaikovsky and Rachmaninov have all been attracted to this art form but for a starter try the compositions of Dmiter Hristov born in Bulgaria in 1933. His four part all-male harmony is sweet to the Western ear.
They sing in Greek, so I have no idea what the words are, but the music is delightful
I was particular moved by the words of O Church Arise:
O Church arise and put your armour on;
Hear the call of Christ our captain.
For now the weak can say that they are strong
In the strength that God has given.
With shield of faith and belt of truth
We'll stand against the Devil's lies;
An Army bold, whose battle cry is love
Reaching out to those in darkness.
Our call to war, to love the captive soul,
But to rage against the captor;
And with the sword that makes the wounded whole,
We'll fight with faith and valour.
When faced with trials on every side
We know the outcome is secure,
And Christ will have the prize for which he died,
An inheritance of nations.
Come see the cross, where love and mercy meet,
As the son of God is stricken;
Then see his foes lie crushed beneath his feet,
For the conqueror has risen!
And as the stone is rolled away,
And Christ emerges from the grave,
this victory march continues 'til the day
Every eye and heart shall see him.
So Spirit, come, put strength in every stride,
give grace for every hurdle.
That we may run with faith to win the prize
Of a servant good and faithful.
As saints of all still line the way,
Retelling triumphs of his grace,
We hear their calls, and hunger for the day
When with Christ we'll stand in glory.
To demonstrate that my musical taste is catholic (not Catholic) I have also enjoyed a CD of Russian Orthodox Chant by Bulgarian choirs from Sofia. Scriabin, Tchaikovsky and Rachmaninov have all been attracted to this art form but for a starter try the compositions of Dmiter Hristov born in Bulgaria in 1933. His four part all-male harmony is sweet to the Western ear.
They sing in Greek, so I have no idea what the words are, but the music is delightful
Tuesday, July 21, 2009
Death of a 22-year old
A man in London has died of alcohol-induced liver failure at the age of 22. You may have seen reports of it in the news. Gary Reinbach died less than 48 hours after his mother had highlighted her son's plight at the weekend. Already some people are using it as a stick to beat the Obama health plan. This is what happens, they say, when the government gets involved in healthcare. This begs the question as to whether or not the government is already involved in the US health care – it is of course heavily involved, spending more on health as a proportion of GDP than the British government spends on the NHS.
However, in this case, no-one in government was remotely involved; these were clinical decisions made by the doctors involved, based on agreed guidelines within the medical profession.
More than 8,000 Britons are awaiting an organ transplant, 259 of whom require livers. More than 400 people died on the waiting list last year. There is undoubtedly a shortage of liver donors. Why? Partly because there are fewer people dying in road accidents, but also because since the outrageous fuss made by the Press some years ago over the Alder Hey scandal of retained organs (see my previous article on Morbid Anatomy), relatives are more reluctant to offer up parts of their dead and dying kin for transplant. In Spain, where consent for organ donation is presumed, they do it better.
So criticism of the government for not introducing a more transplant-favorable regime might be in order, but since supply of livers does not meet the demand there has to be rationing. How should they be rationed? It could be by price. Only rich people get transplants? Not acceptable in the UK; I don’t know about the US. At the moment it is by utility. Those with the greatest need who can make the best use of a transplant should be first in line. On the whole alcoholics are not good candidates for transplants. All they do is ruin the new liver with alcohol. Of course, some are redeemable, but alcoholics are notorious liars. Therefore doctors have introduced a test to see whether they are suitable recipients. Can they stay clean for 6 months out of hospital? If they can they are put on the list for a liver. For the truth is that if someone gets a liver transplant, someone else on the waiting list won’t and will die of their disease. A famous case involved the footballer George Best. He was perhaps the best footballer of his generation, but success went to his head and he drank himself into liver failure. He passed the test of being clean for six months and got his transplant. But having received his new organ he proceeded to ruin it with alcoholic binges. You can see why doctors don’t trust alcoholics.
Moralists might declare that if the disease is self inflicted they should be at the end of the line. We don’t make those judgments in the UK. The list is made up according to who would be likely to benefit.
Poor Gary Reinbach never stood a chance. He started drinking at the age of 11 when his parents’ marriage broke up and by 13 he was binge drinking. The roots of his troubles lie with a lax attitude to family break up and an even laxer attitude to under age drinking.
Binge drinking among young people has led to a sharp rise in deaths from cirrhosis of the liver in the 25-34 age group and hospital admissions among young people have been increasing. In 2007-8 the London Ambulance Service NHS Trust dealt with 8,126 alcohol-related calls for 11 to 21-year-olds, a 27% increase on 2004-5.
The regulation of alcoholic drinks has been heavily influenced by the Portman Institute, a front organization for the alcohol manufacturers. The government is highly reliant on taxes on alcohol. They ignore recommendations from the Chief Medical Officer. This is where I hold them culpable. If the same strict policing of alcohol availability were available in the UK as is present in the USA or better still in Canada, problems like that of Gary Reinbach would not exist.
However, in this case, no-one in government was remotely involved; these were clinical decisions made by the doctors involved, based on agreed guidelines within the medical profession.
More than 8,000 Britons are awaiting an organ transplant, 259 of whom require livers. More than 400 people died on the waiting list last year. There is undoubtedly a shortage of liver donors. Why? Partly because there are fewer people dying in road accidents, but also because since the outrageous fuss made by the Press some years ago over the Alder Hey scandal of retained organs (see my previous article on Morbid Anatomy), relatives are more reluctant to offer up parts of their dead and dying kin for transplant. In Spain, where consent for organ donation is presumed, they do it better.
So criticism of the government for not introducing a more transplant-favorable regime might be in order, but since supply of livers does not meet the demand there has to be rationing. How should they be rationed? It could be by price. Only rich people get transplants? Not acceptable in the UK; I don’t know about the US. At the moment it is by utility. Those with the greatest need who can make the best use of a transplant should be first in line. On the whole alcoholics are not good candidates for transplants. All they do is ruin the new liver with alcohol. Of course, some are redeemable, but alcoholics are notorious liars. Therefore doctors have introduced a test to see whether they are suitable recipients. Can they stay clean for 6 months out of hospital? If they can they are put on the list for a liver. For the truth is that if someone gets a liver transplant, someone else on the waiting list won’t and will die of their disease. A famous case involved the footballer George Best. He was perhaps the best footballer of his generation, but success went to his head and he drank himself into liver failure. He passed the test of being clean for six months and got his transplant. But having received his new organ he proceeded to ruin it with alcoholic binges. You can see why doctors don’t trust alcoholics.
Moralists might declare that if the disease is self inflicted they should be at the end of the line. We don’t make those judgments in the UK. The list is made up according to who would be likely to benefit.
Poor Gary Reinbach never stood a chance. He started drinking at the age of 11 when his parents’ marriage broke up and by 13 he was binge drinking. The roots of his troubles lie with a lax attitude to family break up and an even laxer attitude to under age drinking.
Binge drinking among young people has led to a sharp rise in deaths from cirrhosis of the liver in the 25-34 age group and hospital admissions among young people have been increasing. In 2007-8 the London Ambulance Service NHS Trust dealt with 8,126 alcohol-related calls for 11 to 21-year-olds, a 27% increase on 2004-5.
The regulation of alcoholic drinks has been heavily influenced by the Portman Institute, a front organization for the alcohol manufacturers. The government is highly reliant on taxes on alcohol. They ignore recommendations from the Chief Medical Officer. This is where I hold them culpable. If the same strict policing of alcohol availability were available in the UK as is present in the USA or better still in Canada, problems like that of Gary Reinbach would not exist.
Sunday, July 19, 2009
More health news
I am now into day 5 of the eighth course. This time we have omitted the oxaliplatin because the peripheral neuropathy was getting to a level that long term loss of sensation was becoming likely.
Surprisingly, the new regime has not been easier to bear. On day 3 I was very ill with extreme fatigues and an unsound abdomen with a lot of bloating and funny noises. I am a bit better this morning, but I have noticed that far from improving, the numbness has started to migrate up the outside of my legs. I am also suffering from autonomic neuropathy, with a very labile blood pressure and postural hypotension. Oxaliplatin neuropathy is cumulative and continues to deteriorate for some time after the drug is stopped.
I am concerned that not enough thought is given to side effects of chemotherapy. The clinical trials do address side effects,but only in the round. They will report grade 4 neutropenia occurred in 5%, grade 4 diarrhea in 9%, grade 3 rash in 13% and think that this is acceptable, without thinking what it was like for the patient to suffer these side effects. Sure enough, no-one died of the toxicity, but it may well have been torture for the patient. We almost need a palliative care team plugged into relieving the side effects of chemotherapy.
One of the problems is that we are all different. Doses of cytotoxic drugs are based on what the average Johnnie can stand. Drugs are detoxified by a variety of enzymes, and we not only have polymorphisms of these enzymes which alter their effectiveness, the enzymes are inducible by exposure to toxic agents. Heavy smokers and drinkers, for example, are likely to be able to detoxify their drugs more easily, while those like myself who do not smoke and drink alcohol only very occasionally, may nor metabolise the drugs very well at all. This will mean that for a given dose I will suffer more side effects, but also more beneficial effects.
We should not be surprised then that Oncologists have to titrate the dose intensity to suit the patient, nor think of patients who can't stay the course as wimps.
In my case I think one of the problems making this course so severe is that the anti-emetics that I had for oxaliplatin have been withdrawn as unnecessary for 5-FU. But one of those anti-emetics was dexamethasone, which has other effects in combating fatigue. I am presuming that future courses will also exclude oxaliplatin, in which case I will take a short course of steroids to cover the first few days.
