The Spectre of Socialized Medicine

Yesterday President Obama assured us that healthcare reform was at the top of his agenda. Opponents raise the spectre of socialized medicine and Britain's NHS is held up as an example of what lies down that path.

The truth is that both Britain and America have a mixed economy of social and private healthcare.

The great worry is that socialized medicine leads to rationing. At one time the NHS had a waiting list of five years for a hip replacement and there is a built in delay in getting the new cancer drugs, some of which have not been and may not be approved by NICE.

However, this indictment of the NHS does not tell the whole story. Even when it took 5 years to get a hip replacement on the NHS you could get one next week if you had health insurance. At the time I was practising around 20% of the population had healthcare insurance. This is a far lower percentage than in America, of course, but there are reasons for this, which I will explain. Health insurance for the 20% is largely provided by employers who naturally enough regard it as a good investment since it gives them control over when their employees will be absent on health grounds. The whole private healthcare industry is geared towards elective surgery, since it is this area that is easiest for socialized medicine to ration. If you were paying through your taxes for someone else's treatment you would be happy to cover treatment for cancer and heart attacks but you might be unsure about paying for their varicose veins or their sticking out ears to be remedied.

Private health insurance usually extended to the employees family. Many self-employed individuals were able to write off healthcare insurance as a business expense and saw it as a good investment.

The other element to my thesis is that America also enjoys socialized medicine. The largest plank in this is the VA service. Some commentators have suggested that this is the most efficient part of American healthcare. In addition there is Medicare and Medicaid and a separate provision for children. It is also true that there are government subsidies to the private insurance industry in the form of tax breaks. Finally, there are the county hospital ERs that provide free healthcare to the indigenous poor.

The UK currently spends about 7.4% of GDP on the NHS. Surprisingly, the American government spends a staggering 11% of a much larger GDP on healthcare. The healthcare purchased by insurance is on top of this.

There is no doubt in my mind that the very best healthcare is provided by doctors working in private practise. Isn't that what you would expect? The more you pay for something the more you are likely to receive for you money. After all, Honda makes very good cars, but Rolls Royce make better ones. In any business transaction you largely get what you pay for. It is also true that among the best paid doctors there are some flim flam men who are taking money under false pretenses, but that's the market for you.

The problem with the market is that we can't all afford Rolls Royces and some of us have to settle for a Ford. But even a Ford is expected to get us from A to B on time.

There was a time that the Ford provided by the NHS was a beat-up Edsel, but at that time only about 4% of GDP was being spent on it. I remember when I started as a hospital consultant I was single handed in haematology; now there are 5 people doing the job I was doing and 5 junior doctors being trained in the department where there were none before. There were 3 general physicians in my hospital; now there are 33. I have seen improvements in the quality of medicine that are almost unbelievable. Nonetheless, there are still blackspots in the system that need remedy.

The reason that private medicine has never been purchased by more than 20% of the population in the UK is that the NHS is so good. It is so good because it is very efficient, avoiding buying things that are unnecessary, using the power of central purchasing in the way that the Supermarkets do to drive down prices, yet at the same time allowing a high degree of local autonomy to take advantage of local situations.

I suspect that the reason that so many buy medical insurance in America is because the alternative is so awful.

Let's take some of the specific criticisms of the NHS. How about those long waiting times? Our own hospital has been at the forefront of getting these down. No-one has to wait more than two weeks to see a consultant about a suspected cancer. Hip replacement waiting times are down to six weeks. No-one in the country waits for more than 18 weeks for any procedure.

The NHS won't pay for expensive cancer drugs. There is some truth in this. But until recently the only way you could get rituximab for CLL in America was by terminological inexactitude. If you called your CLL a type of lymphoma then you could get the insurance companies to pay for it. You could do the same in the UK until the authorities got wise to the fact that there was no evidence that rituximab showed benefit in CLL. It was not until the German CLL8 trial reported that we were sure that rituximab improved the length of remissions in CLL. It is the pharmaceutical companies who are to blame for this. They could have conducted the relevant trials a decade earlier if they had had the will.

Doctors all round the world are still performing procedures for which there is no evidence of benefit. NICE has addressed this problem and is reducing the pressures on doctors to continue in their bad old ways. A good example would be the use of protein-pump inhibitors like omeprazole for indigestion. The bill for this is greater than the bill for all cancer chemotherapy put together. Even switching to ranitidine would make lost cancer chemotherapy affordable, but most indigestion responds perfectly well to antacids from the drugstore. If it doesn't then suspect peptic ulcer which can be cured by two weeks omeprazole and some cheap antibiotics.

The other criticism of socialised medicine is that it reduces doctors' incomes. The frightening example of Cuba is often brought up. And it is true. For my few private patients I was paid at 10 times the rate that the NHS paid me. On the other hand the NHS was paying me roughly the same as the Prime Minister was getting, so I shouldn't complain. Lots of people on salaries earn plenty - as we are finding out in the banking crisis.

There is a real problem with bureaucracy in anything run by the government and it is very important that the government is kept at arms length from anything to do with medicine. In the NHS every family doctor is an independent contractor, not a slaried employee. Nor is it necessary for a national health service to come from taxes; most European schemes are insurance-based. But with such a large number of Americans getting such poor healthcare, change is inevitable.

The magic of numbers

I remember the last time I had an accident in my car. I say an accident, but I was entirely culpable. I was late. It was dark and wet and I was driving too fast for the conditions. As I rounded a bend in the road, doing 43.2 mph I was confronted by the red tail lights of a stack of traffic held up in front of me. I ploughed into the back of a 4X4. No-one was hurt, but my car was damaged enough for me to have to abandon my journey.

The odd thing was that when I looked at the odometer it read 70,000.0 miles.

Of course, that number is no more significant than 72,865.7 but we want to attach significance to round numbers. That old car limped on to 131,875.3 miles, about which I have absolutely nothing to say. Perhaps it would have been more perfect had I scrapped it after the accident. Superstition would have forced me to.

Of course the realy significant number was the 43.2 mph and if you go to this website you will see why.

Religious Refugees

The UNHCR defines a refugee as a person who has fled his country owing to well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, is unable or owing to such fear is unwilling to avail himself of the protection of that country. (In every case the male pronoun includes the female). Free countries have a duty to offer asylum to those in such danger.

There is a special problem with converts from Islam. According to Sharia law, leaving Islam is a crime on a par with treason that is punishable by death (or life imprisonment if it is a woman according to some readings). Not every Muslim takes this view, but many countries that operate according to Sharia law do. Even when the government of a country takes an enlightened view, family members and certain rural communities do not. Even enlightened governments are reluctant to interfere in the workings of families and local communities. In Pakistan, for instance, there have been many Christian converts from Islam who have been unmolested, but if you happen to live near the Afghan border, your father or brothers might kill you if you convert.

Recently, a Libyan asylum seeker who had converted to Christianity was beaten almost to death while in the West Drayton Removal Centre in the UK, by Somali and Yemeni detainees, as he left the makeshift church in the centre.

There is a great ignorance on behalf of officials of national immigration services (I am speaking in particular about the UK, Germany and New Zealand) about the danger that Christian converts from Islam are in, and a lack of cultural sensitivity. The UNHCR takes the view that converts are in no danger in Iran - a view that most in the West would regard as laughable were it not so serious. Then take the questions asked of converts to establish the genuineness of their conversions. "How do you prepare a turkey for Christmas?" "Recite the Roman Catholic Mass." "What were the names of the thieves crucified with Jesus on the Cross?"

Some immigrants have been offered Muslim interpreters. Do they not realise the risk of this. Although some interpreters may be scrupulously honest they will hardly be able to present the asylum seekers problems with any insight, and there may be an incentive to mistranslate so that the person is sent home for 'reconversion'.

However, it is not all bad news. In September last year an asylum seeker "George" a Syrian who had previously seen his application for asylum refused because the Inspector could not believe that George's father would truly hurt his son, finally won the right to stay in Britain.

Cataloguing films

I am still cataloguing my movies on DVD and VHS. I now have about 900, including 90 children's films (mostly on VHS).

The directors who now mostly feature are Alfred Hitchcock with 19, David Lean with 14, Steven Spielberg, Billy Wilder and Peter Weir, each with 10, Clint Eastwood and Ingmar Bergman with 8 each, the Coen brothers and Douglas Sirk with 7 and on 6 come James Ivory, John Huston, Martin Scorsese, Michael Powell and Stephen Frears.

As far as male actors are concerned, Humphrey Bogart leads with 18, Anthony Hopkins is next with 14, then Clive Owen with 12 and John Mills with 9. Then tied with 8 films each are Al Pacino, Alec Guinness, Daniel Day Lewis, Morgan Freeman, Robert De Niro, Tom Cruise, William Holden and Alan Rickman.

For Female actors the order is Cate Blanchett and Judi Dench with 10, Helen Mirren and Nicole Kidman with 9, Ingrid Bergman, Kate Winslett, Julia Roberts and Diane Keaton with 8 and Helena Bonham-Carter and Meryl Streep with 7.

I'm not sure what this says about me. I suppose it says I like old war films (John Mills) and I tend to collect everything by certain directors; that I like Film Noir and good actors. Perhaps someone could suggest from these lists which films you think I don't have in my collection and those I ought to have.

Incidentally, I still haven't watched more than 200 of the films.

Cancer Screening

When the CT scanner first appeared people dreamed of everyone having a scan at regular intervals to detect early cancer. We have become used to the mantra that in cancer "Early diagnosis means early treatment means more cures and fewer cancer deaths". Screening has been so heavily backed by government information that we have all bought into it. In today's BMJ is a paper from Peter Gotzsche and his colleagues in Denmark which questions the value of mammography. They produce the following figures: If 2000 women are screened regularly for 10 years, one will avoid dying from breast cancer, but 10 healthy women will as a consequence become cancer patients and be treated unnecessarily. These women will have whole or part of their breast removed and some will also receive unnecessary radiotherapy or chemotherapy. Some will develop a secondary leukemia because of the therapy. Furthermore another 200 healthy women will experience a false alarm and suffer psychological trauma.

