Sunday, September 25, 2011

John 6:67-69. The Holy One of God

"You do not want leave too, do you?" Jesus asked the Twelve. Simon Peter answered him, "Lord, to whom shall we ho? You have the words of eternal life. We believe and know that you are the Holy One of God."

This is Holy Spirit-given faith. Is it ours too? Brother, have you found what you were looking for? Sister, have you stopped your search? Jesus is all in all. Eternally, he has the words of life. That is not going to change. He is God

The image of scientists

If you ask anyone, they will tell you that science has transformed their world with amazing discoveries. But then if you invite them to draw a scientist, what they depict is precisely what people would have described 50 years ago: they draw someone with a hangdog look, frizzy hair and test tube in hand, all in a scene where things are going wrong. There are national variations. In Italy, scientists tend to be scarred and have bolts in their necks, like Frankenstein's monster. In general, though, they are mostly white, male, bald and wearing a white coat.

Perhaps it comes from the image of the old Einstein with tongue out - the one everyone knows – the one taken on his 72nd birthday. But he was a dapper 26-year-old when he had his “annus mirabilis” and wrote the four papers that changed physics.

In fact scientists look like anyone else; many of them are women, most of them are young and some even look like Brian Cox who presents science of TV and looks like a rock star.

Global warming

From this week's New Scientist:

Last week the Times Atlas announced that "For the first time, the new edition… has had to erase 15 per cent of Greenland's once permanent ice cover. This is concrete evidence of how climate change is altering the face of the planet forever.”

Glaciologists cried foul, saying the ice is definitely receding, but the 15 per cent figure is wildly inaccurate.

If what The Times Atlas has said were true, something like a metre of sea level rise would have occurred in the past decade. In fact, Greenland has contributed roughly 3 millimetres to sea level in that time.

So what went wrong? The Times Atlas team say they mapped the ice sheet from ice thickness data on the National Snow and Ice Data Center (NSIDC) in Boulder, Colorado website. But NSIDC says its scientists were not consulted. The data are complex and thickness maps are not intended to show the edge of the ice sheet, so it is possible the cartographers misinterpreted the data.

It is interesting how various media sources handled this piece of information. The Daily Mail assured us that the whole publication would have to be pulped, whereas the BBC passed it off as a trivial error with only the statement having to be withdrawn. The truth is somewhere in between. Publisher Harper Collins apologised for not consulting scientists and retracted the 15 per cent figure, but stood by its map, for now. A spokesperson said it may be modified in annual reprints.

Objections to Christianity

Why does God hate gays and prostitutes?

Does he? When Jesus was walking on planet Earth he used to spend his time talking to prostitutes and other social outcasts. he had more time for them than for religious people.

Why are Christians such hypocrites?

Yes, why? Did you know that that Jesus got so upset with religious hypocrites that he started throwing the furniture about in their religious buildings?

Saturday, September 24, 2011

John 6:66. The soul-searching verse.

From this time many of his disciples turned back and no longer followed him.

This is one of the saddest verses in the whole of the Bible. Having come this far, they desserted him. For them he was just a passing fashion like Moon Boots or mini-skirts. I wonder whether at the Great Excise it will be the same for you? There is much that is superficially attractive about Christianity: the miracles, the ordered life, the rules, the community spirit, the 'niceness' of other Christians, the excitement, the hymns, the wonderful music, the beautiful buildings, the stained glass, the liturgy, the lives of Christian heroes, the wonderful stories - but are you willing to bet your life on it? Do you hold it above all? Do you love God with all your heart, mind and strength? And do you show it by how you treat your neighbor?

Friday, September 23, 2011

John 6:64-65. Willful disobedience

Yet there are some of you who do not believe. For Jesus had known from the beginning which of then did not believe and who would betray him. He went on to say, "This is why I told you that no-one can come to me unless the Father has enabled him."

This alone should put a stop to the idea of universalism - that all will be saved. Sadly, it is exactly the other way round - all are doomed - unless they become special cases. Salvation is all of grace. No-one comes to God unless the Father draws him. Our nature is to be rebellious; God's nature is to be forgiving, but he will not impose his nature on ours. For some of us, we will not believe and we will betray him.

