Sunday, August 30, 2009

All we need is love I Peter 1:22-25

That “God is love” is undoubtedly a Biblical truth, but the Beatles' "All we need is love" goes too far. I remember many years ago when broadcasting became local, I invited the chairman of the nascent local radio station to give a talk one lunchtime to a bunch of doctors. I asked him if they intended to have any religious broadcasting and he told me that his all-sufficient phrase for all religions was "God is Love".

Our passage in 1 Peter certainly affirms the importance of love, but Peter first stresses the need for hope and then for holiness before he gets round to love. But he does indeed get round to love:

"Now that you have purified yourselves by obeying the truth so that you have sincere love for your brothers, love one another deeply, from the heart. For you have been born again, not of perishable seed, but of imperishable, through the living and enduring word of God. For,
"All men are like grass and all their glory is like the flowers of the field; the grass withers and the flowers fall, but the word of the Lord stands forever.

Theologians have distinguished between different types of love. There's eros ie sexual love, phileo or brotherly love and agape, self sacrificing love. But it isn't exactly true. In the Septuagint agape is used to describe rape - not exactly self-sacrificing. In the Bible, there is only one sort of love. This is how we know what love is: Jesus Christ laid down his life for us. And we ought to lay down our lives for our brothers. This is love: not that we loved God, but that he loved us and sent his Son as an atoning sacrifice for our sins.

All other types of love are versions of this love. Do we love our wives or husbands? Are we willing to lay down our lives for him/her? Do we love our children? Would we sacrifice ourselves for them? Do we love our brothers in Christ? Would we lay down our lives for them? Do we love our enemies?

We do love and we do so because we have been saved. It is a consequence of our salvation. "Now that you have purified yourselves by obeying the truth so that you have sincere love for your brothers".

Hold on a minute. Purified yourself? Obeying the truth? Sounds an awful lot like salvation by works. Here is a lesson in not taking a text out of context. The translators of the KJV recognized the danger and translated v22 thus: "Seeing ye have purified your souls in obeying the truth through the Spirit unto unfeigned love of the brethren, see that ye love one another with a pure heart fervently" To ensure that this was not of our doing they have inserted "through the Spirit" though the Spirit is not present in the Greek which in a literal translation says "The souls of you having purified by obedience to the truth to brotherly love unfeigned from the heart one another love ye earnestly". You see why Bible translation is a skilled job.

However, the rest of the chapter makes it clear that we can claim no credit for our salvation. He has given us new birth v3: You were redeemed ... with the precious blood of Christ; v 18-19: Through Him you believe in God v 21. And so it is throughout the New Testament: For it is by grace you have been saved, through faith—and this not from yourselves, it is the gift of God— not by works, so that no one can boast. Ephesians 2:8-9.

What then does this passage of 1 Peter mean? The Bible teaches both divine sovereignty and human responsibility. It is not enough for you to have heard the gospel or even to give assent to it. Being baptized won't save you, nor will reciting the creed, attending services, becoming a church member, saying your prayers or reading your Bible. You have to take the gospel on board and allow it to change your life. The gospel has to get into your very marrow.

A man named George Judson worked for IBM in America. His daughter developed acute leukemia. The main problem with acute leukemia is that you stop making normal blood cells and in particular you stop making the type of white blood cells that cleanse the body from infection. “My daughter needs white cells,” he pestered the doctors, “can't you give her a transfusion?” The doctors explained that a blood transfusion contained only a few white cells; they would need to concentrate them. Working together with Jay Freireich, and with the financial strength of IBM behind them, Judson designed the IBM cell separator which allowed concentrated collections of white cells to be made and transfused.

The only problem with that was that white cell transfusions only last about 6 hours. What Judson's daughter needed was a bone marrow transplant. She needed a seed planted in her bone marrow that would grow and produce a steady supply of healthy white cells that would cleanse and go on cleansing her body from infection and a supply of new red cells that would carry life-giving oxygen around her body and a supply of healthy platelets that would preserve this new life and stop it leaking away. This is an illustration of what the Holy Spirit does when we are saved. But Judson's daughter would have to consent to her transplant and we have to agree to be saved. What a tragedy when we reject the offer of salvation!

Everyone who has a bone marrow transplant will eventually die because the seed that is planted is a perishable seed, but the seed that is planted within us when the Holy Spirit gives us new life, is imperishable. You may try and resist it, but it has an overwhelming resilience. That is why as a natural consequence of conversion you will have an unfeigned love for other Christians.

But in addition to that, Peter tells us that we must love one another deeply from the heart. This is our human responsibility. It is all too easy to sit back and assume that having been converted we will love the brethren. To be honest sometimes people we know at church are not easy to love. There’s the chap who always moans that things aren’t what they use to be under A**** B*******, or the girl who waves her hands about in front of your face, or the person who always prays the same prayer at the prayer meeting, or the sermon-tasters, or the pernickety, or the smelly, or those who write anonymous letters of criticism in green (or even worse, purple) ink, or the woman who has been sulking for ten years because she wasn’t invited to do the flowers, or the chap who sings loudly and flat behind you, or the music leader who doesn’t give you a firm beat to come in on, or the person who gives the children’s talk as if he were lecturing university students with sesquipedalian phrases, or … must I go on? I am sure you get the picture. Don’t many of these complaints sound trivial? You see the battles I have to face.

When we examine the kind of love we are supposed to show, how precipitous is our fall from grace. Peter’s old mate, John, writes about the love that the Father has lavished on us (1 John 3:1). Do you love the brothers lavishly? I’m not sure how I would do that, even though that is the standard set before us. When there are Christian brothers imprisoned unjustly, what do I do about it?

In Uzbekistan it is now commonplace for the police to raid houses where believers are meeting, to beat and arrest everyone present and to confiscate all literature, without a search warrant. Fines of $750-1500 per person are imposed. Many Uzbek Christian students have been expelled from universities. What should we do to support our Christian brothers in Uzbekistan?

In May this year 15 Christian homes were burnt down in a village in Sindh Province, Pakistan. They belonged to converts from Hinduism.

On June 30th around 600 Muslims petrol bombed 117 Christian homes in the village of Bahamani Walla, Punjab, Pakistan, and at the same time sabotaged the water pumps so that the fires could not be extinguished. Nine women and four children were injured when acid was thrown at them when they fled.

What are we doing to help our brothers and sisters in Pakistan?

In Nepal, Sri Lanka, India, Viet Nam, Egypt, Turkey, Laos, Indonesia, Fiji, Israel, Saudi Arabia, Guinea, Uganda, China, North Korea, Iraq, Iran and Mauritania Christians are being persecuted.

What can we do to help our brothers and sisters there? First of all we should pray for them, but prayer should be a spur to action. We could give to organizations like the Barnabas Fund that support persecuted Christians. We could lobby our MP, Congressman, Senator or whatever so as to bring pressure to bear from government to government. Many of these countries are recipients of British or American aid. Our governments should not be involved in sleazy deals over oil or military equipment. Rather they should stick up for the human rights of our fellow Christians. We are not asking for special privileges. Just as Paul stood up for his rights as a Roman citizen, so we should stand up for the human rights of our brothers in Christ.

Not only should we love lavishly, we should love wisely. We should not ‘spoil’ our fellow believers the way that some parents spoil their children by giving in to every demand. You wouldn’t give drugs to a junkie or booze to an alcoholic. But that’s exactly what you are doing when you give cash to many beggars. You might give them food or shelter or advice or encouragement, but supporting their bad habit only reinforces it. The Bible tells us that “He who will not work, neither shall he eat.” A wise principle. Some cannot work because of illness or frailty. Some cannot work because there are no jobs. But some do not work because of indolence or truculence. We have no responsibility to encourage this – but contrariwise a brother who is doing his best should be helped out. Those without a marketable skill who exist in low-wage jobs could well do with some aid from their Christian brothers, for John also writes, “If anyone has material possessions and sees his brother in need but has no pity on him, how can the love of God be in him?” (1 John 3:17)

John goes on, “Dear children, let us not love with words or tongue, but with actions and in truth.” My father-in-law used to tell a story of a man in church who, whenever the collection bag came round used to raise his hands in the air and cry, “Hallelujah!” and leave them there until the bag had passed him by. Dear brothers and sisters let us not allow our piety and prayer be a mask for meanness.

But hesitate before you judge others. This message is meant that we should judge ourselves. A story is told about Sir Ernest Shackleton by Frank Wild. During their expedition to the South Magnetic Pole in 1908 they were very short of food, down to one biscuit a day. As they were trekking across the ice Wild felt Shackleton’s hand in his pocket. Wild was suffering from frostbite and was the weakest one in the expedition. At first he thought that Shackleton was stealing his biscuit, but then he realized that Shackleton was actually giving him his own biscuit. “Your need is greater than mine,” said Shackleton. An Exeter University course on Shackleton’s leadership technique is used at universities all over the world.

Judgement should be left to the one who knows all the facts.

Saturday, August 29, 2009

CCTV cameras

It keeps coming up in the press. I heard it on the radio. Big Brother is watching us. A story the other day about how few crimes are solved by them. Watch 'Spooks' the TV spy program and you would think that your every movement was observed by them. We are told that a third of all the CCTV cameras in the world are concentrated in Britain.

