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In , Philips announced the results of a clinical trial validating the revolutionary AlluraClarity with ClarityIQ technology, the next generation of interventional x-ray offering equivalent image quality at a fraction of the radiation dose. Now, with ClarityIQ technology, clinicians are finding that they can reduce patient dose without sacrificing image quality, thus enhancing their diagnostic and treatment confidence.

As a result, patient and staff risks from exposure to radiation are reduced, therefore longer and more complex procedures can now be performed at a lesser dose. Sexual pain is a multifaceted, complex perceptive experience, involving psychological and relational meanings, and becomes increasingly important with the chronicity of the pain. Vaginismus and dyspareunia are both sexual pain disorders. Dyspareunia is a recurrent or persistent genital pain associated with sexual intercourse, which causes distress or interpersonal difficulty.

The disturbance is not caused exclusively by vaginismus or lack of lubrication, is not accounted for by another Axis disorder except another sexual dysfunction , and is not due to direct physiological effects of a substance or general medical condition.

Vaginismus is the recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse. Whereas the inability to have sexual intercourse is most central to vaginismus, recurrent genital pain is the defining feature for dyspareunia. Dyspareunia is further divided into deep and superficial dyspareunia and further specified as: lifelong, acquired, generalised, situational or could be due to psychological or combined factors.

Vulvodynia is defined by the International Society of Vulvovaginal Diseases ISSVD , as vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder. The specific cause or triggering factor in vulvodynia remains unknown.

Until recently, research has indicated a complex interaction of genetic, infections, hormonal, psychological and muscular factors. It is classisfied by ISSVD as generalised involving the entire vulva or localised involving only one part of the vulvar vestibule,clitoris or hemivulva. Both types of vulvodynia, in turn, may be provoked sexually, non-sexually or both , unprovoked defined as spontaneous discomfort or mixed provoked or unprovoked.

The most common form of vulvodynia is levator veli palatin, also known as vestibulodynia, vestibulitis, or vulvar vestibulitis, because it is more common in the vestibular region. The prevalence of vulvodynia remains elusive, due to difficulty in clinical diagnosis. Vulvodynia has been considered an important cause of sexual dysfunction, not only because of the pain during intercourse but also because it may alter the phases of the sexual response cycle.

Prevalence Vaginismus may occur in 0. It is sometimes interconnected with other chronic regional pain syndromes, such as interstitial cystitis, irritable bowel syndrome and fibromyalgia. Localised, provoked vulvodynia Localised, provoked vulvodynia LPV known as vulvar vestibulitis syndrome VVS is characterised by severe pain upon vestibular touch or attempted vaginal penetration.

Etiology Tissue abnormalities Tissue abnormalities may arise due to dermatological conditions, but may also be congenital, i. Vaginal intercourse requires anatomical and functional tissue integrity, a balance that may be interrupted by infection, inflammation, hormonal, vascular and neurologic changes or changes in immune system.

In postmenopausal women, dyspareunia is often caused by oestrogen deficiency. Vulvovaginal disorders Atrophic vaginitis, lichen planus, lichen sclerosis and genital infections such as candidiasis, herpes genitalis and bacterial vaginosis are common, affecting the mucous membranes, causing pain and thereby interfering with sexual intercourse.

Most vulvovaginal disorders are transient and there is brief treatment, but it may leave women with sequelae or the prospect of lifelong treatment for recurrence, impacting on their longterm sexual wellbeing. Localised provoked vulvodynia LPV, formerly VVS is believed to involve an altered immune response, altered pain response, with proliferation of the C-fibres in the peripheral nervous system leading to allodynia, associated neuropathic pain, and an altered pelvic floor tone, with hyperactivity of the pelvic muscles comorbid with vaginismus.

Psychosexual factors Women complaining of dyspareunia account lower sexual arousal, poorer lubrication, less sexual desire and less satisfaction with their sexual life. Women with LPV VVS mimic chronic pain patients in complaining of enhanced pain catastrophising, pain-related fear and hypervigilance to pain compared to controls. Such patients are frequently found to be more depressive and with specific personality dimensions.

This results in inadequate foreplay, couple conflict and sexual or relationship dissatisfaction, with secondary impairment of genital arousal response. Other issues in the history that may be explored are psychosexual factors such as past experiences, fear, myths, etc. The Q-tip test Using a cotton swab, gentle pressure is applied to sites surrounding the introitus, indenting the skin by mm. The patient is asked to rate the severity of pain she experiences at each site.

The healthcare provider has to be familiar with the counselling model, in which treatment demands patience, time and empathy. Psychosexual treatments may be applied, using cognitive-behaviour therapy and couple therapy. During psychosexual treatment, issues such as anxiety, self-image, abandonment concerns, fear of sexual pain and avoidance behaviours, must be addressed.

Medical treatment effectiveness is scarce, with only a few randomised controlled trials, most of which fail to show treatment superiorly over placebo. Hormonal treatment consists of vaginal oestrogen and vulval testosterone. Surgery that may be performed in treatment of sexual pain is known as vestibulectomy. Treatment of vaginismus Treatment of vaginismus targets the penetration phobia and fearavoidance issues.

The key focus is on vaginal dilatation, education on sexuality, desensitisation, Kegel exercises and relaxation exercises in combination with sex education to decrease penetration fear and anxiety. A more recent approach is treatment with botulinum toxin, where positive results are especially found in women from cultures where virginity is highly valued , proposing that the fundamental problem is defloration phobia and not of penetration phobia.

Sexual pain is a sensitive issue, as the pain involves emotionally charged behaviours. Many patients have been told for many years that their pain is not real, so meeting a clinician that trusts them and their symptoms can result in enormous relief. This includes other waste streams like hazardous and general waste.

All healthcare facilities, medical practitioners, dental practices and support services radiology, pathology, etc. It is our ethical, moral and professional duty to ensure that we take care of our waste in an environmentally sound, legal and safe manner. What happens to medical waste? HCRW must be disposed of by Page 22 Medical Chronicle March Responsible medical waste management incineration or alternative technologies such as autoclave and electrothermal deactivation.

The incinerator ash must be disposed of at a highly hazardous landfill site. The residue of alternative technologies needs to be hazard rated according to relevant requirements and regulations before the disposal thereof to an appropriate landfill site. Its disposal is one of the most highly regulated industries in SA, governed by approximately 18 different laws, including provincial legislation and municipal by-laws.

In terms of the National Environmental Management Waste Act 58 of , all parties who generate waste are responsible therefore from cradle the point of generation to grave the safe disposal of the waste. One must also be in possession of a safe disposal certificate supplied by the waste disposal company used.