All this sounds counter-intuitive. Surely it is better to know what is going on?

The problem with breast screening is not that cancers are missed, but that they are over-diagnosed. It is becoming clear that cancer may be diagnosed when the tumor is very small and despite its grim reputation, many cancers do not progress during the lifetime of the individual. Those of us who work with CLL are well aware of this fact: the commonest treatment applied is watch and wait. I am reminded of an obituary of a man from Oklahoma who died in his eighties, 52 years after his untreated CLL was first diagnosed. If it is true for CLL, why would it not be true for cancers of other tissues. Since CT scanning has become so sensitive we have been recognizing very small lumps in the lungs. Do these represent lung cancer? Or perhaps marginal zone lymphomas? Biopsy is the only way of finding out, but isn't that a bit invasive for what may be a false alarm? So we tend to watch and wait there too.

With mammogram results it is relatively easy to do a biopsy and this leads to the possibility of over diagnosis. For a start there is carcinoma-in-situ, which constitutes 20% of the diagnoses made. We know that fewer than half such cases lead to invasive cancer, but 30% are treated with mastectomy. Then there are patients who really do have cancer, but such an indolent cancer that it would never have become noticeable in the patient's lifetime.

Screening does not lead to fewer mastectomies; indeed in randomized trials 20% more mastectomies are performed in screened patients. You would think that this would be offset by a reduced number of mastectomies in older women whose late-occurring cancer had been forestalled. Unfortunately, this is not so. Radiotherapy is applied to some women whose cancer would not have progressed. It is known that radiotherapy doubles teh rate of mortality from lung cancer and heart disease.

Breast cancer rates are apparently increasing because mammography finds more cases. The cure rate is also improving, but the absolute number of women dying from breast cancer has not changed.

Similar results are available for PSA screening for prostate cancer. The disease is not 10 times more common than it was in the 1990s, but the number of people dying from prostate cancer every year has not changed - it remains the same in countries which adopt both a restrictive and a liberal policy on the use of PSA as a screening test.

I speak with some feeling as someone whose screening colonoscopy has led to two further colonoscopies, and octreatide scan and two CT scans, and still no diagnosis.

To explain the problem it helps to look at the maths. Suppose that a screening test is almost completely accurate; that it misses no positive cases and is 99.99% accurate. That means that one test in 10,000 will be a false positive. Not many tests are as accurate as this, but suppose you are screening for a rare disease with an incidence of 4 in 100,000 in the general population. That means that for every 10 positive tests, 6 will be false positives. (4 in 100,000 is the approximate frequency of CLL).

We underestimate the harm done by worrying patients. Few there are who face impending doom with equanimity.

Vitamin B

The B Vitamins are a group of water-soluble substances which are not otherwise related to each other. There are eight of them, but claims for vitamin status are made for another 23. A vitamin is a substance that is essential for healthy living that cannot be synthesized by teh body. The other 23 eithercan be synthesized by teh human body or are not essential for health. I will deal with teh eight true vitamins and then explain why some of the others are not true vitamins.

Vitamin B1 or thiamine is the substance that is necessary in the diet to prevent beriberi. Chinese medical texts referred to beriberi as early as 2700 BC. Symptoms of beriberi include severe lethargy and fatigue, together with complications affecting the cardiovascular, nervous, muscular, and gastrointestinal systems. The origin of the word is from a Sinhalese phrase meaning "I cannot, I cannot", the word being doubled for emphasis. Two types of beriberi are recognized: the 'wet-type' affects the heart; through a combination of heart failure and weakening of the capillary walls, it causes the peripheral tissues to become edematous. Dry beriberi causes wasting and partial paralysis resulting from damaged peripheral nerves.

In 1884, Takaki Kanehiro, a British-trained Japanese doctor of the Japanese Navy, observed that beriberi was endemic among low-ranking crew who often ate nothing but rice, but not among crews of Western navies and officers who consumed a Western-style diet. Kanehiro initially believed that lack of protein was the chief cause of beriberi. He conducted one of the first cliical trials using the crews of two battleships; one crew was fed only white rice, while the other was fed a diet of meat, fish, barley, rice, and beans. The group that ate only white rice reported 161 crew with beriberi and 25 deaths, while the latter group had only 14 cases of beriberi and no deaths. This convinced Kanehiro and the Japanese Navy that diet was the cause of beriberi. But Kanehiro wrongly thought that protein was the missing element in the diet (Kwashiorkor, which is caused by protein deficiency also causes heart failure).

In 1897 Christian Eijkman, a military doctor in the Dutch Indies, discovered that chickens fed on a diet of cooked, polished rice developed paralysis, which could be reversed by discontinuing rice polishing (he mistakenly attributed that to a nerve poison in the endosperm of rice, from which the outer layers of the grain gave protection to the body. In 1897, Christiaan Eijkman in the Dutch East Indies, discovered that feeding unpolished rice instead of the polished variety to chickens prevented paralysis in the chickens. In 1898, Sir Frederick Hopkins postulated that some foods contained "accessory factors" — in addition to proteins, carbohydrates and fats, — that were necessary for the functions of the human body.

Eijkman was awarded a Nobel Price in Psysiology and Medicine in 1929, because his observations led to the discovery of vitamins). An associate, Gerrit Grijns, correctly interpreted the connection between excessive consumption of polished rice and beriberi in 1901: he concluded that rice contained an essential nutrient in the outer layers of the grain that was removed in polishing. In 1911 Casimir Funk isolated an antineuritic substance from rice bran that he called a “vitamine” (on account of its containing an amino group). Dutch chemists, Jansen and Donath, went on to isolate and crystallize the active agent in 1926, whose structure was determined by R.R.Williams, a US chemist, in 1934. Thiamin (“sulfur-containing vitamin”) was synthesized in 1936 by the same group. It was first named “aneurin” (for anti-neuritic vitamin).

Thiamine occurs naturally in unrefined cereals and fresh foods, particularly whole grain bread, fresh meat, legumes, green vegetables, fruit, and milk. Beriberi is therefore common in people whose diet excludes these particular types of nutrition.

Beriberi may be found in people whose diet consists mainly of polished white rice, which is very low in thiamine because the thiamine-bearing husk has been removed. It can also be seen in chronic alcoholics with an inadequate diet (Wernicke-Korsakoff syndrome), as well as being a rare side effect of gastric bypass surgery. If a baby is mainly fed on the milk of a mother who suffers from thiamine deficiency then that child may develop beriberi as well.

Wernicke’s encephalopathy (WE) is the type of thiaqmine deficiency most frequently seen in Western society. Although it may also occur in patients with impaired nutrition from other causes, it is usually seen in alcoholics. It is a striking neuro-psychiatric disorder characterized by paralysis of eye movements, abnormal stance and gait, and markedly deranged mental function.

Alcoholics may have thiamin deficiency because of the following: 1) inadequate nutritional intake: alcoholics tend to intake less than the recommended amount of thiamin. 2) decreased uptake of thiamin from the GI tract: active transport of thiamin into enterocytes is disturbed during acute alcohol exposure. 3) liver thiamin stores are reduced due to hepatic steatosis or fibrosis. 4) impaired thiamin utilization: magnesium, which is required for the binding of thiamin to thiamin-using enzymes within the cell, is also deficient due to chronic alcohol consumption. The inefficient utilization of any thiamin that does reach the cells will further exacerbate the thiamin deficiency. 5) Ethanol per se inhibits thiamin transport in the gastrointestinal system and blocks phosphorylation of thiamin to its cofactor form, TDP.

Korsakoff Psychosis is generally considered to occur with deterioration of brain function in patients initially diagnosed with WE. This is an amnestic-confabulatory syndrome characterized by retrograde and anterograde amnesia, impairment of conceptual functions, and decreased spontaneity and initiative. Because of their loss of memory they invent the most fantastic explanations for their circumstances.

However, most people on normal diets do not require vitamin B1 supplements.

Current affairs

politicsNo blogging for week because I have been busy preparing a sermon for this evening and for leading a Bible study last Thursday. So a few comments on what has been in the news this week.

Gert Wilders, the Dutch MEP was denied entry to Britain to show his film 'Fitner' to parliamentarians in the House of Lords. Readers of this blog will know that I have seen this film and provided a link to it on the internet. It is a short film that juxtaposes scenes of atrocities committed by Muslims (9/11, 7/7, Madrid and a hostage beheading) with the parts of the Koran that certain Muslims use to justify their actions. Banning Wilders did not stop anyone watching it. Indeed the added publicity ensured that many more people went to the various websites that feature it.

It is obviously true that not all Muslims ascribe to these views any more than Christians and Jews any longer feel the need to totally wipe out the Amalekites. The problems is that some Muslims do, and many of them live in the Western democracies. People over here are frightened by them. Free speech is not an optional extra to protect people who agree with you. The Muslim member of the House of Lords was out of order when he persuaded the Home Secretary to ban Wilders and the Home Secretary was both wimpish and authoritarian.

Jade Goody was treated for metastatic cervical cancer and it was announced that the disease is untreatable and that she has little time left. She is the ultimate in the 'famous for 15 minutes' syndrome. She first came to fame for her outrageous behavior on 'Big Brother' and then was cast off 'I'm a Celebrity Get Me Out of Here' for racist speech. She was held up as an example of the colossal ignorance of the 'underclass'. Then on the Indian version of 'Big Brother' she was told on camera that she had advanced cancer. While the TV world looked on she lost her hair to chemotherapy. She has expressed a desire to die on camera as a warning to the world. Since cervical cancer is mostly caused by Human Papilloma Virus, which is a sexually transmitted infection one wonders whether her display will reduce promiscuity.