Let me let you into a secret. It ain't true.

What is true is that no-one knows how many CCTV cameras there are in the UK. They are mostly put up by private individuals or firms to protect their property. So where does this paranoia come from.

It comes from a survey done 7 years ago in Putney, south-west London. Observers walked up two streets in Putney, which is an affluent area of London, and counted the number of CCTV cameras they could spot. Then they worked out how many people there were in those streets - about a couple of hundred - divided that number into 60 million, and then multiplied the answer by the number of cameras they spotted.

As an exercise in statistics it was ludicrous, about as silly as a newspaper poll that claimed that more than 50% of doctors approved of something or other. It turned out that the newspaper asked 15 doctors their opinion and extrapolated from that.

It used to be said that 90% of statistics were made up on the spot. That probably isn't true, but the abuse of statistics is very common perpetrated by people who ought to know better.

One site to visit if you want to know more about statistics is this

I listen to the pod cast regularly and it never fails to explode silly statistics.

Friday, August 28, 2009

Line infection

When I had my Hickman line flushed on Wednesday I became aware that the tunnel line was a bit inflamed with a small patch of redness around the insertion site. I watched it carefully and by 10 in the evening the red patch was rather larger. I went into the hospital and they swabbed the area and started me on flucloxacillin.

By Thursday morning the red area was three times as large and the entry site was oozing pus. I phoned my oncologist and we decided it was time to take the line out. I phoned the radiologist who inserted it and he kindly agreed to remove it at 4 pm yesterday. It took some getting out as the inflammation had welded it in, but it eventually came out and this morning it is much less painful and inflamed.

All done on the NHS and didn't cost me a penny!

Thursday, August 27, 2009

Elements of Danger - Medical Imaging

An article in today's New England Journal of Medicine needs to be considered by everyone with CLL. It is probably true that patients with CLL are more prone to second malignancies than the general population. In fact it is terribly difficult to prove that this is true. It is certainly correct for virally-induced cancers and may well be true for immunologically controled cancers like melanoma, but evidence that the common cancers - breast, lung, colorectal and prostate - are commoner in CLL is hard to come by. However, there is no doubt that exposure to low-dose ionizing radiation can cause both cancer and leukemia.

Workers in radiation oncology units and in the nuclear power industries are monitored for how much radiation they are exposed to. If they exceed a recommended limit they are removed from the high risk area. That limit is 50 mSv in any given year, and a maximum of 100 mSv over 5 years. Patients are not monitored, which probably didn't matter when all they got were chest X-rays which involve minimal exposure (only 0.02 mSv), but modern imaging procedures involve much large dose.

For example a CT of the chest causes 7 mSV, or the pelvis 6 mSV, the head 2 mSv and the abdomen 8 mSV. So a whole body CT involves your yearly allowance of exposure. Myocardial perfusion imaging, an increasingly popular imaging technique used to predict heart attacks, but which has never been shown to be useful in preventing heart attacks, delivers 15.6 mSv. Mammography delivers only 0.4 mSv.

Defensive medicine and the fact that these procedures are a nice little earner for the radiology department, mean that these procedures are increasingly used in medicine, especially in the US.

I have warned before that most CT scans in CLL are unnecessary. The diagnosis and staging of CLL do not require a CT scan. In fact results obtained by CT scanning are dangerously misleading and often lead to unnecessarily early treatment. The perpetrators are usually medical oncologists who treat CLL as if it were just another lymphoma. The one indication for abdominal imaging is when large abdominal nodes are suspected. Outside of clinical trials precise measurement of these is not required and a non-radiological technique such as abdominal ultrasound is quite sufficient. Regular monitoring during the watchful waiting phase does not require CT scanning. In fact the only firm indication for CT scanning that I can think of is in patients who might have a fungal pneumonia, say, after Campath treatment.

There are scare stories around which tell us that CT scanning delivers 400 times as much radiation as a chest X-ray. This may be true, but a chest X-ray delivers such a small dose, it is a silly comparison, and the doctor who is making it is a proponent of the much more expensive MRI technique. I have no axe to grind except to say why pay for a technique that you don't need?

Monday, August 24, 2009

Fear God? 1 Peter 1:17-21.

Have you ever been really scared? I remember occasions when I have been a bit frightened. Lying awake as a child and picking out monsters from the pattern of the wallpaper; the first time I went on a ghost train; walking along a dark lane at night; in a film called The Serpent when a snake leaped out of the dark and bit the hero in the neck; when I punched a bully in the nose and made it bleed and then sitting in the classroom as the schoolmaster in charge of first aid walked by; but on none of these occasions was I really terrified.

1 Peter 1:17 tells us to live our lives a strangers here in reverent fear. The word 'reverent' is not in the original Greek or in the King James version; fearing God is something the Bible insists we should do. Luke's gospel tells us that we should not fear those who merely have the power to kill us, rather that we should 'fear him, who after the killing of the body has the power to throw you into hell.'

Yet somehow we find the idea of fearing God rather strange. Is this not the same God whom Jesus addresses as Abba (Daddy)? Were you afraid of your father? If he were a brute who came home drunk and beat up your mother before taking his belt to you, you would do well to fear him, but most people's fathers are not like that. I was a bit afraid of my father when I was a young boy. He was a big man and when he wanted he had a loud voice, but he never hit me. He had a temper and he could scare you by shouting, but he was never drunk and never struck any of his children. He loved to teach us things. He took me fishing and taught me how to tie a hook and bait it. He taught me how to play a forward defensive stroke and bowl and of break. He sat down with me to puzzle over maths problems. He taught me to read long before I went to school. He was shy at showing emotions and was never a dad you could hug, but I am sure that he loved his children, and though as we grew older we were no longer afraid of him we respected him as someone in authority over us, and we would do nothing that would upset him.

I think that the fear of God is something like that. If we are strangers to him or in rebellion against him, we would do well to fear him for he does indeed have the power to cast us into hell; but if we have been adopted as sons into his family, we are not terrified of him. We should be in awe of him; we should reverence him and respect him. CS Lewis's description of Aslan sums it up; "If there's anyone who can appear before Aslan without their knees knocking, they're either braver than me or else just silly." "Then he isn't safe?" asked Lucy. "Safe?" said Mr. Beaver. "Don't you hear what Mrs. Beaver tells you? Who said anything about safe? 'Course he isn't safe. But he's good. He's the King, I tell you."

Our God may be loving and caring, certainly, but He's not safe; He's not a tame lion. We should never presume on God; like a loving father he trains us in the way we should go; he might well chastise us when we stray; but if we love God and respect him as we should, he will love us and care for us, protect us and strengthen us, keep us and sustain us as long as we live and then take us home to be with him. So the NIV translators were right to insert that 'reverent' to distinguish the fear from the terror we feel in immediate danger.

The rest of this paragraph tells us why we should fear God. First, v17 tells us he is a judge. But you may ask, are we not free from judgement? Were we not bought with a price? Are we not saved? This passage is not written for the unbeliever, for Peter addresses us as 'Obedient children'. Yes, our salvation is not in doubt, but our reward is. The point is that we were saved for a reason and that reason is to do good works. Let me emphasise: we are not saved by good works, but without good works what evidence is there that we are saved? James, speaking about Abraham tells us that 'his faith and his actions were working together and his faith was made complete by what he did' and again 'faith by itself, if it is not accompanied by action, is dead.'

We shall be judged; not on our righteousness for that is the covering that Christ has bestowed upon us; but by how we used our salvation. If like in the parable of the talents, we simply bury it in the ground, we will be judged appropriately. We will wish for the judgement that says, "Well done, good and faithful servant."

Second, we should fear God with reverence because he has redeemed us. Redemption is a word seldom heard outside a pulpit these days, but when I was young it was commonplace to pawn the Sunday suit on Monday and redeem it on payday. Pawnbrokers provided the cash to see you through the week and if you could not pay on Friday evening because father had drunk his pay then he forfeited his suit. That is the picture of redemption. Our souls are in hock, and because of our sins we have no means to buy them back. We need a benefactor to pay the price - God has redeemed us. We cannot repay him. But we treat him respect. Imagine the boss coming along and sees that you boozed your pay away and must appear in church on Sunday in your work clothes; yet he takes pity on you and pays the pawnbroker. How would you treat him next week. Would you join with your fellow workers and cock a snook at him? OR would you tell them of the good deed he has done for you?

Third, the price he has paid was not mere money. It seems strange to think of silver and gold as perishable things. Every few weeks we read of someone with a metal detector who has found gold or silver artifacts from Roman times or even from Celtic times. They appear in mint condition once the dirt is brushed off. In 2000 years they have not perished. I am reminded of the rich man who was buried with gold ingots in his coffin who was met at the pearly gates with the question, "Why have you brought us paving stones?" The price that was paid was with the imperishable blood of his only son; the precious blood of Christ, a lamb without blemish or defect.