Surprisingly, the new regime has not been easier to bear. On day 3 I was very ill with extreme fatigues and an unsound abdomen with a lot of bloating and funny noises. I am a bit better this morning, but I have noticed that far from improving, the numbness has started to migrate up the outside of my legs. I am also suffering from autonomic neuropathy, with a very labile blood pressure and postural hypotension. Oxaliplatin neuropathy is cumulative and continues to deteriorate for some time after the drug is stopped.
I am concerned that not enough thought is given to side effects of chemotherapy. The clinical trials do address side effects,but only in the round. They will report grade 4 neutropenia occurred in 5%, grade 4 diarrhea in 9%, grade 3 rash in 13% and think that this is acceptable, without thinking what it was like for the patient to suffer these side effects. Sure enough, no-one died of the toxicity, but it may well have been torture for the patient. We almost need a palliative care team plugged into relieving the side effects of chemotherapy.
One of the problems is that we are all different. Doses of cytotoxic drugs are based on what the average Johnnie can stand. Drugs are detoxified by a variety of enzymes, and we not only have polymorphisms of these enzymes which alter their effectiveness, the enzymes are inducible by exposure to toxic agents. Heavy smokers and drinkers, for example, are likely to be able to detoxify their drugs more easily, while those like myself who do not smoke and drink alcohol only very occasionally, may nor metabolise the drugs very well at all. This will mean that for a given dose I will suffer more side effects, but also more beneficial effects.
We should not be surprised then that Oncologists have to titrate the dose intensity to suit the patient, nor think of patients who can't stay the course as wimps.
In my case I think one of the problems making this course so severe is that the anti-emetics that I had for oxaliplatin have been withdrawn as unnecessary for 5-FU. But one of those anti-emetics was dexamethasone, which has other effects in combating fatigue. I am presuming that future courses will also exclude oxaliplatin, in which case I will take a short course of steroids to cover the first few days.
New hymn
Some time ago I wrote a hymn about the Second Coming. It was written for a particular service and as it stood would not find a more general use. I have now written a new first verse and chorus. The tune is "These are the days of Elijah".
Christ is the king of creation
Fallen the world he has made
Soon he’ll return to release our shackles
The ransom is already paid.
Caught in a web of corruption
Stunted and stifled by sin
Jesus the victor has promised to save us
The rescue is ripe to begin
The trumpet sounds;
Listen to the shout!
Heaven opens wide;
Hear the angels sing!
All shall rise!
It’s the voice of victory
Raise your lamps to light
The coming King!
See how the sick need a doctor!
The children are dying for bread;
The Devil delights in his bombs and hatred
As panic and terror are spread.
The Church still debates its tradition,
Recalling the days that are dead,
When into the tumult there strides the Bridegroom
Demanding His Bride to be wed.
The trumpet sounds;
Listen to the shout!
Heaven opens wide;
Hear the angels sing!
All shall rise!
It’s the voice of victory
Raise your lamps to light
The coming King!
See how the world needs a Saviour!
The children are shrivelled and bored;
And mothers despair for their sons and daughters
As claims of the Christ are ignored.
But these are the days of new wineskins;
We watch as new wine is outpoured,
And see in the stretching out hands of Jesus
The joy of the world is restored.
The trumpet sounds;
Listen to the shout!
Heaven opens wide;
Hear the angels sing!
All shall rise!
It’s the voice of victory
Raise your lamps to light
The coming King
Christ is the king of creation
Fallen the world he has made
Soon he’ll return to release our shackles
The ransom is already paid.
Caught in a web of corruption
Stunted and stifled by sin
Jesus the victor has promised to save us
The rescue is ripe to begin
The trumpet sounds;
Listen to the shout!
Heaven opens wide;
Hear the angels sing!
All shall rise!
It’s the voice of victory
Raise your lamps to light
The coming King!
See how the sick need a doctor!
The children are dying for bread;
The Devil delights in his bombs and hatred
As panic and terror are spread.
The Church still debates its tradition,
Recalling the days that are dead,
When into the tumult there strides the Bridegroom
Demanding His Bride to be wed.
The trumpet sounds;
Listen to the shout!
Heaven opens wide;
Hear the angels sing!
All shall rise!
It’s the voice of victory
Raise your lamps to light
The coming King!
See how the world needs a Saviour!
The children are shrivelled and bored;
And mothers despair for their sons and daughters
As claims of the Christ are ignored.
But these are the days of new wineskins;
We watch as new wine is outpoured,
And see in the stretching out hands of Jesus
The joy of the world is restored.
The trumpet sounds;
Listen to the shout!
Heaven opens wide;
Hear the angels sing!
All shall rise!
It’s the voice of victory
Raise your lamps to light
The coming King
Wednesday, July 15, 2009
Physiology
Apart from anatomy, new medical students study physiology, which included biochemistry in my day. I must say I was looking forward to this. At school I had been excited by the descriptions of DNA and protein chemistry in Scientific American. Was I disappointed! In the whole course DNA was not mentioned once. The Professor had qualified in 1923 and had been appointed in 1936. His knowledge was all pre-war and he was also a boring lecturer. Not as boring as some of his underlings who simply read out the relevant chapter of Bell, Davidson and Scarborough, the textbook we were using.
The practicals were designed like the anatomy practicals to coarsen our sensibilities. As I remember they consisted mainly of mutilating small animals. Our behaviour to frogs would nowadays have us petrol bombed by the Animal Liberation Front. It was necessary to stun the animal first. To do this one picked up the frog by its hind legs and swung it to give it a hefty clunk on the edge of the laboratory bench. Then using scissors one cut its head off leaving the lower jaw intact. The next operation was to 'pith' the frog by inserting a metal probe down its spinal cord and pulping it. This was such an unpleasant task that the girls got the boys to do it for them. After that it was necessary to remove a hind leg from the corpse whose heart was still beating. The leg had the femoral nerve attached for this was the purpose of the experiment. We were to show that passing an electric current down the nerve would make the frog's thigh muscle twitch. The electric current was generated by two pieces of wire wrapped round each other, one made of copper and one of zinc. This was an experiment first performed by Galvani (of galvanic current and galvanized buckets fame) in the eighteenth century. The twitching was recorded on a smoked drum.
Smoking drums took more of our time than smoking weed did of a subsequent generation. It was done within a fume cabinet using a Bunsen burner to which was attached a device that produced an evil and oily black plume. The paper covered drum was then placed in the smoke until it was fully blackened. The drum was then attached to a contraption that rotated it. A metal arm moved with every twitch of the frog’s muscle and traced a white line on the blackened paper. The paper was then removed and dunked in varnish to make the tracing permanent.
In our second year we moved from the old Victorian buildings into spankingly modern medical school. We hurried to see the new Physiology lab. Would there be new equipment, perhaps to do experiments with DNA? Of course not. What we saw were row upon row of new fume cabinets, each containing brand new, brass Bunsens to smoke a new generation of drums.
I pass over what we were supposed to do to rats and rabbits but it left me with a distaste for animal experiments. I recognize their necessity and in fact late in my career I became a Council member of the Research Defence Society and made a TV film defending animal experiments. But this was after the RDS had instituted its policy of reducing the number of animal experiments, replacing them with other techniques where possible and refining the way that animals are kept and experimented on so that suffering is kept to a minimum.
I had little personal experience of experimenting on animals myself – I kept a couple of goats and six rabbits that I vaccinated with a harmless vaccine that I had received myself and took blood samples from them (in a way that I had myself been bled). The animals were kept in luxurious conditions that were better than how some of my patients lived. From the days in the 1960s when animal experiments were often unnecessary and crudely performed, there has been a great improvement in animal husbandry and much better designed and humane experiments. Some people won’t listen. I found a great reluctance among scientists to be interviewed for my film, for fear of animal liberation terrorists, and I was advised by then police always to look under my car for bombs before setting out for work in the morning.
Biochemistry was a small part of physiology. We were lectured on the Kreb’s cycle and the glycolytic pathway and had practicals on measuring glucose and urea by simple chemical tests. The macro-equipment that we used made the equipment we had in school look like something out of the Space Age. We were taught by a plump, balding and bespectacled old gentleman and a lady who flirted with the young men. She was certainly over-40, but dressed to look 16. She wore bright red lipstick which always migrated to her teeth and consequently she was known as Dracula’s daughter.
Nobody liked physiology and we took to turning up at five past nine in the morning. The Lecture Theatre’s doors were locked ant nine.
Dave, my dissecting partner, wrote a song for the Christmas Smoker about Anatomy and Physiology. I can’t remember all the words but it was to the tune of Camp Granada (which some of my older readers may remember)
It began:
Hello Mother, Hello Father,
Here I am at my cadaver.
A later verse went something like this:
All around us dogs are dying
Frogs and cats we’re crucifying
It’s not science makes us willing
The truth is that we quite enjoy the killing
The chorus was something like this:
We have sins
Beer, gin and women,
Cigarettes,
The placing of bets.
Can’t you see
Though medicine is our bent
We… want…to…stay…stu…dents.
As I said, Dave left medicine after the fifth term. I often wonder what became of him. I’ve never seen his name in the credits of TV comedy shows.