And as if outrageous behavior had yet to reach its limit, we now have a 12 year-old apparently fathering a child on a 15 year old girl. The boy is clearly pre-pubertal and the claim is probably untrue, but exactly what do the parents think they are doing? Trying to make money from their children's misfortune is the obvious answer. The welfare state will provide the children with somewhere to live and £30,000 a year in benefits, apparently. then there is what the newspapers and TV will pay for the stories. It may all come to nothing since two older boys are now claiming to be the father. It seems to me that the teenagers should be taken into care and the parents prosecuted - and the baby adopted.

But adoption itself in hazardous. One couple have had their three children adopted against there will because social workers thought they had been abusing their middle child. Doubts have now arisen as to the justice of the claim. It seems that the child failed to thrive on formula milk and was switched to a soya substitute that lacked vitamin C. Experts have claimed that the apparent injuries were due to scurvy. Nonetheless, the Appeal Court has ruled that the adoptions are irreversible. As the father said, "If our children had been kidnapped and then recovered, would the children have had to stay with the kidnappers because they had got used to them?"

The financial crisis deepens with Gordon Brown catching most of the stick. He got the plaudits in the good times and must expect criticism in the bad ones. They latest suggest is 'quantitative easing', a euphemism for printing money. The Retail Price Index of inflation was 0.1% this month. This was mainly due to a fall in mortgage interest rates and a cut of 2.5% in VAT. However the Consumer Prices Index, which is the government's favored measure was 3.1%, still way above the 2% target. So have we got inflation or deflation?

The real problem in the economy is the failure of the banks to lend money to people needing cash to keep their businesses active, or to replace their car or to improve their house. The government has given the banks billions of taxpayers money so that they can lend, but it seems that that money is being used to replenish their own financial reserves and pay their employees huge bonuses. Since several of the banks are now nationalized, the government has it in its power to remedy that behavior. However, so many of the bankers are advising the government that I doubt it will happen. The Bank of England thinks 2010 will be better. Presumably because we will by then be shot of the Labor Party.

ADDED LATER 26/5/09. The 12 year old was not the father.

The Prodigal Son

I guess this story and the one about the Good Samaritan are the best known of Jesus' parables. Most people think they know it well. A young man, as young men do, gets fed up with his straight-laced family and wants to see the world. He asks his dad for the money that is coming to him when his father dies and he takes it and splits. He spends the next few years in riotous living. You can imagine him doing a Paris Hilton, getting into all kinds of scrapes and having enough money to bail himself out of them. He would have been a popular chap; lots of fair-weather friends.

You can see where it's heading. All good things come to an end. His money runs out, his friends desert him. There's famine in the land. He tries to get a job but the only work he can get is looking after pigs, which for a Jew would have been especially degrading. In the end he comes to his senses, realizes how much better he would have been had he not left home and goes back to mum and dad, who, as parents do, take him back. They may seem a bit soft, but that's what parents are like, a mother’s love has no limits. After all, he is their flesh and blood.

So, it's a cautionary tale about keeping to the straight and narrow, telling us that we ought to obey our parents and warning us about the sort of life that the young man embarked on.

I guess that's how many people see it, but it is a profound misunderstanding of the text.

To understand a text, we have to look at the context - otherwise it becomes a pretext. This is one of three parables in Luke 15 about losing things: a lost coin, a lost sheep and a lost son. It tells us about the concern the owner has about losing things.
I guess most of us have lost something vital. My son was due to fly to Switzerland on Friday, but his girlfriend lost her passport. They searched high and low for it. They tore her place apart, but it was nowhere to be found and the holiday had to be postponed. Most of us have lost our keys. Do you have one of those devices that causes your key ring to emit an electronic noise when you blow a whistle or clap your hands? I wish I did. I'm always putting my keys down somewhere and not remembering where. When I've lost something like that I can't settle at anything else. I must find it. It plays on my mind.

The lady who lost her coin, the shepherd who lost a sheep - these stories are telling us that our Father's concern for a sinner who goes astray is no less.

To simply say that the returning prodigal was accepted, because that's what parents do, misses the point. The German Poet, Heinrich Heine, who had converted from Judaism to Christianity in order to preserve his German citizenship, was asked on his deathbed by a priest whether he thought that God would forgive his sins. He replied, "Dieu me pardonnera; c'est son metier" - God will forgive me; that's His job.

To assume that we are going to get forgiven so perfunctorily, misreads the younger son's heartfelt repentance. The Bible tells us that he ‘came to his senses’. It reminds us of Legion, the man from whom Jesus cast many Demons. The people came out and found the man sitting at Jesus’ feet, ‘dressed and in his right mind’. Repentance is not a formula for getting forgiven – it literally means ‘think again’. It involves starting with a different premise. In all three parables it is repentance that is stressed. In Luke 15:7, the parable of the lost sheep, Jesus says, “I tell you that in the same way there will be more rejoicing in heaven over one sinner who repents than over ninety-nine righteous persons who do not need to repent.” and in Luke 15:10, the parable of the lost coin, He says, “In the same way, I tell you, there is rejoicing in the presence of the angels of God over one sinner who repents."

Is the young man truly repentant? These days we see many people who swap sides when the going gets tough. Footballers who are proud to pull on the shirt of Portsmouth (or Tottenham or West Ham) and talk about the history of the club and how proud they are to be thought of in the same lineage as Jimmy Dickinson (or Danny Blanchflower of Bobby Moore). Then Real Madrid or Liverpool or Chelsea flash their check books and loyalty is easily bought. Was this prodigal just seeing which side his bread was buttered on? I don’t think so. He accepted that he had forfeited his sonhood and was eager to be a slave in his father’s house.

And if this attitude belittles the son’s repentance, it also diminishes the hurt done to the father. To ask for your inheritance while your father still lives, is tantamount to saying, "I wish you were dead." To take that amount of capital out of the business must have seriously affected how it was run. Presumably the father would have had to borrow to realize the cash. That would have been an added burden on the revenues of the farm.

We have to remember that this parable would have been shocking to his hearers. They would know all about unreasonable love. They would remember what Isaiah had said in chapter 49 v 15: "Can a mother forget the baby at her breast and have no compassion on the child she has borne? Though she may forget, I will not forget you!” In illustrating God’s extreme grace, Isaiah turns to a mother’s nature. Ask a mother, “If your son were making false returns on his Income Tax declaration, would you shop him?” or “Supposing your son was a murderer, would you hand him over to the police?” Time and again mothers help their sons to get away – and who would blame a mother?

Notwithstanding, a mother’s love, the Jew’s life was defined by the Law. In Jewish eyes a woman was weak. A Jewish man would thank God everyday that he was not born a woman. In a court of law a woman’s word was worth much less than a man’s. A man was not sentimental. This young man had broken the Fifth Commandment and the Tenth Commandment and probably the Seventh as well. The Jews believed in forgiveness. The young man could have taken an animal to the Temple and made a sin-offering, but no, he traipses back to his father and his father in his weakness rushes out to meet him with open arms like a mere woman.

I imagine a Jew of the day would have found this depiction of God offensive. And in a way I agree with them. It really won’t do to brush away sin as if it didn’t matter. Two weeks ago the Manchester United midfielder, Michael Carrick, burst into the penalty area and was tripped by the Everton center half. United had already scored from a penalty awarded when the same player had been tripped earlier, and this time the referee waved away the claim. When questioned afterwards, Sir Alex Fergusson, the United manager said, “Of course it was a penalty, even more blatant that the first one. But you can’t expect to get two penalties in a match like this.”

Like many fans I was outraged. Surely we have a right to expect the referee to be fair. No matter how much of an advantage United might have had, fouls can’t simply be ignored. I would be very worried by a God who simply ignored sin as if it had never happened. Winking at my indiscretions is one thing, but if my enemy harms me I want him punished. It’s not fair!

It is interesting to note the actions of the father. As well as putting shoes on his feet, a cloak on his back and a ring on his finger, he has the fattened calf slaughtered. Is it special pleading to see the killing of an animal as having a special meaning? The Jews knew all about animal sacrifices. They knew about the nature of surrogacy. The sacrifice on the Day of Atonement was, as here, a young bull.

Looking backwards we can see that it was the very teller of the story who was to be sacrificed as a surrogate for the prodigal son and for all prodigals since. We can see him as the atoning sacrifice for our sins. God doesn’t wink at our sin, but he doesn’t hold them against us. He has taken the punishment for them on himself in the body of the Son.

So, it’s not just a warning for the young; it’s a description of God’s amazing grace; of how the lost can be saved and the damned redeemed. It’s a message that tells us that no-one is too bad to save; that no-one is so far gone that they cannot be rescued and that God in his great love is not willing that any should perish, but that all should turn from their wicked ways and live. And when we look at the context – that Jesus was sitting down with Tax-collectors and sinners – we see that it is a point well made.

But I don’t think that is the main point of the story. The main point concerns the older brother.

When I was younger I had a lot of sympathy for the older brother. After all, he was the sensible one. He’d kept his nose clean, slaved away at home, been a good example, always been there to help around the house, obeyed the rules and now he felt he was being taken for granted. On the other hand his brother had been an absolute wastrel, spent the family money of wicked things, gone missing when his father had to take out a bigger loan to keep the farm going – not only had he been the cause of the loan in the first place, but he’d not been around to help about the farm to pay off the interest – and now his big plans had all collapsed he had come scurrying back to Papa with his tail between his legs. No wonder he felt hard done by.

There is a story of Elizabeth Elliot’s that I have stolen from Chris Kelly. It’s not a Biblical story, but it is a parable. One day Jesus asked his disciples to carry a stone for him. They each picked up a stone from the ground. Clever old Peter picked up a tiny pebble that slipped easily into his pocket. No burden at all to carry that around. After they had been walking around the Galilean countryside all morning they stopped for lunch. Jesus asked them all to brink their stones to him and we waved his hand over them and turned them into bread. “That’s your lunch,” he said. Poor old Peter had less than a mouthful. After lunch Jesus asked the disciples to do the same again. Peter was not going to be fooled a second time. This time he picked up a boulder. As they walked over the hills of Judea, Peter struggled with his load. Shifting it from one shoulder to the other and then holding it next to his chest, then on his head, he fell further and further behind. Eventually, he caught them up. They had been sitting by the side of the lake for half an hour or so. “Ah, Peter,” said the Lord, “You’ve finally got here. You can chuck the rock in the lake now.”