Fourth, it was not just a whim. Your salvation was not a spur of the moment thing. We sometimes praise a soldier for an instant act of heroism. His colleague is injured and bleeding from a roadside bomb and without a thought for his own safety he leaps to save him. That is heroism indeed, but what do we call the man who having weighed up the situation and seen the risk and despite the fact that it is almost certain death, walks into enemy fire to save his comrade? God's plan of salvation was made before the creation of the world. Jesus was more than a hero.

Fifthly and finally, our hope and faith are in God. We have no other hope. At the test match at Headingly this year England were in dire straits. Australia had played much better. Supporters might hope for a batsman who would bat well and make a high score. They might hope that several of the bowlers would score enough, they might hope for rain so that the match would be abandoned. They had several things to hope for. Alas Australia were not daunted and won easily. But we have no other hope. If Christ is not risen we are of all men most miserable. But Christ is risen indeed and we are safe. Our hope and faith is in him.

We do not put our faith and hope in mere possiblities; we trust in the certainty of Christ. We worship the Father God who prvided all this because he loved us. Fear Him?

Restore, O Lord
The honour of Your name;
In works of sovereign power,
Come shake the earth again,
That men may see
And come with reverent fear
To the living God,
Whose kingdom shall outlast the years.

The Lockerbie bomber

The decision of the Scottish government to release the Lockerbie bomber who is dying of prostate cancer has been very controversial in the UK. Readers may not be aware of the strange governmental set up in Scotland. The British parliament devolved government responsibility to Edinburgh some years ago, so that a parliament there makes its own decisions about many things without asking the British government's permission. In reality Scotland is a lot more socialist than England; were it not for Scottish votes, we would never have a socialist government in England. Scotland has long had its own law which is different from the rest of the country. The ruling party in Scotland is the Scottish National Party made up of defectors from the Labor party who felt the leadership was too right wing, while the Labor party, which is the party of government in Westminster is the chief opposition party in Scotland. It is highly unlikely that the Labor party had anything to do with the release of the Libyan and it has been heartily condemned by the Scottish Labor party. Gordon Brown could do nothing to prevent it any more than Obama could.

Most English people are appalled by the Scottish decision. But then the Scots are a law unto themselves. They have already implemented several domestic policies that cost a lot of money and the English have had to pay for them. When the Tories are elected next year they would do well to stop Scottish MPs from voting on matters that purely affect the English. The Scots haven't been popular in England since Mel Gibson made Braveheart - a complete travesty of history.

Americans are justifiably angry at the release and some are planning a boycott of Scottish goods. Perhaps that is justified though there is no justification in boycotting English goods. However they should remember that an awful lot of Scottish soldiers have died in Iraq and Afghanistan. An independent Scotland would almost certainly cancel Trident (British nuclear subs are based in Scottish ports) and withdraw their troops from foreign wars.

Thursday, August 20, 2009

Alcohol problems.

David Cameron has pledged to raise taxes of high-alcohol beers and alcopops if he wins the next election. He will get brickbats from the right of his party, but many old people will support his stance.

Alcohol is a real problem. When we see 22-year olds dying of cirrhosis, when we see people afraid to go out on the streets at night, when we see a rise in date-rape, when we see young boys and girls collected by a police van late at night because they are too drunk to go home; then we know we have a problem.

How to solve it? Tony Blair thought he could solve it by abolishing licencing hours; he hoped that we would adopt a continental-cafe mentality. He was wrong, the hours of binge drinking simply got longer.

We know what doesn't work - prohibition. During the days of the Speakeasy the number of units of alcohol consumed in America did not diminish, but the mode of consuming it did. Wine and beer consumption was less, but spirit consumption increased. This was the day of the cocktail. Cocktails were invented because raw spirits were unpalatable, so they added sweeteners. Since transport of alcohol was risky and expensive, it made sense to have fewer journeys and lore concentrated truck loads hence spirits rather than wine or beer.

Today in Britain we are seeing a growth of stronger alcoholic drinks. Alcopops are the new cocktails. Beers are getting to be as strong as fortified wines.

So David Cameron's solution seems sensible. He is also intending to stop kebab stalls and other fast-food outlets from selling alcohol in the early hours of the morning. But another problem he has to face is that of youngsters getting drunk before they go out by buying cheap alcohol from supermarkets. In some supermarkets I visit they seem only to sell alcohol, fast food, and sweets. Alcohol is often marketed as a loss-leader to entice people in.

A further hazard is alcohol coming in from France. Vast alcohol supermarkets are situated close to Calais. As long as it is for 'personal use' unlimited amounts of duty-free alcohol can be imported from Europe. You would be surprised how much these 'persons' in their white vans can 'use'. The restriction is regularly flouted but how do you prove it?

I dare say my right-wing friends will be appalled that I suggest that alcohol consumption should be restricted, but all I can say to them is take a turn in an ER and try to staunch the bloody vomit from a 25-year old with esophageal varices.

Wednesday, August 19, 2009

Danny's take on the healthcare debate

A fascinating article in today's Times from Danny Finkelstein. Here is a quote:

The debate about American reform begins with the American system. The debate about British reform begins with the NHS. Voters in both countries fear what they stand to lose more than they look forward to what they stand to gain. Since they fear losing different things — in the US case, for instance, they fear loss of choice and control, while in the UK we fear losing universality — the debates in the two countries will always be different.

The US will never create the NHS and the UK will not adopt the American system because we are starting in different places.

The only meeting point is that we face a common crisis. Available treatments now outstrip our ability (never mind our willingness) to pay for them. In the US this is experienced as a crisis of cost, with health inflation rampant. In the UK it is experienced as a crisis of provision, with the State refusing to finance life-saving procedures.

Health care has just got too expensive.

The World Health Organisation records that in 2006, Americans spent $6,719 per head while Britons spent $2,815. One result of this disparity is the startling fact that the US Government spends more on healthcare per head of population than the UK Government does ($3,076 in the US compared with $2,457 in the UK).

This is the point that I have been trying to get across for a long time. The US already has a taxpayer-funded health service - Medicare, Medicaid, Provision for children, the VA, the NIH, the CDC, medical insurance for government employees, tax breaks for companies. Compared to the NHS, they just don't get value for money.

Meanwhile, in the UK — how do we decide how much of our income to spend on treatment and how do we cope with the fact that, while every person has a different answer to this question, we all still feel that everyone should get a good standard of care.

The truth is that as the very clever Enoch Powell once said, medical care will always cost more than we can afford, and just as we buy Fords rather than Rolls Royces, we have to cut our cloth according to our means. The NHS is predicated on getting value for money. It is reasonable that the public provision of health care should be rationed. There are plenty of conditions that could be done a few weeks later quite safely - I heard of someone who had a cataract operated on privately because the NHS appointment given was too soon to fit in with their arrangements at home. If we have to make a choice between someone waiting an extra two weeks for their hip to be done and someone getting a drug for their breast cancer that gives a 20% chance of their living an extra year, I would always choose the latter. But suppose the choice were between an extra six months wait in pain and a 1% chance of living an extra year? There is always a position of equipoise where choosing is invidious, and the choice that different individuals make will be scattered over a large area - people wouldn't even make the same choice themselves every day.

In a socialized system where the community clubs together to provide for a need, individual choices will always be different. Imagine a poor community joins together to buy a car for communal use. There will be days when more than one person needs the car at exactly the same time; how do you resolve such issues? But 2 cars? Possible but then suppose that three people need the car at exactly the same time. Eventually you reach a point where no more cars can be paid for and the demand exceeds the supply. In a free market the price goes up, but we are not dealing with a free market. For a market to operate there must always be the possibility of someone going bankrupt and their being an unlimited supply of good to sell if the price is high enough. The market in health care is constrained by a limit on the number of physicians and the impossibility of allowing a major provider to fail.

HMOs were an attempt at rationing in the US and very unpopular they were, but the fact is that not everybody in the world can have the best health care. There are scare stories from both sides of the Atlantic where both systems fail individuals.
Doctors dislike giving individuals less than the best. But I guess car salesmen would prefer that their customers drove out of the showroom in a brand new Mercedes. At the moment we are giving away clunkers on both sides of the Atlantic to some poor individuals; we should at least attempt to provide Toyotas.

Tuesday, August 18, 2009

Holiness: an impossible dream? 1 Peter 1:14-16

My old Jaguar S type is getting a bit long in the tooth. I enjoy driving it still, but it has 80k miles on the clock and a few car park fatalities. Both my rear lamps have holes in them and there is a dent in the rear wing and a scrape on the offside rear door. I really ought to fork out for the car doctor (and contrary to the propaganda he does not come on the NHS)to come and repair them.

But supposing someone said to me, "As an obedient child I am giving you a brand new Jaguar XJ." Hey! What a gift!

Imagine I took the gift and then started taking bits off it to try an upgrade my old S type. My son has bought an old VW camper which he is slowly restoring, so he could give me a hand.

Crazy idea, what? Yet that's exactly what some people are doing with their lives. They know they mucked up their old lives, but they are not willing to give up on them. I've mentioned it before but it's like the TV advert for Peugeot. An Indian driving an old Simca taxi spots the new Peugeot 306 and so falls for its looks he decides to change his old Simca. First he gets an elephant to sit on the hood then he takes a hammer to his bodywork.

