The fruit of the Spirit is ...self-control...
Elsewhere we are told not to be controlled by wine but by the Spirit and many have interpreted this as meaning speaking in tongues, singing with hands in the air and generally "Letting go and letting God".
But the fruit of the Spirit is self-control. Is that control of self or control of self? The word used in the Greek means 'keeping oneself in check'. There is a happy balance to be obtained between being as dull as ditch water and going over the top. One must know how and when to show enthusiasm, innovation and imagination, without giving offence by one's behavior. Living with the consciousness of the Holy Spirit every day engenders that balance in us.
Wednesday, June 15, 2011
John 4: 39-42. Encounter, testimony.
Many of the Samaritans from that town believed in him because of the woman’s testimony, “He told me everything I ever did.” So when the Samaritans came to him, they urged him to stay with them, and he stayed two days. And because of his words many more became believers. They said to the woman, “We no longer believe just because of what you said; now we have heard for ourselves, and we know that this man really is the Savior of the world.”
We cannot all be evangelists. We are all called to be witnesses. The woman had given her testimony to the other villagers who then had their own encounter with Jesus. You can't be saved by second-hand hearsay evidence. Everyone needs his own encounter. The evangelistic pattern is encounter, testimony, witness, encounter, testimony; and it should continue exponentially.
We cannot all be evangelists. We are all called to be witnesses. The woman had given her testimony to the other villagers who then had their own encounter with Jesus. You can't be saved by second-hand hearsay evidence. Everyone needs his own encounter. The evangelistic pattern is encounter, testimony, witness, encounter, testimony; and it should continue exponentially.
Tuesday, June 14, 2011
Chronic fatigue syndrome not due to a mouse virus
Two years ago, Vincent Lombardi at the Whittemore Peterson Institute in Reno, Nevada, reported a possible cause of the tiredness and muscle pain of Chronic Fatigue Syndrome (CFS) after discovering a mouse virus called xenotropic murine leukaemia virus-related virus (XMRV) in blood samples from 68 of 101 people with CFS compared with just eight of 218 samples from healthy volunteers.
Now Jay Levy's group at the University of California, San Francisco have evaluated blood samples from 61 patients with CFS from a single clinical practice, 43 of whom had previously been identified as XMRV-positive. Their analysis included polymerase chain reaction and reverse transcription polymerase chain reaction procedures for detection of viral nucleic acids and assays for detection of infectious virus and virus-specific antibodies. They found no evidence of XMRV or other Mouse Leukemia Viruses in these blood samples. In addition, they found that these gammaretroviruses were strongly (X-MLV) or partially (XMRV) susceptible to inactivation by sera from CFS patients and healthy controls, which suggested that establishment of a successful MLV infection in humans would be unlikely. Consistent with previous reports, they detected MLV sequences in commercial laboratory reagents. Their results indicate that previous evidence linking XMRV and MLVs to CFS is likely attributable to laboratory contamination.
In another study, Vinay Pathak at the National Cancer Institute in Frederick, Maryland, suggested that XMRV originated in lab mice between 1993 and 1996 – after many of the people in Lombardi's study were diagnosed with CFS – and so cannot be the cause. Pathak said that researchers grew cancers in mice without immune systems in order to make prostate tumour tissue for study. The tumour cells picked up two leukaemia viruses which combined to form XMRV. The strains in Lombardi's samples are so similar to this “recombinant” virus that it is unlikely to have another source.
Now Jay Levy's group at the University of California, San Francisco have evaluated blood samples from 61 patients with CFS from a single clinical practice, 43 of whom had previously been identified as XMRV-positive. Their analysis included polymerase chain reaction and reverse transcription polymerase chain reaction procedures for detection of viral nucleic acids and assays for detection of infectious virus and virus-specific antibodies. They found no evidence of XMRV or other Mouse Leukemia Viruses in these blood samples. In addition, they found that these gammaretroviruses were strongly (X-MLV) or partially (XMRV) susceptible to inactivation by sera from CFS patients and healthy controls, which suggested that establishment of a successful MLV infection in humans would be unlikely. Consistent with previous reports, they detected MLV sequences in commercial laboratory reagents. Their results indicate that previous evidence linking XMRV and MLVs to CFS is likely attributable to laboratory contamination.
In another study, Vinay Pathak at the National Cancer Institute in Frederick, Maryland, suggested that XMRV originated in lab mice between 1993 and 1996 – after many of the people in Lombardi's study were diagnosed with CFS – and so cannot be the cause. Pathak said that researchers grew cancers in mice without immune systems in order to make prostate tumour tissue for study. The tumour cells picked up two leukaemia viruses which combined to form XMRV. The strains in Lombardi's samples are so similar to this “recombinant” virus that it is unlikely to have another source.
Galatians 5:23 ...gentleness...
The fruit of the Spirit is ...gentleness...
Jesus was the meekest man who ever lived. Before you run away with the idea of a milksop in a white nightdress, 'meekness' has the meaning of strength under control. The other night while I was stranded at various railway stations on the Southern Region I watched a huge Diesel locomotive inch its way into a platform. Had I gone up to London on the Friday as I had planned I would have found my journey disrupted again. Someone stepped off Southampton platform into the path of an oncoming train. The huge locomotive utterly destroyed that frail human body. But the same sort of engine was inching into the station under fingertip control early on Friday morning.
Jesus was meek but he had immense destructive power in his hands. Yet he was gentle. He was gentle with the woman it the well. He was gentle with the woman taken in adultery. He was gentle with the children that the disciples would have turned away. Gentleness is one of the fruits of living with the Spirit.
Jesus was the meekest man who ever lived. Before you run away with the idea of a milksop in a white nightdress, 'meekness' has the meaning of strength under control. The other night while I was stranded at various railway stations on the Southern Region I watched a huge Diesel locomotive inch its way into a platform. Had I gone up to London on the Friday as I had planned I would have found my journey disrupted again. Someone stepped off Southampton platform into the path of an oncoming train. The huge locomotive utterly destroyed that frail human body. But the same sort of engine was inching into the station under fingertip control early on Friday morning.
Jesus was meek but he had immense destructive power in his hands. Yet he was gentle. He was gentle with the woman it the well. He was gentle with the woman taken in adultery. He was gentle with the children that the disciples would have turned away. Gentleness is one of the fruits of living with the Spirit.
John 4:35-38 Harvesting
Don’t you have a saying, ‘It’s still four months until harvest’? I tell you, open your eyes and look at the fields! They are ripe for harvest. Even now the one who reaps draws a wage and harvests a crop for eternal life, so that the sower and the reaper may be glad together. Thus the saying ‘One sows and another reaps’ is true. I sent you to reap what you have not worked for. Others have done the hard work, and you have reaped the benefits of their labor.”
Yesterday I had a busy day actually doing some work on a conference call so I posted something on evangelism from my archives, but it was relevant to our passage for today.
Songs of Praise on Sunday cam from Nottingham where several large city-center churches provided a strong evangelical witness in the city. In Bournemouth, Lansdowne Baptist Church was once by far the largest congregation, but today we have churches taking over Bingo Halls, Theaters and DIY warehouses. I detect the Holy Spirit moving in the UK this Pentecost. Jesus tells his disciples to "reap what you have not worked for". The Holy Spirit has done the work; we are the harvesters.
Yesterday I had a busy day actually doing some work on a conference call so I posted something on evangelism from my archives, but it was relevant to our passage for today.
Songs of Praise on Sunday cam from Nottingham where several large city-center churches provided a strong evangelical witness in the city. In Bournemouth, Lansdowne Baptist Church was once by far the largest congregation, but today we have churches taking over Bingo Halls, Theaters and DIY warehouses. I detect the Holy Spirit moving in the UK this Pentecost. Jesus tells his disciples to "reap what you have not worked for". The Holy Spirit has done the work; we are the harvesters.
Monday, June 13, 2011
Faith versus works
I guess everyone knows the exciting story of Rahab, the prostitute, who sheltered the Israelite spies when they entered Jericho; who lied to the city authorities; and who helped the spies escape safely back to Joshua. (If you don’t, read about it in Joshua Chapter 2). However, have you ever thought about the pivotal role she plays in the argument between those who insist on salvation by faith alone and those who argue for salvation by works.
In the great chapter in Hebrews which tells of the heroes of the faith, she is only woman mentioned by name as such a hero (Hebrews Ch 11 v 31). By faith the prostitute Rahab …was not killed with those who were disobedient. She was certainly a believer. “I know,” she says, ”I know that the LORD has given you this land.” (Joshua Ch 2 v 9).
But in that famous ‘epistle of straw’ (Martin Luther’s words) James uses her as an example of salvation by works. You see a person is justified by what he does, and not by faith alone. In the same way was not even Rahab the prostitute considered righteous for what she did? (James Ch 2 vv24-25).
Of course the conflict is not a real one. Suppose Rahab, having given the spies the assurance that they wanted had immediately ratted on them and betrayed them to the authorities. How then would we have regarded her faith?
In the great chapter in Hebrews which tells of the heroes of the faith, she is only woman mentioned by name as such a hero (Hebrews Ch 11 v 31). By faith the prostitute Rahab …was not killed with those who were disobedient. She was certainly a believer. “I know,” she says, ”I know that the LORD has given you this land.” (Joshua Ch 2 v 9).
But in that famous ‘epistle of straw’ (Martin Luther’s words) James uses her as an example of salvation by works. You see a person is justified by what he does, and not by faith alone. In the same way was not even Rahab the prostitute considered righteous for what she did? (James Ch 2 vv24-25).
Of course the conflict is not a real one. Suppose Rahab, having given the spies the assurance that they wanted had immediately ratted on them and betrayed them to the authorities. How then would we have regarded her faith?
Reaching the lost
The Bournemouth-Poole-Christchurch conurbation is the eleventh largest in Britain. More than that, it is the largest non-industrial conurbation in Europe. More than 480,000 people live here. Although, it is especially notable for the numbers of elderly people (over 30% of the populations of Bournemouth and Christchurch are over 60), we should not neglect the fact that there are many youngsters too. For men the average age is 19! You don’t believe me? It is true. But it is a special kind of average. Mathematicians recognise three different types of average age: the mean - which means all the ages added up and divided by the number of people; the median - which means the age at which 50% are older and 50% younger; and the mode which is the age that comes up most frequently. For men the modal age in Bournemouth is 19 and for women it is 74.
Of that 480,000 how many are Christian? 5%? 10%? 15%? Say it is as many as 15%, this is after all the Bible belt. That still leaves over 400,000 people in this area who are not Christians. What is going to happen to them when they die?
Some modern theologians argue that when you die, you rot. They believe that life for the unbeliever ends in extinction. What a comfortable doctrine that is! We need not be concerned for our friends or relatives who resist the gospel. We need not worry about Muslims in Iraq or animists in Brazil. When they die - extinction. They may not know heaven, but at least they won’t have to suffer for it.
The trouble is that the Bible knows nothing of this. A man is destined to die once, and after that to face judgement (Hebrews 9:27). We must all appear before the judgement seat of Christ, that each one may receive what is due to him for things done while in the body, whether good or bad (2 Cor 5:10). Because of your stubbornness and your unrepentant heart, you are storing up wrath against yourself for the day of God’s wrath when His righteous judgement will be revealed (Romans 2: 5).
Some scholars find an ultimate universal salvation in the New Testament, but this can only be done by ignoring the teaching on Gehenna. This is the word that is translated ‘Hell’ in the AV. It is derived from a Hebrew word which means the ‘valley of Hinnon’, located outside the walls of Jerusalem, where children had been sacrificed by fire to Molech (2 Chron 28:3; 2 Chron 33:6). Jesus talks more about ‘Hell’ than any other in the NT. God has the power to cast both body and soul into hell (Luke 12:5; Matthew 10:28). It is a place of eternal and unquenchable fire (Matthew 18:8; Mark 9:43).
Revelation pictures the final punishment as a lake of fire. It is the destination not only of the beast and the devil, but of the unsaved (Revelation 20:15).
If only the Bible were not so uncompromising. If only there were some hint of a second chance after death. But all have sinned and fallen short of the glory of God (Romans 3:23) and The wages of sin is death (Romans 6:26). We all stand condemned under the same charge. Praise God then that The gift of God is eternal life in Christ Jesus our Lord! (Romans 6:26b). But Salvation is found in no-one else, for there is no other name under heaven given to men by which we must be saved (Acts 4:12). There is only one way.
Although I don’t recommend it, you can understand how rulers of old forced the conversion of their people at sword point. It was not because they were tyrants but because they could not bear their people going to hell. You can even understand why they burnt heretics at the stake. To lead people to hell was a greater sin than murder.
Today we know that everyone must come to Jesus individually, that ritual counts for nothing in salvation and that conversion is the work of the Holy Spirit. But we are all called to be witnesses (Acts 1:8). Since we know the truth, how can we keep it to ourselves?
Several years ago I wrote, “If men and women are going to hell and we do not warn them, either we do not believe it or we do not care.”
The challenge is still the same.
What do we lack as Christians? “A commitment to Evangelism”. But as good physicians, we are not simply concerned with symptoms, we have to discover the underlying disease. Is it, I wonder, that we have no concern for the plight of the lost? Is it that we don’t believe that they are really lost? Or is it that we don’t know how to witness? Are there other more pressing priorities? Are we locked into our very Englishness, our reserve and politeness?
How would you politely shout “Fire!” in a burning building? How would you leave yourself untrained in a smallpox epidemic if only you were immune? What priorities would you put before the lifeboat on a sinking liner?
We need to challenge ourselves over our concern for the lost. Earlier in this article I quoted three texts on judgement. The second one has nothing to do with the judgement of the lost. It refers to the judgement of Christians, on how we perform in the body. We will be judged on our service. How will you face Jesus and tell him, “I knew the way, but I kept it to myself. Being English, I was never so ill-mannered as to thrust it upon those who did not want to hear. I would have done better, but there was so little time.” In this last excuse there is an element of truth. Why are there so many old people in Bournemouth? People move into the area to spend their last few years before they die. But one out of one dies. For each of these there is so little time.
Of that 480,000 how many are Christian? 5%? 10%? 15%? Say it is as many as 15%, this is after all the Bible belt. That still leaves over 400,000 people in this area who are not Christians. What is going to happen to them when they die?
Some modern theologians argue that when you die, you rot. They believe that life for the unbeliever ends in extinction. What a comfortable doctrine that is! We need not be concerned for our friends or relatives who resist the gospel. We need not worry about Muslims in Iraq or animists in Brazil. When they die - extinction. They may not know heaven, but at least they won’t have to suffer for it.
The trouble is that the Bible knows nothing of this. A man is destined to die once, and after that to face judgement (Hebrews 9:27). We must all appear before the judgement seat of Christ, that each one may receive what is due to him for things done while in the body, whether good or bad (2 Cor 5:10). Because of your stubbornness and your unrepentant heart, you are storing up wrath against yourself for the day of God’s wrath when His righteous judgement will be revealed (Romans 2: 5).
Some scholars find an ultimate universal salvation in the New Testament, but this can only be done by ignoring the teaching on Gehenna. This is the word that is translated ‘Hell’ in the AV. It is derived from a Hebrew word which means the ‘valley of Hinnon’, located outside the walls of Jerusalem, where children had been sacrificed by fire to Molech (2 Chron 28:3; 2 Chron 33:6). Jesus talks more about ‘Hell’ than any other in the NT. God has the power to cast both body and soul into hell (Luke 12:5; Matthew 10:28). It is a place of eternal and unquenchable fire (Matthew 18:8; Mark 9:43).
Revelation pictures the final punishment as a lake of fire. It is the destination not only of the beast and the devil, but of the unsaved (Revelation 20:15).
If only the Bible were not so uncompromising. If only there were some hint of a second chance after death. But all have sinned and fallen short of the glory of God (Romans 3:23) and The wages of sin is death (Romans 6:26). We all stand condemned under the same charge. Praise God then that The gift of God is eternal life in Christ Jesus our Lord! (Romans 6:26b). But Salvation is found in no-one else, for there is no other name under heaven given to men by which we must be saved (Acts 4:12). There is only one way.
Although I don’t recommend it, you can understand how rulers of old forced the conversion of their people at sword point. It was not because they were tyrants but because they could not bear their people going to hell. You can even understand why they burnt heretics at the stake. To lead people to hell was a greater sin than murder.
Today we know that everyone must come to Jesus individually, that ritual counts for nothing in salvation and that conversion is the work of the Holy Spirit. But we are all called to be witnesses (Acts 1:8). Since we know the truth, how can we keep it to ourselves?
Several years ago I wrote, “If men and women are going to hell and we do not warn them, either we do not believe it or we do not care.”
The challenge is still the same.
What do we lack as Christians? “A commitment to Evangelism”. But as good physicians, we are not simply concerned with symptoms, we have to discover the underlying disease. Is it, I wonder, that we have no concern for the plight of the lost? Is it that we don’t believe that they are really lost? Or is it that we don’t know how to witness? Are there other more pressing priorities? Are we locked into our very Englishness, our reserve and politeness?
How would you politely shout “Fire!” in a burning building? How would you leave yourself untrained in a smallpox epidemic if only you were immune? What priorities would you put before the lifeboat on a sinking liner?
We need to challenge ourselves over our concern for the lost. Earlier in this article I quoted three texts on judgement. The second one has nothing to do with the judgement of the lost. It refers to the judgement of Christians, on how we perform in the body. We will be judged on our service. How will you face Jesus and tell him, “I knew the way, but I kept it to myself. Being English, I was never so ill-mannered as to thrust it upon those who did not want to hear. I would have done better, but there was so little time.” In this last excuse there is an element of truth. Why are there so many old people in Bournemouth? People move into the area to spend their last few years before they die. But one out of one dies. For each of these there is so little time.
Sunday, June 12, 2011
Snippets from the news
Has the "Peace Process" worked in Northern Ireland? Things are undoubtedly better than they were, but don't kid yourself that everything is cured. Look at these figures:
There are still more than 1,100 people who are on terrorist death lists in Northern Ireland who are being allowed to carry guns for their own protection.
Terrorist bombing incidents are at their highest level in eight years – 100 in 2010-11 (and no, it's not Islamists).
Terrorist attacks are seldom solved – 12 of 272 such attacks between 2008 and 2010 have been successfully detected.