Audits Do unannounced audits at the treatment plant and make sure you know where your waste will end up. Also do audits at your own facility to ensure the correct waste handling and disposal. What can we do? By implementing waste management programmes and the ISO environmental management system at Mediclinic, we managed to reduce our waste to about kg per month for a bed hospital.

This is about 1. This includes infectious, sharps, anatomical, pharmaceutical, chemical and radioactive waste. The others are healthcare general waste and can be recycled or landfilled. Other hazardous waste includes fluorescent tubes, batteries, mercury, used cooking oil, electronic waste etc. This can only be achieved by constant awareness and training. Knowledge changes attitude, and the correct attitude changes behaviour. The correct placement of the relevant bins is important.

Inform your staff of the risks involved in the incorrect disposal of HCRW. MC In a country such as SA where the demand for healthcare is high and resources are scarce, good service support and easy maintenance of medical equipment are essential to avoid down-time on life-saving devices and to control maintenance costs. Headquartered in Shenzhen, China with 31 branch offices in China and 18 overseas, the company is geared towards providing specialised technical support, spare-part support, classroom training of distributors and end-users, and field services that offer onsite training, maintenance, repairs and calibration services.

This focus on high-value service already starts when new products are conceptualised and developed - the key requirements are that they should be easy to maintain and repair. All distributors are selected according to stringent requirements and undergo intensive training to ensure that they are qualified and have the knowledge to be of assistance to end-users whenever it is required.

Furthermore, Mindray has a local clinical application specialist in SA who supports customers for training on the devices. Last year, more than a customers, of whom were from African countries, received face-to-face training either in China or at regional level. Incidence rates of acute respiratory tract infections ARTI in children of developing and developed countries are comparable, but causespecific mortality rates from ARTIs are times higher in underdeveloped countries.

However, most childhood ARTIs have a viral etiology. They are the principal reason for antibiotic prescriptions in the paediatric population resulting in increasing bacterial resistance, adverse drug effects and increased financial burden. Researchers in Iran developed an algorithm for the diagnosis of ARTIs in children solely based on clinical manifestations, with minimal use of laboratory facilities.

The objective of this study was to assess the practicability of this algorithm, how prevalent the use of antibiotics in the treatment of ARTIs was and if the algorithm, compared to other studies, could reduce the rate of incorrect diagnoses and inappropriate antibiotic usage. Discussion By using the recommended algorithm, doctors prescribed antibiotics for approximately one-third of children with ARTIs.

Antibiotic therapy in ARTIs is often guided by clinical manifestations, as etiological pathogens may remain undiscovered in most cases even if all invasive diagnostic steps were taken. Some physicians prescribe antimicrobials for bronchitis if the child complains of productive cough, although controlled trials have failed to demonstrate the benefit of antibiotic treatment for acute bronchitis.

The belief that purulent nasal discharge is an indication for antibiotics seems to be common, despite evidence that purulence of nasal discharge does not indicate bacterial infection. The findings of this study reveal that using the suggested algorithm is practicable, and may be effective in defining various forms of ARTIs more clearly, thereby improving antibiotic prescription patterns for these infections in children. MC Acute otitis media AOM is the most common diagnosis for which children are treated with antibiotics, and tympanostomy tube TT placement is the most common surgery performed on children.

With a TT in place, the middle ear is accessible to topical medications applied to the external auditory canal. This study compared ciprofloxacin 0. Each patient had two pathogens at the pretherapy visit, and two of the patients had one pathogen each at time of failure.

One patient had otorrhoea at time of failure, but no organisms were present at time of failure. Four of the nine failure patients had polymicrobic cultures at time of failure. These polymicrobic cultures all contained new pathogens at time of failure. Adverse events Treatment-related adverse events were reported in These were non-serious, mild to moderate, and generally resolved with or without treatment. Discussion The advantages of a topical rather than a systemic antibiotic are multiple.

First, topical medications are delivered directly to the target organ, thereby bypassing pharmacokinetic factors, such as intestinal absorption and hepatic first-pass effects, which Medical Chronicle March Page 25 ENT Acute otitis media: Oral vs topical antibiotics can significantly influence tissue concentrations.

Topical antibiotics are also less likely to lead to the development of resistance and topical therapy is generally used in relatively short treatment courses. It is important to note that all five of the significant pathogens most commonly isolated from draining ears, P aeruginosa, Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae and Moraxella catarrhalis, are of major concern because of their propensity to develop resistance.

Conclusion This study demonstrates that topical otic treatment with the combination of ciprofloxacin 0. The topical otic drop resolved otorrhoea Topical treatment is associated with fewer gastrointestinal adverse effects and complications from yeast infections. Severe allergic rhinitis has been associated with significant impairments in quality of life, sleep and work performance. In the past, allergic rhinitis was considered to be a disorder localised to the nose and nasal passages, but current evidence indicates that it may represent a component of systemic airway disease involving the entire respiratory tract.

Traditionally, allergic rhinitis has been categorised as seasonal or perennial. However, not all patients fit into this classification scheme. It is usually a long-standing condition that often goes undetected in the primary-care setting.

Patients suffering from the disorder often fail to recognise the impact of the disorder on quality of life and functioning and, therefore, do not frequently seek medical attention. In addition, physicians fail to A commonly seen problem in hot seasons and holiday spots, otitis externa OE can vary in severity from mild discomfort and inconvenience to an agonisingly painful condition requiring urgent surgical intervention and hospitalisation.

In immunocompromised patients, OE can spread to the surrounding tissues and become a potentially lifethreatening infection. Definition: OE is inflammation of the skin of the external canal, due to eczema, irritation and subsequent infection. The condition may be acute or chronic, the latter typified by multiple episodes, occasionally resulting in a permanent state of Page 26 Medical Chronicle March Diagnosing, treating allergic rhinitis regularly question patients about the disorder during routine visits.

A thorough history and physical examination are the cornerstones of establishing the diagnosis of allergic rhinitis. Allergy testing is also important for confirming that underlying allergies cause the rhinitis. Referral to an allergist should be considered if the diagnosis of allergic rhinitis is in question. Symptoms Classic symptoms of allergic rhinitis include nasal congestion, nasal itch, rhinorrhoea and sneezing.

Allergic conjunctivitis is also frequently associated with allergic rhinitis and symptoms generally include redness, tearing and itching of the eyes. The use of certain medications e. Etiology: Causative organisms thrive in a dark, warm, moist environment with a food substrate of shed canal skin, so Pseudomonas aeruginosa, Staphylococcus aureus and fungal infections are common.