Some of us imagine that we can change our old lives so that they are acceptable to God. A bit of hammering here a hacksaw there and an elephant to sit on the front. In the advert we see the Indian eyeing the girls out of what he imagines is a pseudo-Peugeot, but what we see and the girls see, is a young man making a fool of himself out of a battered old Simca.

For we have been given new lives when we were born again. A new XJ not a battered old S type. No hammering or scraping or painting or refit is going to turn my S type into an XJ. It sometimes seems hard work, holiness. An impossible dream. But that's because we are working on the old model. With the new model and with the Holy Spirit as driver, we just have to be sure we don't take it where it is likely to be damaged. I'm not taking the XJ into the hospital car park again. We should not conform to the evil desires that we had when we were in ignorance. We know what God wants. We must put to death whatever belongs to our earthly nature: sexual immorality, impurity, lust, evil desires and greed and rid ourselves of anger, rage, malice, slander and filthy language (Colossians ch 3). We shouldn't lie to each other, because we have taken off the old self and put on the new self which is being renewed in the image of its creator.

A story is told of an open air preacher who was preaching in a farmyard. "Don't smoke, don't drink, don't lust after young women, don't go dancing, don't watch them cinema films..."

One of the farm workers called out, "Hey, Preacher! Come an see my holy horse!"

"There's no such thing as a holy horse," scoffed the preacher.

"Well, he don't do any of those things that you says he shouldn't. So he must be holy."

Being holy is not a negative thing. A friend of mine was rung up by a minister who had been accused of allowing wickedness into his church. His accuser was complaining about the length of the ladies' skirts in his congregation. He seriously suggested that the following week the elders should wait outside the church with a tape measure, measuring how far above the ground were the skirts and to deny admittance to anyone who exceeded four inches.

You can't measure holiness with a ruler, whether it is the length of hair or the length of skirt. You need a stethoscope to examine the heart.

We are to be Holy because he who called us is Holy. Be Holy because I am Holy. Who called us? The Lord Jesus Christ. If we are to be Holy we must be like him.

What as he like? The Bible tells us that he went about doing good. Go thou and do likewise. He was patient and kind to the afflicted. Go thou and do likewise. He allowed little children to come to him and he blessed them. Go thou and do likewise.
He was not afraid to mingle with the outcast: lepers, a Samaritan woman with a terrible reputation, a woman taken in adultery, tax collectors and sinners, a woman with a discharge of blood; he even ate with the self righteous. Go thou and do likewise. He taught those in ignorance with beautiful stories not dry doctrine. He fed the hungry. He healed the sick. Go thou and do likewise.

We will certainly fall short. This side of heaven we will not be perfect. But he will pick us up when we stumble, guide us back when we stray and correct us when we err. He will never forsake us. He will always uphold us. He will never lose us. He has bought us with a price and is unwilling to relinquish us.

Saturday, August 15, 2009

Ostentatious wealth and Christian charity

I saw an amusing comment on a website yesterday. The response was following a newspaper article which picked up on Alan Duncan's remarks about how difficult the MPs (he is a Tory MP) would find it to live on a salary of £55,000 ($90,000) a year plus legitimate expenses. Before the scandal broke, MPs had 'allowances' that effectively meant that they were 'earning' the equivalent of £120,000 ($200,000). The posting was pretending to come from an MP who was bewailing his lot. How can I manage, he said, I need 5 new business suits a year at £3000 each, twenty new shirts at £100 each, silk socks are £10 a pair and one can only wear them twice, I need three new dinner suits at £5000 a time, ties are £100 a time and I need at least 10. The women have it worse. A well fitted bra costs £500 and they need at least 5. Silk knickers are at least £400 a pair. And so on. Of course, other viewers of the the site failed to appreciate the irony.

At the same time the supermarket chain ASDA (Walmart in the US) has been advertizing back-to-school uniforms at £2 ($3.3) a time. The juxtaposition of these two items with the comments on a previous article here prompted me to consider the question of ostentatious wealth and Christian charity.

The rich have no idea how the poor live. In China the rulers have adopted a policy of matching the West for wealth amongst the 300 million coastal dwellers. The billion rural peasants have been abandoned to a feudal lifestyle reminiscent of Britain in the 14th century. The boom of the last two decades in Western economies has been fueled by importing Chinese deflation. What would have otherwise been recognized as dangerous overheating was hidden by the import of cheap goods from China, deflating what would otherwise have been ruinous inflation. The Chinese have overpaid for dollars in order to keep the purchasers of their factory output solvent. Now they are riding a tiger from which they dare not dismount since if they did the world economies would collapse and in economic chaos the poor nations would suffer disproportionately.

Compared to my grandparents I live in unimaginable luxury. Both sets of grandparents started their married life in slum dwellings without running water, gas or electricity. They shared toilets with their neighbors, burned coal on an open fire for heating and cooking, kept chickens and rabbits in their yards for food, grew their own vegetables in poor soil, worked long hours for little pay and could not afford a doctor in sickness - instead consulting the local 'wise-woman'. Hot water from Monday's wash was conserved, sharing it with even poorer neighbors for their washing, then using it for a succession of baths for the children. Children's clothes were hand-me-downs, so that boys were seen in cardigans that buttoned on the wrong side. Second-hand clothes from middle class donors were eagerly accepted. Any sort of dishonesty was abhorred. My grandmother would not allow playing cards in the house. Children were given tasks from an early age and learned what it meant to obey. With seven siblings my mother knew that everybody had to muck in.

Today, I can't even spend my pension, it is so large. I live in a four bedroom detached house in a nice part of a nice town. I have so many clothes that I have become one of those middle class donors of second-hand garments, only instead of seeking the indigenous poor I give them to charity shops that sell them to raise money for cancer research. (Not sure this is a good idea as those clothes they can't sell are shipped to Africa where they undercut the local clothes dealers.) Fuel prices are rising, but my house is so well designed and insulated that they do not trouble me. Food is cheap enough (especially at ASDA) that we throw it away if the sell-by date is exceeded. In the old days we used to judge food by the smell - it was only discarded when it stank. I can employ a gardener and a window cleaner and don't need to give my garden up to Brussels sprouts and potatoes or let chickens run wild; instead I grow begonias and hydrangeas and have plastic frogs and rabbits nestling beneath my fountain.

I see that the Royal Bank of Scotland, which has just been rescued by the taxpayer, has signed on a new investment banker with a golden hello of £8 million. Eight million! How could you ever spend that much? I suppose I could take up golf. Goodness, I could probably buy a golf course. One of those luxury yachts, perhaps? A box to watch Manchester United every week. A plane to fly me there. As it happens I can watch Manchester United every week on television and have an expert explain to me the finer points of the game. It costs me about £250 a year for cable television and they throw in the latest movies as well. Mr Abramovitch bought Chelsea football club and runs it at a loss of about £100 million a year - probably it cuts his tax bill.

The British government provides a safety net for the poor with what they call tax credits. Instead of paying income tax they dole it out to those who can't earn enough. The Conservatives have suggested that they will cut public spending by denying tax credits to those who earn more than £50,000 ($82,500) a year. You can currently get more tax credits by having another child. It all started as an incentive to get people back to work. People were saying that working at a basic rate of pay was not worth doing because you were better off on benefits. So they introduced a grading so that you still got benefits while you were working.

However, if the rich are profligate with their own money, the poor are profligate with mine. People are fat. Poor people are even fatter. I popped into the Council offices to pick a marriage certificate for my daughter's forthcoming wedding. The 'Customer Care' department also houses a benefits office. Every one of the applicants had a beer belly. Obesity may not be such a problem here as in the US, but it's getting there. Recently police in Leicester rounded up the local beggars. None of them turned out to be homeless; many already had jobs but were begging as an evening 'second-job' and could make £200 a night doing it. As a result of similar stories, I would never give to a beggar in Britain, believing that the state has already provided, and if he was still in need the money would just go on booze or drugs. Pictures of skeletal children in Africa might tug at my heart strings, but fat applicants for benefits don't. Of course, the fat applicants may not be typical; perhaps there are some, if not many, who are still poor and managing on less while too proud to pick up benefits.

So in answer to the questioner who inquired whether the state should take on the role of charity dispenser, I have to say I am very dubious of this role and certainly in the UK I think it has gone too far. For example, every man over 65 and woman over 60 is entitled to £100 a year 'winter fuel allowance' even during mild winters (on cold winters they get more) no matter how rich they are. Even the Queen is entitled to it. Similarly all cancer sufferers whose disease cannot be cured by surgery are entitled to £3500 a year 'attendance allowance' even if they are multi-millionaires.

I believe that people in a world of plenty should not be left behind in poverty, but I also believe St Paul's injunction "He that will not work, neither shall he eat."

As to charity, a recent survey found that Christians were the best donors to charities and that left-wing secular socialists were the worst. Perhaps the socialists believe that this is something that the state should do and that they have no responsibility once they have paid their taxes. Certainly the ethos of charity has been lost in the secular community; in fact, the very word 'charity' has become tainted with disdain and disgust. Charitable giving is seen as a way of the rich looking down on the poor. I am reminded of the lady who sent tea-bags to the missionaries. "They have only been used once," she said.