The practicals were designed like the anatomy practicals to coarsen our sensibilities. As I remember they consisted mainly of mutilating small animals. Our behaviour to frogs would nowadays have us petrol bombed by the Animal Liberation Front. It was necessary to stun the animal first. To do this one picked up the frog by its hind legs and swung it to give it a hefty clunk on the edge of the laboratory bench. Then using scissors one cut its head off leaving the lower jaw intact. The next operation was to 'pith' the frog by inserting a metal probe down its spinal cord and pulping it. This was such an unpleasant task that the girls got the boys to do it for them. After that it was necessary to remove a hind leg from the corpse whose heart was still beating. The leg had the femoral nerve attached for this was the purpose of the experiment. We were to show that passing an electric current down the nerve would make the frog's thigh muscle twitch. The electric current was generated by two pieces of wire wrapped round each other, one made of copper and one of zinc. This was an experiment first performed by Galvani (of galvanic current and galvanized buckets fame) in the eighteenth century. The twitching was recorded on a smoked drum.
Smoking drums took more of our time than smoking weed did of a subsequent generation. It was done within a fume cabinet using a Bunsen burner to which was attached a device that produced an evil and oily black plume. The paper covered drum was then placed in the smoke until it was fully blackened. The drum was then attached to a contraption that rotated it. A metal arm moved with every twitch of the frog’s muscle and traced a white line on the blackened paper. The paper was then removed and dunked in varnish to make the tracing permanent.
In our second year we moved from the old Victorian buildings into spankingly modern medical school. We hurried to see the new Physiology lab. Would there be new equipment, perhaps to do experiments with DNA? Of course not. What we saw were row upon row of new fume cabinets, each containing brand new, brass Bunsens to smoke a new generation of drums.
I pass over what we were supposed to do to rats and rabbits but it left me with a distaste for animal experiments. I recognize their necessity and in fact late in my career I became a Council member of the Research Defence Society and made a TV film defending animal experiments. But this was after the RDS had instituted its policy of reducing the number of animal experiments, replacing them with other techniques where possible and refining the way that animals are kept and experimented on so that suffering is kept to a minimum.
I had little personal experience of experimenting on animals myself – I kept a couple of goats and six rabbits that I vaccinated with a harmless vaccine that I had received myself and took blood samples from them (in a way that I had myself been bled). The animals were kept in luxurious conditions that were better than how some of my patients lived. From the days in the 1960s when animal experiments were often unnecessary and crudely performed, there has been a great improvement in animal husbandry and much better designed and humane experiments. Some people won’t listen. I found a great reluctance among scientists to be interviewed for my film, for fear of animal liberation terrorists, and I was advised by then police always to look under my car for bombs before setting out for work in the morning.
Biochemistry was a small part of physiology. We were lectured on the Kreb’s cycle and the glycolytic pathway and had practicals on measuring glucose and urea by simple chemical tests. The macro-equipment that we used made the equipment we had in school look like something out of the Space Age. We were taught by a plump, balding and bespectacled old gentleman and a lady who flirted with the young men. She was certainly over-40, but dressed to look 16. She wore bright red lipstick which always migrated to her teeth and consequently she was known as Dracula’s daughter.
Nobody liked physiology and we took to turning up at five past nine in the morning. The Lecture Theatre’s doors were locked ant nine.
Dave, my dissecting partner, wrote a song for the Christmas Smoker about Anatomy and Physiology. I can’t remember all the words but it was to the tune of Camp Granada (which some of my older readers may remember)
It began:
Hello Mother, Hello Father,
Here I am at my cadaver.
A later verse went something like this:
All around us dogs are dying
Frogs and cats we’re crucifying
It’s not science makes us willing
The truth is that we quite enjoy the killing
The chorus was something like this:
We have sins
Beer, gin and women,
Cigarettes,
The placing of bets.
Can’t you see
Though medicine is our bent
We… want…to…stay…stu…dents.
As I said, Dave left medicine after the fifth term. I often wonder what became of him. I’ve never seen his name in the credits of TV comedy shows.
Tuesday, July 14, 2009
New health update
I saw the oncologist yesterday. He felt that the peripheral neuropathy was getting so bad that we should drop the oxaloplatin for the moment, so my treatment tomorrow (course 8) will consist of 5-FU and folinic acid. Otherwise he was pleased with my progress and ordered another scan for after course 9. Next week the colorectal multi-disciplinary team will discuss my case with a view to thinking about a second look laparotomy to see if the primary around the ileo-cecal junction is now operable.
MBL v CLL
I have beavering away at the chapter I promised to write and have completed this section on monoclonal B-cell lymphocytosis. The references are not yet complete but if anyone particularly needs them, they will be ready in a day or two, so ask.
Monoclonal B-cell lymphocytosis
Having defined CLL as a lymphocytosis with a characteristic immunophenotype it became clear to CLL specialists that early stage CLL was apparently getting commoner. In fact, apparent fluctuations in the incidence of CLL have been occurring for a long time. In the nineteen fifties and sixties several studies reported incidences in excess of 6 per 100,000 [5]. This was in the days before immunophenotyping when any lymphocytosis over 10 x 10^9 per microlitre of relatively appropriate morphology was designated CLL. From our own experience we can be sure that we misdiagnosed many patients during this period and in our work as a reference center we have recognized that these types of mistakes were not rare. Immunophenotyping has excluded the majority of interlopers and as a result the perceived incidence of CLL fell between the nineteen seventies and nineteen nineties. Sgambati et al [6] reporting on statistics from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) Program described a fall in incidence rates for CLL for white males from 4.2 per 100,000 to 3.2 per 100,000 between 1973 and 1976 while the rate for white females fell from 3.8 to 2.6 over the same period. The rates for those of African-American, Hispanic or Asian origin were much lower.
Exactly how many cases of CLL are collected depends on how assiduous is the collection. Simply relying on death certificates or hospital admissions will miss all those early stage patients that never progress and never require treatment. Between 1984 and 1988 Cartwright et al [7] enlisted the help of hematologists performing blood tests for one third of the population of England and Wales to register every new diagnosis of CLL. The annual incidence was 5.54 per 100,000 with a male to female ratio of 1.95. There was no temporal variation, but a threefold difference between districts. Racial differences could not explain the discrepancies, though districts where the disease was commoner tended to have more old people. What was noticeable was that the disease was apparently commoner where the hematologists took a special interest in the disease, suggesting that such specialists would be more likely to make the diagnosis with relatively low lymphocyte counts that less obsessed doctors might pass as normal.
Guidelines for the diagnosis of CLL were published in 1988 by a National Cancer Institute Working Group (NCI-WG) [8] and in 1989 by the International Workshop on CLL (IWCLL) [9]. The former required a lymphocytosis of >5 x 10^9/L but the latter a lymphocytosis of >10 x 10^9/L. This confusion was removed by the 1996 guidelines published by the NCI-WG [10] which settled on a lymphocytosis of >5 x 10^9/L but has been further complicated by the 2008 guidelines published by the IWCLL [11] which raise the threshold to a B-cell lymphocytosis (rather than a total lymphocytosis) of >5 x 10^9/L.
In 2002 Rawstron et al [12], using four-color flow cytometry of the dregs of blood samples taken for other reasons, discovered that 3.5% of the population over the age of 40 harbors a population of cells immunophenotypically similar to those of CLL and this has been confirmed by others, who emphasize that marginal zone lymphoma also exists in this pre-clinical form [13]. The prevalence of such cells rises with age, to 7.7% of people in their seventies. Recently the group from Salamanca, Spain, using a more highly sensitive multicolor flow technique have suggested that as many as 12% of the population over the age of 40 have a small population of CLL-like cells in heir blood [14].
An International Working Group [15] has designated this condition as Monoclonal B-cell Lymphocytosis (MBL) and laid down diagnostic criteria (Table 1). Of course, this new entity did not suddenly appear in 2002, and the International Group also reported on previous sightings of the condition under such names as ‘smoldering CLL’ and ‘benign monoclonal B-lymphocytosis’.
Rawstron et al [16 NEJM 2008] have reported on the relationship between MBL and CLL. Among subjects with a normal blood count, the prevalence of MBL was 78 in 1520 or 5.1%. Because the samples were taken from anonymous subjects no follow-up was possible. In such patients the B-lymphocyte count could be as low as 0.015 x 10^9/L and none were higher than 1.2 x 10^9/L (normal range: 0.025-0.49 X 10^9/L). Another cohort, who did have a lymphocytosis (lymphocyte count >4.0 x 10^9/L) could be followed up. Of 2228 such individuals, 309 had MBL (13.9%) and 185 of these had sequential monitoring for between 0.2 and 11.8 years (median 6.7). While in most cases the lymphocytosis was stable or regressive, in 51 subjects (28%) there was progressive lymphocytosis; in 31 to a lymphocyte count of >30 x 10^9/L. Among the 51, other features of progressive CLL, predominantly lymphadenopathy, developed in 28 (55%) while 13 (25%) required chemotherapy a median of four years after the initial diagnosis. The estimated rate of progression to CLL requiring treatment of MBL with lymphocytosis was 1.1% per year; about the same rate at which monoclonal gammopathy of undetermined significance (MGUS) transforms to myeloma.
The only factor among those examined that predicted progression was the absolute B-lymphocyte count. Those with B-lymphocyte counts below 1.9 x 10^9/L seldom progressed, while of those with a B-lymphocyte count of greater than 4 x 10^9/L, more than half had progressed at 10 years follow-up. There were 62 deaths among the 185 who were followed up; the majority had died from an unrelated cause, but 13 had had progressive CLL, although CLL was mentioned on the death certificate of only four.
Although MBL only seldom transforms to CLL, almost all cases of CLL were once MBL. Taking advantage of the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, Landgren et al [17] were able to identify among 77,469 healthy adults 129 subjects who eventually developed. Of these, 45 had available pre-diagnostic cryopreserved whole blood. Using flow cytometry and molecular techniques they were able to identify an MBL clone in 44 of the specimens.