Thursday, September 22, 2011

John 6:61-63 Life in the Spirit

Aware that his disciples were grumbling about this, Jesus said to them, “Does this offend you? Then what if you see the Son of Man ascend to where he was before! The Spirit gives life; the flesh counts for nothing. The words I have spoken to you—they are full of the Spirit and life.

How different are the spiritual life and the physical life! I suppose that for the majority of people in Britain, 'spiritual' has connotations of crystals and lay-lines. So much has the Devil taken over and corrupted Biblical language! The true spiritual life is about communication with God through God, the Holy Spirit. This is the only true life; the rest is just animal existence. For the Christian this (eternal) life has already begun and will continue after physical death.

When we are caught up with hustle and bustle of physical life - families, career, entertainment - it is hard to focus on the spiritual dimension. That is why we need our quiet times. For an eternity to come it will be nothing but a spiritual life. Hallelujah! No distractions. No wickedness. No tears. No disputes. All will be clear.

Chlorambucil - still not bad: a reappraisal

In the current issue of Clinical Lymphoma and Myeloma are articles by Daniel Catovsky and Kanti Rai about the relative merits of chlorambucil and fludarabine. I won't go into Kanti's article except to quote this "We do not by any means suggest that chlorambucil as a therapeutic agent should be abandoned."

Daniel's article goes much further. He suggests that clinical trials using chlorambucil have been unfairly biased against it. (Why would that be, I wonder? Could it be that there is no money to be made from chlorambucil?)

He presents evidence to show that the dose of chlorambucil needs to be at least 70 mg/sq meter/month and that the duration of treatment needs to exceed 6 months, preferably up to 12 months. I have already written about this until I am blue in the face, but here is additional evidence that I have not previously mentioned.

I had often puzzled over the fact that the French version of CHOP did so much better than other versions. The answer is now clear: they used double the dose of alkylating agent (cyclophosphamide) and half the dose of anthracycline (doxorubicin) as other people. The Jaksic trial of 1997 had impressive overall response rates of 89.5%. He pushed chlorambucil to toxicity at a dose of between 150-180 mg/sq m/month.

Catovsky comments that the chlorambucil arm of the bendamustine trial was a real outlier, with a response rate of only 31% and a PFS of only 7 months. This compares with the CLL4 trial which had a response rate of 72% and a PFS of nearly 2 years. What he doesn't realise is that the dose of chlorambucil in this trial was calculated according to 'ideal weight'. How many of us (especially we older ones) are at our ideal weight. And if you delve into the small print you find that 'ideal weight' is a function of height. So the dose of chlorambucil in that trial was calculated according to the patient's height! Who ever heard of such a thing? I cannot believe that anything other than obfuscation was intended. And to show Bendamustine in a more favorable light.

Chlorambucil is considerably less toxic than fludarabine, even when given in full doses. My spies tell me that Bendamustine is a lot more toxic than it is claimed to be. There is still life in the old dog, yet.

Away from my desk

I'm sorry not to have communicated recently. but I have been very ill. I had to reduce my dose of Capcitabine because of toxicity and initially this improved the side effects, but only for a day and then fatigue and abdominal pain returned with a vengence; so much so that I could not take the full 14 day course. Even after stopping the toxicity continued and I had to stop eating. On water alone by mouth plus Buscupan and Co-codomol the symptoms gradually settled and I woke at 4 am today feeling better. I am due to start the same regime next Monday.

Thanks for all the good wishes.

Thursday, September 15, 2011

Dose reduction

No blogging for the past few days because I have been so unwell. Yesterday, I was aslep for 20/24 hours. It was only pain or diarreah that woke me up. I phoned my oncologist theis morming and he suggested a dose reduction. My chemo-brain was so bad that I could not work out the dose of capecitabine I was taking. 500 mg x 10 was beyond me.