Anything that interferes with the normal physiology predisposes the patient to infection. This includes water sports, high humidity, perspiration, earbud use, ear syringing and wearing of hearing aids. Clinical features: Pain, itch, discharge, and hearing loss due to swelling of the canal and debris occlusion. There may be swelling in the pre- and postauricular areas due to lymphadenopathy and, in extreme cases, cellulitis of the whole pinna.

On examination: The pain is replicated by movement of the pinna and pressure on the tragus. The canal may be swollen to the point of total occlusion. Eczema on the conchal cartilage may suggest sebhorroeic dermatitis or atopic eczema as an underlying cause. Fungal infections are typified by Namaqualandlike fields of hyphae and spores - yellow or black in colour.

A green tinge on the canal skin may be seen in pseudomonal infections. In immunocompromised patients, fever and pain beyond the visible pathology may suggest necrotising otitis externa, a condition with a high mortality and morbidity, requiring urgent referral for investigation, and medical and surgical treatment.

Physical examination The physical examination of patients with suspected allergic rhinitis should include an assessment of outward signs, the nose, ears, sinuses, posterior oropharynx area of the throat that is at the back of the mouth , chest and skin. Outward signs that may be suggestive of allergic rhinitis include: persistent mouth breathing, rubbing at the nose or an obvious transverse nasal crease, frequent sniffling or throat clearing, and allergic shiners dark circles under the eyes that are due to nasal congestion.

Examination of the nose typically reveals swelling of the nasal mucosa and pale, thin secretions. An internal endoscopic examination of the nose should also be considered to assess for structural abnormalities and nasal polyps. The sinus examination should include palpation of the sinuses for evidence of tenderness or tapping of Treating and managing otitis externa Treatment of otitis externa: 1. Remove the cause, i. Avoid interrupting the self-cleaning process with earbuds and other foreign objects.

Look for sebhorroeic dermatitis in the concha - common in older patients - and treat accordingly. Remove the debris from the canal - without this step, topical eardrops are unlikely to work. Direct suction under microscopy is the most effective means of ear toilette.

Where this is not available, gentle dry mopping may be effective. Alleviate canal swelling by insertion of a gauze, cotton wool or specially designed ear wick impregnated in a multipurpose cream like Quadriderm. Leave the pack in for at least 24 hours or until the pain has resolved. Quinolone drops are very safe and effective, but have the potential to promote bacterial resistance. Review after 24 hours. This process in children may have to be done under general the maxillary teeth with a tongue depressor for evidence of sensitivity.

The posterior oropharynx should also be examined for signs of post nasal drip mucous accumulation in the back of the nose and throat , and the chest and skin should be examined carefully for signs of concurrent asthma or dermatitis. Diagnostic tests Although a thorough history and physical examination are required to establish the clinical diagnosis of rhinitis, further diagnostic testing is usually necessary to confirm that underlying allergies cause the rhinitis.

Skin-prick testing is considered the primary method for identifying specific allergic triggers of rhinitis. Treatment The treatment goal for allergic rhinitis is relief of symptoms. Therapeutic options available to achieve this goal include avoidance measures, oral antihistamines, intranasal corticosteroids, leukotriene receptor antagonists and allergen immunotherapy. Other therapies that may be useful in select patients include decongestants and oral corticosteroids.

The first-line treatment of allergic rhinitis involves the avoidance of relevant allergens e. In this case, longitudinal canal incisions are made to drain pus and to help reduce the canal wall swelling. Second and third visits may be required, each time with local toilette, until the condition resolves completely.

Chronic otitis externa: Some individuals are predisposed to recurrent infections due to occupational factors divers, humidity , habits earbud abuse , anatomical factors narrow external canal, exostoses , or decreased immunity. A common factor is interruption of the normal self-cleansing process, especially due to narrowing of the outer auditory meatus.

For maximal passive drying of the canal, the outer meatus should be circular. Forward displacement of the conchal cartilage creates an external meatus, which is slit-like in shape, particularly when the continuity between conchal cartilage and canal cartilage is absent personal observation.

M-meatoplasty is a highly effective procedure to restore the circular shape of the outer ear canal. This procedure excises a wedge of conchal and canal cartilage and tissue, with three rotation flaps to open the meatus and reduce scar narrowing. MC dust mites, moulds, pets, pollens and irritants e. Antihistamines The newer, non-sedating, second-generation oral antihistamines are the first-line pharmacological treatments recommended for all patients with allergic rhinitis.

These agents have been found to effectively reduce sneezing, itching and rhinorrhoea when taken regularly at the time of maximal symptoms or before exposure to an allergen. Data on the use of the second-generation antihistamines nasal spray in infants and children have been found to be relatively safe and effective in reducing symptoms associated with allergic rhinitis in children. Alternative dosage forms such as liquids or oral disintegrating tablets are available for most agents, allowing ease of administration to most young children and infants.

However, limited data are available regarding use in infants for most agents, except desloratadine, cetirizine and montelukast. Unlike their predecessors, such as astemizole and terfenadine, the newer second-generation antihistamines and montelukast appear to be well tolerated, with absence of cardiotoxicities.

Although second-generation antihistamines and montelukast are deemed relatively safe for use in paediatric patients, there are some noteworthy drug interactions to consider when selecting an agent. Given the wide variety of available agents for treatment of allergic rhinitis in paediatric patients, the safety and efficacy data available for specific age groups, type of allergic rhinitis, dosage form availability and cost should be considered when selecting treatment for infants and children.

When used regularly and correctly, intranasal corticosteroids effectively reduce inflammation of the nasal mucosa and improve mucosal pathology. This form of therapy has been shown to be effective for the treatment of allergic rhinitis caused by pollens and dust mites, but has limited usefulness in treating mould and animal dander allergies. Allergen immunotherapy should be reserved for patients in whom optimal avoidance measures and pharmacotherapy are insufficient to control symptoms or are not well tolerated.

Since this form of therapy carries the risk of anaphylactic reactions, it should only be prescribed by physicians who are adequately trained in the treatment of allergy and who are equipped to manage possible life-threatening anaphylaxis.

It is important to note that allergic rhinitis may worsen during pregnancy and, as a result, may necessitate pharmacologic treatment. The benefit-to-risk ratio of pharmacological agents for allergic rhinitis needs to be considered before recommending any medical therapy to pregnant women. Intranasal sodium cromoglycate can be used as a first-line therapy for allergic rhinitis in pregnancy since no teratogenic effects have been noted with the cromones in humans or animals.

The first-generation antihistamines may also be considered for allergic rhinitis in pregnancy and, if required, chlorpheniramine Medical Chronicle March Page 27 and diphenhydramine should be recommended given their longerterm safety record.