The new definition of CLL and its relationship to MBL will change clinical practice. One of the consequences would be a demand to monitor cases of MBL with flow cytometry to check on B-cell numbers. Shanafelt et al [18] have addressed this problem by re-evaluating 459 Rai stage 0 patients in view of the new guidelines. They found that 190 patients would be reclassified as MBL. By studying the likelihood of progression they determined that a threshold B-cell count of 11 x 10^9/L was necessary for the condition to progress to clinically significant CLL. This equates to an absolute lymphocyte count of 20 x 10^9/L. The fascinating corollary is that CLL should not be diagnosed until the absolute lymphocyte count consistently exceeds 20 x 10^9/L. This would obviate the need for expensive flow cytometry measurements for follow-up patients. For those more conservatively minded, their study found that the current CLL definition threshold of a B-cell count of 5 x 10^9/L equates to an absolute lymphocyte count of 11 x 10^9/L. So much for progress over the past 35 years.
Monoclonal B-cell lymphocytosis
Having defined CLL as a lymphocytosis with a characteristic immunophenotype it became clear to CLL specialists that early stage CLL was apparently getting commoner. In fact, apparent fluctuations in the incidence of CLL have been occurring for a long time. In the nineteen fifties and sixties several studies reported incidences in excess of 6 per 100,000 [5]. This was in the days before immunophenotyping when any lymphocytosis over 10 x 10^9 per microlitre of relatively appropriate morphology was designated CLL. From our own experience we can be sure that we misdiagnosed many patients during this period and in our work as a reference center we have recognized that these types of mistakes were not rare. Immunophenotyping has excluded the majority of interlopers and as a result the perceived incidence of CLL fell between the nineteen seventies and nineteen nineties. Sgambati et al [6] reporting on statistics from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) Program described a fall in incidence rates for CLL for white males from 4.2 per 100,000 to 3.2 per 100,000 between 1973 and 1976 while the rate for white females fell from 3.8 to 2.6 over the same period. The rates for those of African-American, Hispanic or Asian origin were much lower.
Exactly how many cases of CLL are collected depends on how assiduous is the collection. Simply relying on death certificates or hospital admissions will miss all those early stage patients that never progress and never require treatment. Between 1984 and 1988 Cartwright et al [7] enlisted the help of hematologists performing blood tests for one third of the population of England and Wales to register every new diagnosis of CLL. The annual incidence was 5.54 per 100,000 with a male to female ratio of 1.95. There was no temporal variation, but a threefold difference between districts. Racial differences could not explain the discrepancies, though districts where the disease was commoner tended to have more old people. What was noticeable was that the disease was apparently commoner where the hematologists took a special interest in the disease, suggesting that such specialists would be more likely to make the diagnosis with relatively low lymphocyte counts that less obsessed doctors might pass as normal.
Guidelines for the diagnosis of CLL were published in 1988 by a National Cancer Institute Working Group (NCI-WG) [8] and in 1989 by the International Workshop on CLL (IWCLL) [9]. The former required a lymphocytosis of >5 x 10^9/L but the latter a lymphocytosis of >10 x 10^9/L. This confusion was removed by the 1996 guidelines published by the NCI-WG [10] which settled on a lymphocytosis of >5 x 10^9/L but has been further complicated by the 2008 guidelines published by the IWCLL [11] which raise the threshold to a B-cell lymphocytosis (rather than a total lymphocytosis) of >5 x 10^9/L.
In 2002 Rawstron et al [12], using four-color flow cytometry of the dregs of blood samples taken for other reasons, discovered that 3.5% of the population over the age of 40 harbors a population of cells immunophenotypically similar to those of CLL and this has been confirmed by others, who emphasize that marginal zone lymphoma also exists in this pre-clinical form [13]. The prevalence of such cells rises with age, to 7.7% of people in their seventies. Recently the group from Salamanca, Spain, using a more highly sensitive multicolor flow technique have suggested that as many as 12% of the population over the age of 40 have a small population of CLL-like cells in heir blood [14].
An International Working Group [15] has designated this condition as Monoclonal B-cell Lymphocytosis (MBL) and laid down diagnostic criteria (Table 1). Of course, this new entity did not suddenly appear in 2002, and the International Group also reported on previous sightings of the condition under such names as ‘smoldering CLL’ and ‘benign monoclonal B-lymphocytosis’.
Rawstron et al [16 NEJM 2008] have reported on the relationship between MBL and CLL. Among subjects with a normal blood count, the prevalence of MBL was 78 in 1520 or 5.1%. Because the samples were taken from anonymous subjects no follow-up was possible. In such patients the B-lymphocyte count could be as low as 0.015 x 10^9/L and none were higher than 1.2 x 10^9/L (normal range: 0.025-0.49 X 10^9/L). Another cohort, who did have a lymphocytosis (lymphocyte count >4.0 x 10^9/L) could be followed up. Of 2228 such individuals, 309 had MBL (13.9%) and 185 of these had sequential monitoring for between 0.2 and 11.8 years (median 6.7). While in most cases the lymphocytosis was stable or regressive, in 51 subjects (28%) there was progressive lymphocytosis; in 31 to a lymphocyte count of >30 x 10^9/L. Among the 51, other features of progressive CLL, predominantly lymphadenopathy, developed in 28 (55%) while 13 (25%) required chemotherapy a median of four years after the initial diagnosis. The estimated rate of progression to CLL requiring treatment of MBL with lymphocytosis was 1.1% per year; about the same rate at which monoclonal gammopathy of undetermined significance (MGUS) transforms to myeloma.
The only factor among those examined that predicted progression was the absolute B-lymphocyte count. Those with B-lymphocyte counts below 1.9 x 10^9/L seldom progressed, while of those with a B-lymphocyte count of greater than 4 x 10^9/L, more than half had progressed at 10 years follow-up. There were 62 deaths among the 185 who were followed up; the majority had died from an unrelated cause, but 13 had had progressive CLL, although CLL was mentioned on the death certificate of only four.
Although MBL only seldom transforms to CLL, almost all cases of CLL were once MBL. Taking advantage of the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, Landgren et al [17] were able to identify among 77,469 healthy adults 129 subjects who eventually developed. Of these, 45 had available pre-diagnostic cryopreserved whole blood. Using flow cytometry and molecular techniques they were able to identify an MBL clone in 44 of the specimens.
The new definition of CLL and its relationship to MBL will change clinical practice. One of the consequences would be a demand to monitor cases of MBL with flow cytometry to check on B-cell numbers. Shanafelt et al [18] have addressed this problem by re-evaluating 459 Rai stage 0 patients in view of the new guidelines. They found that 190 patients would be reclassified as MBL. By studying the likelihood of progression they determined that a threshold B-cell count of 11 x 10^9/L was necessary for the condition to progress to clinically significant CLL. This equates to an absolute lymphocyte count of 20 x 10^9/L. The fascinating corollary is that CLL should not be diagnosed until the absolute lymphocyte count consistently exceeds 20 x 10^9/L. This would obviate the need for expensive flow cytometry measurements for follow-up patients. For those more conservatively minded, their study found that the current CLL definition threshold of a B-cell count of 5 x 10^9/L equates to an absolute lymphocyte count of 11 x 10^9/L. So much for progress over the past 35 years.
Sunday, July 12, 2009
Living anatomy
As opposed to morbid anatomy. I remember well that first evening when I gained access to the dissecting room. It was in a gloomy Victorian building, constructed like a Gothic church. The only light was admitted through the high windows and was that of an orange, sodium streetlight. That October evening in 1962 is etched in my memory. The dissecting room was large with ten lead-topped tables arranged in two rows of five. On each was a body laid and covered with a green cloth so that all you could see was the body's shape - far more frightening than the body itself.
The smell, sweet and sickly, was a mixture of formalin and chalk dust. I'm not sure what scared me, but I was glad to be out of there having ascertained that I would be assigned table number 4 along with Roger, Adrian and Dave.
The next morning was altogether different. The lights were full on and there was an air of jollity, mainly engendered by those students who had done 1st MB, a sort of resits for failed A levels taken at the University instead of school. These, with their year's experience of University life, were the early leaders. We didn't realize at the time that they were the rich but dim kids whose parents could pay the extra cost of resitting their exams at University rather than school. It is easy to be cowed by confidence.
Looking back it is hard not to feel that the medical course was designed to coarsen our sensitivities. We were naive schoolboys (and girls) who needed to be toughened up. Perhaps that was a true perspective; I have since seen several young female residents and one male who found the rough and tumble of medical life too pungent to be tolerated. Interestingly, they have all been Christians. Are Christian doctors such delicate flowers that life and death in the raw are too unpalatable?
We began our dissection in the armpit. I had no idea that smelly armpits hid such a nexus of nerves. We called our body (or cadaver, to give it its professional name) Ernest (because we were always working in dead earnest). For six weeks I had a recurring nightmare. Ernest would be lying there with his great hook nose. As I stuck my scalpel in his armpit he suddenly raise himself up from the table laughing ans said, "Stop tickling!"
Each week we dissected something different or at least Roger and Adrian did - they were keen as mustard on the whole business - while Dave and I nipped down to the Refectory for coffee and to try writing something for the Christmas party. I wonder what became of my earnest colleagues. Last I heard of Dave he was driving a soda-pop delivery truck, having failed his 2nd MB twice. Roger only failed once and became a GP. I did hear that he had some trouble with the GMC; something to do with drugs and prostitutes, I believe. I think Adrian ended up in the Solomon Islands. Every week we had a viva-voce examination with one of the Demonstrators. The Demonstrators were trainee surgeons who were taking time out to learn some serious anatomy. Surgeons are among the few doctors who really need to know anatomy; for the rest of us it is an exercise in rote learning designed to keep us off the streets. The degree of detail is seldom any use to us during clinical practice. We generally managed to pass the vivas, even though Dave's usual answer was, "I think I have a mental block on that one."