I have reduced the dose by 20% and today I have felt much better. I have actually sat for an hour in the garden under a clear blue sky; the first time I have been outside for many days.

Monday, September 12, 2011

CLL and leukemic stem cells

I have been think about cancer stem cells as they might affect CLL. The concept if that there is a damaged hemopoietic stem cell that feeds in to the tumor that does not carry the same markers as the tumor and would therefore not be susceptible to the type of treatment that would be effective for the bulk of the tumor cells. There is strong evidence that leukemic stem cells exist for acute myeloid leukemia, but the B cell malignancies would seem not to be involved with such because clonal commitment is a late event occurring after rearrangement of the immunoglobulin genes..

However, there is some indirect evidence that a leukemic stem cell might exist. First, there are the familial cases; For these to exist there must be a defect in the germ line - and in at least one family case we know there is a mutation in DAPK. We also know that in families with a high incidence of CLL the CLLs are not clonally related, that there is a 3 times higher incidence of monoclonal B cell lymphocytosis than in normals and that other B cell malignancies also have a higher incidence. Moreover some people finds that MBL is frequently oligoclonal and some people have claimed to find a second B cell clone in up to 10% of patients with CLL. WE, ourselves found that about half of MGUS cases are oligoclonal.

Many years ago (1986) we reported 20 patients with B cell malignancies that had MDS without receiving any form of cytotoxic treatment - evidence that a precursor cell to both myeloid and B-cells was injured. One occasionally sees CLL and CML in the same patient.

Freda Stevenson wrote an important paper in 2010 in Blood which showed that the V1-69 stereotype that is common in CLL was also commonly used in the normal immune response.

So this is how a CLL stem cell would work: a] One would expect that there might be an excess of other hematological malignancies. b] one would expect that there would be an excess of other B cell tumors. c] One would expect that there would be some biclonal or even triclonal CLLs. d] One would expect there to be a precursor condition that was oligoclonal. e] One would expect the same maturation pattern as in the normal immune response.

There is one other fact to add: while MBLs with easily detectable lymphocytoses use the same repertoire of V genes as CLL while those with minimally detectable disease use a random repertoire, the very late relapse of some B cells malignancies.

Having been a sceptic on leukemic stem cells in CLL, my views are changing; all this is only possible if we postulate a very slow progression and a very long natural history.

Healthcheck - sleepiness

In me the chief side effect of this new chemotherapy seems to be tiredness. I spent much of the weekend asleep, so no blogging. I am still slogging through the book on Bayesian statistics, so perhaps that is part of the reason, but it is a particularly relaxed form of sleep so I can't complain.

Almost for the first time in my life, I feel no compulsion to do anything. It seems that all my life I felt guilty if I wasn't active, making things happen in a typically alpha-male sort of way. These days it doesn't seem to matter. I drop of to sleep, dream away and then wake up for a bit. Then I fall asleep again. I am quite happy about it.

John 6:59-60: no Jesus plus ...

He said this while teaching in the synagogue in Capernaum. On hearing it, many of his disciples said, “This is a hard teaching. Who can accept it?”

FF Bruce wrote a book entitled "The Hard Sayings of Jesus". It was not that what he said was hard to understand, but they were hard to accept and go along with. These are among the hardest. They are of course metaphorical, but even so they demand a level of committment that most people are inwilling to accept. Shortly we will see 'disciples' beginning to desert Jesus. It is easy to follow a miracle worker of a good speaker, but someone who demands that we change our lives is another matter.

You can't have Jesus and your old ways; he is much more demanding than that.

Friday, September 09, 2011

John 6:57-58. Keep the main thing the main thing

Just as the living Father sent me and I live because of the Father, so the one who feeds on me will live because of me. "This is the bread that came down from heaven. Your ancestors ate manna and died, but whoever feeds on this bread will live forever.”

We are totally dependent on the Lord Jesus. This is why the story of the cross is so central to our faith. There are churches where the cross is barely mentioned, indeed it is a bloody embarrassment. The 'other bread' they are fed includes social work, feeding the hungry, healing the sick, aiding the poor, helping the political underdog. All these are good things but they are not fundamental to the faith. I often ponder that in the new heaven and the new earth they will not need doctors. Or missionaries.