I won't say what I give to charity, but I take the requirement to do so very seriously. As much as I can I seek to see what my charitable donations are doing. I rather distrust big charities like Oxfam, Save the Children, Christian Aid, UNICEF and the like, since I believe that they compromise with terrorists and corrupt regimes and also spend excessively on administration. I prefer to support people I know personally who give an account of every penny. I don't support animal charities of those that have difficulty in spending their donations. My major donations go to Christian charities since I believe that changing people's hearts is the only real way of doing good.

Thursday, August 13, 2009

Treatment holiday

I spoke to my oncologist yesterday. The CT scan after 8 courses shows no improvement on that after 5 courses. What does that mean? It could mean that I have residual disease that is resistant to this chemotherapy, but against this there has been no progression and the only remaining evidence for cancer is a distortion of the ileocecal valve where the presumed primary was. This distortion does not mean cancer - it could just as easily represent scar tissue from where the cancer was. The truth is that a CT scan is not sensitive enough to detect minimal residual disease. I have no systemic marker to detect smaller amounts of disease; my CEA level is in the normal range. I have no symptoms other than chemotherapy-induced ones.

Therefore the decision is that I have a treatment holiday with the presumption that my cancer is in remission. It's rather like watch and wait in CLL. We know that the cancer, while it had spread beyond the bowel into lymph nodes and peritoneal surface, was not extensive. We know that its growth rate was slow. For all we know, all traces of the cancer have gone. I have had at least 4 courses of chemo since the maximal response was achieved. It seems at this point that toxicity is outweighing benefit.

How do I feel? Certainly relieved that I don't have to go through any more chemotherapy for the time being. Anxious about the future. The oncologist is going to take my scans to show the surgeon to discuss the possibility of a second-look laparotomy and possible right hemicolectomy. That will be a difficult decision. If the last operation is a template, the post-operative course is a disincentive to further surgery.

The other option is to forget about the last 6 months and get my life back to normal, doing the things that I normally do. My daughter is getting married on October 3rd and that will provide sufficient distraction to keep me occupied.

Wednesday, August 12, 2009

American health debate

In an editorial in the newspaper, Investor's Business Daily, it was claimed: ' People such as scientist Stephen Hawking wouldn't have a chance in the UK, where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.' An astonishingly ignorant thing to say since Stephen Hawking lives in the UK and survives!

Professor Hawking - who is British, and who as recently as April was treated in an NHS hospital, Addenbrooke's hospital in Cambridge - quickly rubbished the claim. 'I wouldn’t be here today if it were not for the NHS,' he told the Guardian. I have received a large amount of high-quality treatment without which I would not have survived.'

Last week Chuck Grassley, the most senior Republican on the Senate finance Committee, claimed Ted Kennedy would be left to die untreated from a brain tumour in the UK because he would supposedly be too old for treatment. However he admitted he had no evidence to back up his wild claim.

'I don't know for sure,' said Grassley. 'But I've heard several senators say that Ted Kennedy with a brain tumour, being 77 years old as opposed to being 37 years old, if he were in England, would not be treated for his disease, because end of life – when you get to be 77, your life is considered less valuable under those systems.'

Andrew Dillon, chief executive of the National Institute for Health and Clinical Excellence (NICE), told the Guardian it was utterly false that Kennedy would be left untreated in Britain: 'It is neither true nor is it anything you could extrapolate from anything we've ever recommended to the NHS.'

I respect the fact that Americans must chose their own way of paying for health care, but I wish they would do so without publishing falsehoods about the NHS. Having now received 6 months treatment from the NHS I have very little criticism of it. I may be in a more privileged position than most people using it, but my observation of fellow patients does not suggest that my treatment is exceptional. I am receiving exactly the same treatment for my cancer that I would get in the US, and should it be unsuccessful, there are second-line options available even though they are not yet NICE-approved for first line. (NICE does not hold the stranglehold over practice that its critics suggest). There are dangers in jumping in with unproven treatment options. A good example would be Bevacizumab which on the basis of early results seemed to offer improved survival in colon cancer. It was adopted in many countries including Holland, yet more recent results presented at the American Society for Oncology this year demonstrated no therapeutic benefit, just extra toxicity. I am glad I have not been given it.

My treatment has been free at the point of consumption, though I have paid enough in taxes over the years. The ward where I receive the chemo is light and airy with a fine view over the lake. The nurses are cheerful and caring. I have the Oncologist's mobile phone number. I never have to wait. I was offered a second opinion with the leading specialist in the UK for this disorder, or with whomever I would rather see, at no extra cost. I was offered a choice of hospitals to receive my treatment, though naturally I chose the one that is 5 minutes drive away since it is equipped with the latest CT and MRI scanners for which there is no waiting list. In my diagnostic work up there was no delay and I was examined with state of the art radio-scanning equipment.

When I was an in-patient having surgery there were some minor quibbles about silly rules that Health and Safety regulations had forced upon us, though it wasn't so much the rules as the over-zealous interpretation of them by junior members of staff, that was the problem.

Because there is no billing, no third-party payer, no checking on financial status, no local negotiation, no restrictions on which provider goes with what payer and for many other reasons, the cost of bureaucracy in the NHS is much less than in insurance-based systems. Government interference is always a bind, but the essence of the NHS has always been its local nature. Local people make local decisions. I spent a lot of my time in the 1980s and 1990s making those decisions for the benefit of local people. I am now benefiting from the decisions I made then.

The Labor government dislikes the unevenness of the NHS. Some areas are better or worse than others. One correspondent has suggested that Glasgow is as bad as Moscow - but that is because the people there live of whisky, cigarettes and deep-fried Mars bars. The NHS has no responsibility for that.

The idea that we would be better off being treated by vets is laughable. Anything difficult is treated by lethal injection, unless there is money in keeping the beast alive.

Normally, I would go along with Caveat Emptor, but in health care there is so much misinformation that the buyer is not qualified to know what is best for him. Even those with a medical education make wrong choices. As a result there is a huge malpractice industry in the US. My best prescription would be for everyone to have a family doctor who is concerned with the welfare of that particular patient. The NHS provides one for free to everyone. They are not always the shiniest knives in the box, but they are usually more honest than the TV ad or the specialist who sells his wares on a fee for item of service basis.

But my main point was how much the cost of the American system was to the taxpayer, When you consider the cost of Medicare, Medicaid, provision for children, the VA, NIH, CDC, health insurance for government employees, tax breaks for employers, the cost of the FDA, research grants to universities, etc the cost is more than the UK government spends for the whole of the NHS.

Tuesday, August 11, 2009

The cause of CLL

The extreme differences in geographical variation worldwide ought to give us a clue as to the etiology of CLL. Prevalence rates show a 40-fold difference between white Europeans and North Americans, and Asians, but unlike other with malignancies, Asians migrating to the USA retain their low incidence [ 38 Pan et al Cancer causes Control 2002; 13:791-5]. This suggests that genetic factors rather than environmental ones are responsible. Despite the low incidence in Asians, their disease bears a close resemblance to that occurring in Caucasians [39 Irons et al Leuk Res 2009 epub]. The evidence for environmental factors playing a role in the etiology is weak and inconsistent, with some studies having found a link to agriculture (pesticides, herbicides, animal exposure) and some to exposure to benzene and the rubber industry, but others have not found such links [40 Goldin, Slager Hematology 2007; 1:339]. Not unexpectedly, there was no association with exposure to radiation fall-out from the Japanese atomic bombs, since CLL is very rare in Japan, but more recently the role of radiation exposure has been raised again [41 Hamblin Leuk Res, 2007].

There are certainly genetic elements that are important in the pathogenesis of CLL. Somewhere between 5 and 15% of patients have a family history of CLL. Rawstron et al found a prevalence of unsuspected MBL in 13.5% among 59 first-degree relatives in 21 CLL kindreds [42 Rawstron Blood 2002b] and Marti et al found an even higher prevalence of 18% [43 Marti Cytometry B Clin Cytom 2003; 52:1-12]. Familial cases of CLL do not differ significantly from sporadic cases apart from fitting into the more benign categories owing to selection bias [40]. Linkage studies looking at the co-inheritance of genetic markers and CLL have so far been unsuccessful in identifying any genetic defects that make a family member prone to CLL [40]

Searches for single nucleotide polymorphisms (SNP) among candidate genes or molecular pathways have similarly been largely unsuccessful [40], but Raval et al [41 Cell 2007 129, 879-90] identified an SNP of the Death Associated Protein Kinase 1 (DAPK1) gene on chromosome 9 which segregated with the disease in a single large family with CLL and was associated with the downregulation of the enzyme’s expression. DAPK1 is an actin-filament-associated, calcium calmodulin-dependent, serine/threonine kinase that promotes apoptosis in response to various stimuli. Although there were many polymorphisms found, most could be eliminated, but one, an A to G switch at position c.1-6531, was not found in 383 control samples from the US and Northern Europe. Investigation of this polymorphism demonstrated that the A to G switch reduces DAPK1 expression by increasing the affinity of DAPK1 for HOXB7, a transcription factor that normally opposes the expression of DAPK1.
That this might be important can be gathered from the fact that DAPK1 is normally silenced by demethylation in sporadic CLL as it was in this study in 60 out of 62 cases. However, the SNP was found in the germ-line of only one among 263 cases of sporadic CLL from the US and Northern Europe but not among other familial kindreds.