On one occasion we all failed miserably. The viva was on the larynx and we had drawn a demonstrator who was a trainee anesthesiologist rather than a surgeon. Crico-aretinoid muscles were a mystery to me and still are.
Apart from cutting up dead bodies we also had a series of demonstrations of living anatomy. This meant we had to examine our own bodies. For some this had immense attraction as there were girls in the group. In fact there were 12 women out of 60 students. Since we were to be divided into groups of 8, it looked as if at least one group would be mixed. Alas for some the men were separated into 6 groups of eight and the women into 2 groups of six. One coarsened wag posted a poem about it on the anatomy notice board. I think I can remember it:
O living anatomy
Thou dost seem flat to me
Since they did segregate
The sexes into groups of eight
Or so.
O blow!
The shame and degradation
Never to have seen
An hemispherical elevation
Or touched one e'en.
Perhaps it would be best
To entertain our guests
With poetic tales of roses on twin crests,
Or accept the bland
A modified sebaceous gland
Divided by some fibrous strands,
Lest the shock should dull the mind
When in the course of time we find
That as we watch the garments fall
It wasn't really worth it after all.
The culprit was summoned to see Professor Yoffey the head of the Department of Anatomy, and then sent away to return wearing his blackstuff gown. He was given a final warning pending rustication.
Yoffey had more to worry about. Dick Smith, one of the students whose father was a GP, desperately did not want to be a doctor. Instead of dissecting bodies he used to drive in his little Standard Eight to Weston-Super-Mare and from there send Yoffey a postcard saying, "Wish you were here!"
Yoffey was interested in the lymphocyte, which he was convinced turned into red blood cells as it matured. After he retired he emigrated to Israel and became a Professor there. Years later I met his granddaughter who also happened to be related to Victor Hoffbrand, the Professor of Hematology at the Royal Free Medical School. She had written a play about the Song of Deborah and was astonished that anybody else had ever heard of it.
Dick Smith left Medical School and became an Army officer. I met him years later. He still had the old Standard Eight. In the trunk he had a case of smuggled gin, which he tried to flog me.
The smell, sweet and sickly, was a mixture of formalin and chalk dust. I'm not sure what scared me, but I was glad to be out of there having ascertained that I would be assigned table number 4 along with Roger, Adrian and Dave.
The next morning was altogether different. The lights were full on and there was an air of jollity, mainly engendered by those students who had done 1st MB, a sort of resits for failed A levels taken at the University instead of school. These, with their year's experience of University life, were the early leaders. We didn't realize at the time that they were the rich but dim kids whose parents could pay the extra cost of resitting their exams at University rather than school. It is easy to be cowed by confidence.
Looking back it is hard not to feel that the medical course was designed to coarsen our sensitivities. We were naive schoolboys (and girls) who needed to be toughened up. Perhaps that was a true perspective; I have since seen several young female residents and one male who found the rough and tumble of medical life too pungent to be tolerated. Interestingly, they have all been Christians. Are Christian doctors such delicate flowers that life and death in the raw are too unpalatable?
We began our dissection in the armpit. I had no idea that smelly armpits hid such a nexus of nerves. We called our body (or cadaver, to give it its professional name) Ernest (because we were always working in dead earnest). For six weeks I had a recurring nightmare. Ernest would be lying there with his great hook nose. As I stuck my scalpel in his armpit he suddenly raise himself up from the table laughing ans said, "Stop tickling!"
Each week we dissected something different or at least Roger and Adrian did - they were keen as mustard on the whole business - while Dave and I nipped down to the Refectory for coffee and to try writing something for the Christmas party. I wonder what became of my earnest colleagues. Last I heard of Dave he was driving a soda-pop delivery truck, having failed his 2nd MB twice. Roger only failed once and became a GP. I did hear that he had some trouble with the GMC; something to do with drugs and prostitutes, I believe. I think Adrian ended up in the Solomon Islands. Every week we had a viva-voce examination with one of the Demonstrators. The Demonstrators were trainee surgeons who were taking time out to learn some serious anatomy. Surgeons are among the few doctors who really need to know anatomy; for the rest of us it is an exercise in rote learning designed to keep us off the streets. The degree of detail is seldom any use to us during clinical practice. We generally managed to pass the vivas, even though Dave's usual answer was, "I think I have a mental block on that one."
On one occasion we all failed miserably. The viva was on the larynx and we had drawn a demonstrator who was a trainee anesthesiologist rather than a surgeon. Crico-aretinoid muscles were a mystery to me and still are.
Apart from cutting up dead bodies we also had a series of demonstrations of living anatomy. This meant we had to examine our own bodies. For some this had immense attraction as there were girls in the group. In fact there were 12 women out of 60 students. Since we were to be divided into groups of 8, it looked as if at least one group would be mixed. Alas for some the men were separated into 6 groups of eight and the women into 2 groups of six. One coarsened wag posted a poem about it on the anatomy notice board. I think I can remember it:
O living anatomy
Thou dost seem flat to me
Since they did segregate
The sexes into groups of eight
Or so.
O blow!
The shame and degradation
Never to have seen
An hemispherical elevation
Or touched one e'en.
Perhaps it would be best
To entertain our guests
With poetic tales of roses on twin crests,
Or accept the bland
A modified sebaceous gland
Divided by some fibrous strands,
Lest the shock should dull the mind
When in the course of time we find
That as we watch the garments fall
It wasn't really worth it after all.
The culprit was summoned to see Professor Yoffey the head of the Department of Anatomy, and then sent away to return wearing his blackstuff gown. He was given a final warning pending rustication.
Yoffey had more to worry about. Dick Smith, one of the students whose father was a GP, desperately did not want to be a doctor. Instead of dissecting bodies he used to drive in his little Standard Eight to Weston-Super-Mare and from there send Yoffey a postcard saying, "Wish you were here!"
Yoffey was interested in the lymphocyte, which he was convinced turned into red blood cells as it matured. After he retired he emigrated to Israel and became a Professor there. Years later I met his granddaughter who also happened to be related to Victor Hoffbrand, the Professor of Hematology at the Royal Free Medical School. She had written a play about the Song of Deborah and was astonished that anybody else had ever heard of it.
Dick Smith left Medical School and became an Army officer. I met him years later. He still had the old Standard Eight. In the trunk he had a case of smuggled gin, which he tried to flog me.
The myth of more
Do you want to know the secret of contentment? It's hard to be content in an economic downturn. Still harder if you have cancer. Is it knowing you've done your best? Is it in providing for your family? Is it becoming a household name? Is it making enough money that you never have to work again?
I heard a story of a fisherman basking in the afternoon sun, enjoying the warmth and resting contentedly as the evening drew on. He was approached by a young man who asked why he was not out fishing. He replied that he'd been out this morning and had a good catch, sold his produce at the market and now he was relaxing.
"I can see you need someone like me in your business," said the young man, "if you'd gone out this afternoon you could have doubled your profits. Before long, if you kept up the practice of going out twice a day, you could have expanded your business, bought a second boat, then a third and so on. You could have employed other fishermen and eventually you would have made so much money you would never have to work again."
"And what would I have done then?"
"You could sit in the sun and enjoy God's beautiful creation."
"And what do you think I am doing now?"
The myth of more tells us that there is always something better round the corner. A better address, a better car, a more glamorous wife, smarter gadgets; the grass is always greener. In truth, such an attitude leads to discontent.
In Philippians chapter 4 Paul tells us the secret of contentment. "I have learned to be content whatever the circumstances," he says(v 11). "I have learned the secret of being content in any and every situation, whether well fed or hungry, whether living in plenty or in want." (v12)
What is that secret? "I can do everything through him who gives me strength." (v13)
Relying on God is seen as a weakness in this world. It's OK for those who need a crutch, but I can stand on my own two feet. No, actually, you can't. I have seen so many who thought they could, brought low. Beware of the media; they will only build you up to knock you down. Every political career ends in failure, said one very wise man. Obama beware! Look at the ignominy of your predecessors. Bush was caricatured as a monkey, Clinton as a lecher, Bush senior as a time server, Reagan as senile, Carter as naive, Ford as an idiot, Nixon as a crook, Johnson as a warmonger, Kennedy as a womaniser. In the UK Brown is seen as incompetent, Blair as a liar, Major as a no-hoper, Thatcher as bully, Callaghan as worse than useless, Wilson as a crook, Heath as a humorless robot, Douglas-Home as a simpleton, Macmillan as an old dodderer, Eden as a self-serving snob. Only Churchill maintains his reputation, despite his drunkenness, bad judgement and betrayal of his party. Still Churchill was himself a journalist, so perhaps he was immune to criticism.
I have before commented on the hollowness of fame on this blog, but still it is the ambition of young people to be famous. How I wish that young people aimed for Godliness.
In today's paper is a story about Kaka the Brazilian soccer player who has just been transferred to Real Madrid for a huge sum. When he scores a goal Kaka is given to pulling up his shirt to reveal a message on his T-shirt that says, "I belong to Jesus." FIFA has objected to this show of religion. Apparently, too many South American footballers have been making too much of a show of their faith. The majority of those accused are Pentecostals who have abandoned Roman Catholicism. I always warm to them. Why should these young men not display their trust in the Lord? If only more young people would. And old people.