The main thing is the cross. Keep it the main thing.

How you make a writer

I have been asked how I came to be a writer. Can I call myself a writer? Counting this blog I have written about 2500 articles, books, scripts, chapters, abstracts and scientific reports including over 700 that other people have published; so yes I can call myself a writer.

I began by writing poetry. I had a good grounding at school in Latin and English grammar, but I never studied English literature until I was 17 and had free time in the sixth form. I had always been a good reader, though, and as a child had rapidly read through the schoolday adventures of Frank Richards, the military adventures of Captain W E Johns, the detective and horror stories of Peter Cheyney and Dennis Wheatley and the lawyer and doctor stories of Henry Cecil and Richard Gordon. I remember being asked by my headmaster at the age of 13 which authors I read. When I volunteered H E Bates (of the Larkin stories) he had never heard of them. He claimed to be one of 6 Englishmen who had read the whole of Cervantes in Spanish.

At seventeen I was heavily into the science fiction of Isaac Asimov, Ray Bradbury, James Blish, Theodore Sturgeon, Alfred Bester and Frederick Pohl. Later in my life I discovered Tolkien and his lineage: Robert Jordan and Stephen Donaldson. Meanwhile Graham Greene, John LeCarre and Raymond Chandler had captivated me.

When I started writing poetry, my biggest influences were John Donne, Wilfred Owen and Gerrard Manley Hopkins.

After I was married I virtually stopped writing poetry until after I retired. Medicine is a demanding mistress. Someone told me that if I wanted to become an expert on something I should write a book about it. So I did. I wrote the first book about Plasmapheresis. I also wrote a funny article for the Christmas BMJ called Mononucleosis and the Miniskirt about a girl with glandular fever, cold hemaglutinnins and a miniskirt who got a rash on the outside of her thighs on a cold night. This gave me an appetite for writing for a Freebie doctors' journal called World Medicine. I wrote about medical politics and about funny things that happened to me on the lecture circuit. To be honest it was an easy way to make money. I could dash off 500 words in about half an hour and make £100. When World Medicine closed (Jewish businesses refused to advertise in it after someone wrote a pro-Palestinian article) I started selling my wares to other journals, but my research fellow Ghulam Mufti (now Professor at Kings) persuaded me that no-one would ever take me seriously unless I stopped the frippery. Thereafter my writing apprenticeship served me well for writing serious articles.

However buried in one of my CLL articles in B J Haem. is a joke that I as editor would have put the blue pencil through. It would probably be excluded for bad taste in these PC days.

It goes like this. In Bournemouth there is no male excess of CLL patients. Why? Like elephants seeking their burial ground, the old ladies come to die, but whereas elephants have prodigious memories, the old ladies become senile and forget what they have come for.

Thursday, September 08, 2011

Going to war

Both the first and second world wars were started by the UK because we went to the aid of a country with which we had treaty obligations. Germany invaded Belgium and then Poland. When Iraq invaded Kuwait the same principle applied. After that things got complicated.

With the break up of Yugoslavia after Tito died the Serbs committed atrocities against the Bosnians despite a UN peacekeeping force. Tony Blair persuaded Bill Clinton to help him defend the Bosnians, even though their action was very late and subsequently the Kosovans were also protected from the Serbs. Blair had been encouraged in all this by the success of the invasion of Sierra Leone to protect the government against Charles Taylor in a rebellion funded by blood diamonds.

I see today that Tony Blair is advocating regime change in Iran and Syria. On television yesterday there was a worry that Iraq is now an Iranian vassal state. Yer no-one has advocated invading Zimbabwe or Byelorussia where there are really nasty dictatorships.

Interference in the internal affairs of another country is forbidden by the Treaty of Westphalia. Taking sides in a civil war is dangerous if you are found to have supported the loser (as Tony Blair did in Libya).