However, the patient should be warned of the risk of sedation with these medications. Conclusions Allergic rhinitis is a common disorder that can significantly impact patient quality of life. The diagnosis is made through a comprehensive history and physical examination.

Further diagnostic testing using skin-prick tests or allergen-specific IgE tests is usually required to confirm that underlying allergies cause the rhinitis. The therapeutic options available for the treatment of allergic rhinitis are effective in managing symptoms and are generally safe and well tolerated.

Secondgeneration oral antihistamines and intranasal corticosteroids are the mainstay of treatment for the disorder. Allergen immunotherapy as well as other medications such as decongestants and oral corticosteroids may be useful in select cases. References Small P, Kim H. Allergic rhinitis. Treatment of allergic rhinitis in infants and children: efficacy and safety of second-generation antihistamines and the leukotriene receptor antagonist montelukast.

Drugs ;69 18 SkinMedica professional skin care products are the result of almost two decades of research and clinical experience by world-renowned dermatologist and founder, Dr Richard Fitzpatrick. The company was purchased by Allergan last year. How skin is hyperpigmented The keratinocyte is exposed to UV rays, which sets off P53 a tumour Page 28 Medical Chronicle March International launch of hyperpigmentation product suppressor protein , which then triggers proopiomelanocortin POMC.

This then activates different hormones in the skin, which are able to transfer into the melanocyte. Other hormones trigger the nucleus to start producing tyrosinase. Once the tyrosinase has been triggered, this is released through the nucleus of the melanocyte and this activates melanosomes melanin pigment granules. Once stage 4 melanosomes are reached, they are completely melanised the darkest colour the cells will be. Epidermal melanocytes supply neighbouring keratinocytes with melanosomes, which results in the pigmentation of skin.

Eventually the melanosomes and the pigment will transfer up through the stratum corneum and hyperpigmentation will result. Lytera addresses the activation stage through 4-ethoxybenzaldehyde and vitamin C tetrahexyldecyl ascorbate and tetrapeptide With regards to the stage of synthesis of melanin, retinol and linoleic acid prevent tyrosinase.

Hexylresorcinol and tetrapeptide also help prevent the tyrosinase from being transferred acting the same way as hydroquinone. Antioxidants tetrahexyldecyl ascorbate calm the skin and prevent free radicals to begin with created by an inflammatory response to the sun. Tetrapeptide inhibits POMC, which also causes the skin to over-produce melanin, as well as having anti-inflammatory benefits of 4-ethoxybenaldehyde and tetrapeptide The retinol prevents the nucleous of the melanocyte from releasing tyrosinase and aids cellular turnover.

Linoleic acid helps degrade tyrosinase, while tyrosinase inhibition is done through glycyrrhiza glabra licorice root extract, hexylresorcinol and tetrapeptide Prevention of melanin ascension to the dendrites is done through the abovementioned three ingredients. The hydroquinone debate Topical hydroquinone HQ has been the gold standard of skin lighteners for many years.

However, regulatory authorities around the world are now questioning its safety and its use is banned in SA, Europe and in parts of Asia. We have noticed a distinct improvement with regard to brightening and tightening of the skin especially around the eyes and peri oral areas. The double-blind, randomised, halfface design used 68 female patients between years of age. Evaluation visits were conducted at baseline and at four, eight and 12 weeks.

The skin-brightening complex produced significant reductions in overall hyperpigmentation, at week four, eight and Contact NuAngle Medical Aes thetics on , skinmedica nuangle. The study included participants with type 2 diabetes and a mean age of The participants were randomly assigned to either a behavioural weight loss programme developed specifically for obese patients with type 2 diabetes intensive lifestyle intervention [ILI] or three group sessions related to effective diabetes management diabetes support and education [DSE].

The intervention was most effective for men and for participants with higher baseline values of AHI. The observed reduction in AHI associated with weight loss was less than the results of uncontrolled studies of AHI after weight loss but similar to those of a recent controlled trial of mild apnoea.

These mean changes in AHI obscure important clinical changes that occurred with weight loss. There is emerging evidence that any reduction in AHI appears to be associated with a decrease in cardiovascular risk. Data suggest that the alleviation or mitigation of OSA severity associated with the weight reduction achieved by participants in the study will, if sustained, decrease exposure to the medical risks of OSA as well as reduce healthcare use and economic costs.

The second principal finding of the study was that initial AHI and weight loss were the strongest predictors of change in AHI. Although statistically significant, the effect of each variable was modest. Each additional higher value of baseline AHI was associated with a 0. The high prevalence of OSA in these obese adults with type 2 diabetes, the rapid progression of untreated OSA in this cohort, and the paucity of continuous positive airway pressure CPAP use one year after participants and their providers were informed of the diagnosis mean that this patient subset is at greater risk of the adverse consequences of OSA, such as hypertension, stroke, impaired quality of life, and mortality.

This increased risk for adverse consequences of OSA is especially significant for these participants, who are already at greater risk for untoward consequences based on their obesity and type 2 diabetes. Uncomplicated infections need short courses of antibiotic treatment. Complicated infections require longer courses of treatment and further investigation, such as imaging studies and more thorough clinical evaluation.

While it has been conventional to consider all urinary tract infections in men as complicated, since the majority of infections occur in infants or in elderly patients with complicating urological abnormalities, acute Page 30 Medical Chronicle March Uncomplicated urinary tract infections in men uncomplicated urinary tract infections do occur in a small number of men between the ages of 15 and 50 years.

Risk factors include insertive anal intercourse and lack of circumcision. Diagnosis The diagnosis of uncomplicated urinary tract infections begins with a history suggesting irritative bladder symptoms alone in cystitis or with more severe symptoms of pyrexia, renal angle pain, abdominal tenderness and rigors in pyelonephritis. The laboratory diagnosis rests on urine analysis, by microscopy culture and sensitivity data.

Urinalysis is the most valuable laboratory diagnostic test for urinary tract infection. Pyuria is present in almost all men with acute cystitis or pyelonephritis, absence of pyuria suggests an alternative diagnosis or possibly the presence of an obstructing lesion. Meticulous collection of a urine sample is obligatory to avoid confusion and misdiagnosis, which can be associated with a contaminated specimen. A urine gram stain may be helpful in guiding the choice of empiric therapy while awaiting culture results.

A urine culture should be performed in all symptomatic men. Other organisms are rarely found in uncomplicated infections. Further urological evaluation is probably not needed in patients with first-time uncomplicated urinary infections with no obvious causative factors or predisposing features and who respond promptly to antibacterial treatment.