To trust in God is a sign of strength, not weakness.
Paul goes on in the letter to extol generosity. The Philippian church, probably the first European church, had been one of Paul's most faithful supporters. What an example to us! How many years are you away from relying on your income? How much do you have saved against a rainy day? It may be fine in your home, but there is plenty of rain outside. Obama, rightly told African leaders in Ghana that they must take the blame for the poverty in Africa. Corrupt government is rife and most aid is subject to a large surcharge that goes straight into Swiss bank accounts of crooked leaders. That doesn't negate the poverty in Africa. The only hope for Africa is a change of heart of its people. But that can only come if we in the West show winsome ways.
At the G7 meeting in Italy last week the great powers admitted to falling short of the Gleneagles commitment to the third world by $15 billion. We know that politicians are not to be trusted, but for Christians generosity with their time, their service and with their pocket-book should be a watchword.
For why? Because Jesus himself told us, "Do not store up for yourselves treasures on earth, where moth and rust destroy, and where thieves break in and steal. But store up for yourselves treasures in heaven, where moth and rust do not destroy, and thieves do not break in and steal. For where your treasure is, there your heart will be also." (Matthew 6:19-21)
Where is your treasure? Where is your heart?
I heard a story of a fisherman basking in the afternoon sun, enjoying the warmth and resting contentedly as the evening drew on. He was approached by a young man who asked why he was not out fishing. He replied that he'd been out this morning and had a good catch, sold his produce at the market and now he was relaxing.
"I can see you need someone like me in your business," said the young man, "if you'd gone out this afternoon you could have doubled your profits. Before long, if you kept up the practice of going out twice a day, you could have expanded your business, bought a second boat, then a third and so on. You could have employed other fishermen and eventually you would have made so much money you would never have to work again."
"And what would I have done then?"
"You could sit in the sun and enjoy God's beautiful creation."
"And what do you think I am doing now?"
The myth of more tells us that there is always something better round the corner. A better address, a better car, a more glamorous wife, smarter gadgets; the grass is always greener. In truth, such an attitude leads to discontent.
In Philippians chapter 4 Paul tells us the secret of contentment. "I have learned to be content whatever the circumstances," he says(v 11). "I have learned the secret of being content in any and every situation, whether well fed or hungry, whether living in plenty or in want." (v12)
What is that secret? "I can do everything through him who gives me strength." (v13)
Relying on God is seen as a weakness in this world. It's OK for those who need a crutch, but I can stand on my own two feet. No, actually, you can't. I have seen so many who thought they could, brought low. Beware of the media; they will only build you up to knock you down. Every political career ends in failure, said one very wise man. Obama beware! Look at the ignominy of your predecessors. Bush was caricatured as a monkey, Clinton as a lecher, Bush senior as a time server, Reagan as senile, Carter as naive, Ford as an idiot, Nixon as a crook, Johnson as a warmonger, Kennedy as a womaniser. In the UK Brown is seen as incompetent, Blair as a liar, Major as a no-hoper, Thatcher as bully, Callaghan as worse than useless, Wilson as a crook, Heath as a humorless robot, Douglas-Home as a simpleton, Macmillan as an old dodderer, Eden as a self-serving snob. Only Churchill maintains his reputation, despite his drunkenness, bad judgement and betrayal of his party. Still Churchill was himself a journalist, so perhaps he was immune to criticism.
I have before commented on the hollowness of fame on this blog, but still it is the ambition of young people to be famous. How I wish that young people aimed for Godliness.
In today's paper is a story about Kaka the Brazilian soccer player who has just been transferred to Real Madrid for a huge sum. When he scores a goal Kaka is given to pulling up his shirt to reveal a message on his T-shirt that says, "I belong to Jesus." FIFA has objected to this show of religion. Apparently, too many South American footballers have been making too much of a show of their faith. The majority of those accused are Pentecostals who have abandoned Roman Catholicism. I always warm to them. Why should these young men not display their trust in the Lord? If only more young people would. And old people.
To trust in God is a sign of strength, not weakness.
Paul goes on in the letter to extol generosity. The Philippian church, probably the first European church, had been one of Paul's most faithful supporters. What an example to us! How many years are you away from relying on your income? How much do you have saved against a rainy day? It may be fine in your home, but there is plenty of rain outside. Obama, rightly told African leaders in Ghana that they must take the blame for the poverty in Africa. Corrupt government is rife and most aid is subject to a large surcharge that goes straight into Swiss bank accounts of crooked leaders. That doesn't negate the poverty in Africa. The only hope for Africa is a change of heart of its people. But that can only come if we in the West show winsome ways.
At the G7 meeting in Italy last week the great powers admitted to falling short of the Gleneagles commitment to the third world by $15 billion. We know that politicians are not to be trusted, but for Christians generosity with their time, their service and with their pocket-book should be a watchword.
For why? Because Jesus himself told us, "Do not store up for yourselves treasures on earth, where moth and rust destroy, and where thieves break in and steal. But store up for yourselves treasures in heaven, where moth and rust do not destroy, and thieves do not break in and steal. For where your treasure is, there your heart will be also." (Matthew 6:19-21)
Where is your treasure? Where is your heart?
Saturday, July 11, 2009
Morbid Anatomy
I used to wear a hat in those days. Actually, I owned two; one was an oversized Homberg that my father had given me and the other was a 'Robin Hood' with a feather in the hatband, which I bought from Dunns the hatmaker. In 1963 most people wore hats. As a medical student I had been heavily influenced by the Richard Gordon books, 'Doctor in the House', and 'Doctor at Large'. My ambition was to take part in Rag Week, when the students got up to all sorts of pranks. I had been early disappointed by the fact that the medical course ran on facts from the 1930s, and all the recent science that I had done at school like DNA and molecular pathways hadn't penetrated the University. I did not take my studies seriously since there was no chance of being sent own at the end of the first year. I did enough to survive and treated the first year exams as a joke.
This was the year that General DeGaulle rejected Harold Macmillan's application to join the Common Market (as it was then called). We constructed a papier mache caricature of General DeGaulle with a caterpillar's body and called it 'de gall stones bug'. The nights before the Rag Parade we camped out guarding the effigy against the Engineers who had sworn to destroy our float. The Spring of 1963 was one of the coldest on record. It snowed heavily at Easter. The swimming costumed Rag Queen shivered as snowflakes landed on her bare flesh during the Rag parade. We won second prize, first going to the veterinary students who made a giant elephant which contained half a ton of rhinoceros dung that was shoveled out over the watching crowd at discrete intervals. Student humor!
Anyway, in the middle of this I attended a lecture in pathology. We were supposed to spend two hours the first half listening to a talk with slides on a particular pathological topic and then an hour looking down the microscope trying to identify what we had been lectured about. As soon as the lights went out I fell into a deep sleep. When the time came for us to troop out into the microscopy room, the other students left me there fast asleep. Eventually, a lecturer came in to wake me and I had to go and apologize to the Professor. For my pains I was invited to Sunday tea at his house. I didn't realize it at the time, but this involved an afternoon's back-breaking gardening!
I was reminded of this because my wife used the term 'morbid anatomy'. This is a phrase that has gone out of fashion. It used to be the term used to describe that branch of Pathology that did autopsies and looked at dead tissues to find out why someone died. Nowadays they call themselves 'histopathologists' and they mainly deal with the living. The autopsy has died. As a student I was a frequent attender at the mortuary. Every lunchtime there was an autopsy demonstration when three of four bodies that had been dissected that morning were displayed to students. We learned to recognize sago spleens and nutmeg livers. In my last year in practice the pathologist only conducted 11 autopsies in the hospital mortuary. In part this was due to the reluctance of relatives to allow post mortem examinations, but mostly it is a result of CT scans and MRIs. Hardly anyone dies undiagnosed now.
Out in the community people drop dead, but usually their family doctor knows that they had high blood pressure or a dicky heart and they are written up as 'stroke' or 'coronary' and a death certificate issued. People forget that an autopsy would often reveal several other diseases that the person was suffering from.
The reluctance of relatives to consent to autopsy stems from the Dutch Professor of Pathology at Liverpool who kept a collection of children's heats in formalin-filled pots in his office. He said that he needed them as 'research' though research on what no-one knew. More likely they were trophies.
Bereaved parents were outraged that little Betty's heart wasn't buried with them. (Shades of Michael Jackson's brain). This led to Draconian legislation that effectively barred any part of an autopsied body being retained. Distressed relatives were even asking for the paraffin block containing Junior's appendix, removed years before, so that they could exhume the coffin and bury it with the whole body in a new funeral service. Bizarre!
The legislation even extended to the dregs of blood tests, which would otherwise be tipped down the drain. The research on IgVH genes for which I made my name would have been impossible under the new legislation. there was even talk that hairdressers would have to return cut hair to the individual. Such 'reductio ad absurdo' softened the legislation.
Today histopathologists mainly work on the living. Most of their specimens come from biopsies not autopsies. The take part in many 'multi discipline team' meetings where they explain what the biopsies show and why it is important. Their role is vital.
When I was appointed at a Consultant Pathologist I was asked on what day did I want to do my autopsies. This was a perk, since autopsied requested by the coroner attracted a substantial fee. I replied that I had never done an autopsy in my life and I didn't intend to start then. I was one of the first to see hematology as a clinical discipline. I intended to treat patients with blood diseases who at that time were being mistreated by general physicians. But I also intended to build a laboratory where treatment was based on science not tradition. It took me a long time to get what I wanted, but on February 1st 1974 I made a start.