What do you do when pitted against a private army. In Sierra Leone it worked out well, but it took 10 years for the might of the US to kill Osama bin Laden. The private army is unlikely to obey the Geneva conventions. Should you? War has become much more difficult.

Harry Potter

The London Institute for Contemporary Christianity is situated in a an old church just round the corner from the Royal Society for Medicine in Wimpole Street. It was established by the late John Stott and its current Executive Director is Mark Greene was converted out of the advertising industry. We have had him to preach at Lansdowne on being a Christian in the workplace. He was extremely good.

He has written a review of the latest Harry Potter film in the September issue of Evangelicals Now

Many evangelicals in America have criticized the Harry Potter series as dabbling in sorcery. I have always thought this was Baloney. You might as well criticize CS Lewis or Tolkien on the same grounds. The Harry Potter series is a fantasy based on the spiritual battle between good and evil and the 'magic' is just a matter of pointing a 'wand' and shouting a command in cod Latin. Let me tell you, it doesn't work.

The theme of Harry Potter is self sacrificing love and it picks up on many Biblical themes. At the start of the story we have Harry's mother, Lily, sacrificing herself to save her baby - literally covering him with her blood.. In the first book we have Ron putting himself at risk to save Harry and Flammel giving up his own immortality by allowing the destruction of the Philospher's stone. Throughout the series there are several instances of people sacrificing them selves to save Harry's life. In the last film we had Dobby the House-elf and Mad-eye. Snape has been working with Dumbledore at great danger to himself for the sake of the son of a man he despised for the unrequited love for Harry's mother and Dumpledore, Harry's surrogate father has known all along that in order to defeat Voldemort, Harry must subject himself to his power and die. Imagine a father who knew that in order to defeat evil his son must die.

Still it falls short of what Jesus did. The love that Jesus showed was love for his enemies. He didn't just die for his side. While we were yet sinners Christ died for us.

John 6:55-56. What is the value of the Lord's Supper?

For my flesh is real food and my blood is real drink. Whoever eats my flesh and drinks my blood remains in me, and I in them.

Does this refer to the Eucharist? In a sense, as it points forward to the feast of the Last Supper, but it does not mean that the regular consumption of the bread and wine is a pre-requisite for eternal life. Would you exclude all Salvationists and Quakers? Not to mention the Thief on the Cross. Don Carson gives several arcane references as to why this is not so and Ignatius back in the Second Century had already worked it out. So don't worry on this score if you have sometimes missed communion. The value of the Lord's Supper is to keep the cross always before us - so that we remain in him and he in us - but also as we share in the communion of saints. We eat and drink together as part of the Koinonia. We are all, however wealthy of important in this world's view, united in our abjectness before the Holy God. Penitent sinners before a pure and Holy God; we come for grace; undeserved mercy that is our only remedy.

Riots in Northern Ireland

Belfast Child raised the question of the riots in Northern Ireland and to be sure they were more severe and more severely dealt with. They were different, however, in that there was, at least for many, a political motivation.

Most independent observers took an instant 'gut-reaction' side on what was going on in Northern Ireland and tended to be blind to its own side's foibles. My instant reaction was to side with the Unionists, but I know that those on the left politically and most Americans sided with the Republicans. Mrs Thatcher also favored the Unionists and who can blame her? She lost Ian Gow and Airey Neave from her Cabinet and was herself blown up in Brighton by the IRA. (Airey Neave was the first British escaper from Colditz and ran the Escape operation from Germany for MI9 for the rest of the war.)

When the Irish Troubles began there was undoubtedly an abuse of human rights by the Protestant hierarchy in Northern Ireland. The troops were originally sent in by Harold Wilson to protect the Roman Catholics. In some institutions Catholics were denied jobs and the devolved government favored protestants unfairly. The police force (especially the B specials) was biased and unfit for purpose.

On the other hand what was going on in the Republic, and what the North wanted no part in, was far worse. We now know that priestly celibacy was a running joke, that pedophilia was rampant, the abuse of women was legendary and that a conspiracy between the Roman Catholic church and a corrupt government engineered a cover-up of gigantic proportions. So many Irish men had emigrated to New England that similar wickedness existed there. What we now know about the Kennedy clan disgusts right thinking people. People in Northern Ireland regard Eamon Devalera as the devil incarnate.