“What? Aren’t you going to turn it into bread?”

“Peter, were you carrying that stone for me, as I asked, or were you carrying it for yourself?”

The older brother wasn’t being the dutiful son because he loved his father. He was doing it for the reward. He liked being thought of as ‘the good son’. He had the respect of the servants and the neighbors. He was a pillar of the community. He had a good image. And what is more he had expectations. Do you remember the oily character in Pride and Prejudice, Mr. William Collins, who was so nauseatingly obsequious to his patron, Lady Catherine de Bourgh? He too had expectations. The Bennet’s house at Longbourn was entailed to him – if Mr. Bennet were to die, Mrs. Bennet and her five daughters would be turfed out of home and hearth to make way for him. I think Jane Austen had the older brother in mind when she drew Mr. Collins.

The contrast between the two brothers turns on the word ‘slave’. The older brother complains that he has been slaving for his father for years without reward; the younger son regards becoming a slave in his father’s household as the source of his future joy.

Context is all important. Jesus told these three parables because the Pharisees were muttering. Their complaint was that “This man welcomes sinners.” The point Jesus is making is that not only does God welcome sinners, but the Pharisees are like the older brother who doesn’t welcome sinners.

Remember the Pharisee’s prayer, “God, I thank you that I am not like other men – robbers, evildoers, adulterers – or even like this tax collector.”

It is certainly a fine thing not to be a robber, evildoer or an adulterer. But if he thought he was not like other men, he was certainly mistaken.

The Apostle John writing in his old age says, “If we claim to be without sin, we deceive ourselves and the truth is not in us…If we claim we have not sinned we make Him out to be a liar.”

The truth is that even good people need a Savior. Even religious people need salvation. I am afraid that our churches are full of people who think they are safe and are not. They have lived good lives. Everybody thinks well of them. They could stand as MPs and be scrutinized by the scandal sheets and no-one would find anything to make a story about. No hidden mistress, their income tax returns are spotless, no unfortunate ‘perks’ they would be embarrassed by; they go to church twice on Sundays, they tithe religiously, they are always at Holy Communion. They are politically correct, watching their words carefully; “Paki” and “Golliwog” are not even in their vocabulary; they turn their TV off at the mains every night; they drive a hybrid car; their houses have roof insulation nine inches thick and their walls are insulated with polyurethane foam.

Yet these very good people still fall short of the standards Jesus has set. President Carter was a very good man. He may not have been a good President, but his lifestyle was exemplary. He was mocked about the story in Playboy. “Have you ever committed adultery?” he was asked.

“I have committed adultery in my heart,” he replied. He was just being honest. Applying to himself the interpretation of the Ten Commandments that Jesus had opened up in the Sermon on the Mount.

When the prodigal son was yet far off, his father, watching the road, perhaps standing on the roof of his house and scanning the horizon, spotted him. Was there something about the way he walked? Something about his gait or his body shape that he recognized. “I am the good shepherd,” said Jesus elsewhere, “I know my sheep.”

Can’t you feel the excitement, the anticipation, the overwhelming joy as the father ran to his son, threw his arms around him and kissed him? No wonder Jesus said there would be rejoicing in heaven.

What about the older brother? When he heard the music and the dancing he became angry. He skulked around outside and refused to go in. Not a lot of joy there. And it is a characteristic of the Pharisees. Would you not expect them to be pleased, for example, about the story of Zacchaeus, the reformed tax-collector? How about when they saw Lazarus raised from the dead? Or Blind Bartimaeus able to see again?

Supposing Joni Earickson suddenly got up from her wheelchair; would you rejoice? Or would you think it was a trick? When Jonathan Aitken was converted in prison did you suspect he was just trying to curry favor? To re-establish himself as a politician who was accepted in polite society. Did you feel the same about Chuck Colsen, the notorious Watergate plotter?

Have you met joyless Christians; people who are always picking holes in somebody else’s sweater? Oh, they are there. They don’t like the new hymn book. They don’t like the PowerPoint projector. The communion wine should be alcoholic/non-alcoholic (take your choice). They don’t like small groups. They find large meetings too impersonal. Church doesn’t do anything for me.
No wonder they are joyless. Without a Savior they never know whether the good they have done is enough. Is it enough to have double glazing? Should I perhaps get triple glazing? Should I set the house temperature at 68 rather than 70?

The prodigal son was humbled. He fell from a great height. One moment he was surrounded by rich friends, moving in the highest society. In today’s terms he would be lunching at the Savoy with merchant bankers, think it hilarious to send back a £500 bottle of wine because it was ‘corked’; then leave a £1000 tip. In the evening a little dinner party with Jude Law and a bevy of blondes and after the meal, a snort of cocaine. He would be pictured in ‘Hello’ in his Armani suit and Paul Smith shirt.

Just a blink later and he is wallowing with the pigs, his money gone, and he squabbles with the hogs to eat their food. Not difficult for him to be realistic about his situation. Humility comes easy to a man who has been brought down low.

Not so his brother. When you think you’re doing well, when you have a religious ritual to go by, when you’re good, it’s hard to see you need a savior. Did you see David Beckham in the England match on Wednesday? He’s done well to come back to international football hasn’t he? Except that he harassed the referee over what he thought was a wrong decision and got himself a yellow card. When you are convinced you are in the right humility is a hard currency to deal in. Pride keeps us from the kingdom.

Are they irredeemable, these joyless Christians? Listen to what the Apostle Paul says of himself. “If anyone else thinks he has reasons to put confidence in the flesh, I have more: circumcised on the eighth day, of the people of Israel, of the tribe of Benjamin, a Hebrew of Hebrews; in regard to the law, a Pharisee; as for zeal, persecuting the church; as for legalistic righteousness, faultless.”

Elsewhere, he describes himself as the ‘chief of sinners’.

Only the Holy Spirit could change Paul, but the Holy Spirit did just that.

As I examine my heart, I invite you to do the same. Am I an older brother? Do I lack joy? Do I lack humility? If any of these accusations stick then turn to the Savior now. Pray that the Holy Spirit will give you the joy of your salvation. For he is not only able to do so, he is more than willing.

NICE picture

This morning in the post I received this remarkable picture. "What's remarkable about it?" you may ask, "Just an old couple cutting a cake." Edith and John are celebrating their Diamond Wedding anniversary.

Eighteen years ago John had been given just a few weeks to live. He had been diagnosed with kidney cancer which was regarded as inoperable. His lungs were almost totally replaced by secondary cancer and he had very large lymph nodes in his abdomen. There was no effective chemotherapy for kidney cancer, and in fact the recommended treatment was the female sex hormone, progesterone. This did no good, but it was pretty harmless.

About that time there had been a television program about a new type of agent called interleukin-2 (IL-2). It was a terrible treatment. Patients suffered terrific shivering attacks, their blood pressures dropped, they went into kidney failure, some died of heart failure, some developed horrific rashes, but some got better.

John came to see me. I wasn't sure who mentioned IL-2 first, it may well have been him. Ar first I dismissed it out of hand. It was not a licensed product. It was impossibly expensive (£9000 then seemed an awful lot of money when you find it difficult to get the NHS to pay an extra £300 for mitoxantrone).

John offered to raise the £9000 but even then there was a rule that if you paid for your drugs privately your whole treatment had to be private. Had we gone down that route we would have been talking about £25,000+.

Instead I suggested that John make a contribution to our research fund so that we could start a clinical trial of interleukin-2 in kidney cancer. I wrote a protocol and got ethical approval even though I knew that without funding I would only be able to treat one patient.

We weren't really sure what to expect, but my team were up for it and we gave John the drug. The toxicity was bad, though not as bad as it had appeared on television. All the secondaries disappeared and the cancerous kidney shrunk to such a size that it could be removed.

When we took this result to the company that made it, they funded me to treat another 24 kidney cancer patients, 25 melanomas and 10 colon cancer patients. We had one other kidney cancer complete remission, and she also is still alive, and 5 complete remissions in melanoma patients, but they all relapsed within a year. One of the colon cancer patients had a partial remission.

Several points to learn from this. The median is not the message, as Stephen J Gould said. Despite a poor median survival, some patients do very well on strange treatments that have no apparent survival benefit. Patient drive and determination is sometimes the most important factor. The looser arrangements for clinical trials that used to obtain had their good points as well as their bad ones.

In 1991 I was at the peak of my powers. Everything I touched turned to gold. My confidence was high and I felt I had magic in my fingers. What a dangerous state for any man to aspire to! If I felt like that now I would seek absolution.

What is a CR?

I spent yesterday wrestling with the CLL Guidelines - both the 1996 and the 2008 versions - trying to evaluate a clinical trial results as part of a Review Panel. It used to be quite easy, though pretty meaningless. To say you had a complete remission (CR) in CLL you had to have disappearance of all disease that could be detected by physical examination, and restoration of the blood count to reasonable levels - neutrophils > 1500/cu mm, lymphocytes <4000/cu mm, platelets >100,000/cu mm and Hb >11 g/dL. This had to last for two months, and at the end of those two months a bone marrow biopsy had to contain fewer than 30% lymphocytes and to be of reasonably normal cellularity.

Of course, the 1996 guidelines were written before imaging became a routine practice, so hepatomegaly meant that you could feel the liver below the edge of the ribs and splenomegaly meant that you could feel the spleen below the edge of the ribs.