The urological evaluation by means of imaging studies and possibly cystoscopy should be carried out in patients who have features suggestive of complicating factors or who have recurrent urinary tract infections. A diagnosis of prostatitis should be considered in men who have obstructive urinary symptoms associated with cystitis. A diagnosis of urethritis should be considered in men who are sexually active and who might have a urethral discharge or evidence of genital ulceration.

Treatment Appropriate choice of antibiotics for men with acute uncomplicated cystitis includes fluoroquinolones as well as trimethoprim sulphamethoxazole compounds. This choice of agents is extrapolated from studies in women, evidence in the effectiveness of treatment of urinary infections in men is limited.

The choice of fluoroquinolones for empiric therapy of acute uncomplicated cystitis in men includes ciprofloxacin mg twice daily or mg extended-release tablets one per day. Levofloxacin mg once daily or norfloxacin mg twice daily are recommended. Antimicrobials, which do not achieve adequate tissue concentration levels such as nitrofurantoin , are not recommended in the treatment of acute urinary infections in men.

Data for fosfomycin in the treatment of men with urinary infections is limited. The optimal duration of treatment for uncomplicated urinary tract infections in men has not been well defined. Most reports suggest treatment duration of days. Men with persistent or recurrent symptoms after initial treatment of seven days warrant further investigation and evaluation for the possibility of prostatitis.

The approach to initial treatment of men with uncomplicated pyelonephritis depends on the severity of the illness. Less severe infections may be initially treated for 12 hours in the emergency room with intravenous antibiotics and, if the patient is able to maintain hydration and tolerate oral antibiotic therapy without the assistance of intravenous infusion, he may be discharged and treated with oral medication. More severe infections and those who do not respond to initial treatment require hospital admission with intravenous antibiotic therapy.

Urine culture as well as blood culture should be performed in all patients with suspected pyelonephritis. Oral quinolones are the drug of choice for outpatient management of acute uncomplicated pyelonephritis. Causes The main contributing factor to ascites in cirrhosis is splanchnic vasodilation. As portal hypertension progresses due to increased intra-hepatic resistance, blood is shunted into the systemic circulation. This leads to the release of nitric oxide resulting in splanchnic vasodilatation.

The effective intra-arterial pressure is reduced leading to the activation of neurohumoral systems renin-angiotensin-aldosterone system, sympathetic nervous system and ADH , resulting in salt and water retention and, as the disease progresses, renal vasoconstriction. This, in turn, may lead to the development of ascites, refractory ascites, dilutional hyponatraemia and hepatorenal syndrome. Cirrhosis is the most common cause of ascites in the US and Europe.

Other causes that need to be excluded include heart failure, infections such as TB, malignancy, pancreatic disease and other conditions. Inflammatory bowel disease IBD is a condition that can affect women during their reproductive years. Therefore, understanding the nuances of IBD management in women who are considering pregnancy, attempting to conceive or already pregnant is an important task for physicians who treat IBD. Children with one parent affected by IBD have a two- to fold higher risk of developing IBD in their lifetime compared with the general population, which translates to a 5.

Fertility Fertility is reduced in active IBD. Reasons for this are multifactorial and may be related to fever, pain, diarrhoea and malnutrition frequently seen in IBD flares, as well as dyspareunia, decreased libido and depression. Among women with inactive disease, the major IBD-associated factor affecting their fertility is prior pelvic surgery.

For women who have not had previous pelvic surgery, their fertility is similar to age-matched peers in the general population. Women who have undergone pelvic surgery have increased rates of infertility, particularly those who have had proctocolectomy with ileal pouch-anal anastomosis. Effect of pregnancy on disease activity Pregnancy has not been shown to increase likelihood of disease flare.

Diagnosis The patient should be evaluated clinically, and appropriate investigations instituted. Do abdominal ultrasound, laboratory investigations to assess liver function, renal function, as well as analysis of ascitic fluid. The serum-ascites albumin gradient SAAG can assist in the differentiation of ascites due to portal hypertension from ascites due to other causes. The latter should be excluded by obtaining a neutrophil count in the ascitic fluid and ascitic fluid culture in all patients with cirrhosis.

Ascites in cirrhosis indicates a poor prognosis with increased mortality rates. Complications of cirrhosis such as variceal bleeding, SBP and hepatorenal syndrome should be prevented to reduce morbidity. Treatment Treatment aim is to counteract renal sodium retention and to achieve a negative sodium balance.

This can be achieved by dietary salt restriction to mmol of sodium per day and Medical Chronicle March Page 31 Gastroenterology Forum Ascites in Cirrhosis Large population-based studies conducted in the s in Europe by Nielsen et al established that in both UC and CD patients, rates of disease flare are similar between pregnant and non-pregnant women.

A similar finding was seen among CD patients. Whether or not a woman experiences a flare during her pregnancy is influenced greatly by her disease activity at the time of conception. Prior literature suggests only a third of UC and CD patients with quiescent disease at conception will relapse during pregnancy, while two-thirds of patients with active disease at conception will continue to have active disease during pregnancy.

This emphasises the importance of attaining disease remission before pregnancy when possible. Management of IBD flares Should a pregnant IBD patient develop symptoms suggestive of an IBD flare, the ensuing workup should be similar to that typically initiated for non-pregnant patients. Stool studies should be sent to rule out an infectious etiology, particularly as Clostridium difficile infection is increased in the peripartum period. Most medications used to treat IBD flares are compatible with pregnancy.

The major exception is methotrexate, which has been shown to cause multiple congenital anomalies, induce spontaneous abortion and affect cellular metabolism. Cyclosporine can be used successfully in pregnancy, although the use of diuretics. They are the mainstay of management until the development of refractory ascites. Both proximal and distal diuretics are required to achieve diuresis.

Aldosterone antagonists are the diuretics of choice. They are usually used in combination with loop diuretics. In patients who do not respond no weight loss , urinary sodium measurement might aid on the decision on diuretics dose adjustments or salt restriction. Patients with gross ascites require large-volume paracentesis besides diuretics.

Pregnancy complications There has been a large volume of literature to suggest that women with IBD are at increased risk of pregnancy complications compared with agematched non-IBD peers. In concordance with these prior findings are two recent Scandinavian population-based studies conducted by Stephansson et al in and on UC and CD, respectively. Among women with UC compared with controls, there was an increased risk of moderately preterm birth defined as weeks gestation , very preterm birth defined as before 32 weeks, SGA birth, C-section and neonatal death.

In contrast to these findings is a prospective study by the European Crohn-Colitis Organisation, which looked at pregnant women with IBD CD and UC and found no statistically significant difference in the frequency of preterm deliveries, C-sections, birth weight or spontaneous abortions between babies of IBD Patients should be monitored for complications of diuretic therapy including electrolyte disturbances, renal impairment, hepatic en cephalopathy, muscle cramps and gynaecomastia.