The troubles in Northern Ireland have a long history and I know people will point back to the potato blight, absentee landlords and even Cromwell. The point is that whatever the justification nothing can excuse the terrible things that were going on on both sides, nor the breakdown in Law and Order that resulted in the deaths of thousands. Since the Good Friday resolution people who were regarded by the other side as monsters have sat down together and formed a government, putting the past behind them. In some respects they have found a common enemy - secularism. Northern Ireland is the most religious part of the UK; both Protestant and Catholic are anti-abortion and in favor of Holy living. That they have different concepts of quite what that means is not surprising in a modern state, but it surely includes the rule of law. The fundemental differences between each side are not that great; what separates them are the acretions on to each side's religious basis. Segregation of schools is the greatest barrier remaining and for this I hold the Roman Catholic Church to blame.

The British Government has done as much as it could to favor peace and has continued to subsidize the cost of Northern Ireland even more than it subsidizes Scotland. So it should, England is still one of the rishest countries in the world. From John Major's onwards British governments cannot really be faulted in their benevolence.

Wednesday, September 07, 2011

The rule of Law

How do you stop people doing what is wrong?

One answer might be, you don't. What you call 'wrong' is only wrong in your opinion and it's their business not yours.

If you live in a society which is supposed to function as a whole, it all eventually depends on the use of force. We employ a police force to restrain and even, if necessary, kill those who are breaking the law. The law that they break has many origins but comes down, in a democracy, to the will of the majority demonstrated in a ballot. There are fine checks and balances in a mature society. There is also separation of powers so that the executive, the parliament and the judiciary are able to disagree. The fourth estate is empowered to investigate. The balance between these four powers must be preserved so that no-one predominates. Who judges that? The Demos; the people.

In the recent riots in London and elsewhere in England, 75% of those arrested were known criminals and I dare say the rest were mostly criminals who had hitherto escaped arrest. One 11 year old was on police bail for setting fire to a bus the previous week. They seemed to have thought that the Law had been suspended or switched off for a day. Result: anarchy.

Not for nothing does the magistrate bear a sword, says St Paul.

Liberal opinion seems to think that rioters and looters should be treated lightly. Police tactics are expected to be those with a 'light touch'. But the public (in opinion polls) favor a more robust approach. In many European countries they go beyond the riot shields and police batons used in the UK. Water canon, tear gas, plastic bullets and even live rounds may be used.

The problem with such escalation is that people must be allowed to demonstrate freely against perceived ills. Drawing the line between a peaceful demonstration and a riot may be difficult. Regimes like Syria have clearly got it wrong, but often the decision lands on one man's lap and a quick answer is needed. In the UK the police tend to act with caution. In the recent riots, rather than escalate the violence the police chose to photograph it and use the images to prosecute the perpetrators afterwards. If the justice now seems harsh - 4 months in prison for stealing a pullover - it should be remembered that it was not for the theft that the punishment was exacted, but for the riot and looting, which was a threat to the structure of society.

The Director of Public Prosecution has protested about the harshness of the sentencing. This man was a Tony Blair appointment who was named after the founder of the Labour party and has been a lifelong Marxist. Th American idea that functionaries such as he are reappointed by an incoming administration is a good one. The man should be dismissed.

Samuel Rutherford during the Glorious Revolution of 1688 summed it up in a Latin phrase: Lex rex; the Law rules. The Riot Act, which was repealed by the last Labour government, allowed the police to fire live rounds at a mob that refused to disperse after it had been read to them. Undoubtedly, it has been misused (though not for a century) but we need it back on the statute book, not least to demonstrate that law and order is ultimately guaranteed by the use of force. We may be 'slow to chide and swift to bless' but the eventual sanction is the use of force.