Another polymorphism of possible relevance was discovered by Pekarsky et al [37 PNAS 2008; 105: 19643-8] They demonstrated two mutant sequences of TCL1 among 600 CLL patients studied, one of which was present in the germ line. Activator protein 1 (AP-1) –dependent transcription, which includes both c-Jun and c-Fos, induces apoptosis by transactivating proapoptotic genes. Wild type TCL1 inhibited AP-1 dependent transactivation around 2.5 fold, whereas the mutant forms inhibited it around 100 fold.

It is likely that no simple genetic defect is responsible for the occurrence of CLL in families, but rather that a large number of components of molecular pathways appear in variant forms which together influence the rates of proliferation and apoptosis of B lymphocytes.

Monday, August 10, 2009

Peripheral neuropathy

If you knock your elbow you often experience the sensation. The outside of your hand becomes numb and it's like an electric shock going down your fingers. This strange and inappropriate tingling is the hallmark of peripheral neuropathy (sometimes called peipheral neuritis, the terms are interchangeable). I am writing this because what I read in the textbooks and on the Internet seems to me to be inaccurate. I have peripheral neuropathy from my cancer chemotherapy, so there is no investigation as to cause required, but an accurate description is required. Actually there is some dispute as to cause; I had assumed that the neuropathy was all down to oxaliplatin, but I know believe that there is a contribution from 5-fluorouracil too.

The most obvious feature of oxaliplatin toxicity is cold-induced parasthesiae. Parasthesiae are the sensations produced in nerves that are inappropriate to the stimulus. Just touching something should not produce tingling in your fingers, but that's what it does if you touch something cold after oxaliplatin. The sensation continues for 4 or 5 days after the drug is given, but gradually abates until the next course is given. It is a nuisance, but one that can be coped with. I managed by avoiding anything cold, warming up my cutlery and wearing light cotton gloves because even things at room temperature could set off the tingling.

A worse threat was the suggestion that a non-cold-induced neuropathy would follow. Sure enough, this happened. Starting at my fingertips I began to develop loss of sensation. Now different sensations are carried by different types of nerve fibers. Light touch is separate from pain and temperature. Tickle is also carried by the pain and temperature fibers, but deep touch is separate again. Movement messages are carried by different fibers and so is positional sense or propriaception. What has gone missing in me is light touch. In fact where I should be experiencing light touch I am experiencing tingle.

Pain and temperature are not reduced, in fact I am more conscious of them, though this might be because the precautionary sensation of loss touch is lost. I do not seem to have lost propriaception or movement. The distribution of the loss is characteristic. I have a 'glove and stocking' neuropathy - that is the numbness is only in the area that would be covered by gloves and calf-length socks. But even that is not an accurate description. Perhaps because of the normal distribution of nerve endings, the worst effects are on the palms of my hands and the soles of my feet. Even on the palms, the area supplied by the median nerve - the thumb, index and middle fingers - are worse with the two other fingers less affected, as is the area supplied by the radial nerve on the back of the hand.

The reputation of oxaliplatin for causing a peripheral neuropathy is well known and it is also known that the neuropathy goes on deteriorating after the platinum drug is stopped and make take months or even years to recover. This is the major reason for stopping the drug, as they did with me. My experience with stopping the oxaliplatin is that the symptoms began to improve, but when I had the 5-FU alone they got worse again. Indeed they didn't start to creep up my legs until the 8th curse of 5-FU. Again after the 9th course they have deteriorated having improved during the three week gap betwen the 8th and 9th. Looking back to the old literature from before the time when platinum compounds were routinely given with 5-FU, there are reports of neuropathy caused by the fluorouracil alone.

Autonomic neuropathy involves those nerves that are not under conscious control; largely those that control smooth muscle. The most important nerve is the vagus nerve which controls the speed of the heartbeat. Blood pressure and the movement of the bowels are also under the control of the autonomic nervous system. I believe that I was suffering from autonomic neuropathy while I was on the platinum, because I was suffering fainting fits, occasions when my heart raced and quite severe bowel dysfunctions. I haven't noticed these side effects for the past few weeks, so I am inclined to blame the platinum for that.

What this means as far as further oxaliplatin is concerned, I'm not sure, but I wll convey my observations to the oncologist when I next talk to him about my scan from last week.

Sunday, August 09, 2009

Prepare the mind; control the self. 1 Peter 1:13

Whenever there's a 'therefore' ask yourself what it's there for. A silly little ditty, but Peter begins verse 13 of his letter with a 'therefore' which refers back to the 'living hope' referred to in verses 3-12. In order to set our hope fully on the grace you when Christ is revealed we are told of two preparations: to prepare our minds for action and to be self controlled.

In the past 40 years the evangelical church has retreated from thinking. No doubt this was a reaction to some of the thinking coming out of Seminaries, which had become contaminated by the 'higher criticism' from the nineteenth century. We despaired to see some of out brightest young men emerge from Bible Schools and Universities with their faith in tatters and preaching another gospel. Instead the church has become filled with those who prioritize their feelings. Even when Scripture clearly forbids something believers will trust their feelings rather than the clear teaching of the Bible.

I heard of a young man who wanted to divorce his 23-year old wife of two years to marry a 16-year old girl he had 'fallen in love with'. "It seems so right," he said. We can be overwhelmed by feelings so that what is clearly wrong seems right. We have all been there. Young people are a mess of hormones; old people are awash with self-righteousness. They forget that they were once young and subject to different temptations. If we trust to our natural feelings we will be led astray.

Yet we were never so well provided for with orthodox Christian knowledge. We have so many translations of the Bible in English. To be sure you can pick up discrepancies and quibble about what an individual verse means, but these are trivial problems and thinking about them will often advance our knowledge of Scripture. But instead of reading the Bible we are content with Bible Reading Notes, where we are instructed to read a single verse and then a page of tortured exposition that reveals the writer's view, often on something totally out of context. We have many orthodox Christian books - an in this context may I recommend Tim Keller's "The reason for God" which I have just started, but which both my son and our Church Evangelist, Michael Otts enthuse about. Instead millions are reading "The Shack" which may be an interesting story, but it is fiction and has many misleading threads in it.

On the Internet you can listen to sermons from many of the greatest preachers in the world. Yet who these days has the attention span to listen for 40 or 60 minutes? Sadly, few are prepared to prepare their minds. You don't have to be a genius or have a mind as big as a planet to appreciate the Word of God. You don't have to read huge passages every day. This exposition is based on just one verse and I doubt that I shall do it justice in this one blog.

Just think about the individual words. "Prepare" your minds. In order to prepare your mind, you must give it time. Scripture reading is not to be shoved into the odd five minutes and then forgotten when something unexpected appears on TV or someone visits unexpectedly. Try to set aside the same time every day. Even 15 minutes can be a joy: think what else you might be doing and consider which is the most value. Alone with the Bible and pencil and notebook is a great discipline and of great value. Try to get inside the mind of the writer. Ask, "Why is he writing this? What is he saying to me personally, into my particular situation." Try to remember similar passages. If you have a commentary, read it. Often we can lean on great men and women of the past, but remember that commentaries are not Holy Writ; you are allowed to disagree with them. It helps to pray a thought in; we used to say, "Water it with prayer." You will find that the more you practise this discipline, the more necessary you will find it and the more joy you will derive from it.

Prepare your minds for "action". What action is this? The rest of the passage tells us that it is something to do with holiness. We art to avoid evil and conform to holiness. Let me tell you there is a war going on out there. You wouldn't send untrained troops out to Afghanistan. They would soon be destroyed by improvised explosive devices. Similarly, we need training as Christians. Throwing young Christians in at the deep end and hoping that they will swim is foolhardy. Spiritual temptations are plentiful and young Christians too easily fall into the traps. We may be appalled by the loss or twos and threes and fours in Afghanistan, but the funerals of Harry Patch and Henry Allingham, the last two British survivors of the first world war, reminds us that inexperienced young men were told to get out of their trenches and march slowly and fearlessly towards the enemy machine guns. Tens of thousands were killed in a single day. We are not confronted by German machine guns, but with the wiles of the Devil who goes around like a roaring lion seeking whom he may devour. We want not inexperienced troops but wise leaders and teachers. In Africa, in Asia, in South America there are millions of enthusiastic converts, who lack not faith but teaching. If the Western Church has anything to contribute to the church abroad it is the wisdom of Scripture knowledge. Prepare for the action of sharing the gospel; how will they hear without a preacher?