Refractory ascites cannot be mobilised with medical therapy in combination with low salt diet diuretic-resistant ascites or because of complications of diuretic therapy diuretic-intractable ascites. Non-steroidal anti-inflammatory drugs can be a contributing factor. They are contraindicated in patients with ascites because of the risk of worsening sodium retention, hyponatraemia, refractory ascites and renal impairment. Refractory ascites is a sign of disease progression and the patient should be referred for liver transplant evaluation.

Promising new therapies such as vasopressin V2-receptor antagonists vaptans and a1-adrenergic agonists such as midodrine may enhance survival of patients with ascites while awaiting liver transplantation. Prof Ally would like to thank Dr W Abuelhassan for his contribution. MC women and matched non-IBD controls.

A majority of patients Disease activity during pregnancy has traditionally been thought to lead to worse pregnancy outcomes. Earlier studies showed active disease at conception was associated with a higher rate of fetal loss and preterm birth. Disease activity during pregnancy has also previously been associated with preterm birth and low birth weight.

IBD can also complicate a pregnancy course by placing the expectant mother at increased risk of thromboembolism and malnutrition. Thus, care should be taken to ensure appropriate deep venous thromboembolism prophylaxis when patients are hospitalised Conclusion Most women with IBD can have healthy pregnancies with stable disease management.

The key to successful symptom management and optimised pregnancy outcomes in IBD depends on an interdisciplinary approach involving the patient, her partner, primary care provider, gastroenterologist and obstetrician with close monitoring and ample counselling throughout. Management of inflammatory bowel disease in pregnancy. Expert Review of Clinical Immunology ;9 2 The adverse impact of smoking on health is well defined in people who are HIV-negative.

Several studies in recent years have examined the effects of smoking on the HIV-infected population. These have shown that the impact of smoking is more hazardous in this setting than in the general population.

Four categories of risk appear to be particularly important: the impact of smoking on life expectancy and mortality, alterations in the risk of developing lung carcinoma, elevated cardiovascular risk and the potential for altered antiretroviral drug levels. This data was published online in the 19 December, issue of Clinical Infectious Diseases.

Overall, HIV-positive smokers had a near four-fold increase in risk of death when carefully matched with those who did not smoke. In addition, survival was adversely affected. Patients who were aged between years and who never smoked, lost 5. Smokers with HIV in the same range lost The reduction in survival was most marked in those who smoked more than 30 cigarettes per day.

The mechanisms are uncertain but are thought to include both immunosuppression and the chronic immune stimulation that exists because of the life-long persistence of the virus. Lung cancer rates per person-years are approximately in the HIV-positive population compared with in the HIVnegative population. Against this elevated background rate, smoking increases the risk considerably.

This is another reason why smoking is an important behaviour to target in reducing all-cause morbidity in the setting of HIV infection. It is currently unclear whether more assertive lung cancer screening might be beneficial for HIV-positive smokers. There is also no clear data yet on whether lung cancer in this setting is more aggressive than in the HIVnegative population. The risk factors include those that apply to the general population, such as advancing age, smoking and dyslipidaemia as well as direct effects of HIV on endothelial function and haemostasis, and adverse effects of certain antiretroviral medications.

The study found that at the end of the first year of cessation, HIV-positive smokers had a 2. The risk declined to 1. Tobacco and ARV levels Data presented at the 49 th Interscience Conference on Antimicrobial Agents and Chemotherapy Abstract H; 12 September, showed that tobacco might alter the metabolism of certain antiretroviral medications.

In particular, the trough levels of the protease inhibitor atazanavir were significantly decreased. Since maintaining an adequate blood level of anti-HIV medications is essential for successful treatment, reducing plasma concentrations of ARVs could impair the efficacy of therapy.

The lifetime risk for breast cancer increases with age. This makes breast cancer much more prevalent in the older women in the Western world. We are now faced with an ageing population acquiring better access to healthcare and, hence, a significant burden of breast cancer to the local health services. The biology of breast cancer in the older woman shows steroid receptor sensitivity, low Bloom and Richardson grade, with a low proliferative index and a normal human epidermal growth factor receptor HER 2 status.

This indicates a relatively favourable histology, but despite what appears to be a very good phenotype, there is no real benefit for older folk over their younger counterparts. The latest figures indicate the smallest proportional decrease in the over age group. Also, women presenting with cancer as the first diagnosis, over the age of 75 years, have been shown to have a very poor prognosis. This disparity is almost certainly the result of the involvement of the elderly patient.

Most breast cancer studies reveal a paucity of patients enrolled for investigation. All this epidemiological data indicate that older patients do poorly when affected by breast cancer, and should therefore be treated appropriately, so that we may attempt to positively impact on this cohort of women.

Adjuvant systemic therapy Systemic treatment modalities include endocrine therapy and chemotherapy with or without trastuzumab. Treatment decisions need to take into consideration the risk of morbidity and mortality from breast cancer as well as treatment-induced effects.

A great part of this decisionmaking process involves assessment of suitability for systemic care. These factors need to be seriously considered when pursuing adjuvant systemic therapy in elderly patients. Endocrine therapy This forms the cornerstone of adjuvant therapy in elderly patients. Endocrine manipulation in these patients results in a greater proportional decrease in risk better than any chemotherapeutic intervention.

With a few exceptions, almost all consensus panels and published guidelines advocate the use of adjuvant endocrine therapy for hormone receptor-positive breast cancer regardless of any other clinical or biological factors. The International Society of Geriatric Oncology recommends that elderly women with endocrine responsive breast cancer should be offered endocrine therapy. This should always be offered on the background of a risk-benefit analysis.

Tamoxifen has long been regarded as the standard of care for adjuvant therapy in young and older women. There is also non-breast benefit in older women, reducing the occurrence of osteoporosis and diminishing the risk of cardiovascular disease. This drug, however, is underutilised in older women with early breast cancer. Not only is the discussion not had with these patients, but these women also tend to discontinue treatment more easily.

This would be the ideal group for novel strategies to reinforce treatment compliance. The use of adjuvant aromatase inhibitors in postmenopausal women has been extensively evaluated. Whether used sequentially after tamoxifen or as extended adjuvant, the results seem to indicate that aromatase inhibitors are beneficial in postmenopausal women with steroid receptor-positive breast tumours.

This effect is regardless of age, it affects both ipsilateral and contralateral breast cancers and distant spread. No survival benefit has been demonstrated when used in the upfront strategy when compared to tamoxifen. The toxicity profile does not result in a malignancy risk, nor is there a problem with clotting. The side effects include an increased risk of osteoporosis and musculoskeletal problems.