People are still being driven from their homes. The number rose by a third in 2009-10. Terrorist and sectarian intimidation was cited in 85 per cent of these cases.
Sectarian incidents rose from 1,595 in 2008-09 to 1,840 in 2009-10 – a 15 per cent increase. Sectarian crimes in the same period went up from 1,017 to 1,264 – a 24 per cent increase.
British people cannot give blood in America because of BSE. People from America cannot give blood in Europe because of West Nile Virus. There is apparently an ‘epidemic’ of West Nile Fever in North America. The United States has a population of 311 million. Last year, the entire country had 629 serious cases of this virus – 144 of them fatal encephalitis. In 24 of the 50 states, there were no deaths at all. Five states had only one death each; another five only two. There were precisely no cases of West Nile in this country in 2004, 2005, 2008, 2009 and 2010. There was one in 2006 (from Canada) and one in 2007 (also from Canada).
Nobody in this country has any discretion or control over this rule, because it was made by the EU (our real government). Directive 2004/33/EC of March 22, 2004, over which you, I, the Blood Service and Parliament have no control, demands this concrete-headed regulation.
Why does the Archbishop of Canterbury (in his new guise of Left-wing politician) speak as if it was obvious that we should treat people who can work, but won’t, in the same way as we treat those who are truly in need?
In St Paul’s first epistle to Timothy, Chapter 5, we read: ‘If any provide not for his own, and specially for those of his own house, he hath denied the faith, and is worse than an infidel.’
In his second epistle to the Thessalonians, St Paul rubs it in, in that way he has: ‘This we commanded you, that if any will not work, neither shall he eat.’
Germany has decided to close its nuclear power stations in case they get hit by a tsunami or an earthquake. Germany’s dirty secret is its unfashionable and un-green attachment to coal. Because Germany has oceans of the stuff, and because Germany’s coal miners are better organised and led than ours were and mostly because German coal is conveniently near to the surface meaning it can be strip mined by a bloke on a bulldozer, Germany never fell out of love with the black stuff the way we did (a lot of it is a very soft and very dirty type of coal). As a result Germany still make a great deal of its electricity (nearly half) by burning coal, a major source of the 830m tonnes of CO2 the Federal Republic emits annually. That total figure amounts to about 10.15 tonnes of CO2 for every German compared to 9.25 tonnes in the UK and 6.4 tonnes in France where they are more dependent of nuclear.
About a quarter of Germany’s electricity comes from nuclear power and so the dramatic closure of all of Germany’s nuclear plants in the next decade will push up emissions dramatically. In fact, German energy-industry emissions are about 355mt a year, so the nuclear shortfall could result in a 70-million-tonne increase in carbon emissions every year if the balance is taken up by fossil fuels. Perhaps, like me, the German government secretly does not really beieve in CO2 being the driving force behind climate change.
The outrages in Syria get worse. The supposed 120 security forces killed in Jisr al-Shughour has never rung true. From other sources we hear that many in the Syrian Army mutinied when ordered to fire on unarmed civilians. It was these mutineers who were killed by the military secret police. After so much faking of evidence by the Libyans earlier and by Hezbollah a couple of years ago, I never automatically believe anything that an Arab Muslim tells me. However, to give the other side of the story (also from an Arab Muslim) Sergeant-Major Ali Hassan Satouf claims to have deserted. When he was sent to the port refinery of Banias to fight “terrorist armed groups” he did not hesitate — until he realised that he had been deceived. “We didn’t find any terrorist groups,” he said in a video released last week. “We found only peaceful demonstrations." The sergeant-major describes how soldiers broke into homes in a village and stole private property before arresting dozens of men, prompting women to pelt them with stones. “In response to the stone-throwing, we were ordered to open fire ... and we had a massacre. Four women were killed.” (Only a small massacre then).
A senior Turkish official said 4,300 Syrians had crossed into Turkey. “All the accusations of residents sheltering gangs are false,” said a man from Jisr al-Shughour. “And we never asked the army for help or to enter our town. It is them firing on us.” The regime has sought to play down a video that shows Syrian soldiers beating shackled prisoners and placing weapons on corpses which appear to have been shot at point blank range.
Also in the Muslim world Pakistan was in shock today after two explosions in the northwest city of Peshawar killed at least 34 people and left a further 100 injured, many severely, in one of the deadliest attacks since last month's US mission which ended in the death of Al-Qaeda figurehead Osama Bin Laden. The explosions occurred in a neighbourhood of the city which houses military personnel and has many political offices, and which has been the site of bomb attacks in the past. The first blast took place shortly after midnight and was the smaller of the two. As emergency services made their way to the scene of the attack, a suicide bomber rode a motorcycle carrying 10kg of explosives to the site and detonated his deadly payload.
The head of Al-Qaeda in east Africa, who was accused of playing a key role in the bombing of two American embassies in 1998, has been killed in Somalia, police said yesterday. Fazul Abdullah Mohammed was reportedly shot last week after an exchange of fire at a police checkpoint. He had been travelling on a fake South African passport. Mohammed had spent 12 years on the run after the bombings in Nairobi, the capital of Kenya, and the Tanzanian city of Dar es Salaam, which had killed more than 240 people and brought Bin Laden and Al-Qaeda to world attention.
What with the slaying of Al Qaeda's Ilyas Kashmiri in a drone attack in Pakistan, Western force seem to be getting more successful. Perhaps because of intelligence gathered from the attack on Bin Laden?
There are still more than 1,100 people who are on terrorist death lists in Northern Ireland who are being allowed to carry guns for their own protection.
Terrorist bombing incidents are at their highest level in eight years – 100 in 2010-11 (and no, it's not Islamists).
Terrorist attacks are seldom solved – 12 of 272 such attacks between 2008 and 2010 have been successfully detected.
People are still being driven from their homes. The number rose by a third in 2009-10. Terrorist and sectarian intimidation was cited in 85 per cent of these cases.
Sectarian incidents rose from 1,595 in 2008-09 to 1,840 in 2009-10 – a 15 per cent increase. Sectarian crimes in the same period went up from 1,017 to 1,264 – a 24 per cent increase.
British people cannot give blood in America because of BSE. People from America cannot give blood in Europe because of West Nile Virus. There is apparently an ‘epidemic’ of West Nile Fever in North America. The United States has a population of 311 million. Last year, the entire country had 629 serious cases of this virus – 144 of them fatal encephalitis. In 24 of the 50 states, there were no deaths at all. Five states had only one death each; another five only two. There were precisely no cases of West Nile in this country in 2004, 2005, 2008, 2009 and 2010. There was one in 2006 (from Canada) and one in 2007 (also from Canada).
Nobody in this country has any discretion or control over this rule, because it was made by the EU (our real government). Directive 2004/33/EC of March 22, 2004, over which you, I, the Blood Service and Parliament have no control, demands this concrete-headed regulation.
Why does the Archbishop of Canterbury (in his new guise of Left-wing politician) speak as if it was obvious that we should treat people who can work, but won’t, in the same way as we treat those who are truly in need?
In St Paul’s first epistle to Timothy, Chapter 5, we read: ‘If any provide not for his own, and specially for those of his own house, he hath denied the faith, and is worse than an infidel.’
In his second epistle to the Thessalonians, St Paul rubs it in, in that way he has: ‘This we commanded you, that if any will not work, neither shall he eat.’
Germany has decided to close its nuclear power stations in case they get hit by a tsunami or an earthquake. Germany’s dirty secret is its unfashionable and un-green attachment to coal. Because Germany has oceans of the stuff, and because Germany’s coal miners are better organised and led than ours were and mostly because German coal is conveniently near to the surface meaning it can be strip mined by a bloke on a bulldozer, Germany never fell out of love with the black stuff the way we did (a lot of it is a very soft and very dirty type of coal). As a result Germany still make a great deal of its electricity (nearly half) by burning coal, a major source of the 830m tonnes of CO2 the Federal Republic emits annually. That total figure amounts to about 10.15 tonnes of CO2 for every German compared to 9.25 tonnes in the UK and 6.4 tonnes in France where they are more dependent of nuclear.
About a quarter of Germany’s electricity comes from nuclear power and so the dramatic closure of all of Germany’s nuclear plants in the next decade will push up emissions dramatically. In fact, German energy-industry emissions are about 355mt a year, so the nuclear shortfall could result in a 70-million-tonne increase in carbon emissions every year if the balance is taken up by fossil fuels. Perhaps, like me, the German government secretly does not really beieve in CO2 being the driving force behind climate change.
The outrages in Syria get worse. The supposed 120 security forces killed in Jisr al-Shughour has never rung true. From other sources we hear that many in the Syrian Army mutinied when ordered to fire on unarmed civilians. It was these mutineers who were killed by the military secret police. After so much faking of evidence by the Libyans earlier and by Hezbollah a couple of years ago, I never automatically believe anything that an Arab Muslim tells me. However, to give the other side of the story (also from an Arab Muslim) Sergeant-Major Ali Hassan Satouf claims to have deserted. When he was sent to the port refinery of Banias to fight “terrorist armed groups” he did not hesitate — until he realised that he had been deceived. “We didn’t find any terrorist groups,” he said in a video released last week. “We found only peaceful demonstrations." The sergeant-major describes how soldiers broke into homes in a village and stole private property before arresting dozens of men, prompting women to pelt them with stones. “In response to the stone-throwing, we were ordered to open fire ... and we had a massacre. Four women were killed.” (Only a small massacre then).
A senior Turkish official said 4,300 Syrians had crossed into Turkey. “All the accusations of residents sheltering gangs are false,” said a man from Jisr al-Shughour. “And we never asked the army for help or to enter our town. It is them firing on us.” The regime has sought to play down a video that shows Syrian soldiers beating shackled prisoners and placing weapons on corpses which appear to have been shot at point blank range.
Also in the Muslim world Pakistan was in shock today after two explosions in the northwest city of Peshawar killed at least 34 people and left a further 100 injured, many severely, in one of the deadliest attacks since last month's US mission which ended in the death of Al-Qaeda figurehead Osama Bin Laden. The explosions occurred in a neighbourhood of the city which houses military personnel and has many political offices, and which has been the site of bomb attacks in the past. The first blast took place shortly after midnight and was the smaller of the two. As emergency services made their way to the scene of the attack, a suicide bomber rode a motorcycle carrying 10kg of explosives to the site and detonated his deadly payload.
The head of Al-Qaeda in east Africa, who was accused of playing a key role in the bombing of two American embassies in 1998, has been killed in Somalia, police said yesterday. Fazul Abdullah Mohammed was reportedly shot last week after an exchange of fire at a police checkpoint. He had been travelling on a fake South African passport. Mohammed had spent 12 years on the run after the bombings in Nairobi, the capital of Kenya, and the Tanzanian city of Dar es Salaam, which had killed more than 240 people and brought Bin Laden and Al-Qaeda to world attention.
What with the slaying of Al Qaeda's Ilyas Kashmiri in a drone attack in Pakistan, Western force seem to be getting more successful. Perhaps because of intelligence gathered from the attack on Bin Laden?
Galatians 5:22 ...faithfulness...
But the fruit of the Spirit is ...faithfulness...
Great is thy faithfulness, Oh God my Father. God promised Abraham that he would be the father of many nations. His promise is true. Despite regular rebellions by the Jews he kept constant watch over his chosen people. Like the adulterous wife of Hosea they were always going after other gods that were no gods. Yet he was faithful.
Christians often backslide; yet God is faithful. He is the God of seconds chances. And third, and fourth, and fifth...
The Holy Spirit is God. Today is Pentecost Sunday; the day when the Spirit came. Faithfulness is one of his most precious gifts. Note, though, it is described here as a fruit. Like the other fruits in this passage it is something that results from the longstanding presence of God the Spirit in our lives. Stay strong; stay faithful; stay Spirit filled.
Great is thy faithfulness, Oh God my Father. God promised Abraham that he would be the father of many nations. His promise is true. Despite regular rebellions by the Jews he kept constant watch over his chosen people. Like the adulterous wife of Hosea they were always going after other gods that were no gods. Yet he was faithful.
Christians often backslide; yet God is faithful. He is the God of seconds chances. And third, and fourth, and fifth...
The Holy Spirit is God. Today is Pentecost Sunday; the day when the Spirit came. Faithfulness is one of his most precious gifts. Note, though, it is described here as a fruit. Like the other fruits in this passage it is something that results from the longstanding presence of God the Spirit in our lives. Stay strong; stay faithful; stay Spirit filled.
John 4:31-34 Giving
Meanwhile his disciples urged him, “Rabbi, eat something.” But he said to them, “I have food to eat that you know nothing about.” Then his disciples said to each other, “Could someone have brought him food?” “My food,” said Jesus, “is to do the will of him who sent me and to finish his work.
Even the disciples have fallen into the trap of literalism. Jesus is speaking metaphorically. Yet he has a clear message for us as missionaries and evangelists. The word for men's minds and hearts is more important than food for their bellies. With so much Christian aid going on disaster relief how much is going on telling others about the food that really satisfies and the water that never needs replenishing. I know Spurgeon said, "If you want to give them a tract, make sure it's wrapped in a sandwich," but the point is that a sandwich satisfies for a couple of hours but a tract can satisfy for life.
Big secular charities like OXFAM and Christian Aid are better than governments at aiding the needy but they don't reach into their real requirements. I have recently adjusted my giving to agencies like Barnabas Trust, Open Doors, and Samaritan's Purse and away from charities like OXFAM, Red Cross and UNICEF. Tear Fund is one worth watching. I'm not sure that in its desire to be one of the big boys it has kept close to its evangelical origins.
Even the disciples have fallen into the trap of literalism. Jesus is speaking metaphorically. Yet he has a clear message for us as missionaries and evangelists. The word for men's minds and hearts is more important than food for their bellies. With so much Christian aid going on disaster relief how much is going on telling others about the food that really satisfies and the water that never needs replenishing. I know Spurgeon said, "If you want to give them a tract, make sure it's wrapped in a sandwich," but the point is that a sandwich satisfies for a couple of hours but a tract can satisfy for life.
Big secular charities like OXFAM and Christian Aid are better than governments at aiding the needy but they don't reach into their real requirements. I have recently adjusted my giving to agencies like Barnabas Trust, Open Doors, and Samaritan's Purse and away from charities like OXFAM, Red Cross and UNICEF. Tear Fund is one worth watching. I'm not sure that in its desire to be one of the big boys it has kept close to its evangelical origins.
Saturday, June 11, 2011
EHA was more of a problem
I had my trip to EHA. I went to London on Thursday afternoon having had a major computer crash. I lost three quarters of my files following an attack by a Trojan. Fortunately, I had everything backed up on a separate hard drive.
The meeting was fine. I met some of my old friends including Michael Hallek, Emili Montserrat, Estella Matutes, Claire Dearden, Richard Rosenquist, Freda Stevenson, Federico Caligaris Cappio, Paulo Ghia, Kostas Stamatopoulos, Christian Giesler, Aaron Poliak, Eva Kimby Ted Gordon Smith, David Linch and Andy Rawstron. Four talks on the B cell receptor were excellent.
It was going home that the problem arose. Waterloo Station was more crowded than normal and the indicator board showed no trains leaving. Apparently there had been a signal failure the other side of Woking. It later turned out that there had been an attempted theft of copper cabling that had inactivated the signals.
On the station I met Pipril Pete, aka Peter Mainprice who had helped me organize a series of scientific meetings in the 1970s. He suggested that we could by-pass the blockage by going through Reading from Paddington. And so we did. It meant four separate and very slow and crowded trains, but I finally made it home at 1-30 am Friday.
I was so exhausted by the experience that I abandoned plans to go up to London yesterday and today.
The rail network has issued an apology and told us that next time they will do better at communication. Communication! There are several areas that they need to do better at. They could do better at protecting their signaling. I read in the paper yesterday that another attempted-copper-cabling-thief is in hospital having suffered third degree burns from the 22,000 volts that were passing through the cables.
They can use their brains. Signaling is to signal. It conveys the message that the line ahead is clear (or not). Modern trains can communicate with signal boxes by radio. Why did they not use this other means of signaling that the track was clear?
Finally, even if they had to rely on the signals, why not hire buses to bridge the gap between Woking and Farnborough where there were no signals? I am afraid the train company has got itself a very poor reputation. Some passengers were kept on a stationary train for 2 hours and eventually took the law into their own hand and broke out before walking along teh track to the next station.
Some sad news. Daniel Catovsky's daughter was knocked over and killed by a motor bike on London Bridge last week. Our thoughts and prayers are with Daniel and Julia at this time.
The meeting was fine. I met some of my old friends including Michael Hallek, Emili Montserrat, Estella Matutes, Claire Dearden, Richard Rosenquist, Freda Stevenson, Federico Caligaris Cappio, Paulo Ghia, Kostas Stamatopoulos, Christian Giesler, Aaron Poliak, Eva Kimby Ted Gordon Smith, David Linch and Andy Rawstron. Four talks on the B cell receptor were excellent.
It was going home that the problem arose. Waterloo Station was more crowded than normal and the indicator board showed no trains leaving. Apparently there had been a signal failure the other side of Woking. It later turned out that there had been an attempted theft of copper cabling that had inactivated the signals.
On the station I met Pipril Pete, aka Peter Mainprice who had helped me organize a series of scientific meetings in the 1970s. He suggested that we could by-pass the blockage by going through Reading from Paddington. And so we did. It meant four separate and very slow and crowded trains, but I finally made it home at 1-30 am Friday.
I was so exhausted by the experience that I abandoned plans to go up to London yesterday and today.
The rail network has issued an apology and told us that next time they will do better at communication. Communication! There are several areas that they need to do better at. They could do better at protecting their signaling. I read in the paper yesterday that another attempted-copper-cabling-thief is in hospital having suffered third degree burns from the 22,000 volts that were passing through the cables.
They can use their brains. Signaling is to signal. It conveys the message that the line ahead is clear (or not). Modern trains can communicate with signal boxes by radio. Why did they not use this other means of signaling that the track was clear?
Finally, even if they had to rely on the signals, why not hire buses to bridge the gap between Woking and Farnborough where there were no signals? I am afraid the train company has got itself a very poor reputation. Some passengers were kept on a stationary train for 2 hours and eventually took the law into their own hand and broke out before walking along teh track to the next station.