Men and women who teach must have as their first attribute, not a honeyed voice, not a well-tuned phrase, not even an encyclopedic knowledge, but personal holiness. How many times have we seen a ministry destroyed or saints wounded by a pastor who couldn't keep his trousers buttoned or his bank balance from swelling, who thought more about celebrity than service? Holiness is a constant battle against the world, the flesh and the Devil: the worlds because the world hates non-conformists - they would have everyone following the fashion; the flesh because our bodies make us slaves to sin; and the Devil because he knows that that is the way he can win. Weakened and sickly Christians are no match for him because they forget that their strength is in the LORD; without our daily meal of Scripture, we forget too soon.

Secondly, we should be self-controlled. No, say some, we should be Spirit-controlled. But if we look in Galatians 5 at the fruits of the Spirit, we see that one of them is self-control. The Greek here refers to sobriety. My daughter was shopping in the center of Bournemouth at 9pm on Saturday night. Already, young people were gathering outside nightclubs is various states of drunkenness. Bournemouth is Mecca for young people wanting a 'good time'. Since licensing hours for alcohol became extended under Tony Blair they seems no limit on bad behavior. Booze is cheap and Ecstasy available. Bands blare out there thumping beat and young boys and girls mesmerized by the rhythm and chemicals lose all self control and are thus bamboozled into sin. Some Christian young people are sucked into it by their friends for fear of seeming different. Some churches mimic the effects by producing ecstatic excitement. Let yourself go into God, they say. No, says the Scripture. be self-controlled.

Self-control should never be confused with selfishness or self-centeredness. Self must always be under the control of Scripture. That is why the first demand is to prepare our minds. The discipline of Bible study and prayer allows us to control our selves. Neither should it be confused with self-righteousness - Oh! What a temptation for the older Christian. We think we have seen it all and we have all the answers, but how often we are pulled up short by a remark from the young and innocent. This is a battle we never complete until our days in glory. Beware he that standeth lest he fall!

Thursday, August 06, 2009

New hymn.

In 1989 Rich Mullins wrote a short chorus "Our God is an awesome God" which we often sing in church. The tune sounds Israeli and we tend to sing the chorus five times going faster for each repeat and perhaps raising the key a semitone each time until it builds to crescendo. I often have the irreverent temptation to shout "Hey!" and smash a plate as it finishes. (Or is that Greeks?) I also feel quite guilty about singing it as it seems to me to smack of 'vain repetition'. Here are the words:

Our God is an awesome God,
He reigns from heaven above,
With wisdom power and love,
Our God is an awesome God!

This seems to me to be a final verse and there is scope for adding four more to precede it. It's not easy though. Essentially it means writing four rhyming couplets for the second and third lines of each verse. The content needs to tell the story from creation to salvation and the lines need to be very short; only six syllables.

With the benefit of steroids for my current course of chemotherapy, I woke early and thought about it. Here is my attempt at a first verse:

Our God is an awesome God,
Behold the world He's made,
And praise His power displayed,
Our God is an awesome God!

I'm not entirely happy with 'Behold' as it's a word much loved by the old hymn writers but not used today in normal speech. Is there a two syllable synonym with the beat on the second syllable? My Thesaurus offers 'observe' 'inspect' 'espy' or 'regard', none of which carries the commanding force of 'behold'. I can't see a way out.

The second constraint I foresee with such a tight verse structure is how to avoid the impression that it is God, the Father, who suffers on the cross but explaining the Trinity is too hard a task for such a short verse hence the next verse:

Our God is an awesome God,
Just glimpse His glorious grace,
To free this fallen race,
Our God is an awesome God!

Thesaurus coming in handy again for 'glimpse'. Am I overdoing the alliteration? Is 'free' OK or should it be 'save'? Is 'race' clear enough to stand for 'human race'?

Verses 3 and 4 must refer to the cross and the resurrection. To reduce the cross to just 12 syllables seems like blasphemy but I guess it can be done. Some of those 12 have to be linking words or the lines become too dense.

We have to assume knowledge of the meaning and effect of the crucifixion and just refer to it in the shorthand of a couple of words. How about:

Our God is an awesome God,
Nailed on a cross to die,
We watch and wonder why,
Our God is an awesome God!

or perhaps lines 2 and 3 should be reversed?

If we are assuming knowledge of the meaning of the cross isn’t line three nonsense? No because it places us in the immediacy of the cross; we stand with the disciples marvelling at what is happening. Does this avoid the error of God the father suffering or does it emphasise that Jesus is God?

Our God is an awesome God,
He rises from the grave,
With all He came to save,
Our God is an awesome God!

Not literally of course but it refers to I Corinthians 15:: 22 and following, also Romans 5:15 and Ephesians 4:8.

Finally we can place Rich Mullins’ verse at the end of the crescendo. So the whole hymn goes like this:

Our God is an awesome God,
Behold the world He's made,
And praise His power displayed,
Our God is an awesome God!

Our God is an awesome God,
Just glimpse His glorious grace,
To free this fallen race,
Our God is an awesome God!

Our God is an awesome God,
We watch and wonder why
He's nailed to a cross to die,
Our God is an awesome God!

Our God is an awesome God,
He rises from the grave,
With all He came to save,
Our God is an awesome God!

Our God is an awesome God,
He reigns from heaven above,
With wisdom power and love,
Our God is an awesome God!

Perhaps verse 3 should read

We watch and wonder why
He's nailed to a cross to die?

What do you think?

Yes, I've changed it.

Tuesday, August 04, 2009

Another day

Quite a quiet day today. The weather, while not as bad as 2008 and 2007, still remains very changeable with more rain today. We took a trip out to the Doll's hospital, where we had left my wife's china doll 6 weeks ago. The poor thing had toppled off her chair on several occasions and had smashed her right foot. The hospital had to cast two new legs and fire them, then fit them. Now she was back to pristine condition so we bought her a new chair that she wouldn't fall out of. I took the opportunity to see what these dolls retail at now - the answer is about $250.

I managed to get the TCL1 article off to Leukemia Research for publication and started to referee an article for Blood - my first since my illness. But tomorrow the 9th course begins and I will have to shut up shop as far as thinking is concerned.

In the afternoon I watched another episode of The Wire and then this evening we watched the final episode of To The Manor Born and then watched a few episodes of Yes Minister. I'm not the only person who yearns for the comedy of the 1970s.

I am reading the autobiography of Michael Parkinson and found an interesting insight on Neville Cardus, the great writer for the Manchester Guardian, who wrote on the Halle Orchestra and Sir John Barbarolli and on cricket. (I once took blood from Barbarolli who died in a nursing home in Bournemouth). Parkinson asked Cardus how he managed to get such pithy quotes from cricketers. "I don't," said Cardus, "I make them up. Cricketers are generally unable to string words together to form a sentence." For those who don't know him, Parkinson has had a TV show for 30 years interviewing celebrities, rather like Jay Leno or David Letterman.

I am a little disappointed that my health hasn't completely returned to normal after the three week break. I still have bloating and tiredness in the evenings and a reduced appetite. I hope it is just the chemotherapy. I have another CT scan on Thursday, so I should soon find out.

Saturday, August 01, 2009

The TCL1 story

For the past couple of weeks I have been seeking to understand the TCL1 story. This is the result, though I have to confess that it is very complicated and you may want to skip it. I will try to come up with a more user friendly version a bit later.

I was a bit of a sceptic about TCL1 when it was first brought to my attention but now a real story about TCL1 and CLL seems to be emerging.

TCL1 is an oncogene activated by recurrent reciprocal translocations at chromosome segment 14q32.1 in the most common of the mature T-cell malignancies, T-cell prolymphocytic leukemia. It was first recognized in Carlo Croce’s lab in a patient with Ataxia Telangectasia who developed T-PLL (Proc Natl Acad Sci U S A. 1989; 86:602-6). In T-PLL it acts to transport the protein Akt1 to the nucleus and enhance Akt1's enzyme activity.

It was also found that TCL1 is expressed in B-cell chronic lymphocytic leukemia (CLL) and the similar disorder of mature B cells, splenic lymphoma with villous lymphocytes, though not in normal mature B-cells (Yuile et al, Genes Chromosomes Cancer. 2001;30:336-41).

The following year in Croce’s lab (Bichi et al, PNAS 2002; 99:6955-60) they produced a transgenic mouse in which the TCL1 gene was placed under the control of the immunoglobulin heavy chain promoter so that more of the protein was produced. These mice began to develop a proliferation of CD5+ B cells, starting in the peritoneal cavity at 2 months (where classical B1 cells live in mice, though not in humans). These cells became evident in the spleen at 3-5 months and in the bone marrow at 5-8 months. Cells in the spleen were located in the marginal zone but did not have marginal zone cell markers. Oligo- or monoclonality began appearing at 8 months, first in peritoneal cells and later in other populations. At the age of 13-18 months the mice became visibly ill with enlarged spleens, marked lymphadenopathy and high white cell counts, the blood films showed smudge cells but the predominant cells was a large CD5+/IgM+ lymphocyte; the picture being more characteristic of prolymphocytic transformation of CLL (CLL/PLL) than of CLL itself. The authors suggested that these transgenic mice might serve as an animal model for CLL.