There seems to be a signal indicating an increased cardiovascular risk in clinical trials. In older women, the bone effects may prove very significant, given the higher incidence of osteoporosis with advancing age. Current clinical guidelines recommend the use of aromatase inhibitors in postmenopausal women prior to the introduction of tamoxifen, but in the elderly, the better approach would be to initiate tamoxifen therapy, with the intention of switching to an aromatase inhibitor only a bit later.

In older patients with a small As a healthcare professional, how often do you ask your patients whether they smoke, inform them of the dangers of tobacco smoking and offer to help them quit? If the answer is never or rarely, you may be neglecting your moral duty to stop your patients from putting their lives and that of the people around them at risk. It is also imperative that health professionals are alerted to the signs of smoking-related illnesses in non-smokers and speak to the smokers about the risks they pose to other people.

He was speaking ahead of the implementation of new regulations to the Tobacco Products Control Amendment Act of that will criminalise smoking in all buildings and public places like parking areas, parks, beaches and walkways in the country. The way of God is not that of ostentation but of ultimate success.

Just as Daniel taught, Jesus teaches that the kingdom grows gradually, progressively, and pervasively to dominance. The Great Commission After his death on the cross Matthew , burial , and glorious resurrection , Jesus gathers his disciples at Galilee and commissions them to fulfill the covenant promises designed to bless all the families of the earth.

Go therefore and make disciples of all the nations, baptizing them in the name of the Father and the Son and the Holy Spirit, teaching them to observe all that I commanded you; and lo, I am with you always, even to the end of the age. Christ has now assumed this responsibility and delegated the means by which it will be accomplished to his Church.

Israel failed, but the Messiah cannot and will not fail. Romans In any study of eschatology Romans cannot be overlooked. Paul explains that salvation is never a birthright, even for the descendants of Abraham , and that eth- nic Israel has been cast aside while Gentiles pour into the kingdom May it never be! This chosen remnant has obtained salvation while the rest of ethnic Israel has been hardened This alone would demonstrate that God is faithful and that his promises have not failed, but Paul continues by explaining that the hardening of the greater part of ethnic Israel has a purpose and is not permanent.

For the remainder of this chapter the subject focuses on hardened ethnic Israel who has stumbled over Christ. Paul explains the purpose of her rejection and looks forward to their future acceptance. Several times in the remainder of chapter 11, Paul explains the purpose and future of ethnic Israel in terms of a threefold progression.

Paul re-. But once we grasp the context of these words, the interpretation becomes much clearer. To begin analyzing this text we must first note the immediate context. Verse 26 is a continuation of a sen- tence that begins in verse The second major clue to the interpretation of verse 26 is the proximate context. In Paul con- tinually distinguishes between ethnic Israel and the Gentiles.

This militates against the first interpretation. Contrary to the second interpretation, we must ob- serve that the subject of as a whole is the. Over thirty times in these verses Paul refers specifi- cally to hardened Israel. They, and not the remnant, are the subject of these verses. Finally, the time reference in these verses indicates that the hardening of ethnic Israel is temporary. Her rejection is not permanent: it continues until the full- ness of the Gentiles comes in, and then ethnic Israel will be restored cf.

This is indi- cated in verse In addition, Paul states that the hardening of Israel will continue until the full- ness of the Gentiles comes in. When Romans is read as a whole, it clearly points to a future restoration of ethnic Israel to faith in God, to an acceptance of her Messiah, to a regrafting back into the Olive Tree. As her transgression resulted in blessing for the entire world, her fullness will result in unimaginable blessings. I Corinthians 15 Another important eschatological passage in Paul appears in his famous resurrection chapter, I Corinthians For He must reign until He has put all His enemies under His feet.

Acts ; Ephesians ; Philippians ; I Peter ; cf. Daniel Psalm ; Isaiah 9; Daniel 2, 7; Zechariah 9. During the course of his present reign Christ is gradually over- coming all opposition and is putting all of his enemies under his feet. The last enemy to be destroyed will be death, and this will be brought about by the future resurrection of our bodies at the Second Coming cf. I Corinthians , Revelation 20 Many discussions of eschatology in general and the millennium in particular focus on Revelation 20 virtu- ally to the exclusion of the remainder of Scripture.

When it is read in light. Revelation 20 describes a vision of the Millennium vv. A comparison with the previous Scriptures reveals that this Millennium is the present age between the two advents of Christ. The revelation that he will be briefly released at the end of the age disallows any form of perfectionist utopianism.

Satan, sin, and death will not be completely destroyed until the Second Coming. Scripture also declares repeatedly that Christ was given his kingdom at his first advent Daniel 2, 7; Matthew ; Acts ; ; Colossians ; Revelation and that Christians now reign with him Romans ; Ephesians ; Revelation I Corinthians Only those who are in Christ partake of this res- urrection. Our participation in it is spoken of in the past tense in terms of our regeneration, or spiritual resurrection Ephesians ; Colossians , and in the future tense in terms of our bodily resurrection Romans ; I Corinthians , ; I Thessalonians All who have been raised spiritually will be raised bodily.

John tells us that the second death, the lake of fire, has no power over those who have a part in the first resurrection Revelation , In Revelation John describes a second resurrec- tion of those who are not in Christ and who will be judged at the Great White Throne.

This judgment is graphically described in verses This second resurrection is qualitatively dis- tinct from the first resurrection because unbelievers never partake in the resurrection of Christ. They remain in a state of spiritual death and they will be raised to face the second death Revelation , Through him God is bringing and will continue bringing bless- ings to all the nations of the earth even as he subdues every enemy.

Jesus was given his kingdom at his as- cension, and during his present reign he is putting all of his enemies under his feet. He has commissioned his. Church to be the instrument by which he accomplishes these purposes of blessing and judgment. Mathison, Ph. He is the author of four books, including two on eschatology: Dispensationalism: Rightly Dividing the People of God?

Hodge, James Henley Thornwell, and B. Warfield to realize the complete inaccuracy of the dispensationalist descriptions of postmillennialism. Tyler, Tex. God reveals his holy law to Israel and reveals that obedience to the covenant would bring blessing while disobedience would bring cursing Leviticus 26; Deuteronomy Throughout the historical books, we see the truth of these promises and warnings in the history of Israel. A LL evangelicals agree that the kingdom of God will ultimately triumph over the king- dom of darkness, but they do not agree on the time or the circumstances of that victory.