Some sad news. Daniel Catovsky's daughter was knocked over and killed by a motor bike on London Bridge last week. Our thoughts and prayers are with Daniel and Julia at this time.
Galatians 5:22 ...goodness...
The fruit of the Spirit is ...goodness...
God is good. Since the Holy Spirit is God, he is also good and brings out goodness in those who follow him. What does it mean to be good? It means always doing what is right. It menans being god like. It means not being compromized. But this is just about not being bad. Being good means more. It is generosity, kindness, thoughfulness, lovingkindness, care, taking time, patience, love, forgiveness, watchfulness, looking after, saying the right word, being there, bravery, standing up to be counted and staying. All these are encompassed by goodness and many more.
God is good. Since the Holy Spirit is God, he is also good and brings out goodness in those who follow him. What does it mean to be good? It means always doing what is right. It menans being god like. It means not being compromized. But this is just about not being bad. Being good means more. It is generosity, kindness, thoughfulness, lovingkindness, care, taking time, patience, love, forgiveness, watchfulness, looking after, saying the right word, being there, bravery, standing up to be counted and staying. All these are encompassed by goodness and many more.
John 4:30. They will come
They came out of the town and made their way towards him.
We are often intimidated by the evangelistic task before us. The Samaritans must have seemed and infertile ground for evangelism to Jesus' disciples, but if the message is right the crowds will come. The message is always right if we tell people that Jesus loves them and died to save them.
If you build it he will come. This was the message of the Kevin Costner baseball movie "Field of Dreams" and it is the message of evangelism. If we build our outreach the converts will come. This is the promise of teh Holy Spirit whose responsibility it is to convert them.
We are often intimidated by the evangelistic task before us. The Samaritans must have seemed and infertile ground for evangelism to Jesus' disciples, but if the message is right the crowds will come. The message is always right if we tell people that Jesus loves them and died to save them.
If you build it he will come. This was the message of the Kevin Costner baseball movie "Field of Dreams" and it is the message of evangelism. If we build our outreach the converts will come. This is the promise of teh Holy Spirit whose responsibility it is to convert them.
Restricting alcohol.
In Australia there have been increased governmental restrictions on the availability of alcohol. Perhaps as a result between 2008 and 2010 teh number of serious injuries retrieved by teh Royal Flying Doctor Sevice has fgallen from 30 per 1000 to 14 per 1000. The rstrictions were introduced in 2003 and reinforced in 2008.
Another Christian sacked for her beliefs?
Of course we don't always get the whole story from the newspapers but on the face of it there is yet another Christian martyr in the Daily Telegraph. Margaret Forrester shared with a fellow worker a booklet that questioned the belief that women who have an abortion are not psychologically scarred. This has been a matter of polarized debate recently in the medical journals, so it is at least a matter for which there is legitimate debate. My own view is that some women are and some are not. However, Ms Forrester was a psychological wellbeing practitioner in Westminster, central London. Her managers found out about her views and suspended her from her duties at Central North West London Mental Health Trust. Last month, after a series of lengthy hearings and an unsuccessful appeal, she was sacked. The ultimate reason for her dismissal was her refusal to work in a new role in a different mental health team, to which she was transferred as a disciplinary measure. Ms Forrester accepted the job verbally but claimed she was give insufficient information and lacked training.
Is this another case of persecution of Christians for their beliefs or a stroppy woman making trouble? For myself I would sack all psychological wellbeing practitioners. This looks to me to be a bloated public sector funding non-jobs for people who prefer talking to working. Employment in the public sector is not a platform for declaring your beliefs. If you don't believe in abortion (and I don't) then try and spread your belief in your own time, not when you are paid to do something else. If you don't agree with the ethos of a particular employer then don't work for them. By all means campaign against the taxpayer being asked to fund an outlandish policy, but don't do it like this. It does not win hearts and minds.
Is this another case of persecution of Christians for their beliefs or a stroppy woman making trouble? For myself I would sack all psychological wellbeing practitioners. This looks to me to be a bloated public sector funding non-jobs for people who prefer talking to working. Employment in the public sector is not a platform for declaring your beliefs. If you don't believe in abortion (and I don't) then try and spread your belief in your own time, not when you are paid to do something else. If you don't agree with the ethos of a particular employer then don't work for them. By all means campaign against the taxpayer being asked to fund an outlandish policy, but don't do it like this. It does not win hearts and minds.
Friday, June 10, 2011
War crimes in Eritrea
Eritrean Christian refugees have fled the brutal regime of their homeland to Egypt where hundreds are in prison or taken hostage for ransom, and subjected to torture, beatings and sexual assault.
They risk their lives escaping Eritrea, which can be regarded as the second worst place in the world to be a Christian, after North Korea. Christians, particularly evangelicals, are tortured and imprisoned in notoriously horrendous conditions for their faith; they are viewed as a threat to national unity because they give their ultimate allegiance to God and not to the state.
Those who manage to escape often flee to Egypt, where hundreds of refugees arrive every month, with the aim of crossing its border into Israel. Channel Four’s Unreported World highlighted the desperate plight of Eritrean refugees on Friday (3 June). The programme, “Breaking into Israel”, exposed how they are forced to put themselves in the hands of people-smugglers and make the arduous 900-mile journey across the Sinai desert. Some die along the way; others are shot dead as they attempt to cross the Egypt-Israel border; and those who are caught are sent home to almost certain torture and death.
The majority of Eritrean refugees are Christians. Many end up in Egyptian prisons or being held hostage for ransom by Bedouin Muslim nomads, who work with the traffickers, in the deserts of Sinai. There are currently around 500-600 Eritrean prisoners in Egyptian custody and an estimated 100-200 in the hands of traffickers, who have been less restricted in their criminal activities since the Egyptian revolution in January. The hostage-takers are now demanding up to US$20,000 per person for their release; if their families don’t pay, the hostage is killed and there are unconfirmed reports that the captors are turning to forced organ harvesting, especially if the ransom is not paid. Unwary Eritreans are also being kidnapped from UN refugee camps in Sudan.
The refugees suffer inhumane treatment, including rape, sexual harassment, torture, beatings and slavery at the hands of the Egyptian authorities or the Bedouin gangs. Those in prison are denied medical care, suffer malnutrition as a result of meagre daily rations such as a piece of bread and a tomato, and have restricted access to visitors. Christians receive more severe treatment than Muslim prisoners because of their faith. Some have consequently adopted common Muslim names in an effort to alleviate their suffering.
NATO is fighting against an oppressive government is Libya and the EU has instituted sanctions against Syria. In both cases the cause is crime against its own people. Why has there been no similar action against Eritrea
They risk their lives escaping Eritrea, which can be regarded as the second worst place in the world to be a Christian, after North Korea. Christians, particularly evangelicals, are tortured and imprisoned in notoriously horrendous conditions for their faith; they are viewed as a threat to national unity because they give their ultimate allegiance to God and not to the state.
Those who manage to escape often flee to Egypt, where hundreds of refugees arrive every month, with the aim of crossing its border into Israel. Channel Four’s Unreported World highlighted the desperate plight of Eritrean refugees on Friday (3 June). The programme, “Breaking into Israel”, exposed how they are forced to put themselves in the hands of people-smugglers and make the arduous 900-mile journey across the Sinai desert. Some die along the way; others are shot dead as they attempt to cross the Egypt-Israel border; and those who are caught are sent home to almost certain torture and death.
The majority of Eritrean refugees are Christians. Many end up in Egyptian prisons or being held hostage for ransom by Bedouin Muslim nomads, who work with the traffickers, in the deserts of Sinai. There are currently around 500-600 Eritrean prisoners in Egyptian custody and an estimated 100-200 in the hands of traffickers, who have been less restricted in their criminal activities since the Egyptian revolution in January. The hostage-takers are now demanding up to US$20,000 per person for their release; if their families don’t pay, the hostage is killed and there are unconfirmed reports that the captors are turning to forced organ harvesting, especially if the ransom is not paid. Unwary Eritreans are also being kidnapped from UN refugee camps in Sudan.
The refugees suffer inhumane treatment, including rape, sexual harassment, torture, beatings and slavery at the hands of the Egyptian authorities or the Bedouin gangs. Those in prison are denied medical care, suffer malnutrition as a result of meagre daily rations such as a piece of bread and a tomato, and have restricted access to visitors. Christians receive more severe treatment than Muslim prisoners because of their faith. Some have consequently adopted common Muslim names in an effort to alleviate their suffering.
NATO is fighting against an oppressive government is Libya and the EU has instituted sanctions against Syria. In both cases the cause is crime against its own people. Why has there been no similar action against Eritrea
How to care for the elderly?
How to care for the elderly?
A story is told of a community of Native Americans. Grandfather was becoming very old and forgetful and was really a lot of trouble to the tribe. One day, son says to grandson, “It’s time to take grandfather to meet the ancestors.”
Grandson replied, “Is he dying?”
Son says, “No, but it’s his time.”
Son and grandson put grandfather on a litter and carry him up to the high place where there were many wooden constructions decorated with feathers. There were tepees and strange bundles wrapped in animal skins, but no people. Son showed grandson how to sit grandfather up in one of the tepees. Grandson asked son, “Where are the ancestors?”
Son replied, “They are all around. They will come for grandfather shortly.”
Son and grandson began to make their way down the mountain.
Grandson says to son, “I’m really glad that you brought me with you today, Dad, because when it is your time I shall know where to take you.”
Son says to grandson, “You know what? Perhaps it isn’t grandfather’s time quite yet. Let’s go back and fetch him home to the village.”
Euthanasia is one way of dealing with Alzheimer’s disease, but most physicians do not support this as a way out, and despite the Assisted Suicide Bill regularly appearing before Parliament, it is always soundly defeated.
Although we see old age as one of the most difficult problems faced by any health care system, it is really a sign of the success of modern medicine. People used to die of infection, heart disease, pneumonia and the rest with an average longevity when I was young of 68 years; now they go on living into their 90s. They go on living until their brain breaks.
How do you deal with a broken brain living in a healthy body?
Might there be a medical solution? If there is we are probably a decade away from discovering it. About 10% of patients with dementia have a remediable condition – vitamin B12 deficiency and thyroid deficiency are the commonest causes but there are others. Perhaps another 10% have incurable dementia but also have a remediable condition such as pneumonia or heart failure that has recently made them worse. These problems should be looked for and treated. However, it is very important that these investigations are done by the primary care physicians while the patient is in his or her own home. The worst possible thing that can be done for patients with Alzheimer’s disease is to admit them to a ward of a general hospital.
When I was younger and inspecting a London teaching hospital, I was astonished to hear that 30% of the acute beds of the hospital were filled with what they called ‘bed-blockers’. These were patients for whom the hospital had done all it could and now wanted to discharge. Many of these patients had dementia and the relatives quite correctly determined that they could not cope at home. The only sensible alternative was a nursing home and to pay for this would involve selling the family home. But this was the kid’s inheritance and they were resisting the sale. They were doubly incensed because prior to the admission to hospital, Mum was managing at home reasonably well.
It is quite clear that when an elderly mildly demented patient is admitted to hospital, the disorientation involved frequently leads to an exacerbation of the dementia.
Apart from the factors I have mentioned, dementia is not really a medical problem and doesn’t have a medical solution, yet it is one of the reasons that the government gives for requiring 20% efficiency savings from the NHS in the next four years.
It is hard to credit it now, but when I was young, one woman in seven became a nurse. Of course, they didn’t all become State Registered Nurses (SRNs, what RGNs used to be called) with qualifications, but the type of nurse that we train now is a specialized creature, able to administer complicated drug regimens, to do ‘procedures’ like erecting a drip and passing a nasogastric tube. Most nurses didn’t do that and still don’t. They may be called ‘Health Care Assistants’, but the public knows them as nurses and they do the sort of tasks that nurses have always done. They wash and feed patients, they make beds, they wipe their bottoms, they take temperatures, pulses and blood pressures, they take blood samples, they dress wounds, they help patients out of bed and back into bed, and they generally make life a lot more pleasant than it would otherwise be. Many of them are also male. Quite a lot of what a demented patient needs is included in the above list. They seldom need an RGN but they do need the aid of health care assistants.
My sister works for a private company that provides these services in a person’s own home. It is funded mainly by the taxpayer and includes among its ministrations some element of entertainment like trips out and attendance at day-centers. My sister has no nursing training but she has been a mother and she has run her own small business. She knows how to organize things and is able to manage the other ‘home-helps’ as they used to be called. The point is that most people with mild dementia, or indeed mild failure of other bits of their bodies, can and ought to be helped to remain living in their own home. It is not costly to do so and it is worth the public investing in this resource. Of course, there is a place for family and church to contribute to this enterprise and there really is a ‘Big Society’ out there already doing it.
My mother is 91 and although she has all her marbles, she is inevitably slowing down and a little off her legs. My siblings do her shopping, tend her garden and clean her house. We do our part as much as we can, living much further away. A lady from her church lives around the corner and, although in her 80s, is a great help. Other people from her church provide transport to three church meetings every week. For Mum, life is worth living because of the support she gets.
Unfortunately, however good the support, dementia patients cannot always be kept in their own home. Often the main carer is a spouse of the same age and when the spouse gets ill someone must take over. If the children have the responsibility of caring, the care is often shared out unequally. High flying sons are too busy and their trophy wives don’t see why they should be involved. They may provide some money, but often this lifestyle is only maintained on tick. Other children may live too far away to get involved. On many occasions it is the youngest daughter who happens to live locally who has to give up her job or neglect her own family. Resentment is easily engendered.
For many the answer is a nursing home. But how to pay for it? In Scotland and Denmark the governments have decided that the general taxpayer should pay. Scotland has the advantage of a generous subsidy from England and Denmark has a basic tax rate of 53%. Joan Bakewell, who was advisor on old people to the last Labour government thought that the old person should sell his or her large house to pay for it.
The Dilman report has suggested that there should be a cap of about £50,000 on how much old people should pay towards their nursing home care. If they have total assets of less than £23,000 they are currently not expected to pay anything. £50,000 barely pays for 2 years in a nursing home – the average stay for a demented patient is about 18 months. Down south and in London £50,000 can often be found from income alone. Up north £50,000 often represents a person’s total assets, house and all. However, since the taxpayer picks up the rest of the tab and the biggest taxpayers are down south, there is a sort of equality about it.
Southern Cross, the largest provider of nursing home care in the UK is in financial difficulty. It sounds as though it has made an unwise investment, but it looks as though 32,000 individuals in Southern Cross Care Homes are going to find that their nursing homes are no longer secure. Nursing Homes are usually large houses that have been converted, Sometimes several houses are knocked into one. However they could be converted into flats of be used for other purposes. This very flexibility is a danger since it is price-sensitive. With the house sale market static there is a great demand for rented properties and some landlords have felt that nursing homes are not as profitable as flats.
There does not seem to be an easy answer to the conundrum, which is perhaps why the Labour Party has cried, "No contest" and has offered to work together with the government on a joint approach. For me the lesson to be learnt is that more people are going to have to work as carers and that the qualities that these people are going to need are patience, kindness and faithfulness. Rare qualities indeed!
A story is told of a community of Native Americans. Grandfather was becoming very old and forgetful and was really a lot of trouble to the tribe. One day, son says to grandson, “It’s time to take grandfather to meet the ancestors.”
Grandson replied, “Is he dying?”
Son says, “No, but it’s his time.”
Son and grandson put grandfather on a litter and carry him up to the high place where there were many wooden constructions decorated with feathers. There were tepees and strange bundles wrapped in animal skins, but no people. Son showed grandson how to sit grandfather up in one of the tepees. Grandson asked son, “Where are the ancestors?”
Son replied, “They are all around. They will come for grandfather shortly.”
Son and grandson began to make their way down the mountain.
Grandson says to son, “I’m really glad that you brought me with you today, Dad, because when it is your time I shall know where to take you.”
Son says to grandson, “You know what? Perhaps it isn’t grandfather’s time quite yet. Let’s go back and fetch him home to the village.”
Euthanasia is one way of dealing with Alzheimer’s disease, but most physicians do not support this as a way out, and despite the Assisted Suicide Bill regularly appearing before Parliament, it is always soundly defeated.
Although we see old age as one of the most difficult problems faced by any health care system, it is really a sign of the success of modern medicine. People used to die of infection, heart disease, pneumonia and the rest with an average longevity when I was young of 68 years; now they go on living into their 90s. They go on living until their brain breaks.
How do you deal with a broken brain living in a healthy body?
Might there be a medical solution? If there is we are probably a decade away from discovering it. About 10% of patients with dementia have a remediable condition – vitamin B12 deficiency and thyroid deficiency are the commonest causes but there are others. Perhaps another 10% have incurable dementia but also have a remediable condition such as pneumonia or heart failure that has recently made them worse. These problems should be looked for and treated. However, it is very important that these investigations are done by the primary care physicians while the patient is in his or her own home. The worst possible thing that can be done for patients with Alzheimer’s disease is to admit them to a ward of a general hospital.
When I was younger and inspecting a London teaching hospital, I was astonished to hear that 30% of the acute beds of the hospital were filled with what they called ‘bed-blockers’. These were patients for whom the hospital had done all it could and now wanted to discharge. Many of these patients had dementia and the relatives quite correctly determined that they could not cope at home. The only sensible alternative was a nursing home and to pay for this would involve selling the family home. But this was the kid’s inheritance and they were resisting the sale. They were doubly incensed because prior to the admission to hospital, Mum was managing at home reasonably well.
It is quite clear that when an elderly mildly demented patient is admitted to hospital, the disorientation involved frequently leads to an exacerbation of the dementia.
Apart from the factors I have mentioned, dementia is not really a medical problem and doesn’t have a medical solution, yet it is one of the reasons that the government gives for requiring 20% efficiency savings from the NHS in the next four years.
It is hard to credit it now, but when I was young, one woman in seven became a nurse. Of course, they didn’t all become State Registered Nurses (SRNs, what RGNs used to be called) with qualifications, but the type of nurse that we train now is a specialized creature, able to administer complicated drug regimens, to do ‘procedures’ like erecting a drip and passing a nasogastric tube. Most nurses didn’t do that and still don’t. They may be called ‘Health Care Assistants’, but the public knows them as nurses and they do the sort of tasks that nurses have always done. They wash and feed patients, they make beds, they wipe their bottoms, they take temperatures, pulses and blood pressures, they take blood samples, they dress wounds, they help patients out of bed and back into bed, and they generally make life a lot more pleasant than it would otherwise be. Many of them are also male. Quite a lot of what a demented patient needs is included in the above list. They seldom need an RGN but they do need the aid of health care assistants.