If the patient did not fulfill the criteria for a CR the next test was to see if the conditions for a partial remission (PR) were met. These required a >50% decrease in the lymphocyte count, a >50% reduction in the size of the lymph nodes and a >50% reduction in hepatosplenomegaly plus the restoration of (or considerable improvement in) one of the elements of the blood count (ie platelets over 100,000/cu mm, Hb over 11 g/dL and neutrophils over 1500, or if these are not achieved a >50% increase over the baseline levels).

Patients who fail treatment might have progressive disease (PD) which was defined as a >50% increase in the sum of the products of at least two lymph nodes on two consecutive determinations at least 2 weeks apart (at least one node must be > than 2cm) or the appearance of new nodes that could be felt. Or a >50% increase in the size of the liver or spleen below the ribs or the appearance of one of these which was not previously present, or a >50% in the absolute number of circulating lymphocytes (as long as the number is greater than 5000/cu mm.

(It should be noted that all the >50% signs in this essay mean greater or equal to 50%; I don’t know how to make the sign for greater or equal to.)

Those who don’t improve enough to be called a PR or who don’t deteriorate enough to be called PD were designated as having stable disease (SD).

Although this system was fairly easy to operate it was a bit of a joke. This wasn’t a CR like the CRs of acute leukemia where getting a CR is a prelude to a cure. Everybody knew that obtaining a CR in CLL (and that itself was pretty rare) didn’t mean a cure. It was possible that 30% of the cells in the bone marrow were still leukemia cells. And since lymph nodes in the belly couldn’t be felt there could be a couple of kilograms of cancer there undetected. In fat people it’s almost impossible to feel lymph nodes in the armpits and in very thin people you can often feel very small lymph nodes, which may be enlarged because of infection rather than CLL. A spleen has to enlarge threefold to be felt below the ribs, and measuring the liver by physical examination is fraught with difficulties; for example, if the lungs are over expanded, as in emphysema, a normal sized liver can be felt below the ribs.

The new guidelines were prompted by a number of things. It had long been recognized that some patients apparently achieved CR, but their marrow biopsies, while mainly being free of CLL, contained lymphoid nodules. Were these lymphoid nodules foci of CLL or just reactive nodules of normal tissue? They clearly needed to be studied separately and so such patients were designated nPR. We do know that such patients have a shorter time to progression than those with CR. Then there were some patients who seemed to be in CR but their blood counts did not return to normal. It seemed that their bone marrow had been damaged by the CLL. Of course, it could have been the case that residual CLL was suppressing their bone marrow and preventing normalization. The 1996 guidelines regarded this as a controversial issue, but decided that they should be called PR – except that if Hb was still <11 g/dL, neutrophils <1500/cu mm and platelets <100,000 /cu mm they had to be regarded as stable disease.

The other confusing thing about the guidelines was that despite stressing that size measurements are to be determined by physical examination, they add “and appropriate radiographic techniques” for lymph node sizing, and “or appropriate radiographic techniques if in a clinical trial” for liver and spleen measurement, as if physical examination and ‘appropriate radiological techniques’ were interchangeable. We know for certain that radiological techniques will detect disease that is undetectable to the examiner’s hand.

For evaluating clinical trials it turns out that measurements are not noted down in the notes, and investigations are forgotten. There may be ‘after’ CT scans but no ‘before’ or vice versa.

So do the new guidelines help?

Now CR needs all the following criteria as assessed at least three months after the completion of treatment:
1. No clonal lymphocytes. This is more stringent than before – all you needed then was fewer than 4000 lymphocytes.
2. No significantly enlarged lymph nodes. In clinical trials CT scanning is now positively encouraged. So we are talking about the largest diameter of lymph nodes anywhere in the body, not being greater than 1.5 cm.
3. No hepatomegaly or splenomegaly by physical examination. We have now reverted to physical examination even though a CT scan will have been done to look for enlarged lymph nodes. The guidelines advise that if liver or spleen were found to be abnormal before treatment then a scan should be performed at evaluation; this should also be done if the evaluation was inconclusive by physical examination.
4. No constitutional symptoms.
5. Neutrophils >1500 / cu mm, platelets >100,000 /. Cu mm Hb >11 g/dL (untransfused). For more than 20 years I have been protesting that to choose the same Hb level for men and women is insane.
6. If all these points have been achieved a bone marrow aspirate and trephine biopsy should be performed. The marrow should be examined by flow cytometry and immunohistochemistry to look for clonal B cells. If clonal cells are found then the case is demoted to PR. It must be stressed here that the flow cytometry is not the powerful 4-color flow used to detect MRD, but the simpler 2-color flow that detects one cell in 100.If lymphoid nodules are found in the trephine, then immunohistochemistry should distinguish between CLL and reactive nodules. The nPR category therefore disappears. If the marrow is hypercellular, then it should be repeated in 4-6 weeks, provided the blood counts have recovered. In some cases it is necessary to continue to postpone the marrow, but this time interval should not exceed 6 months.
7. The question of apparent CR with a failure to recover the bone marrow also seems to have been resolved. Those who fulfill all the criteria for a CR including the marrow examination, but who have a persistent anemia, thrombocytopenia or neutropenia unrelated to CLL but related to drug toxicity are designated CRi (‘i’ stands for incomplete marrow recovery). In view of the fact that a PR still requires recovery of at least one of the marrow lineages, I am not clear whether CRi can be applied to a patient with complete pancytopenia.

PR is similar to before – slightly confusing. There are four things that must be achieved:
1. A decrease in blood lymphocytes to fewer than 50% of the starting value.
2. A reduction in the size of the lymph nodes. This has to be assessed by CT in a clinical trial, and is defined as a decrease of 50% or more of the ‘sum products’ of up to six lymph nodes ‘Sum products’ are the figure you get when you multiply the perpendicular diameters of individual lymph nodes. It doesn’t say which six nodes, but most people would take the six biggest ones – of course if only three are enlarged you’d just do it with three. If there is just one big node then you can take a 50% reduction in its diameter. As far as lymph nodes are concerned there must be no increase in size in any of them, though in small nodes of less than 2cm diameter, an increase of less than 25% is not considered significant. There must also be no new enlarged node that wasn’t enlarged before.
3. A decrease in the size of the liver or spleen by 50% or more defined by CT in clinical trials. This is the one I take issue with. Enlarged spleens are often 18 cm long when measured by CT. A 50% reduction in size to 9cm would make it smaller than normal – up to 12 cm – and measurement of livers will have a similar drawback. We don’t want treatment that will make the liver shrink to the size of someone’s with cirrhosis. What they mean is a 50% reduction in the enlargement of either organ, but since we don’t know what the normal was for that patient, we are unable to calculate an answer. Livers and spleens vary with body size – they are certainly larger in men than women. Until this issue is resolved I recommend that any liver or spleen that can’t be felt by clinical examination should be regarded as normal.
4. One of the following should be present: neutrophils >1500 / cu mm, platelets >100,000 / cu mm, Hb >11 g/dL, or if not then at least one should show a 50% improvement over baseline.

A further proviso is that at least one of these parameters should persist for at least 2 months. It is not clear to me from the paper whether this refers to all the 4 measurements or just one of those in section 4. I’m assuming it means any of the four sections.

Systemic symptoms don’t come into it. Although CR requires these to remit, a PR does not, although they have to be noted.

PD is generally obvious from blood counts and therefore need not be looked for by CT scanning, though clearly from the instructions in the paper, it can be. So if any of the following occur PD is said to have occurred:
1. Any new lesions appearing such as an new lymph node enlarged to >1.5 cm diameter, splenomegaly, hepatomegaly or any other organ infiltration.
2. An increase by 50% or more of the greatest diameter of any previous lymph node.
3. An increase of 50% or more of the sum of the product of diameters of multiple nodes.
4. An increase in the size of liver or spleen by 50% or more or the appearance of spleens or livers that can now be felt.
5. An increase of50% or more in the absolute lymphocyte count, as long as it is greater than 5000.
6. Transformation to aggressive histology (eg Richter’s syndrome). This should be confirmed by biopsy.
7. The appearance of cytopenia unrelated to treatment or autoimmunity. This can only be assessed after treatment and so is defined as a fall in Hb by 2g/dL or to less than 10g/dL or by a decrease in platelet count by more than 50% or to below 100,000 per cu mm, that occurs at least 3 months after treatment ends and associated with an infiltrate of clonal lymphoid cells in the marrow. Note, the guidelines say nothing about late neutropenia.

SD is anything between PR and PD.

The duration of a response is measured from the end of the last treatment, but, confusingly, progression-free survival is measured from the first day of treatment.

Trials that are designed to eradicate the CLL should include testing for minimal residual disease (MRD). Either 4-color flow cytometry or allele-specific oligonucleotide PCR should be used using a threshold of one cell in 10,000. It is permissible to use blood for this assay except within 3 months of completing therapy, especially when alemtuzumab, rituximab or other antibodies have been used, in which case, bone marrow should be used.

Although the new guidelines make sense, there are still some ambiguities and in places the application of common sense runs counter to the wording of the document.

Should I have a transplant 2?

Here is the attraction of stem cell transplants: they cure people. Here is the problem with stem cell transplants in CLL: they kill people. Full blown transplants for any condition are of dubious value; they work best for people under the age of 20. Hardly anybody has CLL under the age of 20 – my youngest patient was 21. The older you get the worse the problem – the total body irradiation and the high dose chemotherapy are so toxic that even the best centers in the world struggle to keep anyone over the age of 50 alive after that insult, and even 50 is stretching it. The one disease where standard transplants were absolutely the treatment of choice was chronic myeloid leukemia (CML) – until imatinib (Glivec or Gleevec) came along. When Glivec became available for CML hardly anyone continued to transplant patients over 30, even though it seemed that 10% of patients had relapsed after Glivec after the first year. Nowadays CML doctors like to confine transplants to patients under 20.

Since half of patients with CLL are aged 70 or over when they present, you can see that there was very little call for transplants in CLL. There are some younger patients of course, but the toxicity of the treatment in these was still very great. Treatment-related-mortality (defined as deaths in the first 100 days) was 40% even in the best centers.