Workers at MD Anderson Cancer Center studied the expression of TCL1 in 213 patients with CLL (Herling et al, Leukemia 2006; 20:280-5). 90% of samples expressed TCL1 whether detected by flow cytometry, immunohistochemistry or Western blotting. The highest levels were less than is seen in T-PLL but correlated with the presence of unmutated IGHV genes, ZAP-70 positivity and the presence of deletions of the long arm of chromosome 11. Stimulation of CLL cells with interleukin-4 caused the expression of TCL1 to irreversibly diminish in association with proliferation.

The question then arises as to whether the TCL1 B-cell lymphoma of mice is not a model of human CLL as a whole, but rather of the more aggressive form with unmutated IGHV genes. Confirmation of this idea seemed to come from a study by Yan et al (PNAS 2006; 103:11713-11718). They found that like the more aggressive form of human CLL, the leukaemia of TCL1 mice uses unmutated IGHV genes, shows a biased use of these genes and stereotypy between cases of the B-cell receptor (BCR) structure. They also showed that these stereotypic BCRs reacted with autoantigens and antigens found in bacterial cell membranes.

More recently, workers from Austria (Holler et al. Blood 2009; 113:2791-4) have found evidence that BCR signalling plays an important part in the development of the leukaemia from the expanded polyclonal CD5+ B cell population. Transgenic TCL1 mice in which the protein kinase C beta gene (PKCbeta) was knocked out failed to develop the CLL like disease despite developing an expanded CD5+ B-cell population. PKCbeta is an important component of the BCR signalling mechanism.

Micro RNAs (miR) are a large family of highly-conserved, non-coding genes involved in the regulation of what genes are expressed in different tissue and at different times in the cell cycle. They range in size from 19-25 nucleotides and are typically excised from a hairpin RNA structure of 60-110 nucleotides that is transcribed from a larger primary transcript. They are able to bind to other RNAs to reduce the level of their target transcripts as well as the protein coded by the transcript. The first evidence that they were involved in malignancy was the finding by Calin and his colleagues that miR-15a and miR-16-1 were absent or down-regulated in patients with CLL who had chromosomal deletions at 13q14 – the commonest chromosomal abnormality in CLL (PNAS 2002; 99:15524-9).

The same group identified a micro RNA signature associated with prognosis and progression in CLL. Among the miRs associated with a short period between diagnosis and treatment were members of the miR-29 family (NEJM 2005; 353:1793-1800). Another miR characteristically identified with B-cell lineage tumor cell lines is miR-181 (Ramkissoon et al. Leuk Res 2006; 30:643-7). In a study of micro RNA expression profiling Pekarsky et al found that the levels of expression of these two micro RNAs were inversely related to the expression of TCL1 (Cancer Res 2006; 66:11590-3). Patients with CLL were divided into three groups: indolent, aggressive and aggressive with an 11q23 chromosomal deletion. TCL1 expression was low in 65% and high in 4% of indolent cases, low in 44% and high in 56% of aggressive cases and low in 3% and high in 75% of aggressive cases with 11q deletions. Levels of expression of miR-29b and miR-181 are inversely correlated with TCL1 protein expression in patients with CLL.

Pekarsky et al also demonstrated that these two micro RNAs could individually inhibit the expression of TCL1 messenger RNA by transfected cell lines and that by transfecting TCL1 together with miR-29b and miR-181 into a mammalian expression vector they demonstrated that the presence of the micro RNAs significantly decreased TCL1 protein expression. Furthermore, both miR-29b and miR-181b show reciprocal sequence homology with the 3 prime untranslated region (3’ UTR) of TCL1. Taken together, these results suggest that TCL1 expression is, at least in part, regulated by these two micro RNAs.

Exactly how TCL1 influences the behaviour of CLL cells was made clearer by another paper by Pekarsky et al (PNAS 2008; 105:19643-8). In contrast to T-PLL, the AKT oncoprotein does not seem to be involved. The cAmp Response Element Binding (CREB) protein, p300, is a transcription activator involved in transactivation mediated by several signalling pathways including NF-kappaB. Co-precipitation experiments showed that TCL1 interacts with p300. However, sequence analysis demonstrated two mutant sequences of TCL1 among the CLL patients studied. These mutant forms of TCL1 did not upregulate the NF-kappaB pathway to the same extent as wild type TCL1, leading the investigators to expect that another pathway might also be involved. One of the best known pathways involving p300 is activator protein 1 (AP-1) –dependent transcription. This complex contains c-Jun and c-Fos. AP-1 induces apoptosis by transactivating proapoptotic genes. Wild type TCL1 inhibits AP-1 dependent transactivation ~ 2.5 fold, however the mutant forms inhibit it ~ 100 fold. Co-precipitation and co-transfection experiments demonstrated that TCL1 interacts physically with AP-1 components c-Fos, c-Jun and JunB and inhibits their pro-apoptotic function, but that the mutant forms did this more effectively.

It is reasonable to conclude that the upregulation of TCL1 in certain CLL cells has multiple consequences including the suppression of apoptosis and increase of NF-kappaB dependent transcription. The fact that mutant forms with increased anti-apoptotic activity may have implications for certain types of transformation of CLL. One of the mutants was present in germ-line DNA, suggesting that it may be implicated in some cases of familial CLL.

The TCL1 mouse seems to have established itself as an animal model for the more aggressive forms of CLL and has been adopted by several groups in order to study putative new therapeutic agents (Lucas et al. Blood. 2009; 113:4656-66), the effect of that CLL has on T-cell function (Gorgun et al. Proc Natl Acad Sci U S A. 2009;106:6250-5) and the importance of macrophages in a novel immunotherapeutic approach (Wu et al. J Immunol 2009; 182:6771-8). We await evidence that predictions based on the mouse model come true in the human version of CLL.

The art of captaincy

Yesterday was the day I was supposed to be going to the Test Match. My son had bought me a ticket. This was the first Test Match that I was to be going to since I was a child. Alas, I was not well enough to make an eight hour there-and-back journey and I was reduced to watching it on TV.

Test Cricket is the prince of games, and Tests in England rank higher than anywhere else because of the uncertainty of the weather. A match lasting over five days requires strategic thinking as well as tactics, and for that reason it is worth playing a c aptain even if he is not the best batsman or bowler. Several players in the past have been selected even when they were not worth their place in the team on cricketing excellence alone. The captain must direct the play, choose whether to bat or bowl, when to declare, whether to enforce the follow-on, in which order to deploy his bowlers, how to set the field and what tactics to employ against particular batsmen. Mike Brearley was the last player to be picked purely as a captain. In Andrew Strauss, England may have another. Interestingly, since he has been appointed captain his batting has improved. Australians always feel that they were cheated by the bodyline tour of 1931-2, when Jardine had Harold Larwood, Bill Bowes and Voce bowl at the batsman rather than the stumps, but it was within the rules and kept Don Bradman, their star batsman, relatively quiet. Bradman retired with a batting average of 99.4 runs in every test innings. No-one before or since has got above the 60s and anything over 40 is regarded as very good. The West Indian bowlers between 1960 and 1980 were more effective at bowling at the man - it was they that prompted batsmen to kit themselves out like motor bike riders - but nobody complained that it was unfair.

But to return to the current test series. Australia have been world beaters for a very long time. Only India playing at home could threaten them. Cricket in India is a different game; hot, dry and dusty conditions call for different skills, particularly in spin bowling, that are not mastered except in the sub-continent. The rise of Sri Lanka as a test team bears witness to that. Australia had a strong batting line up, but their supremacy was based on their two bowlers, fast-man McGrath and leg-spinner Warne. In 2005, England beat Australia to everyone's surprise, though the same team lost in the return rubber in Australia a couple of years later. England's triumph in 2005 was put down to the performance of captain, Michael Vaughan, and the all-round performance of the giant, Andrew Flintoff (known as Freddie). This year Vaughan has retired but so have McGrath and Warne. Freddie has a dodgy knee and the other English giant to emerge, Peterson, is out with a damaged ankle. Australia have also lost their third best bowler, Bret Lee, to injury.

In the first Test, at Cardiff, it was Australia's game, but a last ditch batting performance meant that England held out for a draw that they didn't deserve. In the second Test at Lord's, England had an easy win. This is an inexperienced Australian side, with only their captain, Rickie Ponting, remaining from their years of dominance. The third Test in Birmingham is going to be heavily affected by rain, so that on the first day only 30 overs were bowled, which Australia negotiated easily. Yesterday, on what should have been my day, England bowled splendidly. They took 9 wickets on a day perfect for swing bowling - damp, overcast and not too cold. Swing bowling is an art particularly suited to English condition. Ideally, the ball should appear to be straight, but late in its flight veer to the left or right to catch the edge of the bat and give a catch to the slips or miss the bat completely and crash into the stumps. Jimmie Anderson is probably the best swing bowler in the world at the moment, and he took 5 wickets, while Graham Onions is not far behind him.

I remember watching Reg Perks bowl for Worcestershire in the 1950s. He could make the bowl swing for yards, but it was uncontrolled and while spectacular to watch, he took no wickets. No, the art is to move the ball inches so that the batsman must play at it, but is likely to miss. Alas for the Australians they do not possess great swing bowlers at the moment. England are on top so far but it is pouring with rain here this morning and the Test has all the hallmarks of a Draw.