My sister works for a private company that provides these services in a person’s own home. It is funded mainly by the taxpayer and includes among its ministrations some element of entertainment like trips out and attendance at day-centers. My sister has no nursing training but she has been a mother and she has run her own small business. She knows how to organize things and is able to manage the other ‘home-helps’ as they used to be called. The point is that most people with mild dementia, or indeed mild failure of other bits of their bodies, can and ought to be helped to remain living in their own home. It is not costly to do so and it is worth the public investing in this resource. Of course, there is a place for family and church to contribute to this enterprise and there really is a ‘Big Society’ out there already doing it.
My mother is 91 and although she has all her marbles, she is inevitably slowing down and a little off her legs. My siblings do her shopping, tend her garden and clean her house. We do our part as much as we can, living much further away. A lady from her church lives around the corner and, although in her 80s, is a great help. Other people from her church provide transport to three church meetings every week. For Mum, life is worth living because of the support she gets.
Unfortunately, however good the support, dementia patients cannot always be kept in their own home. Often the main carer is a spouse of the same age and when the spouse gets ill someone must take over. If the children have the responsibility of caring, the care is often shared out unequally. High flying sons are too busy and their trophy wives don’t see why they should be involved. They may provide some money, but often this lifestyle is only maintained on tick. Other children may live too far away to get involved. On many occasions it is the youngest daughter who happens to live locally who has to give up her job or neglect her own family. Resentment is easily engendered.
For many the answer is a nursing home. But how to pay for it? In Scotland and Denmark the governments have decided that the general taxpayer should pay. Scotland has the advantage of a generous subsidy from England and Denmark has a basic tax rate of 53%. Joan Bakewell, who was advisor on old people to the last Labour government thought that the old person should sell his or her large house to pay for it.
The Dilman report has suggested that there should be a cap of about £50,000 on how much old people should pay towards their nursing home care. If they have total assets of less than £23,000 they are currently not expected to pay anything. £50,000 barely pays for 2 years in a nursing home – the average stay for a demented patient is about 18 months. Down south and in London £50,000 can often be found from income alone. Up north £50,000 often represents a person’s total assets, house and all. However, since the taxpayer picks up the rest of the tab and the biggest taxpayers are down south, there is a sort of equality about it.
Southern Cross, the largest provider of nursing home care in the UK is in financial difficulty. It sounds as though it has made an unwise investment, but it looks as though 32,000 individuals in Southern Cross Care Homes are going to find that their nursing homes are no longer secure. Nursing Homes are usually large houses that have been converted, Sometimes several houses are knocked into one. However they could be converted into flats of be used for other purposes. This very flexibility is a danger since it is price-sensitive. With the house sale market static there is a great demand for rented properties and some landlords have felt that nursing homes are not as profitable as flats.
There does not seem to be an easy answer to the conundrum, which is perhaps why the Labour Party has cried, "No contest" and has offered to work together with the government on a joint approach. For me the lesson to be learnt is that more people are going to have to work as carers and that the qualities that these people are going to need are patience, kindness and faithfulness. Rare qualities indeed!
Galatians 5:22 ...kindness...
The fruit of the Spirit is …kindness…
Kindness is a quality we see all too little of. In our bluff and efficient world kindness often goes out the window. It goes well alongside patience because kindness often takes a moment longer. But it is only a moment longer. Imagine the difference made by a doctor’s receptionist who instead of hurrying on to the “Next!” takes the time to treat each patient as an individual. Many of Jesus’ instructions involve kindness. Going the extra mile, offering your cloak as well, and turning the other cheek, are all examples. Can you think of an occasion when you were brusque when you should have been kind?
Jesus showed us kindness in that he did not condemn us despite our rebellion; instead he went the extra mile for us, gave us another chance and in effect turned the other cheek. When he was attacked and humiliated he did not react by condemnation but by grace. Kindness has an element of this. It means that when you are in a position of superiority you don’t take advantage of it, but instead humble yourself and act like a slave for the benefit of your adversary.
Kindness is a quality we see all too little of. In our bluff and efficient world kindness often goes out the window. It goes well alongside patience because kindness often takes a moment longer. But it is only a moment longer. Imagine the difference made by a doctor’s receptionist who instead of hurrying on to the “Next!” takes the time to treat each patient as an individual. Many of Jesus’ instructions involve kindness. Going the extra mile, offering your cloak as well, and turning the other cheek, are all examples. Can you think of an occasion when you were brusque when you should have been kind?
Jesus showed us kindness in that he did not condemn us despite our rebellion; instead he went the extra mile for us, gave us another chance and in effect turned the other cheek. When he was attacked and humiliated he did not react by condemnation but by grace. Kindness has an element of this. It means that when you are in a position of superiority you don’t take advantage of it, but instead humble yourself and act like a slave for the benefit of your adversary.
John 4:28-29 Conversion
Then leaving her water jar, the woman went back to the town and said to the people, “Come and see a man who told me everything I ever did. Could this be the Christ?”
The woman has been converted and her first reaction is to share her testimony. People will not listen to dreary talks about doctrine, but testimony has them all ears. If you want to share your faith, make sure that it is your faith you are sharing, not something got up out of a book.
People are impressed by the spectacular and the unusual. What was unusual about your conversion? How was it spectacular? For me it was the occasion, the unlikelihood of a scientist being converted, the coincidence of how it happened and the personal label attached to it. For this woman it was the omniscience of Jesus, his effrontery at speaking to a woman who was one of the enemy and his lack of shame or condemnation at her lifestyle
The woman has been converted and her first reaction is to share her testimony. People will not listen to dreary talks about doctrine, but testimony has them all ears. If you want to share your faith, make sure that it is your faith you are sharing, not something got up out of a book.
People are impressed by the spectacular and the unusual. What was unusual about your conversion? How was it spectacular? For me it was the occasion, the unlikelihood of a scientist being converted, the coincidence of how it happened and the personal label attached to it. For this woman it was the omniscience of Jesus, his effrontery at speaking to a woman who was one of the enemy and his lack of shame or condemnation at her lifestyle
Wednesday, June 08, 2011
The economy
Growth is slowing down. Official figures have reduced the expected growth in the UK economy this year by 0.2% while keeping next year's figures the same at 2.5% It looks as though the economic recovery is stalling. Despite this, teh recent visit of the IMF was supportive of George Osborne's policies and dismissive of Labour's plans. The reason given was that the setbacks that have taken place this year are temporary ones. Four have been identified. Oil prices have risen because of the turmoil in North Africa, the Japanese earthquake has caused a breakdown of manufacturing supply chains, the Greek crisis has renewed the threat to the European financial systemhas and the European Central Bank’s has decided to start raising interest rates somewhat prematurely.
The Greek crisis seems to have settled again and Spain has not joined teh failed economies, quite, Japanese parts are signaled to start moving shortly and Saudi Arabia seems secure so that OPEC are talking about switching on the oil again.
It is going to be a long slow recovery but 20 years from now it will be seen as a blip.
Meantime over 400,000 new jobs have been created in the private sector in the past year.
The Greek crisis seems to have settled again and Spain has not joined teh failed economies, quite, Japanese parts are signaled to start moving shortly and Saudi Arabia seems secure so that OPEC are talking about switching on the oil again.
It is going to be a long slow recovery but 20 years from now it will be seen as a blip.
Meantime over 400,000 new jobs have been created in the private sector in the past year.
Fraud
In total, the National Fraud Authority estimates that fraud costs the public sector in the UK £21 billion a year of which £2.4 billion is lost to procurement fraud and £515m is lost to grant fraud. The Department of Work and Pensions lose more than £1 billion each year to benefit fraud. Local government loses £2.1 billion pounds each year to fraud. And Her majesty's Revenue and Customs (HMRC) estimates a whopping £15 billion each year is not paid to the Exchequer due to tax fraud.
The crisis in the health service is that it is expected to find £20 billion in efficiency savings over the next 4 years. Were fraud eliminated this would not be necessary.
How well is the government doing in eliminating fraud?
HMRC recently implemented a "fraud firewall" designed to identify fraud and error through new screening techniques. This pilot scheme is detecting up to 90 per cent of estimated error and fraud in new claims, saving £260 million over four years as a result. Last month George Osborne announced that HMRC had stopped more than £1billion of fraudulent and incorrect tax credit payments in 2010/11 – a 60 per cent increase on the year before. The Spending Review invested £917m in HMRC to tackle evasion, avoidance and criminal fraud – this will bring in £7bn extra over the Parliament.
Still a long way to go then.
The crisis in the health service is that it is expected to find £20 billion in efficiency savings over the next 4 years. Were fraud eliminated this would not be necessary.
How well is the government doing in eliminating fraud?
HMRC recently implemented a "fraud firewall" designed to identify fraud and error through new screening techniques. This pilot scheme is detecting up to 90 per cent of estimated error and fraud in new claims, saving £260 million over four years as a result. Last month George Osborne announced that HMRC had stopped more than £1billion of fraudulent and incorrect tax credit payments in 2010/11 – a 60 per cent increase on the year before. The Spending Review invested £917m in HMRC to tackle evasion, avoidance and criminal fraud – this will bring in £7bn extra over the Parliament.
Still a long way to go then.
Galatians 5:22 ...patience...
But the fruit of the Spirit is ...patience...
I used to be an impatient driver. I would take silly risks to be two places nearer the head of the line. Since I retired I have lost all that and I smile at the boy-racers who make obscene signs at me as they hurry past. What convinced me of the folly of it was when my daughter returned to Oxford having left her keys behind. I chased after her leaving 5 minutes behind her. I found that after driving as fast as I could on the 80 minute journey, I was still 5 minutes behind her at Oxford.
The Holy Spirit takes the long view and so should we. I know patience is difficult. That's why we need the Holy Spirit.
I used to be an impatient driver. I would take silly risks to be two places nearer the head of the line. Since I retired I have lost all that and I smile at the boy-racers who make obscene signs at me as they hurry past. What convinced me of the folly of it was when my daughter returned to Oxford having left her keys behind. I chased after her leaving 5 minutes behind her. I found that after driving as fast as I could on the 80 minute journey, I was still 5 minutes behind her at Oxford.
The Holy Spirit takes the long view and so should we. I know patience is difficult. That's why we need the Holy Spirit.
John 4:27 misogyny
Just then his disciples returned and were surprised to find him talking with a woman. But no one asked, “What do you want?” or “Why are you talking with her?”
And Christianity is often accused of misogyny! This particular woman was a Samaritan and almost certainly a serial adulterer yet Jesus thought her worth speaking to and offering her the message of salvation. The disciples by now had recognized the authority of Jesus and knew that what he did might shatter old beliefs but still it was right. Jesus sees individuals, not categories. Do we?
And Christianity is often accused of misogyny! This particular woman was a Samaritan and almost certainly a serial adulterer yet Jesus thought her worth speaking to and offering her the message of salvation. The disciples by now had recognized the authority of Jesus and knew that what he did might shatter old beliefs but still it was right. Jesus sees individuals, not categories. Do we?
Tuesday, June 07, 2011
The Nature paper sequencing the CLL genome
There has been great excitement in the CLL world about the paper in Nature which describes the first whole genome sequencing of four patients with CLL. The paper which has 65 authors comes from Spain, and hematologists will recognize the names of Emili Montserrat, Jesus San Miguel and Elias Campo among others.
Two of the patients had mutated and two unmutated IGHV genes. The whole genome sequencing identified 46 somatic mutations that might affect gene function. Further analysis of 363 patients identified four of these genes that were recurrently mutated, NOTCH1, Exportin 1 (XPO1), myeloid differentiation primary response gene 88 (MYD88) and kelch-like 6 (KLHL6). The first three of these were identified as oncogenic changes that contribute to the clinical evolution of the disease.
NOTCH1 was found to be mutated in 12% of CLLs. NOTCH1 is constitutively expressed in CLL but the mutations identified generate a more stable and active form of the protein. It was later found that 23 of the 46 original mutated genes were assigned to the NOTCH1 signaling pathway. Furthermore NOTCH1 mutated patients had a more advanced clinical stage, more adverse biological features, a more likely Richter's transformation (7/31 v 3/224), and a significantly shorter overall survival than those with an unmutated NOTCH1. The same IGHV clonal arrangement and the same NOTCH1 mutations were found in the diffise large B cells transformations studied as in the original corresponding CLLs.
A recurrent mutation of the MYD88 gene was found in 2.9% of CLLs and the same mutation has been detected in other lymphomas. This protein participates in the signaling pathways of IL-1 and Toll-like receptors during the immune response. This mutation was associated with increased cytokine secretion. Cytokine secretion has been associated with recruitment of Macrophages and T lymphocytes which create a favorable niche for CLL cell survival. Patients with this mutation tended to present at an earlier age and with a more advanced stage, but they tend to have mutated IGHV genes and not to have worse progression or survival rates.
A recurrent mutation at XPO1 occurred in four patients. XPO1 is implicated in the nuclear export of proteins including members of the MAP kinase pathway. Two of the four cases also had NOTCH1 mutations.
It was thought that the mutations of KLH6 were likely to be caused by the same follicular center mutating mechanism that is active for IGHV genes and which is known to spill over onto other genes including BLC6, MYC and PIM1.
NOTCH1 has been written about before on this blog and so have Toll-like receptors. It looks as though we have some new targets for therapy.
Two of the patients had mutated and two unmutated IGHV genes. The whole genome sequencing identified 46 somatic mutations that might affect gene function. Further analysis of 363 patients identified four of these genes that were recurrently mutated, NOTCH1, Exportin 1 (XPO1), myeloid differentiation primary response gene 88 (MYD88) and kelch-like 6 (KLHL6). The first three of these were identified as oncogenic changes that contribute to the clinical evolution of the disease.
NOTCH1 was found to be mutated in 12% of CLLs. NOTCH1 is constitutively expressed in CLL but the mutations identified generate a more stable and active form of the protein. It was later found that 23 of the 46 original mutated genes were assigned to the NOTCH1 signaling pathway. Furthermore NOTCH1 mutated patients had a more advanced clinical stage, more adverse biological features, a more likely Richter's transformation (7/31 v 3/224), and a significantly shorter overall survival than those with an unmutated NOTCH1. The same IGHV clonal arrangement and the same NOTCH1 mutations were found in the diffise large B cells transformations studied as in the original corresponding CLLs.
A recurrent mutation of the MYD88 gene was found in 2.9% of CLLs and the same mutation has been detected in other lymphomas. This protein participates in the signaling pathways of IL-1 and Toll-like receptors during the immune response. This mutation was associated with increased cytokine secretion. Cytokine secretion has been associated with recruitment of Macrophages and T lymphocytes which create a favorable niche for CLL cell survival. Patients with this mutation tended to present at an earlier age and with a more advanced stage, but they tend to have mutated IGHV genes and not to have worse progression or survival rates.
A recurrent mutation at XPO1 occurred in four patients. XPO1 is implicated in the nuclear export of proteins including members of the MAP kinase pathway. Two of the four cases also had NOTCH1 mutations.
It was thought that the mutations of KLH6 were likely to be caused by the same follicular center mutating mechanism that is active for IGHV genes and which is known to spill over onto other genes including BLC6, MYC and PIM1.
NOTCH1 has been written about before on this blog and so have Toll-like receptors. It looks as though we have some new targets for therapy.
A salutary tale.
A woman who was inadvertently issued with a prescription for the wrong sort of hormone replacement for a year resulting in her taking unopposed estrogen, developed endometrial cancer. She sued the GPs concerned. The Medical Protection Society issued the following words of advice. If a specialist in secondary care issues the first prescription mistakes are much less likely to happen.
Most cancer specialists have occasions to remember when generalists have blundered in with treatments that are 'nearly' right. It is important for doctors to stay within their competence. Not every oncologist is a specialist in CLL. Most oncologists think they are.
Most cancer specialists have occasions to remember when generalists have blundered in with treatments that are 'nearly' right. It is important for doctors to stay within their competence. Not every oncologist is a specialist in CLL. Most oncologists think they are.
See how your Jesus will save you
"See how your Jesus will save you!" yelled the assailants as they attacked 13-year-old Sum with a machete. "Jesus has already saved me, and by killing me you would only be making it possible for me to be with Him," she replied. That day little Sum, her two siblings and mother lost their lives when their village was attacked by Muslim extremists who set more than twenty Christian homes ablaze and shot another twelve Christians. Her younger brother and father were left to pick up the pieces.
For more go to Open Doors
For more go to Open Doors
Autoimmunity and CLL
A very good article on CLL and autoimmunity from the Barcelona group has appeared in Haematologica. The article is available on open access, so I will just summarize the main points it makes.
1] Most recent papers have put the incidence of autoimmune hemolytic anemia in CLL at between 4.3 and 9.8% whereas the incidence of ITP, pure red cell aplasia and autoimmune neutropenia is much less - perhaps 2% for ITP and < 1% for the other two. There is no evidence linking CLL with acquired hemophilia or acquired von Willebrand's disease.
2] Although lymphomas generally are more common in patients with non-hemic autoimmunity, any association with CLL is confused because CLL may exist for many years before it is diagnosed. Case control studies suggest that non-hemic autoimmunity is no commoner in CLL than in the general population.
3] The risk of developing CLL in patients with AIHA is not clear. It is possible that many of the reported cases might have had occult CLL when the AIHA was diagnosed. One of my own patients was diagnosed with CLL and AIHA, but after treatment of the AIHA the CLL disappeared and did not reappear for another 5 years. MBL is more common in patients with de novo AIHA than in controls.
4] The biological reason for the explanation for increased AIHA in CLL is not clear. Stories about autoreactive surface Ig and B1a cells seem wide of the mark since the autoimmune antibodies are polyclonal not monoclonal. The Barker hypothesis seems to be the most convincing explanation. CLL cells are very poor antigen presenting cells except for the red cell Rh antigen. An alternative red cell antigen, B3, seems also to be processed by CLL cells which provoke a T cell response.