Then along came reduced-intensity-conditioning (RIC). The idea works like this: if you have an autograft – that is your own bone marrow stem cells are taken out and frozen down and this is followed by strong chemo- or radiotherapy, after which the stem cells are returned – you get the same dose of chemo- or radiotherapy as when you are having an allograft (where the stem cells come from somebody else. Theoretically this should be better (I certainly thought so in the 1980s) since there is no bother with the immunological consequences of someone else’s bone marrow growing inside you. However, when you look at the long term consequences, for most diseases patients having allografts survive for longer than those having autografts.

There must be something special about an allograft that an autograft hasn’t got. And what could it be except that those very immunological effects that we were worried about? These immunological effects weren’t rejection (which is the problem with kidney transplants or heart transplants), but quite the reverse. The graft tries to reject the patient! This graft-versus-host disease (GVHD) can be very unpleasant. Mild acute forms just have a bit of a rash, particularly on the palms and soles, which fades after a while, but severe forms have a rash that scales and won’t heal, diarrhea that won’t stop and severe liver damage. It also damages the immune system making rotten infections more likely. With chronic GVHD the skin becomes fixed to the underlying tissue so that its like walking around in a suit of scar tissue, with loss of hair and teeth. I’ve seen an 18-year old looking like an old man of 80. I have also had patients kill themselves because their condition was intolerable. But within the GVHD there is also a graft-versus-leukaemia (GVL) effect and it is this effect that can really cure disease that doesn’t respond to anything else.

In fact it’s not the chemotherapy that cures you with an allograft, but the GVL effect. So why have the chemotherapy? Rainer Storb at the Hutch in Seattle was the person who realized this and put it into practice. Using immunosuppressive drugs rather than marrow ablative drugs an allograft can successfully be transplanted, and because the damaging chemo- or radiotherapy is not used you can give it to older patients. But you still have the GVHD problem to contend with. Usually this is done with immunosuppressive drugs after the transplant like ciclosporin and methotrexate, but one thing that has been tried for a long time is T depletion. This simply means removing the T cells from the graft. It is a very effective way of getting rid of GVHD, though if too many are removed the patient rejects the graft. The problem is that getting rid of GVHD often means getting rid of GVL, so although such grafts are safer, they are usually less effective and patients start relapsing. Theoretically, Campath ought to be a more efficient way of T-depleting because not only does it get rid of the T cells, it is also an anti-CLL drug and will get rid of any residual disease. As we saw yesterday, Campath does exactly this. Much less GVHD, but more relapses than not using it. Nonetheless, still pretty good long term survivals.

As it happens, another paper was published in the Journal of Clinical Oncology in October last year from Seattle. 82 patients aged between 42 and 72 who had CLL no longer responding to fludarabine were treated with a RIC allograft between 1997 and 2006. The conditioning regime was low dose total body irradiation (200 centiGray) with or without fludarabine. 78 patients still had measurable disease when transplanted; only four has no detectable disease. So what happened to them? Let’s take the four already in remission: one died of relapsed leukemia, two died of treatment complications while in complete remission and on remains in complete remission. But no-one should read into this that if you are in CR and have a RIC transplant you have a 75% chance of dying. The numbers are just too small to know. The next 50 patients might all survive.

What about the other 78? 55% got a complete remission and 15% a partial remission. Remember these were patients who did not respond to fludarabine, so getting any sort of remission is remarkable. There is a sort of randomization going on here, between those who have a matched sibling donor and those who don’t. Interestingly, the chance of getting a complete remission was significantly greater in those who didn’t. This suggests that a matched unrelated transplant has greater immunological power at killing the CLL than a sibling transplant.

Of the 41 patients who achieved a complete remission, 30 are still alive in CR, 8 died of the complications of the transplant and 3 relapsed (one of these still alive the other two now dead). Of the 13 who achieved PR, 4 are still alive and in PR, 3 died of the complications of the transplant and six developed progressive disease (4 of these dead, 2 still alive in PR after treatment with Campath or Rituximab). In addition there were four who died of transplant complications before their response could be assessed, three who had stable disease, two of whom died of transplant complications and one who remains alive with stable disease. 17 patients had disease progression despite the transplant; 14 of these have died of progressive disease and three are alive after antibody treatment.

To summarize all this: 23% died of the complications of transplant, 38% progressed, and the actuarial survival at 5 years was 50%, while progression-free survival was 39%.

There were no significant differences for any of these 4 measurements between those who had a sibling and those who had a matched unrelated transplant, nor between those who had their transplants at Seattle compared to those who had theirs with the same protocol at a sister organization. However, the numbers are relatively small and ‘no significant difference’ doesn’t mean ‘no difference’; it just means there were not enough numbers to demonstrate a difference. In any case even if there were differences, unless the trial was designed to look for differences, any that were found would be examples of data dredging. Data dredgers always find differences one in 20 dredges because ‘significance’ is defined as p<0/05.

Grade 3 and 4 GVHD was found in 16% of those having a sibling transplant and 23% of those with matched unrelated transplants. However, bad chronic GVHD was worse, occurring in 49% of related and 53% of unrelated transplants. The transplant-related causes of death were as follows: acute GVHD 5, chronic GVHD 6, bleeding from the lungs 1, stroke 1, cardiac arrest 2, lung cancer 1, sepsis 2, multi-organ failure after cardiac surgery 1.

A lot of factors did not affect the outcome including age, donor type, CD34+ cell dose, CD3+ cell dose, CD38 positivity, cytogenetics, splenomegaly, or time between diagnosis and transplant. The following did influence outcome: lymph nodes more than 5 cm in diameter and co-morbidities. In a univariate analysis heavier marrow infiltration, higher beta-2 microglobulin levels and higher white counts added to the prognosis but these were subsidiary to the large lymph nodes in a multivariate analysis.

What we learn from today’s posting is that RIC transplants extend the age range where transplants become a possibility, and the toxicity of the chemo-radiotherapy is removed, but people still die and/or suffer from having a transplant. The major reason for this is GVHD.

What we learned from yesterday’s posting is that we can reduce GVHD by removing the T cells with Campath. But when we reduce the graft versus host disease we also reduce the effectiveness of the transplant.

As I said at the beginning; the attraction of a transplant is that it cures. The problem with a transplant is that it kills.

Should I go for a transplant?

Should I go for a transplant or not? This is often a difficult question for patients with CLL. Until recently the answer was, “Not if you can avoid it,” but since the introduction of reduced intensity conditioning regimens, toxicity has been reduced and the age range for which allografting is contemplated has increased. The question has to be asked anew, and to help us with that a series of 62 patients with CLL has recently been published by a consortium of doctors from Britain and Spain.

This is not a clinical trial. Although there were two cohorts of patients, there was no randomization. It was a retrospective look-back at experience between 1999 and 2007. Four institutions were involved, and patients who were eligible were generally young, with disease refractory to chemotherapy or in early relapse, and/or had poor risk cytogenetics. All the patients had reduced intensity conditioning with fludarabine and melphalan. The results were analyzed according to whether the patient had had alemtuzumab (Campath) for prevention of graft-versus-host disease (GVHD). Unfortunately, the categories were not clean cut, which probably explains why the paper has been published in a relatively obscure journal (Biol Blood Bone Marrow Transplant 2008; 14:1288-97). In the first cohort, 40 patients received ciclosporin and alemtuzumab to prevent GVHD. The dose of alemtuzumab was 100mg given over 5 days from day -8 to -4; but 8 patients received only 60mg, 3 received 40mg, 2 got 30mg and 5 had 20mg. In the second cohort, patients with a sibling donor with a complete tissue match were given methotrexate as well as ciclosporin while those with matched unrelated donors received mycofenolate mofetil (MMF) with their ciclosporin. In addition, two patients with 1 locus mismatched unrelated donors also received anti-thymocyte globulin.

The characteristics of the two cohorts were not significantly different, though with numbers this small that statement may be meaningless. The median age at transplant was 53 (range 34-64) and 73% were male. Transplantation took place at a median of 55 months after diagnosis (range 5-132 months).

Since this was not a randomized trial, differences in outcome between the two cohorts, or indeed similarities could be due to a whole host of different causes other than the treatment protocol. The comparisons therefore cannot be used for anything other than hypothesis generating. Bearing that in mind, how did the two cohorts compare? There was no significant difference between them in terms of overall survival. For both cohorts there seems to be a plateau at 60% alive extending out from 3 years to nine years when nobody died. But the numbers are so small that this cannot be said to be predictive of what would happen to you.

In terms of progression-free survival there is again no significant difference between the cohorts, but whereas the non-Campath cohort seems to have a plateau at 50% non-progressive after 3 years, the Campath group continues to relapse. Again, because the numbers are so small this is not a statistically significant difference, but it is what you might expect – if you wipe out more of the T cells, you are more likely to relapse.

Another consequence of wiping out all the T cells might be failure to engraft. The incidence of mixed donor chimerism (this means that you have a mixture of the donor cells and the patient’s own cells) at 6 months was significantly greater in the Campath cohort (43% v 11%; p=0.03), however, most of these attained full engraftment following donor lymphocyte infusion (DLI) and the incidence of secondary graft failure was the same in both cohorts (12% v 9%).

Acute graft versus host disease was not significantly different in either cohort (37% v 57%; p=0.18) though this could be a type II error where you don’t have enough patients to detect a difference. Similarly with severe acute GVHD, 20% is not significantly different from 38% with such low numbers (p=0.14), though GVHD that didn’t respond to treatment with steroids was significantly more common in the non-Campath cohort (10% v 33%; p=0.03). Chronic GVHD was greater in the non-Campath cohort 68% v 29%; p=0.016) and extensive chronic GVHD needing systemic rather than local therapy was also greater (48% v 10%; p=0.03). Mortality from GVHD was also greater in the non-Campath cohort (33% v 10%; p=0.034)

Severe infections were common in both cohorts (73% v 67%; not significant) and 18% died of infection which was often related to GVHD. There was no difference between the two cohorts. As might be suspected there were a lot of viral infections in patients who received Campath – herpes simplex in 7, EBV in 6, adenovirus in 5, RSV in 4, influenza in 3, zoster in 2, and metapneumovirus and parainfluenza each in one. CMV reactivation occurred in 66%, neither for viral infection nor CMV reactivation did the excess in the first cohort reach statistical significance. Again, this is probably because the numbers were so small. Fungal and bacterial infections were equally distributed between the cohorts.