This was the year that General DeGaulle rejected Harold Macmillan's application to join the Common Market (as it was then called). We constructed a papier mache caricature of General DeGaulle with a caterpillar's body and called it 'de gall stones bug'. The nights before the Rag Parade we camped out guarding the effigy against the Engineers who had sworn to destroy our float. The Spring of 1963 was one of the coldest on record. It snowed heavily at Easter. The swimming costumed Rag Queen shivered as snowflakes landed on her bare flesh during the Rag parade. We won second prize, first going to the veterinary students who made a giant elephant which contained half a ton of rhinoceros dung that was shoveled out over the watching crowd at discrete intervals. Student humor!
Anyway, in the middle of this I attended a lecture in pathology. We were supposed to spend two hours the first half listening to a talk with slides on a particular pathological topic and then an hour looking down the microscope trying to identify what we had been lectured about. As soon as the lights went out I fell into a deep sleep. When the time came for us to troop out into the microscopy room, the other students left me there fast asleep. Eventually, a lecturer came in to wake me and I had to go and apologize to the Professor. For my pains I was invited to Sunday tea at his house. I didn't realize it at the time, but this involved an afternoon's back-breaking gardening!
I was reminded of this because my wife used the term 'morbid anatomy'. This is a phrase that has gone out of fashion. It used to be the term used to describe that branch of Pathology that did autopsies and looked at dead tissues to find out why someone died. Nowadays they call themselves 'histopathologists' and they mainly deal with the living. The autopsy has died. As a student I was a frequent attender at the mortuary. Every lunchtime there was an autopsy demonstration when three of four bodies that had been dissected that morning were displayed to students. We learned to recognize sago spleens and nutmeg livers. In my last year in practice the pathologist only conducted 11 autopsies in the hospital mortuary. In part this was due to the reluctance of relatives to allow post mortem examinations, but mostly it is a result of CT scans and MRIs. Hardly anyone dies undiagnosed now.
Out in the community people drop dead, but usually their family doctor knows that they had high blood pressure or a dicky heart and they are written up as 'stroke' or 'coronary' and a death certificate issued. People forget that an autopsy would often reveal several other diseases that the person was suffering from.
The reluctance of relatives to consent to autopsy stems from the Dutch Professor of Pathology at Liverpool who kept a collection of children's heats in formalin-filled pots in his office. He said that he needed them as 'research' though research on what no-one knew. More likely they were trophies.
Bereaved parents were outraged that little Betty's heart wasn't buried with them. (Shades of Michael Jackson's brain). This led to Draconian legislation that effectively barred any part of an autopsied body being retained. Distressed relatives were even asking for the paraffin block containing Junior's appendix, removed years before, so that they could exhume the coffin and bury it with the whole body in a new funeral service. Bizarre!
The legislation even extended to the dregs of blood tests, which would otherwise be tipped down the drain. The research on IgVH genes for which I made my name would have been impossible under the new legislation. there was even talk that hairdressers would have to return cut hair to the individual. Such 'reductio ad absurdo' softened the legislation.
Today histopathologists mainly work on the living. Most of their specimens come from biopsies not autopsies. The take part in many 'multi discipline team' meetings where they explain what the biopsies show and why it is important. Their role is vital.
When I was appointed at a Consultant Pathologist I was asked on what day did I want to do my autopsies. This was a perk, since autopsied requested by the coroner attracted a substantial fee. I replied that I had never done an autopsy in my life and I didn't intend to start then. I was one of the first to see hematology as a clinical discipline. I intended to treat patients with blood diseases who at that time were being mistreated by general physicians. But I also intended to build a laboratory where treatment was based on science not tradition. It took me a long time to get what I wanted, but on February 1st 1974 I made a start.
Thursday, July 09, 2009
Codex
The Codex Sinaiticus has been virtually reassembled and made available on line to those who can read Hellenistic Greek. It has been an occasion for atheists to disparage the Bible and talk about discrepancies.
Actually there is only one major point of issue between early manuscripts, and that is whether or not to include the story of the woman taken in adultery at the end of John chapter 8. (Though I suppose there are some who believe that the strange ending to Mark 16 was not a late addition.) The John story should be included, I believe, since it is more likely to have been removed by prudes than inserted by liberals. In any case there is another instance of Jesus being forgiving to promiscuous women; the Samaritan woman at the well.
I have a book on my shelf entitled 'Alleged discrepancies in the Bible' which goes to great length to explain and refute every alleged discrepancy. I believe that most are due to failure to appreciate literary form.
Any story can be told in many ways. I once wrote anonymous leaders for both the BMJ and the Lancet in the same week on the same topic, but wrote them in their respective house styles that were so different that nobody suspected that they were by the same author. In Japan a story might be told according to the tradition of tyhe Noh play; in Russia the story might be told by dance according to classical ballet. Falstaff can be a character in Shakespeare's plays (Henry IV parts I and II, Henry V and Merry Wives of Windsor) or a character in Verdi's opera. In each case his story is told differently. We are used to reading novels, where action usually follows sequentially in a fairly naturalistic way, but the novel as a literary form is only about 400 years old. And some novels are not in this form at all. Ulysses by James Joyce certainly isn't. When we watch a movie we often assume it to be naturalistic, but listen, there is usually no music playing in real life action. Homer and Virgil wrote they stories as poetry; Sophocles wrote drama where the actors covered their faces with sad or happy masks. The same story may be told in several literary genres. Science fiction, chick lit, western, cops and robbers, period drama or impressionist modern novel may all be telling the same story of love and betrayal or greed and rebellion.
We should not assume when reading the gospels that they should flow sequentially like a novel or a biography, on the contrary they were polemics, designed to convince their readers or hearers that Jesus Christ was the Messiah. Form was dependent on the message. Matthew's gospel is replete with Old Testament references, designed to stress how Jesus fulfilled the prophecies about the coming Messiah; Mark on the other hand almost certainly is dependent on Peter's recollections and reflects his experience of accepting and preaching to the Gentiles. Time and again we see teh Jews-to-Gentiles transition. It is the structure that dictates the sequence of stories, not the time line.
Actually there is only one major point of issue between early manuscripts, and that is whether or not to include the story of the woman taken in adultery at the end of John chapter 8. (Though I suppose there are some who believe that the strange ending to Mark 16 was not a late addition.) The John story should be included, I believe, since it is more likely to have been removed by prudes than inserted by liberals. In any case there is another instance of Jesus being forgiving to promiscuous women; the Samaritan woman at the well.
I have a book on my shelf entitled 'Alleged discrepancies in the Bible' which goes to great length to explain and refute every alleged discrepancy. I believe that most are due to failure to appreciate literary form.
Any story can be told in many ways. I once wrote anonymous leaders for both the BMJ and the Lancet in the same week on the same topic, but wrote them in their respective house styles that were so different that nobody suspected that they were by the same author. In Japan a story might be told according to the tradition of tyhe Noh play; in Russia the story might be told by dance according to classical ballet. Falstaff can be a character in Shakespeare's plays (Henry IV parts I and II, Henry V and Merry Wives of Windsor) or a character in Verdi's opera. In each case his story is told differently. We are used to reading novels, where action usually follows sequentially in a fairly naturalistic way, but the novel as a literary form is only about 400 years old. And some novels are not in this form at all. Ulysses by James Joyce certainly isn't. When we watch a movie we often assume it to be naturalistic, but listen, there is usually no music playing in real life action. Homer and Virgil wrote they stories as poetry; Sophocles wrote drama where the actors covered their faces with sad or happy masks. The same story may be told in several literary genres. Science fiction, chick lit, western, cops and robbers, period drama or impressionist modern novel may all be telling the same story of love and betrayal or greed and rebellion.
We should not assume when reading the gospels that they should flow sequentially like a novel or a biography, on the contrary they were polemics, designed to convince their readers or hearers that Jesus Christ was the Messiah. Form was dependent on the message. Matthew's gospel is replete with Old Testament references, designed to stress how Jesus fulfilled the prophecies about the coming Messiah; Mark on the other hand almost certainly is dependent on Peter's recollections and reflects his experience of accepting and preaching to the Gentiles. Time and again we see teh Jews-to-Gentiles transition. It is the structure that dictates the sequence of stories, not the time line.
Monday, July 06, 2009
Sleeping Jesus
In Mark chapter 4 we meet a Jesus who seems not to care. There he is sleeping on a pillow at the bottom of the boat while the squall rages and the water is coming in. These disciples were not landlubbers. They were seasoned fishermen, well aware of the way a storm could get up on Galilee. They were really afraid; they feared for their lives. And it was Jesus's idea to cross the lake. Another fine mess you've got us into, they might well have said.
Yet here was Jesus sleeping. Of course he'd had a busy day. What with healing and preaching, and casting out demons, he's every right to be tired. But didn't he care that they were perishing?
Sometimes we worry that Jesus has abandoned us. We get into all sorts of trouble and when we cry out and nobody comes. I remember as a small child I used to get earache at night. I would scream in pain and every time my mother would come to me and sleep in my bed to comfort me. Why should Jesus abandon them? But, of course, he had not left them. He was still there in the stern, sleeping. They could see the Savior; our problem is that we can't. We must rely on His promises, "I will never leave you or forsake you." "All that the Father has given me shall come to me and no man can snatch them from my hand."
The problem of the disciples was not that they could not see Jesus, but they didn't realise who he is.
This may seem a bit surprising. They had already seen many healed including a leper and a demon-possessed man. He had claimed to be able to forgive sins and proved it by healing a paralytic. But all this had happened to somebody else. for the first time their own lives were threatened.