5] Autoimmunity is associated with advanced stage, older age, unmutated IGHV status, ZAP-70 positivity, and increased beta-2M levels.
6] Treatment can trigger AIHA. Although both purine analogs and alkylating agents do this equally frequently, the anemia after fludarabine may be more severe and life threatening. Multiply treated patients are more vulnerable. Adding cyclophosphamide and/or rituximab to fludarabine seems to lessen the risk and indeed this may be how patients with AIHA need to be treated. It is generally accepted that patients with a positive Coombs teat (DAT) should not be treated with single agent fludarabine.
7] In patients who definitely need to be treated a positive DAT is a poor prognostic feature. However, anemia or thrombocytopenia that is immune mediated does not carry the same poor prognostic emphasis as it does when caused by bone marrow infiltration. Such patients should not be staged as Binet C or Rai III of IV until the autoimmunity has been treated.
8] Diagnosis of autoimmunity requires a high degree of suspicion. For AIHA, DAT, LDH, bilirubin, haptoglobins, and reticulocyte count should be performed. There need to be some caveats, however. Bilirubin levels are often only high at the start of the hemolysis as the liver rapidly conjugates the fat soluble bilirubin and excretes it. If there is heavy marrow infiltration the reticulocyte count may be normal. LDH rises in advanced CLL without hemolysis. Sometimes the DAT is negative. I find the haptoglobin level the most reliable test. For ITP there is no similar test to the DAT. To rule out the possibility of hypersplenism or marrow infiltration as a cause of thrombocytopenia, bone marrow biopsy will likely be necessary. It may be considered likely to be immune mediated if the platelet count falls suddenly by more than 50 in the absence of splenomegaly or chemotherapy and with plenty of megakaryocytes in the bone marrow.
7] It is possible that the immunoglobulin produced by the CLL may cause an autoimmune disease. Candidates for such conditions include cold hemaggluinin disease, paraneoplastic pmphigus, polyneuropathy and nephrotic syndrome. Acquired angioedema is more likely to be associated with SMZL than CLL and it is doubtful whether any cases associated with CLL have in fact been reported.
1] Most recent papers have put the incidence of autoimmune hemolytic anemia in CLL at between 4.3 and 9.8% whereas the incidence of ITP, pure red cell aplasia and autoimmune neutropenia is much less - perhaps 2% for ITP and < 1% for the other two. There is no evidence linking CLL with acquired hemophilia or acquired von Willebrand's disease.
2] Although lymphomas generally are more common in patients with non-hemic autoimmunity, any association with CLL is confused because CLL may exist for many years before it is diagnosed. Case control studies suggest that non-hemic autoimmunity is no commoner in CLL than in the general population.
3] The risk of developing CLL in patients with AIHA is not clear. It is possible that many of the reported cases might have had occult CLL when the AIHA was diagnosed. One of my own patients was diagnosed with CLL and AIHA, but after treatment of the AIHA the CLL disappeared and did not reappear for another 5 years. MBL is more common in patients with de novo AIHA than in controls.
4] The biological reason for the explanation for increased AIHA in CLL is not clear. Stories about autoreactive surface Ig and B1a cells seem wide of the mark since the autoimmune antibodies are polyclonal not monoclonal. The Barker hypothesis seems to be the most convincing explanation. CLL cells are very poor antigen presenting cells except for the red cell Rh antigen. An alternative red cell antigen, B3, seems also to be processed by CLL cells which provoke a T cell response.
5] Autoimmunity is associated with advanced stage, older age, unmutated IGHV status, ZAP-70 positivity, and increased beta-2M levels.
6] Treatment can trigger AIHA. Although both purine analogs and alkylating agents do this equally frequently, the anemia after fludarabine may be more severe and life threatening. Multiply treated patients are more vulnerable. Adding cyclophosphamide and/or rituximab to fludarabine seems to lessen the risk and indeed this may be how patients with AIHA need to be treated. It is generally accepted that patients with a positive Coombs teat (DAT) should not be treated with single agent fludarabine.
7] In patients who definitely need to be treated a positive DAT is a poor prognostic feature. However, anemia or thrombocytopenia that is immune mediated does not carry the same poor prognostic emphasis as it does when caused by bone marrow infiltration. Such patients should not be staged as Binet C or Rai III of IV until the autoimmunity has been treated.
8] Diagnosis of autoimmunity requires a high degree of suspicion. For AIHA, DAT, LDH, bilirubin, haptoglobins, and reticulocyte count should be performed. There need to be some caveats, however. Bilirubin levels are often only high at the start of the hemolysis as the liver rapidly conjugates the fat soluble bilirubin and excretes it. If there is heavy marrow infiltration the reticulocyte count may be normal. LDH rises in advanced CLL without hemolysis. Sometimes the DAT is negative. I find the haptoglobin level the most reliable test. For ITP there is no similar test to the DAT. To rule out the possibility of hypersplenism or marrow infiltration as a cause of thrombocytopenia, bone marrow biopsy will likely be necessary. It may be considered likely to be immune mediated if the platelet count falls suddenly by more than 50 in the absence of splenomegaly or chemotherapy and with plenty of megakaryocytes in the bone marrow.
7] It is possible that the immunoglobulin produced by the CLL may cause an autoimmune disease. Candidates for such conditions include cold hemaggluinin disease, paraneoplastic pmphigus, polyneuropathy and nephrotic syndrome. Acquired angioedema is more likely to be associated with SMZL than CLL and it is doubtful whether any cases associated with CLL have in fact been reported.
John 4:25-26. Jesus is the Messiah
The woman said, “I know that Messiah” (called Christ) “is coming. When he comes, he will explain everything to us.” Then Jesus declared, “I, the one speaking to you—I am he.”
Did you ever doubt that Jesus is the Christ, the Messiah, the anointed one? Here he proclaims it! He is the Christ! He is given other names in Scripture, but lest we forget it, he is the Lord Jesus Christ!
He is the promised one. Not just a leader, not just David's greater son, not just a friend, not just a teacher, not just a prophet, not just the Son of man, not just a son of God, not just a king, not just the lamb of God who takes away the sin of the world; he is all of those things. He is the Christ! Praise His name!
Did you ever doubt that Jesus is the Christ, the Messiah, the anointed one? Here he proclaims it! He is the Christ! He is given other names in Scripture, but lest we forget it, he is the Lord Jesus Christ!
He is the promised one. Not just a leader, not just David's greater son, not just a friend, not just a teacher, not just a prophet, not just the Son of man, not just a son of God, not just a king, not just the lamb of God who takes away the sin of the world; he is all of those things. He is the Christ! Praise His name!
Galatians 5:22. ...peace...
But the fruit of the Spirit is love, joy, peace...
In the twentieth century there was hardly a year when there was peace on earth and the twenty-first century has been no better. But the peace that the Spirit brings is not about the absence of warfare. Indeed the Bible promises us that we will be involved with Spiritual warfare until Lord returns. But we have changed sides. Italy and Japan changed sides between the first and second world wars and we have changed sides since we were converted. We were formerly aides to Satan; now we have peace with God and enmity with the devil. Peace with the creator of the universe and its rightful ruler; that is more comfortable than being on the side of the would-be usurper.
Being at peace with God (purchased by the atoning sacrifice of Jesus Christ) gives us rest and comfort in our souls. So whatever the outside circumstances we have an inner peace.
In the twentieth century there was hardly a year when there was peace on earth and the twenty-first century has been no better. But the peace that the Spirit brings is not about the absence of warfare. Indeed the Bible promises us that we will be involved with Spiritual warfare until Lord returns. But we have changed sides. Italy and Japan changed sides between the first and second world wars and we have changed sides since we were converted. We were formerly aides to Satan; now we have peace with God and enmity with the devil. Peace with the creator of the universe and its rightful ruler; that is more comfortable than being on the side of the would-be usurper.
Being at peace with God (purchased by the atoning sacrifice of Jesus Christ) gives us rest and comfort in our souls. So whatever the outside circumstances we have an inner peace.
Monday, June 06, 2011
tMDS/AML in CLL after FC
A paper in Biomedicine and Pharmacotherapy reports on the risk of therapy-related MDS and acute myeloid leukemia (tMDS/AML) in patients with CLL treated with fludarabine and cyclophosphamide.
This was a retropective look-back from Serbia. They found 4 cases among 210 patients treated with FC at a single center. Two of the patients had only been treated with FC (2/130, 1.7%), but two had been previously treated with CHOP or CHOP + Fludarabine, mitoxantrone and dexamethasone (FND) (2/80, 2.3%). The median time to develop the secondary disease was 41 months (range 7-56) and the median survival after diagnosis was 4 months (2-8).
Reviewing the literature they note that in the CALGB 9011 study the frontline combination of fludarabine plus chlorambucil was responsible for the development of 3.5% tMDS/AML wheras fludarabine or chlorambucil were responsible for only 0.5% and 0% respectively, suggesting that it is the combination of purine analog and alkylating agent that is dangerous.
A rate of 4% was found in NHL treated with FND followed by alpha interferon maintenance. A much higher incidence of 20% was found in a mixed bag of indolent lymphomas, including about 40% CLLs who received FC as second line after prior alkylating agent treatment. In another study 137 patients with lymphoma (38% CLLs) developed 2.5% tMDS/AML in previously untreated patients and 9.3% in previously treated patients.
A particularly high rate of tMDS/AML (12.4%) was found in patients treated with fludarabine who proceeded to autologous transplant.
This paper largely confirms what was already known. In CLL the fludarabine/cyclophosphamide combination carries a small risk of tMDS/AML and this is greater in patients who have been treated previously with alkylating agents. My own theory for why this combination is particularly dangerous is that the alkylating agent causes genetic damage, allowing a malignant clone to emerge. The clone is normally controlled by regulatory T cells but these are abolished by fludarabine treatment allowing the tMDS/AML to emerge. tMDS/AML is a very unpleasant condition that is often rapidly fatal.
I have often stressed that we should be looking for less aggressive regimens in patients who need treatment but whose disease is not particularly aggressive such as those with mutated IGHV genes. It looks as if John Byrd's study with FR might be supporting this idea.
This was a retropective look-back from Serbia. They found 4 cases among 210 patients treated with FC at a single center. Two of the patients had only been treated with FC (2/130, 1.7%), but two had been previously treated with CHOP or CHOP + Fludarabine, mitoxantrone and dexamethasone (FND) (2/80, 2.3%). The median time to develop the secondary disease was 41 months (range 7-56) and the median survival after diagnosis was 4 months (2-8).
Reviewing the literature they note that in the CALGB 9011 study the frontline combination of fludarabine plus chlorambucil was responsible for the development of 3.5% tMDS/AML wheras fludarabine or chlorambucil were responsible for only 0.5% and 0% respectively, suggesting that it is the combination of purine analog and alkylating agent that is dangerous.
A rate of 4% was found in NHL treated with FND followed by alpha interferon maintenance. A much higher incidence of 20% was found in a mixed bag of indolent lymphomas, including about 40% CLLs who received FC as second line after prior alkylating agent treatment. In another study 137 patients with lymphoma (38% CLLs) developed 2.5% tMDS/AML in previously untreated patients and 9.3% in previously treated patients.
A particularly high rate of tMDS/AML (12.4%) was found in patients treated with fludarabine who proceeded to autologous transplant.
This paper largely confirms what was already known. In CLL the fludarabine/cyclophosphamide combination carries a small risk of tMDS/AML and this is greater in patients who have been treated previously with alkylating agents. My own theory for why this combination is particularly dangerous is that the alkylating agent causes genetic damage, allowing a malignant clone to emerge. The clone is normally controlled by regulatory T cells but these are abolished by fludarabine treatment allowing the tMDS/AML to emerge. tMDS/AML is a very unpleasant condition that is often rapidly fatal.
I have often stressed that we should be looking for less aggressive regimens in patients who need treatment but whose disease is not particularly aggressive such as those with mutated IGHV genes. It looks as if John Byrd's study with FR might be supporting this idea.
The history of the twentieth century
I have not posted much recently about what I have been reading. That is because I have been reading a very thick book, Martin Gilbert's History of the Twentieth Century, Volume 1 1900-1933.
I knew very little about when my parents and grandparents were alive. What tumultuous times!
AT the start of this period history was dominated by the machinations of the Great Powers - Britain, France, Germany, Russia, Austro-Hungary, Turkey, the United States and Japan. Between them they owned practically the whole world. There were small Portuguese and Belgian Empires, but the Spanish Empire had been lost to the United States. The sick man of Europe was undoubtedly Turkey. The Ottoman Empire, which included the Arab lands and the Balkans had once extended to the Gates of Vienna, but nationalistic fervor in Bulgaria, Serbia, Montenegro, Bosnia and Albania had meant that it had to withdraw its hegemony in the Balkans. Serbia, in particular, protected as it was by Russia as a fellow Slav state, was keen to gain its independence. Roumania did not involve itself in the first Balkan war but managed to mop up territory when it ended. The Greeks were the biggest gainers winning part of Macedonia, Thrace and many of the islands.
Austro-Hungary was itself beset by nationalist uprising. Poland and Czechoslovakia were weary of being part of the Empire. Meanwhile the Empire saw itself as protector of Roman Catholics outside its borders, so that Croatia and Slovenia sought protection from Turkish Muslims and Serbian Orthodox alike. They have long memories in the Balkans so that after the death of Tito the same towns involved in the 1900s were again prominent in the news; towns like Pristina and Sarajevo.
In Africa, the German colonies continued to be a drain on their economy, the British colonies were well controlled apart from South Africa, which was now running itself and had adopted racist policies of which Britain did not approve. Gandhi had emerged as a champion of both black and Indian races in South Africa, but after the Boer war Britain was reluctant to send troops on behalf of the Blacks. France had its own troubles in North Africa. While Egypt was under control, the same could not be said for the rest of North Africa. Morocco saw a succession of assassinations requiring French troops to restore order. In Libya the Italians sought an Empire of their own by fomenting discontent in both Tripoli and Benghazi, then as now, the centers of two different tribes.
In Russia the attempted revolution of 1905 left the Tsar in autocratic power. The Duma was a talking shop without much influence. It allowed subject nations like Poland, Finland, and the Baltic states to have their say without anybody listening.
Meanwhile the United States was growing in power so that its manufacturing output by 1913 exceeded that of Britain, France and Germany combined.
Then came the First World War. It was a time when people thought of war as a time of glory and honor. They reckoned without the Maxim machine gun. Millions were mown down in the trenches of Normandy and northern France. There were four years of stalemate while the European powers wore themselves out. The United States waited them out, lending them money, growing more powerful and richer. Eventually, the Russian, German, Turkish and Austro-Hungarian empires collapsed, America came in on the side of the democracies losing a lot of men, almost as many as were killed in two years in America in traffic accidents.
Germany and Austria were humiliated by France at the Treaty of Versailles. Reparations were crippling. Woodrow Wilson set up the League of Nations which outlawed war even though new weapons of war were now available - the airplane and the tank. All European nations were bankrupt and even though Britain cheered itself up that it still had its Empire and the Royal Navy, these things were more handicap than a power base.
Then America withdrew into isolationism, failed to join the League of Nations and left the world safe for communism.
The Twenties and Thirties were terrible years. In America prohibition gave rise to criminality. It wasn't just Al Capone. In Chicago there was graft and corruption amongst those who were supposed to be running things let alone amongst those who weren't. Before long the Stock Market collapsed and kept on collapsing. The financial woes spread throughout the globe until deficit spending became respectable in 1933.
The rest of the world was worse. By 1933 Europe had descended into dictatorships, which were the form of government in Italy, Germany, Spain, Portugal, Austria, Poland, Russia, Yugoslavia and Turkey. Russia was by far the worst, not only subjecting the nations of the Baltic but also those of the Caucasus and western Asia. Even its own people were subject to the Great Terror. Show trials on trumped up charges, whole groups of citizens sent into slave labor because of their social class, even good and faithful communists executed to encourage the others. Stalin was terrifyingly mad, but so powerful that he went unchallenged. Famously even Beria did not disturb him when he was alone in his room sitting in an armchair dying of a stroke.
In China the young Emperor had been deposed. The Nationalists under Chiang Kai-shek were ruling in Nankiing but were opposed by the Russian supported communists under Chou En-lai and rather more effectively by the guerrilla warfare of Mao Tse-tung. Meanwhile the Japanese had annexed Manchuria. The League of Nations was not pleased, but having abolished war, found that they had nothing they could do about it except send a stiff note.
The British Empire persisted, but had already relinquished Ireland and was making plans to give up India, Egypt and the Sudan. The League had given it part of the old Ottoman Empire to administer. Britain took it on as part of the white man's burden. Who would want Palestine, Iraq and the Yemen? Britain thought of itself as an enlightened colonial power and so it was as colonial powers go. Can you imagine how Stalin would have treated Gandhi? But the wind of change was already in the air. The only reason for staying a colony was for the largess of the colonial power, which is why Puerto Rico stays one until this day, eschewing statehood when it was offered. Britain had run out of largess, but there was to be one final gesture of loyalty to the colonial power.
I knew very little about when my parents and grandparents were alive. What tumultuous times!
AT the start of this period history was dominated by the machinations of the Great Powers - Britain, France, Germany, Russia, Austro-Hungary, Turkey, the United States and Japan. Between them they owned practically the whole world. There were small Portuguese and Belgian Empires, but the Spanish Empire had been lost to the United States. The sick man of Europe was undoubtedly Turkey. The Ottoman Empire, which included the Arab lands and the Balkans had once extended to the Gates of Vienna, but nationalistic fervor in Bulgaria, Serbia, Montenegro, Bosnia and Albania had meant that it had to withdraw its hegemony in the Balkans. Serbia, in particular, protected as it was by Russia as a fellow Slav state, was keen to gain its independence. Roumania did not involve itself in the first Balkan war but managed to mop up territory when it ended. The Greeks were the biggest gainers winning part of Macedonia, Thrace and many of the islands.
Austro-Hungary was itself beset by nationalist uprising. Poland and Czechoslovakia were weary of being part of the Empire. Meanwhile the Empire saw itself as protector of Roman Catholics outside its borders, so that Croatia and Slovenia sought protection from Turkish Muslims and Serbian Orthodox alike. They have long memories in the Balkans so that after the death of Tito the same towns involved in the 1900s were again prominent in the news; towns like Pristina and Sarajevo.