To summarize, reduced intensity conditioning has extended allografting into the CLL community by raising the age of eligible patients. It becomes an immunologic treatment where the graft attacks both the CLL and the patient. Reducing the number of T cells in the graft diminishes both attacks. GVHD is a dangerous thing to have: it can kill you directly, it can make infection more likely and it can make life not worth living. Getting rid of T cells (which is what Campath does) reduces the amount of GVHD but also reduces the attack on the CLL. So if you use Campath you have less GVHD but also you are more likely to have residual leukemia. Less T cells also means less able to fight virus infections, and although some of these can be withstood by other means (ganciclovir for CMV, rituximab for EBV) others can’t be resisted.

So it’s swings and roundabouts; you gain on one and lose on the other. This study identifies the problems, but because it is not a randomized prospective trial it can’t weigh up the relative risks.

The Placebo Effect

Penicillin was a wonderful discovery. Before that doctors had very few medicines that worked - morphine, aspirin, digoxin, ether, chloroform, atropine, adrenaline, cocaine, and very few others. Penicillin opened the door to a huge pharmaceutical revolution that continues to this day. Despite this, there have been doctors around for thousands of years. Whatever did they do?

Their practice was very similar to that of the purveyors of alternative medicine today. First, they had a uniform. It differed from age to age, but when I was young it included a frock coat, top hat and arrogant affect. Later doctors had white coats and other paraphernalia. Nowadays it is likely to be surgical scrubs.

Second, they had equipment. To be honest it is very hard to distinguish the various noises heard down a stethoscope - chest physicians always believe the X-ray rather than their 'tubes' and cardiologists want an ECHO whatever their stethoscope tells them. Anyone other than an ophthalmologist looking with an ophthalmoscope is probably making it up, and ophthalmologists prefer to use a slit lamp.

Third, they had a ritual. Part of this is the medical examination. We hospital doctors are apt to scoff at general practitioners who don't examine their patients, and certainly the physical is good for some things. I once was referred a case of anemia to investigate by a consultant surgeon. Imagine his embarrassment when I stuck a finger in the rectum and detected a stonking great, bleeding carcinoma. Most complicated is the neurological examination with its reflexes and finger-nose pointing. But whenever a neurologist came to see one of my patients the first thing he would do was ask for an MRI scan, no matter what we had found on examination.

The physical examination is of absolutely no use when performed by a junior doctor. They do not have sufficient gravitas. The examination should be undertaken with a serious face at a deliberate pace, with pauses for reflection and many a "Hmm" interspacing the touching. "Say '99'" is a wonderful device; it shuts the patient up and adds a sense of mystery. It is very important that the patient completely disrobes. Stethoscopes poked through a gap in the clothing do not have the same therapeutic effect.

Ritual is very important. The consultation should always begin with the doctor rising to greet the patient. Hand shaking is very effective even if it does spread germs. Eye contact is good. Taking the history well is more important than anything and it is vital to let the patient tell his or her story in his or her own words. Leading the witness misleads the physician. It is important to get the story right, but of even more meaningful is the process of instilling in the patient the feeling that he or she is of value and worth listening to. Without the enormous modern medical bureaucracy the doctor of old had time to listen and put the patient at ease.

Never let anyone tell you that alternative practitioners have nothing to offer. Of course their oils and needles have no therapeutic effect, vast doses of vitamins and strange diets are completely useless. Enemas are good for constipation and colonic washouts are useful as preparation for colonoscopy, but they incorporate no magic cures. A recent study demonstrated that acupuncture needles stuck in the wrong places were as effective as needles stuck in the proper meridians - but they were effective. Just as doctors in the 1930s were effective. They all make use of the placebo effect.

'Placebo' is Latin for 'I please'. The placebo effect is what happens when a doctor goes through all the ritual of diagnosing and treating a patient and prescribes colored water. Although this sounds like deceit and fraud, the fact is that a proportion of patients will get better from whatever they are suffering. Ye, whatever they are suffering from. You might well expect a response from patients with chronic fatigue or headaches or backache, but placebos can heal up ulcers, abolish angina and even produce remissions in cancer.

Studies have been done on the placebo. Two pills are better than one. Injections are better than pills. Green pills are better than red ones, unless you are looking for a stimulant effect when red or orange ones are best. It is even possible to cure nausea by instilling a drug designed to make you vomit, directly into the stomach if you are able to convince the patient that what you are giving is an anti-emetic rather than an emetic.

You may believe that you are immune to the placebo effect, but if you are then why do you buy branded painkillers rather than straight ibuprofen. I know they work better but why? Because of the placebo effect. And they cost more. That's part of the placebo effect; expensive placebos work better than cheap ones.

Back in 1972, that sensible physician Richard Asher (yes, he was Jane's father) wrote, "If you can believe fervently in your treatment, even though controlled tests show that it is quite useless, then your results are much better, your patients are much better, and your income is much better too. I believe this accounts for the remarkable success of some of the less gifted, but more credulous members of our profession, and also for the violent dislike of statistics and controlled tests which fashionable and successful doctors are accustomed to display."

The problem with placebos is that they involve lying to patients. Placebos don't work if you say to a patient, "I'm giving you a sugar pill. There is absolutely no reason why it should make you better except for the 'placebo effect' which no-one understands but it probably acts psychologically." Or do they? A trial of sugar pills for pain that had been diagnosed as 'neurotic' was carried out at Johns Hopkins Hospital, with just such an explanation. The patients improved considerably.

Never apologise, never explain, goes the old adage. But we can't get away with that these days. We are obliged to tell patients the truth and to explain fully what we are about to do. The Philosopher and doctor Raymond Tallis has written, "The drive to keep patients fully informed has led to exponential increases in the formal requirements for consent that only serve to confuse and frighten patients while delaying their access to needed medical attention."

Alternative practitioners are not burdened by the same restrictions. They can look into your eyes and give you an explanation that sounds sciencey, but is in fact gobbledygook. Watch the TV for adverts for anti-aging creams to see what I mean by sciencey.

Actually, I think it is possible to invoke the placebo effect without telling lies and good doctors do it all the time. After I retired I handed on my patients to other physicians. I was surprised at how many of them promptly died. There was no change in treatment, only a change of treater. One patients illustrates the case starkly. She had cancer of the body of the uterus. She had refused surgery, chemotherapy and radiotherapy and all I did was see her, take a blood test and talk to her. I was astonished that her cancer did not progress. It remained static for three years. Then I retired and six months later she died. Somehow she had fixed on me as a walking placebo.

It should be possible to say to a patient without too much mendacity, "We have exhausted the latest treatment - we must now start thinking for ourselves. This is a concoction that I have tried before in cases like yours and it sometimes works. I don't know how it works - I could make up a scientific sounding explanation if you like - but I won't insult your intelligence. It is important though that you take it in the way that it is prescribed. You must take it on an empty stomach (and here you can invoke any ritual you think they will wear - standing on one leg, facing Mecca, drinking out of the back of the cup or prunes for breakfast) and I will see you every week if you can afford it. Unfortunately, it's not cheap, but if it works it will certainly be worth it."

Some of these people could sell snow to the Eskimos.

More on global warming

Last week a report in Nature sought to undermine the case of the global-warming-deniers. Although there are certainly observations that suggest that, especially during the nineties the world was mostly warming up, the exception has always been Antarctica. The BBC continues to broadcast archive footage of great sheets of ice falling from Antarctica into the sea, without emphasizing that this is a particular area of the Peninsular that reaches up towards South America near to which volcanic activity is taking place undersea. It is a case of a picture being more powerful than 1000 words. In fact The vast mass of Antarctica, all satellite evidence has shown, has been getting colder over the past 30 years. Last year's sea-ice cover was 30 per cent above average.

The new paper from Eric Steig 'demonstrates' that Western Antarctica has also been warming up. At the moment I am reading a book by Ben Goldacre called 'Bad Science' in which the junior doctor and Guardian columnist takes apart the quack nutritionists and other perpetrators of media fraud, so I have my nonsense antennae primed. My suspicions are further raised when I see that one of Steig's co-workers is Michael Mann inventor of the notorious 'hockey stick' graph that has been so disparaged. So we need to examine the data.

It turns out that the data were produced by a computer model based on combining the satellite evidence since 1979 with temperature readings from surface weather stations. The problem is that there are very few surface weather stations, and those that there are are predominately on the warmer peninsular. Even arch-warmist Dr Kevin Trenberth expressed some surprise. He wryly observed "it is hard to make data where none exists". But perhaps the most telling comment comes in a letter sent to Steig by Ross Hays, an atmospheric scientist who has often visited the Antarctic for NASA.

Eric,

Let me first say that this is my own opinion and does not represent the agency I work for. I feel your study is absolutely wrong.

There are very few stations in Antarctica to begin with and only a hand full with 50 years of data. Satellite data is just approaching thirty years of available information. In my experience as a day to day forecaster that has to travel and do field work in Antarctica the summer seasons have been getting colder. In the late 1980s helicopters were used to take our personnel to Williams Field from McMurdo Station due to the annual receding of the Ross Ice Shelf, but in the past few years the thaw has been limited and vehicles can continue to make the transition and drive on the ice. One climate note to pass along is December 2006 was the coldest December ever for McMurdo Station. In a synoptic perspective the cooler sea surface temperatures have kept the maritime storms farther offshore in the summer season and the colder more dense air has rolled from the South Pole to the ice shelf.