It's amazing what a difference this makes. I have seen hundreds of patients with cancer. Having cancer myself put me in a totally different position. I used to have all sorts of doubting questions - How could prayer work? Do miracles still happen? How to reconcile Man's responsibility with God's Sovereignty? - Now I know that the secret thing of God are God's to know, not mine. Job was tormented greatly by his family's demise and his loss of his wealth, but only when his body was touched by Satan was he brought low enough for God to really reach him.
Jesus had not been sleeping to put the disciples in danger. His purpose was to demonstrate to the disciples who he really was. They were slow to learn, but in stilling the storm with a single word he revealed himself "He stilled the storm to a whisper; the waves of the sea were hushed" (Psalm 107:29). "You rule over the surging sea; when the waves mount up you still them" (Psalm 89:9). Who is it who controls the Sea? It is Yahweh the Creator God. When the disciples ask the question, "Who is this, even the wind and waves obey him?" they know the answer. Jesus is the Creator God.
God's purpose is not our comfort but our holiness. For this we need to submit to him, accept the gift of salvation, and follow him. Through our changing circumstances he cajoles us into acceptance. Is he there? Is he sleeping? Doesn't he care? He's there, he cares, and he's wide awake; but he knows what's best for us and he leads us into it.
Yet here was Jesus sleeping. Of course he'd had a busy day. What with healing and preaching, and casting out demons, he's every right to be tired. But didn't he care that they were perishing?
Sometimes we worry that Jesus has abandoned us. We get into all sorts of trouble and when we cry out and nobody comes. I remember as a small child I used to get earache at night. I would scream in pain and every time my mother would come to me and sleep in my bed to comfort me. Why should Jesus abandon them? But, of course, he had not left them. He was still there in the stern, sleeping. They could see the Savior; our problem is that we can't. We must rely on His promises, "I will never leave you or forsake you." "All that the Father has given me shall come to me and no man can snatch them from my hand."
The problem of the disciples was not that they could not see Jesus, but they didn't realise who he is.
This may seem a bit surprising. They had already seen many healed including a leper and a demon-possessed man. He had claimed to be able to forgive sins and proved it by healing a paralytic. But all this had happened to somebody else. for the first time their own lives were threatened.
It's amazing what a difference this makes. I have seen hundreds of patients with cancer. Having cancer myself put me in a totally different position. I used to have all sorts of doubting questions - How could prayer work? Do miracles still happen? How to reconcile Man's responsibility with God's Sovereignty? - Now I know that the secret thing of God are God's to know, not mine. Job was tormented greatly by his family's demise and his loss of his wealth, but only when his body was touched by Satan was he brought low enough for God to really reach him.
Jesus had not been sleeping to put the disciples in danger. His purpose was to demonstrate to the disciples who he really was. They were slow to learn, but in stilling the storm with a single word he revealed himself "He stilled the storm to a whisper; the waves of the sea were hushed" (Psalm 107:29). "You rule over the surging sea; when the waves mount up you still them" (Psalm 89:9). Who is it who controls the Sea? It is Yahweh the Creator God. When the disciples ask the question, "Who is this, even the wind and waves obey him?" they know the answer. Jesus is the Creator God.
God's purpose is not our comfort but our holiness. For this we need to submit to him, accept the gift of salvation, and follow him. Through our changing circumstances he cajoles us into acceptance. Is he there? Is he sleeping? Doesn't he care? He's there, he cares, and he's wide awake; but he knows what's best for us and he leads us into it.
Saturday, July 04, 2009
Wimbledon
Gary Lineker once said that the best way to watch Wimbledon was on teletext. He was speaking about the soccer club AFC Wimbledon, home of mute movie star, Vinnie Jones. But he could have been talking about tennis. I mean Veneria versus Senus - who cares?
But nice to see the Lions give South Africa a stuffing. Notice how many South Africans play for the Cheetahs?
But nice to see the Lions give South Africa a stuffing. Notice how many South Africans play for the Cheetahs?
Hope
Seventh course completed, now for the side effects. Actually I have weathered this course much better. The dose of oxaloplatin has been reduced and I am back taking the steroids, but I think the greatest improvement has been in my psyche. Simply by seeing the improvement in the CT and entertaining to prospect of a curative resection of the primary after the chemotherapy is completed, I have rediscovered some hope.
Spiritual hope is something I have always had, of course. Hope in a Biblical sense is not just a benign expectation, but a certainty achieved by believing the promises of God, but earthly hope is a lot more chancy. Andy Murray hoped to win Wimbledon but there was no certainty in that hope. Perhaps next year...
As an oncologist, I always believed in leaving patients with some hope. Survival curves always have a long tail and though it may be a long thin one like a laboratory rat's someone has to ride that tail and it may be you.
Anyway something has raised my spirits. Thanks for all those who have been praying.
Spiritual hope is something I have always had, of course. Hope in a Biblical sense is not just a benign expectation, but a certainty achieved by believing the promises of God, but earthly hope is a lot more chancy. Andy Murray hoped to win Wimbledon but there was no certainty in that hope. Perhaps next year...
As an oncologist, I always believed in leaving patients with some hope. Survival curves always have a long tail and though it may be a long thin one like a laboratory rat's someone has to ride that tail and it may be you.
Anyway something has raised my spirits. Thanks for all those who have been praying.
Thursday, July 02, 2009
Deserving rich; deserving poor.
John Denham, one of the few members of the British Labor cabinet from the south of England made an interesting speech yesterday. It is well known that the Labor party is only in power because Scotland is massively over-represented in Parliament and that their ranks are packed with representatives of deserted inner cities with low voter numbers (apart from the vote rigging by mainly Muslim tribe leaders in northern cities who commandeer the postal votes of non-English speaking recent immigrants and give them to Labor).
The substance of the speech was inequality. Labor has made a big thing about level playing fields in employment, social benefits, housing and so on. Hutton's point is really about the deserving poor as opposed to the undeserving poor and more to the point, the deserving rich as contrasted with the undeserving rich.
It is easy to pick out poor people who deserve to be helped: those born with physical handicaps, those struck down with life-threatening diseases, those whose ethnicity exposes them to prejudice (though as prejudice has massively diminished this is a dwindling number that should not include most black and Asian people, and certainly not the East Asians who do very well for themselves), and a few other individual cases not easily categorised.
It is possible to get rich by hard work. Enterprising entrepreneurs who take risks with their own money should be rewarded. Nobody even minds the odd Lottery winner. However, most people who are very rich have bent a few rules on the way up and many are consummate criminals. At the moment the public's ire is directed at bankers who have gambled knowing that if they win they will reap ridiculous rewards but if they lose the public purse will bail them out, and members of parliament who have gamed the system to enjoy rewards that were never intended and particularly those who represent members of the public who are living on minimum wages. But others will be caught in their sights before the recession ends. Executives who work for the publicly funded BBC will be next.
When my son was redecorating his house in Oxford prior to selling it, he was up a ladder and unseen by his neighbors sunning themselves in their garden. They were two young women. The fact that they were both black is probably irrelevant; there are just as many white tarts in the Blackbird Leys estate. One was obviously impressed by the quality of housing, "How did you manage to get yourself a nice house like this when you're on the dole?"
"That's simple," replied the other one with a toddler on her lap, "Just get yourself a kid and council will find you one."
When my son's house was burgled during his absence, when the police finally arrived they found evidence that the burglar had entered and exited the property via next door's fence. On knocking on his neighbor's door they immediately recognized the occupant, found drug paraphernalia, and enquire about her well long term associate, who had a record for burglary.
To my mind most burglars and drug addicts and benefit cheats are not the deserving poor. Labor promised to follow Bill Clinton's Workfare policies, but too many of their grassroots supporters objected.
The substance of the speech was inequality. Labor has made a big thing about level playing fields in employment, social benefits, housing and so on. Hutton's point is really about the deserving poor as opposed to the undeserving poor and more to the point, the deserving rich as contrasted with the undeserving rich.
It is easy to pick out poor people who deserve to be helped: those born with physical handicaps, those struck down with life-threatening diseases, those whose ethnicity exposes them to prejudice (though as prejudice has massively diminished this is a dwindling number that should not include most black and Asian people, and certainly not the East Asians who do very well for themselves), and a few other individual cases not easily categorised.
It is possible to get rich by hard work. Enterprising entrepreneurs who take risks with their own money should be rewarded. Nobody even minds the odd Lottery winner. However, most people who are very rich have bent a few rules on the way up and many are consummate criminals. At the moment the public's ire is directed at bankers who have gambled knowing that if they win they will reap ridiculous rewards but if they lose the public purse will bail them out, and members of parliament who have gamed the system to enjoy rewards that were never intended and particularly those who represent members of the public who are living on minimum wages. But others will be caught in their sights before the recession ends. Executives who work for the publicly funded BBC will be next.
When my son was redecorating his house in Oxford prior to selling it, he was up a ladder and unseen by his neighbors sunning themselves in their garden. They were two young women. The fact that they were both black is probably irrelevant; there are just as many white tarts in the Blackbird Leys estate. One was obviously impressed by the quality of housing, "How did you manage to get yourself a nice house like this when you're on the dole?"
"That's simple," replied the other one with a toddler on her lap, "Just get yourself a kid and council will find you one."
When my son's house was burgled during his absence, when the police finally arrived they found evidence that the burglar had entered and exited the property via next door's fence. On knocking on his neighbor's door they immediately recognized the occupant, found drug paraphernalia, and enquire about her well long term associate, who had a record for burglary.
To my mind most burglars and drug addicts and benefit cheats are not the deserving poor. Labor promised to follow Bill Clinton's Workfare policies, but too many of their grassroots supporters objected.
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