In Africa, the German colonies continued to be a drain on their economy, the British colonies were well controlled apart from South Africa, which was now running itself and had adopted racist policies of which Britain did not approve. Gandhi had emerged as a champion of both black and Indian races in South Africa, but after the Boer war Britain was reluctant to send troops on behalf of the Blacks. France had its own troubles in North Africa. While Egypt was under control, the same could not be said for the rest of North Africa. Morocco saw a succession of assassinations requiring French troops to restore order. In Libya the Italians sought an Empire of their own by fomenting discontent in both Tripoli and Benghazi, then as now, the centers of two different tribes.
In Russia the attempted revolution of 1905 left the Tsar in autocratic power. The Duma was a talking shop without much influence. It allowed subject nations like Poland, Finland, and the Baltic states to have their say without anybody listening.
Meanwhile the United States was growing in power so that its manufacturing output by 1913 exceeded that of Britain, France and Germany combined.
Then came the First World War. It was a time when people thought of war as a time of glory and honor. They reckoned without the Maxim machine gun. Millions were mown down in the trenches of Normandy and northern France. There were four years of stalemate while the European powers wore themselves out. The United States waited them out, lending them money, growing more powerful and richer. Eventually, the Russian, German, Turkish and Austro-Hungarian empires collapsed, America came in on the side of the democracies losing a lot of men, almost as many as were killed in two years in America in traffic accidents.
Germany and Austria were humiliated by France at the Treaty of Versailles. Reparations were crippling. Woodrow Wilson set up the League of Nations which outlawed war even though new weapons of war were now available - the airplane and the tank. All European nations were bankrupt and even though Britain cheered itself up that it still had its Empire and the Royal Navy, these things were more handicap than a power base.
Then America withdrew into isolationism, failed to join the League of Nations and left the world safe for communism.
The Twenties and Thirties were terrible years. In America prohibition gave rise to criminality. It wasn't just Al Capone. In Chicago there was graft and corruption amongst those who were supposed to be running things let alone amongst those who weren't. Before long the Stock Market collapsed and kept on collapsing. The financial woes spread throughout the globe until deficit spending became respectable in 1933.
The rest of the world was worse. By 1933 Europe had descended into dictatorships, which were the form of government in Italy, Germany, Spain, Portugal, Austria, Poland, Russia, Yugoslavia and Turkey. Russia was by far the worst, not only subjecting the nations of the Baltic but also those of the Caucasus and western Asia. Even its own people were subject to the Great Terror. Show trials on trumped up charges, whole groups of citizens sent into slave labor because of their social class, even good and faithful communists executed to encourage the others. Stalin was terrifyingly mad, but so powerful that he went unchallenged. Famously even Beria did not disturb him when he was alone in his room sitting in an armchair dying of a stroke.
In China the young Emperor had been deposed. The Nationalists under Chiang Kai-shek were ruling in Nankiing but were opposed by the Russian supported communists under Chou En-lai and rather more effectively by the guerrilla warfare of Mao Tse-tung. Meanwhile the Japanese had annexed Manchuria. The League of Nations was not pleased, but having abolished war, found that they had nothing they could do about it except send a stiff note.
The British Empire persisted, but had already relinquished Ireland and was making plans to give up India, Egypt and the Sudan. The League had given it part of the old Ottoman Empire to administer. Britain took it on as part of the white man's burden. Who would want Palestine, Iraq and the Yemen? Britain thought of itself as an enlightened colonial power and so it was as colonial powers go. Can you imagine how Stalin would have treated Gandhi? But the wind of change was already in the air. The only reason for staying a colony was for the largess of the colonial power, which is why Puerto Rico stays one until this day, eschewing statehood when it was offered. Britain had run out of largess, but there was to be one final gesture of loyalty to the colonial power.
Galatians 5:22. ...Joy...
But the fruit of the Spirit is love, joy...
If love was a special kind of love, then joy is not mere happiness. I have been happy in my life many times but happiness is ephemeral is is replaced by sadness as circumstances change, but joy is everlasting. Knowing that my savior loves me and gave his life for me brings me a joy unspeakable. Words cannot contain it.
On the night that I was baptized I was shaking with joy, my emotions were running high. I was excited, pleased, exhilarated and overwhelmed, but none of these are necessary for me to be joyful.
The evening that I was converted, when I realized that the minister was talking directly to me, I shivered with emotion, but that was not necessary for me to be joyful.
On the day that I walked on Hengistbury Head, the wind rushing through my hair and a different minister explained to me the doctrines of grace and I understood for the first time that I was not responsible in the slightest way for my salvation, but that Jesus had done everything, I was crushed with joy. But that was not necessary for me to be joyful.
There is a picture of me on my wedding day. I look like the cat that got the cream. You can see a photograph of me holding my first child. And my second third and fourth children. They are pictures of joy. I remember my children's graduations, their marriages, my grandchildren being born, when they got promoted at work, seeing them on television; these things all made me proud and full of joy.
I know that when I die I shall see the Lord. I know that I will be welcomed into heaven for His sake (not for mine, never for mine). But it is not for some future benefit that I am joyful. I am full of joy for the Spirit's presence here and now. I know that whatever hard times I may pass through (and I have passed through difficult days) he is with me like the Good Shepherd. The 23rd Psalm is a great comfort and everybody thinks it refers to Jesus. But Jesus was here bodily for 33 years 2000 years ago. He ascended into heaven and sent his Spirit instead. The one who stands alongside us, who carries us when we are winded and wounded, whose rod and staff, they comfort me is the Holy Spirit. That's who brings us joy.
If love was a special kind of love, then joy is not mere happiness. I have been happy in my life many times but happiness is ephemeral is is replaced by sadness as circumstances change, but joy is everlasting. Knowing that my savior loves me and gave his life for me brings me a joy unspeakable. Words cannot contain it.
On the night that I was baptized I was shaking with joy, my emotions were running high. I was excited, pleased, exhilarated and overwhelmed, but none of these are necessary for me to be joyful.
The evening that I was converted, when I realized that the minister was talking directly to me, I shivered with emotion, but that was not necessary for me to be joyful.
On the day that I walked on Hengistbury Head, the wind rushing through my hair and a different minister explained to me the doctrines of grace and I understood for the first time that I was not responsible in the slightest way for my salvation, but that Jesus had done everything, I was crushed with joy. But that was not necessary for me to be joyful.
There is a picture of me on my wedding day. I look like the cat that got the cream. You can see a photograph of me holding my first child. And my second third and fourth children. They are pictures of joy. I remember my children's graduations, their marriages, my grandchildren being born, when they got promoted at work, seeing them on television; these things all made me proud and full of joy.
I know that when I die I shall see the Lord. I know that I will be welcomed into heaven for His sake (not for mine, never for mine). But it is not for some future benefit that I am joyful. I am full of joy for the Spirit's presence here and now. I know that whatever hard times I may pass through (and I have passed through difficult days) he is with me like the Good Shepherd. The 23rd Psalm is a great comfort and everybody thinks it refers to Jesus. But Jesus was here bodily for 33 years 2000 years ago. He ascended into heaven and sent his Spirit instead. The one who stands alongside us, who carries us when we are winded and wounded, whose rod and staff, they comfort me is the Holy Spirit. That's who brings us joy.
John 4:21-24. Salvation is from the Jew.
“Woman,” Jesus replied, “believe me, a time is coming when you will worship the Father neither on this mountain nor in Jerusalem. You Samaritans worship what you do not know; we worship what we do know, for salvation is from the Jews. Yet a time is coming and has now come when the true worshipers will worship the Father in the Spirit and in truth, for they are the kind of worshipers the Father seeks. God is spirit, and his worshipers must worship in the Spirit and in truth.”
Jesus responds to her without giving way on the historical issue; the Jews were indeed God's chosen instrument with which to reveal himself to the world. Yet a time is coming. The time is coming for all symbolism and ritual to be wiped away so that mankind can have no confusion or argument. True worshipers will worship the Father in Spirit.
No longer will worshipers have to visit the Temple in Jerusalem, buy a couple of doves for sacrifice, exchange their money at the money-changers booths, observe certain days as sabbaths, rely on priests to approach God. To approach the Father the Spirit will be as close as breathing. Jesus is going to do this. He, and only he, is going to find a way through that curtain of separation. It is the way of sacrifice and it is God the Son who will make the access available. This is the way of truth.
Salvation is from the Jews; and one Jew in particular.
Jesus responds to her without giving way on the historical issue; the Jews were indeed God's chosen instrument with which to reveal himself to the world. Yet a time is coming. The time is coming for all symbolism and ritual to be wiped away so that mankind can have no confusion or argument. True worshipers will worship the Father in Spirit.
No longer will worshipers have to visit the Temple in Jerusalem, buy a couple of doves for sacrifice, exchange their money at the money-changers booths, observe certain days as sabbaths, rely on priests to approach God. To approach the Father the Spirit will be as close as breathing. Jesus is going to do this. He, and only he, is going to find a way through that curtain of separation. It is the way of sacrifice and it is God the Son who will make the access available. This is the way of truth.
Salvation is from the Jews; and one Jew in particular.
Sunday, June 05, 2011
Reducing the cancer bill.
Thomas Smith and Bruce Hillner from Virginia Commonwealth University have developed a scheme for making cancer treatment cheaper. Their program involves the following:
1] Abandoning regular scheduled surveillance testing with serum tumor markers and imaging for most cancers,especially for pancreas, ovary or lung because such screening does not alter prognosis - (We don't do it this side of the pond anyway)
2] Cancer drugs should be sequential monotherapy rather than as combined treatment, because combination treatment offers few benefits, is more expensive, and causes more toxicity - (this is not true for hematological cancers and has been clinical trial driven. Sometimes we reduce the number of drugs, eg FR seems to be just as suitable as FCR for mutated CLL)
3] The decision to offer chemotherapy to advanced metastatic cancer should depend on the patient's performance status. As a general rule patients should be able to walk unaided into the clinic to receive chemotherapy - (Again this may not be true for rapidly progressive hematological cancers, which can be reversed just as rapidly. But for solid tumors this would be the rule in the NHS.)
4] Hematopoietic growth factors should be avoided or lower doses used. Although they stimulate white cell growth after chemotherapy they do not improve survival in either lymphoma or small cell lung cancer - (I agree with this one. We use too many growth factors)
5] Patients with progressive disease should be switched to palliative care after three consecutive regimens of chemotherapy because the chances of success are minimal with subsequent courses - (again this is very true and too much futile chemotherapy only inflicts harm on patients.)
1] Abandoning regular scheduled surveillance testing with serum tumor markers and imaging for most cancers,especially for pancreas, ovary or lung because such screening does not alter prognosis - (We don't do it this side of the pond anyway)
2] Cancer drugs should be sequential monotherapy rather than as combined treatment, because combination treatment offers few benefits, is more expensive, and causes more toxicity - (this is not true for hematological cancers and has been clinical trial driven. Sometimes we reduce the number of drugs, eg FR seems to be just as suitable as FCR for mutated CLL)
3] The decision to offer chemotherapy to advanced metastatic cancer should depend on the patient's performance status. As a general rule patients should be able to walk unaided into the clinic to receive chemotherapy - (Again this may not be true for rapidly progressive hematological cancers, which can be reversed just as rapidly. But for solid tumors this would be the rule in the NHS.)
4] Hematopoietic growth factors should be avoided or lower doses used. Although they stimulate white cell growth after chemotherapy they do not improve survival in either lymphoma or small cell lung cancer - (I agree with this one. We use too many growth factors)
5] Patients with progressive disease should be switched to palliative care after three consecutive regimens of chemotherapy because the chances of success are minimal with subsequent courses - (again this is very true and too much futile chemotherapy only inflicts harm on patients.)
The Olympic torch
In the run-up to next year's London Olympics, the Olympic torch will pass through and stay overnight here in Bournemouth. I have been asked if I would agree to be nominated as one of the torch bearers. In view of my health problems and lack of fitness I have had to decline, but an article in the Sunday Times today justifies my attitude.
It turns out that a lot of free tickets for the Olympics will go to the representatives of FIFA. If you were paying attention last weeks you will have seen that FIFA president Bepp Splatter was re-elected unopposed amid accusations of corruption. The English FA made the rather moderate suggestion that the election ought to be postponed until the corruption enquiries were completed, but this was met with a vituperative reaction from some of the delegates. This is a comment from the Sunday Times: Among those who’ll get whatever access he wants to the Games will be the fat, English-hating Julio Grondona, the Fifa vice-president from Argentina. This is the man who, when canvassed for his vote for our World Cup bid, reportedly told the Football Association: “Let us be brief. If you give us back the Falkland Islands, which belong to us, you get my vote.” I wasn’t aware that this was, in footballing terms, strictly relevant and you might have hoped that Sepp Blatter would have had something to say about it. He did — he said: “Julio is a monumental man. We are friends for ever.”
Sepp is not Julio’s only friend, mind; Grondona was also rumoured to have known the mass murderer who led the fascist Argentinian junta after 1976, Jorge Rafael Videla, now serving a life sentence. Perhaps Julio would protest that his political views have changed since then — but in truth they haven’t much. In 2003 he told a journalist: “I do not believe a Jew can ever be a referee at this level. It’s hard work and, you know, Jews don’t like hard work.” But if Grondona wants to attend one or another Olympic event — I’d suggest the shooting, for nostalgic reasons — then we will carry him to the arena on a litter.
Remarkably, Grondona is probably not the worst of the bunch, although he is fabulously vile. There isn’t space here to run through the rest of the thick and grasping Third-Worlders perpetually on the make, the Jack Warners and Nicolas Leozes and the rest of them, all of whom will be given free access should they want it, which they probably will. It’s time we told them all to clear off.
Ones enemies certainly make it hard to love them.
It turns out that a lot of free tickets for the Olympics will go to the representatives of FIFA. If you were paying attention last weeks you will have seen that FIFA president Bepp Splatter was re-elected unopposed amid accusations of corruption. The English FA made the rather moderate suggestion that the election ought to be postponed until the corruption enquiries were completed, but this was met with a vituperative reaction from some of the delegates. This is a comment from the Sunday Times: Among those who’ll get whatever access he wants to the Games will be the fat, English-hating Julio Grondona, the Fifa vice-president from Argentina. This is the man who, when canvassed for his vote for our World Cup bid, reportedly told the Football Association: “Let us be brief. If you give us back the Falkland Islands, which belong to us, you get my vote.” I wasn’t aware that this was, in footballing terms, strictly relevant and you might have hoped that Sepp Blatter would have had something to say about it. He did — he said: “Julio is a monumental man. We are friends for ever.”
Sepp is not Julio’s only friend, mind; Grondona was also rumoured to have known the mass murderer who led the fascist Argentinian junta after 1976, Jorge Rafael Videla, now serving a life sentence. Perhaps Julio would protest that his political views have changed since then — but in truth they haven’t much. In 2003 he told a journalist: “I do not believe a Jew can ever be a referee at this level. It’s hard work and, you know, Jews don’t like hard work.” But if Grondona wants to attend one or another Olympic event — I’d suggest the shooting, for nostalgic reasons — then we will carry him to the arena on a litter.
Remarkably, Grondona is probably not the worst of the bunch, although he is fabulously vile. There isn’t space here to run through the rest of the thick and grasping Third-Worlders perpetually on the make, the Jack Warners and Nicolas Leozes and the rest of them, all of whom will be given free access should they want it, which they probably will. It’s time we told them all to clear off.
Ones enemies certainly make it hard to love them.
Galatians 5:22 Love...
But the fruit of the Spirit is love...
I have been pondering on how to finish my exposition of Galatians. This tremendous passage is so full of meaning that it could take months to expound. I have finally decided to go one word at a time.
The word translated 'love' here is 'agape' which is not the love one feels for a spouse or a brother or a child or a friend, but the self-sacrificing love that is all about the will and not feelings. When Jesus told us to love our enemies, this was the sort of love he meant. To love someone means to want the best for them. It means you want to save them from suffering, for them to be pleased with life and above all for them to be saved from the destruction to come.
Think about some of the worst people alive. Suicide bombers, rapists, murderers, pedophiles, callous fraudsters, abusers of the old and handicapped; these are all people that Jesus died for. Surely the Lord can't mean us to love these? But he does. Without exception. His grace is sufficient for everyone of these to turn from his wicked ways and live. The tragedy is that so few do. But that does not mean that we should not pray for them.
This does not mean that heaven should be open to unrepentant murderers and rapists. They cannot enter there; it would be physically impossible. But there are many who have repented. Think of John Newton; a slave ship captain who turned away from sin and became a Christian minister, and who wrote many fine hymns including Amazing Grace. It was indeed amazing grace that saved him, but the same Spirit who gives us love as a fruit deals in amazing grace and only he can make a difference in the life of the criminal and blackguard. He graciously allows us to take part in grace by giving us agape love as one of his fruits.
I have been pondering on how to finish my exposition of Galatians. This tremendous passage is so full of meaning that it could take months to expound. I have finally decided to go one word at a time.
The word translated 'love' here is 'agape' which is not the love one feels for a spouse or a brother or a child or a friend, but the self-sacrificing love that is all about the will and not feelings. When Jesus told us to love our enemies, this was the sort of love he meant. To love someone means to want the best for them. It means you want to save them from suffering, for them to be pleased with life and above all for them to be saved from the destruction to come.
Think about some of the worst people alive. Suicide bombers, rapists, murderers, pedophiles, callous fraudsters, abusers of the old and handicapped; these are all people that Jesus died for. Surely the Lord can't mean us to love these? But he does. Without exception. His grace is sufficient for everyone of these to turn from his wicked ways and live. The tragedy is that so few do. But that does not mean that we should not pray for them.
This does not mean that heaven should be open to unrepentant murderers and rapists. They cannot enter there; it would be physically impossible. But there are many who have repented. Think of John Newton; a slave ship captain who turned away from sin and became a Christian minister, and who wrote many fine hymns including Amazing Grace. It was indeed amazing grace that saved him, but the same Spirit who gives us love as a fruit deals in amazing grace and only he can make a difference in the life of the criminal and blackguard. He graciously allows us to take part in grace by giving us agape love as one of his fruits.