There was a paper presented at the AMS Conference in New Orleans last year noting over 70% of the continent was cooling due to the ozone hole. We launch balloons into the stratosphere and the anticyclone that develops over the South Pole has been displaced and slow to establish itself over the past five seasons. The pattern in the troposphere has reflected this trend with more maritime (warmer) air around the Antarctic Peninsula which is also where most of the automated weather stations are located for West Antarctica which will give you the average warmer readings and skew the data for all of West Antarctica.

With statistics you can make numbers go to almost any conclusion you want. It saddens me to see members of the scientific community do this for media coverage.

Sincerely,

Ross Hays

The link is to an anti-global warming site so it has to be handled with care, but as someone with no expertise in climate science, but with a healthy scepticism about scientists, I conclude that the anthropogenic global warming case is not proven

Mode of Baptism

As a Baptist I believe that baptism is for believers. In the Bible it comes after repentance ('Repent and be baptized, everyone of you'), and since infants can't repent, I think that paedo-baptism is a mistake. I was baptized as an infant, I am told, but I can't remember anything about it.

There are some who believe that a child becomes 'born again' through baptism. "This child is now regenerate" goes one form of words. But I cannot see how this could be so. Many who are baptized with such a ritual never give evidence of being regenerate. A whole tribe of Mafiosa has been 'done' in such away, yet turned out to be a murderous group of extortioners and crooks.

Similarly, such people have undertaken confirmation as if it, like baptism, were a ritual designed to get them to heaven rather than a life changing experience. So my first point is there is nothing magical about either ceremony. The water isn't holy; saying words over it doesn't impart a special purifying quality, even if it is done by someone who has hands laid upon him by someone who has hands laid upon him by someone ... who has had hands laid upon him by the Apostle Peter.

There used to be a tradition in neonatal units for the (usually Irish) midwife to rush off and sprinkle any newborn who looked a bit frail so that the child would not die unbaptized. Let me say that this is a cruel superstition. What does it say about the child who doesn't make it to the sink? How must such parents feel?

Some Christians of the Reformed tradition see infant baptism as a continuation of the Covenantal relationship of people within the family of God - as a replacement of the ritual of circumcision. Now, it is certainly good for children to be brought up within God's Family but nowhere in Scripture do I find circumcision being replaced by baptism. Moreover circumcision (at least in the Jewish tradition) is only for males on the eighth day of life). Both males and females are baptized and hardly ever on the eighth day.

I think it is increasingly accepted in evangelical circles that baptism is for believers. Many converts within the Church of England are now baptized as believers. This blog is not meant to be an exhaustive investigation into the Biblical basis of baptism but rather to talk about the mode of baptism.

Within the Greek Orthodox Church, while they practise infant baptism, they dunk the baby in whole, right up to his noggin. The English translators of the Bible when they came across the word for 'baptize' in the Greek original, instead of translating it, they simply transliterated it - Anglicizing the same word. Of course, this is not an option for the Greeks, as they know what the word means. It is a technical term from the dyeing industry. It means to dunk or dip in the dye so the piece of cloth is completely covered. Hence the ceremony in the Greek Orthodox Church. They would have no truck with simply sprinkling a few drops on the person's forehead. Again, whether 'dip' means 'totally immerse' is another matter, though to dye a piece of cloth leaving a small part of the cloth like the heel of Achilles out of the liquid would seem to defeat the purpose.

Evangelicals see the process of baptism as a symbol. Symbols have a power beyond an intellectual exercise. That is why the Old Testament Prophets often acted out their message. Think of Jeremiah or Ezekiel. When you take your driving test your examiner expects you to turn your head to use your mirrors and to check no one is coming from right or left. It is not good enough to protest that you made the requisite eye movements. He doesn't do this to deliberately fail you - he is looking to see if you have absorbed the ritual; do you have the body memory of safety? When I was batting at cricket I used to have a ritual after every ball of walking around the stumps. It looked like superstition, but it wasn't; it was a ritual to get me in the right position to face the next ball. It gave me a body memory of how I should settle. Baptism is a major body memory in every Baptist that reminds us that we have committed our lives to the Lord - and the symbolism has a meaning that rubs in our commitment.

So what is the symbolism? First, it is a good wash. We are acting out the fact that our sins have been washed away. We start with a clean slate; we have been washed in the waters of baptism. I think this must have been the meaning of the baptism of John the Baptist, which, of course, was how Jesus was baptized, even though we know that John thought it unseemly that he should baptize Jesus. Jesus himself needed no washing, so why was he baptized? Some have seen it as his priestly anointing.

A good example of washing as the meaning of the symbol comes from the baptism of Saul of Tarsus himself; the words of Ananias to Saul were (Acts 22.16): "Get up, be baptised and wash your sins way."

But many Baptists see another symbol. It comes from Romans 6:3-4: 'Don't you know that all of us who were baptized into Christ Jesus were baptized into his death? We were therefore buried with him through baptism into death in order that, just as Christ was raised from the dead through the glory of the Father, we too may live a new life.' It is reinforced by Colossians 2:12: 'having been buried with him in baptism and raised with him through your faith in the power of God, who raised him from the dead.' They see it as a symbol of our old life entering the grave and our new life rising from it. This could not have been the symbolism of John the Baptist, because at that time Christ had not risen from the dead.

To accept this symbolism is not straightforward, and many evangelicals see problems. Just put 'mode of baptism' into any search engine and you will come up with a myriad of opposing views. One of the most serious problems is that Jesus did not in fact go down into a grave, but his dead body was put into a tomb (probably horizontally). Our own methods of burial, which are quite different to those of First Century Palestine add to our appreciation of this symbolism, but what Paul was talking about was a spiritual union with Christ to defend against the heresy of antinomianism.

Of course, some evangelicals have abandoned all this symbolism completely. The Salvation Army, for example, has neither baptism nor Holy Communion but has adopted an entirely different symbolism that was potent for people living in the Nineteenth and early Twentieth Centuries, but is probably very dated today.

I really don't think that this is a reason for Christians to fall out and I worry when individual churches make mode of baptism a rule for church membership or holding office. There are some with physical handicaps who could not undergo baptism by immersion, for example. Should their baptism by effusion be a reason for denying them office in a church?

Jesus submitted to the baptism of John, even though it was unnecessary for him. This should be our pattern. Should we be required to be baptized in a certain way to join a church or to hold office, we should humble ourselves and obey. There should be no question of someone saying, "I have already been baptized and I don't need to do it again." That displays an arrogance that is not appropriate in a follower of Christ. Remember the Apostle Paul said, "Everything is permissible—but not everything is beneficial. Everything is permissible—but not everything is constructive. Nobody should seek his own good, but the good of others."

The DVD race

Now up to 628 films. A slight change in the running order for Directors, Steven Spielberg is now on his own at number 5 with 7 films - I just found a copy of A.I. in the garage. John Ford now has 5 and Michael Apted enters with 4. (Nell, Amazing Grace, Coalminer's Daughter and Enigma). For Male Actors Bogie is still in the lead, now with 18, Clive Owen moves into 4th place with 11, and Daniel Day-Lewis and Robert De Niro come in with 7. For Female Actors Angelina Jolie comes in in second place with 7 and Scarlet Johansson enters with 5 (Match Point, Girl with a Pearl Earring, A Good Woman [a new version of Lady Windemere's Fan], Lost in Translation, and The Horse Whisperer). I still have another cupboard full of films to add.

Look out for Al Pacino, Jack Nicholson, Judi Dench, Jake Gyllenhaal, and Kevin Spacey who are all close behind.

The Resurrection

For some time I have been taking the Sunday morning sermon from Lansdowne Baptist Church and on Sunday afternoons I meditate upon it. What comes out of that appears on my blog. A few of weeks ago we started a new series in 1 Peter. Christ Kelly preached a sermon on 1 Peter 1:3-5 and I started to think about it. You can find what I wrote here. As you can see I got stuck on the phrase "A living hope through the resurrection" which had been only mentioned in passing in the sermon. However, this turned out to be such an important topic that Chris has gone back and preached two sermons on the Resurrection. Rather than meditate on them, I will just give you the link. Here you will see what a real preacher makes of a phrase.

Favorite Film Stars

It can be measured by how many of their films I have on DVD.
1. Humphrey Bogart 16
2. Anthony Hopkins 14
3. Cary Grant 13
4=. Clint Eastwood 8
Clive Owen 8
6=. Michael Caine 7
Tom Cruise 7
Alan Rickman 7

As far as women go:
1. Cate Blanchett 8
2.= Nicole Kidman 7
Diane Keaton 7
4.= Bette Davis 6
Helen Mirren 6
Kate Winslett 6
7.= Helena Bonham-Carter 5
Jodie Foster 5
Julia Roberts 5
Ingrid Bergman 5
Susan Sarandon 5

Of course, it is not a fair comparison since there are still some films I want to own and haven't got around to buying yet and there are some series like the BBC Shakespeare where there are so many actors that my database doesn't mention them all. Nevertheless, the only surprises for me are how high Julia Roberts and Tom Cruise feature. I would have put Al Pacino higher than Cruise and Sissy Spacek higher than Roberts.

Movies on DVD

I have been cataloguing my movie collection. My most popular director is Alfred Hitchcock with 17 movies, followed by Peter Weir with 9, Clint Eastwood and Ingmar Bergman with 8 each, The Coen Brothers, James Ivory, Martin Scorsese and Steven Spielberg each have 6, Billy Wilder, Francis Ford Coppola, John Huston, Mike Leigh, Stephen Frears, William Wyler, Stephen Poliakoff, and David Lean have 5 and John Ford, Steven Soderbergh, Woody Allen, Peter Jackson, Leo McCarey, Howard Hawks and Christopher Nolan have 4 each. Anyone else has three or fewer. The total number is 579, but I still have a couple of dozen still to catalogue.