In international affairs the problem is even more complex. If we are attacked we have the right to defend ourselves, but how far does that extend to the defence of a third party; especially if that third party is a citizen of the country doing the attacking. And suppose the attacker is not a state but an armed gang beyond the control of that state? Tomorrow I shall try and explore that question.

Health report

I have completed day 1 of my chemotherapy - 13 more to come. I acually feel better than before I started; probably because my bowel was acting in slow motion (boom!boom!) and now is more free flowing.

This treatment consists of a 5 minute injection then 5 tablets twice a day for 2 weeks. The side effects are mainly associated with the gastrointestinal tract, which I won't mention further apart from saying that a computer friend has described it as the rapid downloading some software.

My bruises from the fall in the garden (I mean my garden, not the Garden of Eden) are gradually healing; they are at the less painful but more colorful stage. Still, I have to take regular painkillers.

John 6:54b: Raised by him.

I will raise them up at the last day.

But doesn't St Paul tell us that "all will be raised"? This phrase has been used earlier in verse 40 in the context of believing in him.

I think that the emphasis here is that we don't believe in the way that we believe in the sky being blue - if it were red I would believe that too - in a way that nothing really depends on it. It means believing with an intesity that trusts absolutely.

As for being raised by Jesus this means being raised as one of his own. Sure, all will be raise but some for glory and some for destruction.

Tuesday, September 06, 2011

John 6:53-54. Vampires and cannibals

Jesus said to them, “Very truly I tell you, unless you eat the flesh of the Son of Man and drink his blood, you have no life in you. Whoever eats my flesh and drinks my blood has eternal life, and I will raise them up at the last day.

This is about as gruesome as it gets. Vampires and cannibals. The Jews drained the blood from their meat so this saying is doubly offensive. Blood does not have the connotation of life, but of death. The implication is that we must participate fully in the death and resurrection of Jesus. We are not simply giving assent or going along with the whole thing. This is a message that rams home. Do we truly believe? Are we completely trusting in Jesus? Has all other hope been dismissed?

Monday, September 05, 2011

Why experts do better.

What has got the CLL world talking at the moment is a paper in Cancer from the Mayo Clinic which suggests that patients treated by the CLL team live almost 2 years longer than those treated by teams at the Mayo that are expert in other hematological conditions like myeloma, lymphoma or MDS. Why should this be?

This was not a randomized prospective trial so the obvious explanation would be that the groups were not well matched. However a multivariate analysis of known prognostic factors such as age, stage, sex, and total white count still leaves the expertise of the doctor as a significant factor.

The most striking difference between the two groups was that the experts kept the patients on watch and wait longer. Once treatment starts then hazards are introduced. The patient is more likely to develop infections, autoimmunity, extra chromosomal abnormalities, pancytopenia, Richter's transformation and MDS. The commonest mistake I see made by general oncologists is to treat just because of a high white count - not an indication in the international guidelines.

Non-experts are much less likely to request biological prognostic markers; so much so that it was not possible to separate the two groups of patients according to these parameters. Even the cheap Beta-2M test was not done sufficiently frequently, so it was more likely ignorance rather than expense that was the deterrent.

Non-experts were much less likely to enter patients into clinical trials even though it is well known that patients entered into trials fare better tan those treated according to physicians' choice.

Non-experts were more likely to choose chlorambucil or rituximab alone than a purine analog combination. Now I think there is a place for chlorambucil alone in the right patient, especially at the right dose, but this should be chosen from a position of expertise rather than ignorance.

So I find the paper believable. It is not necessary to be treated by an expert - their fellows do even better than they do, but make use of an experts expertise.

Sunday, September 04, 2011

The FAB Group

I had a visit yesterday from Jerry Marti from Washington. Jerry is writing a history of CLL and he interviewed me for 3 hours in my office. By interviewing senior figures he is able to get a seecond-hand look at the truly greats like Davic Galton who are no longer with us.