John 4:19-20. The main thing
“Sir,” the woman said, “I can see that you are a prophet. Our ancestors worshiped on this mountain, but you Jews claim that the place where we must worship is in Jerusalem.”
Embarrassed, the woman tries to change the subject. Evangelists find this to be a common tactic among the evangelized. Remember the main thing is the main thing. Beware of being drawn into the minutiae of theology. At the earliest opportunity switch back to the main thing.
Embarrassed, the woman tries to change the subject. Evangelists find this to be a common tactic among the evangelized. Remember the main thing is the main thing. Beware of being drawn into the minutiae of theology. At the earliest opportunity switch back to the main thing.
Saturday, June 04, 2011
John 4:16-18. Jesus knows everything
He told her, “Go, call your husband and come back.” “I have no husband,” she replied. Jesus said to her, “You are right when you say you have no husband. The fact is, you have had five husbands, and the man you now have is not your husband. What you have just said is quite true.”
In his encounter with this woman Jesus now puts his finger on the nub of her problem. She had been gathering water by herself, not with the other women of the village. Why? Because she had been ostracized by the other villagers for her sexual behavior. Of these 5 husbands, how many had she stolen from other women?
All have sinned and fall short. When we approach the Master have we confessed our sins or do we hope to brazen it out thinking we can keep things from God?
This is the second example of Jesus' omniscience; the first was more oblique with Nicodemus, but here is it more overt.
In his encounter with this woman Jesus now puts his finger on the nub of her problem. She had been gathering water by herself, not with the other women of the village. Why? Because she had been ostracized by the other villagers for her sexual behavior. Of these 5 husbands, how many had she stolen from other women?
All have sinned and fall short. When we approach the Master have we confessed our sins or do we hope to brazen it out thinking we can keep things from God?
This is the second example of Jesus' omniscience; the first was more oblique with Nicodemus, but here is it more overt.
Friday, June 03, 2011
My letter to Mr Lansley
The Rt. Hon. Andrew Lansley CBE, MP
Secretary of State for Health
Department of Health
London
SW1A 2NS
2nd June 2011.
Dear Mr Lansley,
I hope I am not too late to comment on the proposed reforms to the NHS. I am afraid that I have been rather ill of late and this is my earliest opportunity. However, I am conscious that the service that I worked for for 40 years is in great danger from the demographic drift and greater than the average health-specific inflation and I would feel that I was lacking in my duty were I not to give you the benefit of my acquired knowledge. There are many vested interests in the NHS and I am conscious that many of my profession want to retain the status quo.
1. Justification for my giving advice.
1.1 I worked in the NHS from 1967 to 2003. I was consultant haematologist in a DGH from 1974 to 2003 and involved in hospital management for 11 of those years, four of which were spent as medical director. During this time I managed an acute services review which involved dividing services between two DGHs to the satisfaction of both and quelling a local newspaper campaign of dissatisfaction. I was also involved in commissioning a new hospital and gaining Foundation Trust status. The Hospital Trust that I worked for has been one of the best performing in England.
1.2 I worked in Academic Medicine from 1974 to 2008 rising to full professor in 1987 at the University of Southampton. I raised several million pounds worth of research grants, published over 300 medical and scientific research papers and was recognized by my peers as the first British winner of the International Binet-Rai silver medal for outstanding research in chronic lymphocytic leukemia. I have also edited an international specialist medical journal for 25 years.
1.3 I have been a cancer patient for the past two and a half years. As such I have experienced first hand both in-patient and day-case care from surgeons, physicians, junior doctors, nurses, health-care assistants, cleaners, physios, radiographers, phlebotomists, O.T.s, receptionists, caterers and social workers. In that time I have come across a couple of incidents of poor administration and one (agency) nurse with a bad attitude, but overwhelmingly I have been impressed by the dedication and competence of NHS staff. Happily, I am enjoying a remission at present.
1.4 I have always been involved in medical charities. During my career, through Tenovus and other cancer charities I raised over £3 million for cancer research. Since retirement I have been heavily involved in disease-specific charities. I founded the UKCLL Forum and the UK MDS Forum and helped to found the UK Myeloma Forum. All three are dedicated to democratizing how these three chronic leukemias of the elderly are managed by involving a much greater variety of doctors and scientists together with representatives from industry and especially patients. For the past five years I have been advising the Association of Cancer Online Resources (ACOR) for patients with chronic lymphocytic leukemia as well as some other internet advice sites. It is extremely important that such internet sites have the help of a qualified professional. This is a voluntary activity.
1.5 I am kept up to date on NHS matters by family members. My older son is Director of Intelligence at the Care Quality Commission and my younger daughter is a registrar in Haematology on the Oxford rotation having just completed a PhD in oncology.
2 My advice
2.1 GP purchasing: I have endured several NHS reorganizations and can hark back to the days when we went to local councilors for improvements to the service. I’m sorry to be cynical but in my experience one ends up dealing with the same people as before with different job titles. Although I can see the justification for GP commissioning, along with many of my consultant colleagues I have many doubts as to whether it is a wise move. Most doctors are more concerned with their individual patients than with the structure of the NHS. For many years general practice attracted in large degree those doctors who could not make it in hospital practice, though recent uprating in GP incomes has reversed that trend. There were always those GPs who were dedicated to the concept of the NHS, of course, but are there enough of them to go around? GPs will also be conflicted since they would be providers as well as commissioners of the service. Whether adding other providers (nurses and hospital doctors) to the commissioning teams is helpful or harmful is moot.
2.2 Competition: In general I have no problem with the introduction of competition to the NHS. It is important that quality is maintained, however. I have experience of inspecting pathology laboratories with Clinical Pathology Accreditation UK. I inspected the haematology laboratory of the largest private laboratory in London. I am afraid that although they competed on price, they could not compete on quality. They had chosen the cheapest options and were not fit for purpose to service a modern haematology department. I also had the opportunity to inspect several the laboratories of London teaching hospitals and these also fell short of the quality required, often because of the idiosyncrasies of famous leaders. So, my recommendation is that quality standards have to be agreed and adhered to (if it is not a forbidden word) religiously.
2.3 Efficiency savings: Much of the efficiency savings that were possible in the NHS have already been made, being chiefly the switch from in-patient to day-patient elective surgery. To save 5% per year for four years cannot be achieved by reduction of bureaucracy. There are some obvious options such a bulk purchasing, forbidding the changing of logos, pressure on pharmaceutical companies by multi-unit negotiation of contracts, and facilitating the participation in clinical trials so as to obtain free drugs from the manufacturers (clinical trials have moved to Eastern Europe, but from my contacts with Big Pharma I know that there is great dissatisfaction with the quality).
2.4 Doing less: The NHS should consider doing less than it does. This is not a new idea; Nye Bevan’s NHS used to prescribe free hot water bottles! While NICE tried to restrict expensive treatments, these are the very things that the NHS ought to provide; it is the trivial things that patients ought to provide for themselves. A few years ago the NHS was paying over £2 billion for the treatment of indigestion but only £167 million for all cancer chemotherapy. This was because the best treatment for heartburn was the PPI class of drugs which had been newly introduced and were expensive. On the other hand most people’s indigestion can be satisfactorily treated with over-the-counter (OTC) drugs which the local pharmacist can advise on. There are many other conditions where OTC drugs are the most sensible option. Many patients demand antibiotics for colds and flu. They don’t work, of course, but GPs are often browbeaten into prescribing them. Why not make the most commonly prescribed, Amoxil, available OTC? Resistance to it is already widely developed among bacteria, so making it more widely available would not affect that. It is already available OTC in many European countries and this measure would reduce the NHS bill at a stroke. Similarly, back pain can usually only be treated by pain killers which are already available OTC. There is a silly limit on the amount of paracetamol that can be purchased, as if those who wanted to kill themselves with it didn’t have the wit to visit several different chemists. So my fourth recommendation is to free up the OTC market and ‘nudge’ patients to the pharmacist rather than the GP for trivial illness.
2.5 Private practice: The Conservative party should not have Labour’s horror of private practice. It is a little known fact that the American government spends a greater proportion of its GDP on what some critics call ‘socialized medicine’ than the British government does (the CDC, VA, Medicare and Medicaid, tax subsidies and yet others). The big difference in America is that it also has a thriving private practice market. There are elements of the American (and indeed most European) health care systems that it would be difficult to reproduce in the free-at-the point-of-consumption system that we have here. Examples would be single rooms in hospital for all, elective surgery at the patient’s convenience, some cosmetic surgery, and costly treatment that has been approved by EMA but not by NICE. In America and most of continental Europe this is funded by the private sector. Measures to encourage private medical insurance should be introduced.
2.6 Social care: The really big extra cost of the NHS is in the area of social care. The government really has to grasp the nettle of how this is to be provided in the future. Best of all is for old people to stay in their own homes with the state and charities funding the supplementary requirements to make this possible. Churches and other charities are already providing enormous resources – shopping, transport, entertainment, cleaning, laundry, cooked meals, even furniture and clothing – at no cost to the recipient. This is David Cameron’s Big Society in action. With the number of unemployed on benefits, it should be possible to use some of them as an untapped labour source and if the worst comes to the worst the state could oil the wheels of these endeavours with the sparing use of cash. But we come up against the barrier of dementia. This has largely been the province of private care homes which in Bournemouth have worked fairly well. Although not concerned with the elderly demented, the recent disaster in Bristol, featured on Panorama, puts the situation of all private care homes in jeopardy. The problems associated with private care homes have been several. The change to unitary authorities has meant that because they now work for smaller units, specialism among social workers has diminished and they can no longer form one-to one relationships with consultant geriatricians in hospitals. The vagaries of the housing rental market has altered the balance between using large houses as care homes, apartments or buy-to let investments. Staffing has largely been by Eastern European immigrants working for minimum wage. This makes language a problem. Funding is still dependent on the children of the elderly being willing to forgo their expected inheritance. I am not sure why this social problem should have a medical solution and therefore impact on health service funding.
2.7 My big idea: The management of chronic disease should be controlled by those who know most about it. This is not GPs or hospital consultants, but the patients themselves. For conditions like arthritis, diabetes, heart disease, MS, and even cancer there are expert patients. The big charities like ARC, CRUK, BHF, Diabetes UK, MS Society and MacMillan have unrivalled expertise in the management of these chronic conditions and should be asked to take the lead in their management. MacMillan does palliative care far better than DGHs or GPs. They even employ their own staff. Given a block grant these charities would raise charitable money in excess of this and provide a superlative service to the NHS. Being national bodies, everyone would have access to the very best. After all they have a vested interest not in making a profit, nor in providing employment for professional staff, but in giving patients the best possible management.
Yours sincerely,
Professor Terry Hamblin DM, FRCP, FRCPath FMedSci
Secretary of State for Health
Department of Health
London
SW1A 2NS
2nd June 2011.
Dear Mr Lansley,
I hope I am not too late to comment on the proposed reforms to the NHS. I am afraid that I have been rather ill of late and this is my earliest opportunity. However, I am conscious that the service that I worked for for 40 years is in great danger from the demographic drift and greater than the average health-specific inflation and I would feel that I was lacking in my duty were I not to give you the benefit of my acquired knowledge. There are many vested interests in the NHS and I am conscious that many of my profession want to retain the status quo.
1. Justification for my giving advice.
1.1 I worked in the NHS from 1967 to 2003. I was consultant haematologist in a DGH from 1974 to 2003 and involved in hospital management for 11 of those years, four of which were spent as medical director. During this time I managed an acute services review which involved dividing services between two DGHs to the satisfaction of both and quelling a local newspaper campaign of dissatisfaction. I was also involved in commissioning a new hospital and gaining Foundation Trust status. The Hospital Trust that I worked for has been one of the best performing in England.
1.2 I worked in Academic Medicine from 1974 to 2008 rising to full professor in 1987 at the University of Southampton. I raised several million pounds worth of research grants, published over 300 medical and scientific research papers and was recognized by my peers as the first British winner of the International Binet-Rai silver medal for outstanding research in chronic lymphocytic leukemia. I have also edited an international specialist medical journal for 25 years.
1.3 I have been a cancer patient for the past two and a half years. As such I have experienced first hand both in-patient and day-case care from surgeons, physicians, junior doctors, nurses, health-care assistants, cleaners, physios, radiographers, phlebotomists, O.T.s, receptionists, caterers and social workers. In that time I have come across a couple of incidents of poor administration and one (agency) nurse with a bad attitude, but overwhelmingly I have been impressed by the dedication and competence of NHS staff. Happily, I am enjoying a remission at present.
1.4 I have always been involved in medical charities. During my career, through Tenovus and other cancer charities I raised over £3 million for cancer research. Since retirement I have been heavily involved in disease-specific charities. I founded the UKCLL Forum and the UK MDS Forum and helped to found the UK Myeloma Forum. All three are dedicated to democratizing how these three chronic leukemias of the elderly are managed by involving a much greater variety of doctors and scientists together with representatives from industry and especially patients. For the past five years I have been advising the Association of Cancer Online Resources (ACOR) for patients with chronic lymphocytic leukemia as well as some other internet advice sites. It is extremely important that such internet sites have the help of a qualified professional. This is a voluntary activity.
1.5 I am kept up to date on NHS matters by family members. My older son is Director of Intelligence at the Care Quality Commission and my younger daughter is a registrar in Haematology on the Oxford rotation having just completed a PhD in oncology.
2 My advice
2.1 GP purchasing: I have endured several NHS reorganizations and can hark back to the days when we went to local councilors for improvements to the service. I’m sorry to be cynical but in my experience one ends up dealing with the same people as before with different job titles. Although I can see the justification for GP commissioning, along with many of my consultant colleagues I have many doubts as to whether it is a wise move. Most doctors are more concerned with their individual patients than with the structure of the NHS. For many years general practice attracted in large degree those doctors who could not make it in hospital practice, though recent uprating in GP incomes has reversed that trend. There were always those GPs who were dedicated to the concept of the NHS, of course, but are there enough of them to go around? GPs will also be conflicted since they would be providers as well as commissioners of the service. Whether adding other providers (nurses and hospital doctors) to the commissioning teams is helpful or harmful is moot.
2.2 Competition: In general I have no problem with the introduction of competition to the NHS. It is important that quality is maintained, however. I have experience of inspecting pathology laboratories with Clinical Pathology Accreditation UK. I inspected the haematology laboratory of the largest private laboratory in London. I am afraid that although they competed on price, they could not compete on quality. They had chosen the cheapest options and were not fit for purpose to service a modern haematology department. I also had the opportunity to inspect several the laboratories of London teaching hospitals and these also fell short of the quality required, often because of the idiosyncrasies of famous leaders. So, my recommendation is that quality standards have to be agreed and adhered to (if it is not a forbidden word) religiously.
2.3 Efficiency savings: Much of the efficiency savings that were possible in the NHS have already been made, being chiefly the switch from in-patient to day-patient elective surgery. To save 5% per year for four years cannot be achieved by reduction of bureaucracy. There are some obvious options such a bulk purchasing, forbidding the changing of logos, pressure on pharmaceutical companies by multi-unit negotiation of contracts, and facilitating the participation in clinical trials so as to obtain free drugs from the manufacturers (clinical trials have moved to Eastern Europe, but from my contacts with Big Pharma I know that there is great dissatisfaction with the quality).
2.4 Doing less: The NHS should consider doing less than it does. This is not a new idea; Nye Bevan’s NHS used to prescribe free hot water bottles! While NICE tried to restrict expensive treatments, these are the very things that the NHS ought to provide; it is the trivial things that patients ought to provide for themselves. A few years ago the NHS was paying over £2 billion for the treatment of indigestion but only £167 million for all cancer chemotherapy. This was because the best treatment for heartburn was the PPI class of drugs which had been newly introduced and were expensive. On the other hand most people’s indigestion can be satisfactorily treated with over-the-counter (OTC) drugs which the local pharmacist can advise on. There are many other conditions where OTC drugs are the most sensible option. Many patients demand antibiotics for colds and flu. They don’t work, of course, but GPs are often browbeaten into prescribing them. Why not make the most commonly prescribed, Amoxil, available OTC? Resistance to it is already widely developed among bacteria, so making it more widely available would not affect that. It is already available OTC in many European countries and this measure would reduce the NHS bill at a stroke. Similarly, back pain can usually only be treated by pain killers which are already available OTC. There is a silly limit on the amount of paracetamol that can be purchased, as if those who wanted to kill themselves with it didn’t have the wit to visit several different chemists. So my fourth recommendation is to free up the OTC market and ‘nudge’ patients to the pharmacist rather than the GP for trivial illness.
2.5 Private practice: The Conservative party should not have Labour’s horror of private practice. It is a little known fact that the American government spends a greater proportion of its GDP on what some critics call ‘socialized medicine’ than the British government does (the CDC, VA, Medicare and Medicaid, tax subsidies and yet others). The big difference in America is that it also has a thriving private practice market. There are elements of the American (and indeed most European) health care systems that it would be difficult to reproduce in the free-at-the point-of-consumption system that we have here. Examples would be single rooms in hospital for all, elective surgery at the patient’s convenience, some cosmetic surgery, and costly treatment that has been approved by EMA but not by NICE. In America and most of continental Europe this is funded by the private sector. Measures to encourage private medical insurance should be introduced.
2.6 Social care: The really big extra cost of the NHS is in the area of social care. The government really has to grasp the nettle of how this is to be provided in the future. Best of all is for old people to stay in their own homes with the state and charities funding the supplementary requirements to make this possible. Churches and other charities are already providing enormous resources – shopping, transport, entertainment, cleaning, laundry, cooked meals, even furniture and clothing – at no cost to the recipient. This is David Cameron’s Big Society in action. With the number of unemployed on benefits, it should be possible to use some of them as an untapped labour source and if the worst comes to the worst the state could oil the wheels of these endeavours with the sparing use of cash. But we come up against the barrier of dementia. This has largely been the province of private care homes which in Bournemouth have worked fairly well. Although not concerned with the elderly demented, the recent disaster in Bristol, featured on Panorama, puts the situation of all private care homes in jeopardy. The problems associated with private care homes have been several. The change to unitary authorities has meant that because they now work for smaller units, specialism among social workers has diminished and they can no longer form one-to one relationships with consultant geriatricians in hospitals. The vagaries of the housing rental market has altered the balance between using large houses as care homes, apartments or buy-to let investments. Staffing has largely been by Eastern European immigrants working for minimum wage. This makes language a problem. Funding is still dependent on the children of the elderly being willing to forgo their expected inheritance. I am not sure why this social problem should have a medical solution and therefore impact on health service funding.
2.7 My big idea: The management of chronic disease should be controlled by those who know most about it. This is not GPs or hospital consultants, but the patients themselves. For conditions like arthritis, diabetes, heart disease, MS, and even cancer there are expert patients. The big charities like ARC, CRUK, BHF, Diabetes UK, MS Society and MacMillan have unrivalled expertise in the management of these chronic conditions and should be asked to take the lead in their management. MacMillan does palliative care far better than DGHs or GPs. They even employ their own staff. Given a block grant these charities would raise charitable money in excess of this and provide a superlative service to the NHS. Being national bodies, everyone would have access to the very best. After all they have a vested interest not in making a profit, nor in providing employment for professional staff, but in giving patients the best possible management.
Yours sincerely,
Professor Terry Hamblin DM, FRCP, FRCPath FMedSci
Set a crook...
From today's Times:
Management consultancy firms have lost more than £800 million in revenues during the past year as the Government has slashed public contracts and renegotiated far lower fees, it emerged yesterday.
Francis Maude, the Cabinet Office Minister, disclosed yesterday that the central government consultancy bill has been cut from £1.6 billion to £800 million this year because Whitehall has stopped hiring consultants at £2,500 a day. In the previous Parliament the bill rose to £3 billion a year for consultancy because firms with financial or IT skills were routinely hired by Whitehall departments.
Mr Maude told The Times that departments could no longer hire consultants to advise on procurement contracts and daily rates of £1,600 to £2,500 were no longer acceptable.
“Consultants were being regularly hired on daily rates by departments to run the procurement process,” Mr Maude said. “Not surprisingly the negotiations were very protracted and very expensive.”
Instead consultants will be hired on “blended rates” for three to six-month contracts where no premium can be added if a very senior adviser is part of the team.
The contract is also tied much more tightly to performance targets rather than to time and materials as in the past. All consultancy contracts have to be reviewed by departments within three months and have to be re-signed by the Government’s procurement chief, John Collington, every nine months.
Research compiled by the Management Consultancies Association shows that fees in central government have fallen by 11 per cent while fees for local government contracts have dropped by 35 per cent.
Mr Maude also disclosed that big government contracts including IT deals were being renegotiated to save up to £3 billion a year by cutting profits and centralising purchasing deals. More than £1 billion has already been saved since last June after expensive deals by individual departments had been banned, he said.
Profit margins are being cut by up to 50 per cent after market research showed that company margins with European governments were much lower, at 7 to 15 per cent, than those with the British Government, which were routinely more than 20 per cent.
The move to centralise purchasing follows an efficiency review carried out by Sir Philip Green last autumn that uncovered huge variations in the cost of Whitehall contracts.
The move to centralise purchasing follows an efficiency review carried out by Sir Philip Green last autumn that uncovered huge variations in the cost of Whitehall contracts.
“We are putting a stop to this madness,” Mr Maude said.
It makes one wonder what New Labour thought it was buying with all our money. Philip Green has been much criticised for putting his assets in his wife's name while she is domiciled in the tax-haven of Monte Carlo. However, it it is good principle to set a crook to catch a crook and the savings that his report have engendered probably outweigh whatever he might have paid in income tax
Management consultancy firms have lost more than £800 million in revenues during the past year as the Government has slashed public contracts and renegotiated far lower fees, it emerged yesterday.
Francis Maude, the Cabinet Office Minister, disclosed yesterday that the central government consultancy bill has been cut from £1.6 billion to £800 million this year because Whitehall has stopped hiring consultants at £2,500 a day. In the previous Parliament the bill rose to £3 billion a year for consultancy because firms with financial or IT skills were routinely hired by Whitehall departments.
Mr Maude told The Times that departments could no longer hire consultants to advise on procurement contracts and daily rates of £1,600 to £2,500 were no longer acceptable.
“Consultants were being regularly hired on daily rates by departments to run the procurement process,” Mr Maude said. “Not surprisingly the negotiations were very protracted and very expensive.”
Instead consultants will be hired on “blended rates” for three to six-month contracts where no premium can be added if a very senior adviser is part of the team.
The contract is also tied much more tightly to performance targets rather than to time and materials as in the past. All consultancy contracts have to be reviewed by departments within three months and have to be re-signed by the Government’s procurement chief, John Collington, every nine months.
Research compiled by the Management Consultancies Association shows that fees in central government have fallen by 11 per cent while fees for local government contracts have dropped by 35 per cent.
Mr Maude also disclosed that big government contracts including IT deals were being renegotiated to save up to £3 billion a year by cutting profits and centralising purchasing deals. More than £1 billion has already been saved since last June after expensive deals by individual departments had been banned, he said.
Profit margins are being cut by up to 50 per cent after market research showed that company margins with European governments were much lower, at 7 to 15 per cent, than those with the British Government, which were routinely more than 20 per cent.
The move to centralise purchasing follows an efficiency review carried out by Sir Philip Green last autumn that uncovered huge variations in the cost of Whitehall contracts.
The move to centralise purchasing follows an efficiency review carried out by Sir Philip Green last autumn that uncovered huge variations in the cost of Whitehall contracts.
“We are putting a stop to this madness,” Mr Maude said.
It makes one wonder what New Labour thought it was buying with all our money. Philip Green has been much criticised for putting his assets in his wife's name while she is domiciled in the tax-haven of Monte Carlo. However, it it is good principle to set a crook to catch a crook and the savings that his report have engendered probably outweigh whatever he might have paid in income tax
John 4:15. Analytical geometry of Jesus' sayings
The woman said to him, "Sir, give me this water so that I won't get thirsty and have to keep coming here to draw water."
Once again she is interpreting Jesus literally and failing to see the metaphorical allusion. Bible believing Christians are apt to fall into the same error. The book of Revelations is easy to misinterpret in this way. Jesus warns us that his teachings were elliptical and parabolic (strange that these are two of the standard shapes of analytical geometry - the other is hyperbolic and Jesus used this as well).
But just to stay on the literal for a moment. There are still many who have to journey to fetch their daily water. With so many dying of water-borne diseases it is an international disgrace that the international community has not provided fresh water and separate sewerage for the whole population of the world. And it is a disgrace that various national governments have seen luxury palaces, AK47s tanks and fighter aircraft as a greater priority than fresh water. Pakistan has atom bombs and India a space program. There is no defence against that accusation when it comes to the judgement bar.
Once again she is interpreting Jesus literally and failing to see the metaphorical allusion. Bible believing Christians are apt to fall into the same error. The book of Revelations is easy to misinterpret in this way. Jesus warns us that his teachings were elliptical and parabolic (strange that these are two of the standard shapes of analytical geometry - the other is hyperbolic and Jesus used this as well).
But just to stay on the literal for a moment. There are still many who have to journey to fetch their daily water. With so many dying of water-borne diseases it is an international disgrace that the international community has not provided fresh water and separate sewerage for the whole population of the world. And it is a disgrace that various national governments have seen luxury palaces, AK47s tanks and fighter aircraft as a greater priority than fresh water. Pakistan has atom bombs and India a space program. There is no defence against that accusation when it comes to the judgement bar.
Thursday, June 02, 2011
John 4:13-14. Spiritual water.
Jesus answered, “Everyone who drinks this water will be thirsty again, but whoever drinks the water I give them will never thirst. Indeed, the water I give them will become in them a spring of water welling up to eternal life.”
Jesus continues to speak obliquely. Just as water is essential for life itself, so the spiritual water that Jesus gives is essential for spiritual life. What is this 'spiritual water'? It is nothing less than the Holy Spirit himself. He comes with belief in Jesus as the only way of salvation. He comes with repentance and a change of direction. He comes with commitment. It is impossible to believe without the Spirit and impossible not to receive the Spirit if one truly believes.
But we keep on getting thirsty and have to drink water every day. The Holy Spirit is self sustaining like a never-ending spring that keps welling up.
Jesus continues to speak obliquely. Just as water is essential for life itself, so the spiritual water that Jesus gives is essential for spiritual life. What is this 'spiritual water'? It is nothing less than the Holy Spirit himself. He comes with belief in Jesus as the only way of salvation. He comes with repentance and a change of direction. He comes with commitment. It is impossible to believe without the Spirit and impossible not to receive the Spirit if one truly believes.
But we keep on getting thirsty and have to drink water every day. The Holy Spirit is self sustaining like a never-ending spring that keps welling up.
Wednesday, June 01, 2011
Gene therapy for CLL
Although monoclonal antibodies have proved reasonably successful in treating CLL, the arm of the immune system that ought to kill CLL cells better is the cellular immune response, particularly T cells. T cells recognize their targets through peptides that are placed within the groove of the major histocompatability complex. WE are quite unsure what might be a reasonable target for T cells in CLL and this approach has not borne any fruit.
Many groups have had the idea of redirecting T cells from their primary target by using an antibody target (like CD20) and linking this to the attack mechanism of T cells. One such attempt is reported in the May 2011 Blood.
This makes use of gene therapy technology to express in T cells a chimeric antigen receptor (CAR). The target chosen was CD23, a molecule found on almost all CLL cells but not on normal B cells. A CAR was constructed comprising a single chain variable fragment (scFv) coupled to the zeta chain of the T-cell receptor complex. This receptor was cloned into T cells from healthy donors.
Incubation of these T cells showed effective killing of CD23+ cell lines and of primary CLL cells. It also released large amounts of inflammatory cytokines (TNF alpha and beta, gamma interferon and IL-2). In a xenograft mouse model there was also effective immunotherapy.
An important element of the CAR is the incorporation of the CD28 costimulatory endodomain within the construct which allows the production of IL-2 which sustains the expansion of the adoptedly transferred T cells in response to primary tumors.
Many groups have had the idea of redirecting T cells from their primary target by using an antibody target (like CD20) and linking this to the attack mechanism of T cells. One such attempt is reported in the May 2011 Blood.
This makes use of gene therapy technology to express in T cells a chimeric antigen receptor (CAR). The target chosen was CD23, a molecule found on almost all CLL cells but not on normal B cells. A CAR was constructed comprising a single chain variable fragment (scFv) coupled to the zeta chain of the T-cell receptor complex. This receptor was cloned into T cells from healthy donors.
Incubation of these T cells showed effective killing of CD23+ cell lines and of primary CLL cells. It also released large amounts of inflammatory cytokines (TNF alpha and beta, gamma interferon and IL-2). In a xenograft mouse model there was also effective immunotherapy.
An important element of the CAR is the incorporation of the CD28 costimulatory endodomain within the construct which allows the production of IL-2 which sustains the expansion of the adoptedly transferred T cells in response to primary tumors.
Alcohol report
The release of 2011's alcohol statistics report from the NHS Information Centre has prompted several newspaper reports.
The report found that in England in 2009/10:
•There were 1,057,000 alcohol-related admissions to hospital. This was an increase of 12% on the 2008/09 figure, and more than twice as many as in 2002/03.
•Most (63%) of alcohol-related admissions were men. There were more admissions in the older age groups than in the younger age groups, in both men and women.
•When the researchers looked at the rate of admissions and standardised the figures for gender and age, they found that the rates of alcohol-related admissions varied across different Strategic Health Authorities (SHAs). The rate ranged from 1,223 admissions per 100,000 of the population in the South Central SHA (this includes Southampton and Oxford), to 2,406 and 2,295 admissions per 100,000 in the North East SHA (around Newcastle) and the North West SHA (Manchester and Liverpool), respectively.
The NHS Information Centre also reported on deaths related to alcohol. It said that in 2009, there were 6,584 deaths directly related to alcohol. This was a 3% decrease from the 2008 figure but an increase of 20% on the 2001 figure. Of these alcohol-related deaths, the majority of people (4,154 people) died from alcoholic liver disease.
•Among adults aged over 16, just over two-thirds of men and half of women reported drinking an alcoholic drink on at least one day in the week before they were interviewed. A tenth of men and 6% of women reported drinking every day in the previous week.
•Over a third of men drank over four units on at least one day in the week prior to interview and 29% of women drank more than three units at least one day in the week prior to interview (that is, more than the daily maximum levels recommended by the government). A fifth of men reported drinking over eight units and 13% of women reported drinking over six units on at least one day in the week prior to interview.
•Average weekly alcohol consumption was 16.4 units for men and 8.0 units for women.
•Just over a quarter of men reported drinking more than 21 units in an average week. For women, 18% reported drinking more than 14 units in an average week.
•The overall volume of alcoholic drinks purchased for consumption outside the home decreased from 733millilitres (ml) of alcohol for each person a week in 2001/02 to 446ml for each person a week in 2009. This reduction is mainly due to a 45% decrease in the volume of beer purchases.
•In 2007 (the last date for which figures are available), 33% of men and 16% of women were classified as hazardous drinkers. This included 6% of men and 2% of women estimated to be harmful drinkers.
•Among adults aged 16 to 74, 9% of men and 4% of women showed some signs of alcohol dependence.
•The prevalence of alcohol dependence was slightly lower for men than it was in 2000, when 11.5% of men showed some signs of dependence. In children aged 11 to 15 in England in 2009, the results showed some improvement:
•Eighteen percent of secondary school pupils aged 11 to 15 reported drinking alcohol in the week prior to interview, compared with 26% in 2001.
•Around half of pupils had ever had an alcoholic drink,
•Those pupils who had drunk in the last week consumed an average of 11.6 units
The NHS report also looked at the treatment of alcohol dependency in the NHS in England. It found that:
•In 2010, there were 160,181 prescription items for drugs for the treatment of alcohol dependency prescribed in primary care settings or NHS hospitals, and dispensed in the community. This was an increase of 6% on the amount prescribed in 2009 and an increase of 56% on the amount prescribed in 2003.
•The net cost of these prescription items was £2.41 million in 2010. This was an increase of 1.4% on the cost in 2009 and an increase of 40% on the cost in 2003.
These figures are worrying. I am strongly behind moves to raise the price of alcohol. Experience with tobacco suggests that raising the price is an efficient wasy of reducing consumption.
The report found that in England in 2009/10:
•There were 1,057,000 alcohol-related admissions to hospital. This was an increase of 12% on the 2008/09 figure, and more than twice as many as in 2002/03.
•Most (63%) of alcohol-related admissions were men. There were more admissions in the older age groups than in the younger age groups, in both men and women.
•When the researchers looked at the rate of admissions and standardised the figures for gender and age, they found that the rates of alcohol-related admissions varied across different Strategic Health Authorities (SHAs). The rate ranged from 1,223 admissions per 100,000 of the population in the South Central SHA (this includes Southampton and Oxford), to 2,406 and 2,295 admissions per 100,000 in the North East SHA (around Newcastle) and the North West SHA (Manchester and Liverpool), respectively.
The NHS Information Centre also reported on deaths related to alcohol. It said that in 2009, there were 6,584 deaths directly related to alcohol. This was a 3% decrease from the 2008 figure but an increase of 20% on the 2001 figure. Of these alcohol-related deaths, the majority of people (4,154 people) died from alcoholic liver disease.
•Among adults aged over 16, just over two-thirds of men and half of women reported drinking an alcoholic drink on at least one day in the week before they were interviewed. A tenth of men and 6% of women reported drinking every day in the previous week.
•Over a third of men drank over four units on at least one day in the week prior to interview and 29% of women drank more than three units at least one day in the week prior to interview (that is, more than the daily maximum levels recommended by the government). A fifth of men reported drinking over eight units and 13% of women reported drinking over six units on at least one day in the week prior to interview.
•Average weekly alcohol consumption was 16.4 units for men and 8.0 units for women.
•Just over a quarter of men reported drinking more than 21 units in an average week. For women, 18% reported drinking more than 14 units in an average week.
•The overall volume of alcoholic drinks purchased for consumption outside the home decreased from 733millilitres (ml) of alcohol for each person a week in 2001/02 to 446ml for each person a week in 2009. This reduction is mainly due to a 45% decrease in the volume of beer purchases.
•In 2007 (the last date for which figures are available), 33% of men and 16% of women were classified as hazardous drinkers. This included 6% of men and 2% of women estimated to be harmful drinkers.
•Among adults aged 16 to 74, 9% of men and 4% of women showed some signs of alcohol dependence.
•The prevalence of alcohol dependence was slightly lower for men than it was in 2000, when 11.5% of men showed some signs of dependence. In children aged 11 to 15 in England in 2009, the results showed some improvement:
•Eighteen percent of secondary school pupils aged 11 to 15 reported drinking alcohol in the week prior to interview, compared with 26% in 2001.
•Around half of pupils had ever had an alcoholic drink,
•Those pupils who had drunk in the last week consumed an average of 11.6 units
The NHS report also looked at the treatment of alcohol dependency in the NHS in England. It found that:
•In 2010, there were 160,181 prescription items for drugs for the treatment of alcohol dependency prescribed in primary care settings or NHS hospitals, and dispensed in the community. This was an increase of 6% on the amount prescribed in 2009 and an increase of 56% on the amount prescribed in 2003.
•The net cost of these prescription items was £2.41 million in 2010. This was an increase of 1.4% on the cost in 2009 and an increase of 40% on the cost in 2003.
These figures are worrying. I am strongly behind moves to raise the price of alcohol. Experience with tobacco suggests that raising the price is an efficient wasy of reducing consumption.
John 4:11-12. Puzzling sayings
“Sir,” the woman said, “you have nothing to draw with and the well is deep. Where can you get this living water? Are you greater than our father Jacob, who gave us the well and drank from it himself, as did also his sons and his livestock?”
Just as with Nicodemus the woman fails to see the metaphor and takes things literally. She also harks back to Jacob. The message of out with the old and in with the new has not got through to her.
We have become so familiar with the inner meanings of Jesus' sayings that we forget how puzzling his teaching was to his hearers. Hearing they never hear.
Just as with Nicodemus the woman fails to see the metaphor and takes things literally. She also harks back to Jacob. The message of out with the old and in with the new has not got through to her.
We have become so familiar with the inner meanings of Jesus' sayings that we forget how puzzling his teaching was to his hearers. Hearing they never hear.
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