David was one of the FAB group (French-American-British) who defined many of the malignant hematology diseases that we treat today. My link to David was via Ghulam Mufti, who was my research fellow for 6 years in the 1980s. Ghulam, who is now a Professor of Haematology at Kings Collge London, was a young fellow at the time and we had received a research grant from the the LRF for me to supervise him in research into MDS. One of the specifications of the grant was that we should both learn from David Galton and so we had regular trips to the Hammersmith hospital where David would serve us Darjeeling tea and teach us from his vast experience. Any case we mentioned would trigger a memory and he would pull down a blue notebook in which he had kept a record of a similar case.

Of the other members of the FAB group, I, of course, know John Bennett very well since we jointly edit Leukemia Research, but I also met Claude Sultan fron the Henri Mondor hospital in Paris. I was attending the World Apheresis Association meeting in Dijon, when I was president of the European Haemapheresis Society. Claude picked me up at Gare de Nord off the Eurostar, took me to lunch (oysters), showed me over his hospital and then put me on the train at Gare de Lyons.

Last chance Harvey

Last chance Harvey is about a middle aged divorced man who goes to his daughter's wedding and has his life changed around by a middle aged spinster. Dustin Hoffman and Emma Thompson play the principals and it has a feel-good factor, but you can't quite see where it comes from.

Thursday, September 01, 2011

Early days

Mr Grosch was my Latin master. He played a game with his first year boys. They sat in rows and lines and he would ask them questions in turn if you answered a question that the others had got wrong you moved up closer to the front, supplanting those in error. This competitive game suited 11-year old boys and would be useful, even today, in instilling a sense of competition where it is needed.

Mr Morgan was my Maths teacher. He hated untidiness. I was and always have been untidy. He thought I was useless at Maths. His particular punishment for untidiness was to percuss the perpetrator's skull with his middle finger as a doctor percusses an abdomen or a chest. It hurt. He was very surprised when I came top of the class in Maths.

Mr Sweet was my French teacher. His particular punishment was to lift the boy from sitting to standing position by the short hair in front of the ear. That is even more painful even though it doesn't leave a mark. It did not improve my French, though this was the first time I heard someone use the 'F' word at school.

As methods of carrot and stick, the carrot was more successful than the stick. Although I was good at Maths, my handwriting never improved. I trace my proficiency at Maths (and indeed all maths-based sciences, to my rote learning my tables from the age of 4 onwards.

Mr Wetton was my primary school teacher. He was keen that we should do sport and keen on mental arithmetic. I was the only child in his care who had achieved 100% for three successive mental arithmetic tests. He gave me his silver pocket watch as a reward.

Is a pattern emerging here?

John 6:52. The word became flesh

Then the Jews began to argue sharply among themselves, “How can this man give us his flesh to eat?”

Don Carson writes, "Any dullard can see that Jesus was not speaking literally!"

Jesus is so explicit about this metaphor that these days we would call him a 'wind-up' merchant. Yet for those who have read the whole gospel, we remember that "The word became flesh." and the Greek word used there 'sarx' is the same word for flesh as is used in John 6 and not 'soma' as is used for the Eucharist "this is my body".

My first memories

The other day we had a visit from my youngest granddaughter. She is 18 months old and not quite used to us. She wants to be holding on to her mother's hand. I think it is a case of
'Always keep a hold of nurse
For fear of finding something worse.'

I was trying to imagine what it might be like for her by recalling my own memories of being that age.

My earliest memory is of visiting my rich Jewish great grandmother. I am told that she died when I was 18 months old and I know that as a family we visited Worcester at Christmas and in the summer, so I must have been either 9 or 15 months old at the time. I remember that I was still in napkins (diapers) and not walking. Although I understood many words I didn't know the difference between a wireless and a piano. I could speak but I was too shy to do so. I was sitting on my father's knee. I therefore suspect that this was Christmas 1943.

Even then, although I could not and cannot remember what they were, I already had memories. What I remember of the day was that everybody was talking about things I didn't understand, but at one stage of the afternoon I became the center of attention. I was asked if I wanted to play the piano which left me confused because perched on the piano was a Bakelite radio which I knew I had been forbidden to touch. I clearly didn't know the difference.

So I suspect that my granddaughter still finds life very confusing.