That question has been answered in three basic ways: the premillennial view, the amillennial view, and the postmillennial view. Thus, the premillennialist. In fact, they believe that evil will increase throughout history until the end of this age when Satan will triumph through the arising of the Antichrist imposing a worldwide geo- political kingdom of darkness. This accounts for the rising apostasy and the decline of Christianity In fact, one day God will remove the restrainer and hell on earth will be the order during the tribulation.

The amillennialist, at best, sees good and evil growing together during this age. They see no definitive triumph of the king- dom of Christ in history. William Cox compares and contrasts amillennialism with premillennialism and postmillennialism, and in so doing expresses the pes- simism of amillennialism: Is the world getting better or worse? Postmillenarians say it is getting better, and that the preaching of the gospel will eventually see most of the world converted, thus ushering in an earthly millennium before the sec- ond coming.

Premillenarians believe the world is. Amillenarians agree with premillenarians on this point. Although we be- lieve the kingdom of God began as a small mustard seed and grows steadily larger, we also believe that evil grows proportionately faster. Good and evil will exist side by side until the very harvest, which Jesus said will be the end of the world Matthew We believe this growth will culminate with the appear- ance of the antichrist, which Paul called the man of sin, and which John referred to as Satan being loosed for a little season.

This loosing will take place in the very endtime of the present historical church age. Gentry, a postmillennialist, defines this view as follows: Postmillennialism is that system of eschatology which understands the Messianic kingdom to have been founded upon the earth during the earthly ministry and through the redemptive labors of the Lord Jesus Christ in fulfillment of Old Testament prophetic expectation.

The nature of that kingdom is essentially redemptive and spiritual and will exercise a transformational socio-cultural influence in history, as more and more people are converted to Christ. Postmillennialism con- fidently anticipates a time in earth history in which the gospel will have won the victory throughout the earth in fulfillment of the Great Commission.

After an extended period of gospel prosperity, earth history will be drawn to a close by the personal, visible, bodily return of Jesus Christ accompanied by a literal res- urrection and a general judgment. After all, the issue is whether postmillennialism is taught in the Bible. This chapter aims to provide an answer to that ques- tion by a study of Psalm and its usage in the New Testament.

Psalm is a significant passage in the debate between the three millennial positions. It is rec- ognized by all as one of the most important of the messianic psalms. Certainly, the New Testament writ- ers considered it so, for they quote and refer to it more than any other single Old Testament text. Thus, a proper interpretation of Psalm and its New Testa- ment usage is imperative for understanding the work of the Messiah and the course of his kingdom. But, again as elsewhere, exegesis must proceed in theological depth.

But in spite of this, some have disputed its authorship. However, for those who accept the authority of the New Testa- ment the question of authorship is not in doubt, for both Jesus Matthew and Peter Acts testify that David was indeed the inspired writer of Psalm David rejoices before God and his people as he prophesies of the fu- ture victorious reign of the Messiah.

Regarding the time of composition or the historical setting of the psalm, neither the heading nor contents provide any definite clues. Nevertheless, it seems evi- dent that David wrote Psalm some time after he had received the promises of the Davidic Covenant through the prophet Nathan I Chronicles From beginning to end, David states the prophetic word that he had received concerning the Messiah.

In this psalm David emphatically proclaims the vic- tory of the Messiah over all of his enemies due to his exaltation to the right hand of God. The structure of Psalm is discerned by noting that David addresses himself first in a general manner to all v. The truth that is revealed in this verse forms the basis for the entire psalm.

Exposition of Psalm We must now carefully analyze the passage to de- termine its significance for the eschatological debate. It is only used of prophetic communication, i. I Samuel ; Isaiah ; Hence its appearance calls special attention to the origin and authority of what is said. In the context, this can only refer to the Messiah.

David understood from the promises given to him in the Davidic Covenant II Samuel ; I Chronicles that God would establish his kingdom for- ever through one of his descendants. David understood that even he must bow be- fore the coming Messiah as his master and Lord. Having established the origin and authority for the psalm, David now gives the divine word concerning the Messiah.

It is not a mere invitation but a di- vine, unalterable decree—the Messiah will one day sit at the right hand of God. The right hand is a place of honor and privilege, but in this context it means more than that. To understand the full import of what it means to sit at the right hand of God, we must con- sider the scriptural teaching on where God himself is seated. God is sovereign over all, and he rules over all from his holy throne in heaven.

Thus, the LORD is giving to the Messiah the privilege and honor of joining him as he sits on the divine throne in heaven. Certainly not. Therefore, the Messiah is no ordinary man. In fact, to rule with God. The text here does not state the time or the circumstances of his exaltation. Joshua ; I Kings Therefore, the distinct reign of the Messiah that is in view in Psalm has both a beginning and an ending. Genesis ; ; Psalm But it will undergo a change for it will no longer be a reign involving conflict with his enemies because they will all have been totally defeated.

This revelation states that the Messiah will be exalted to the right hand of God, and while seated on his heav- enly throne, will achieve victory over his enemies. This verse sets the theme for the Psalm: the victorious reign of the Messiah.

The place from which he will reign is the throne of God. His reign i. His kingdom will, therefore, triumph over all the kingdoms of this world. This is a prophetic word that reveals the means whereby the Messiah shall reign victoriously.

Psalm Psalm ; ; ; ; Hebrews David ruled from the earthly Zion, but his Lord will rule from the heavenly Zion. Therefore, verse 2 reveals that the Mes- siah will not be passive at the right hand of God in the. Having been enthroned at the right hand of God and given all power and author- ity, the Messiah will go forth from Zion to extend his dominion over the rebellious nations, and they will become his footstool.

Significantly, we find many parallels between Psalm 2 and Psalm LORD and his Anointed. Psalm indicates that the Messiah will not be alone as he goes forth to conquer his enemies. Throughout this period of conflict and kingdom expansion, he will be served by a host of willing servants soldiers who follow him into battle.

David describes the army of the Messiah with two highly poetic phrases. It is a priestly people which he leads forth to holy battle. It is a metaphor of freshness and is beautifully applied to the young men of the kingdom who fill the ranks of the army. When He sets forth to give evidence of His power and control, there will be a great army of men in the prime of their youth who shall cheerfully volunteer their services and shall come fittingly equipped for holy warfare in holy garments, that is arrayed in true righteousness and holiness.

As dew in unnumbered globules is born at each new dawn, so shall these warriors be, number- less and continually fresh. Psalm reveals that the Messiah will hold a second major office. Not only is he a king vv. The priest was appointed to offer up prayers and sacrifices to God on behalf of sinners cf.

Hebrews Therefore, the Messiah is a priest appointed to serve as the mediator for his people. Isaiah However, we must note the connection between the Messiah and his people that is given in verses 3 and 4. The people he leads are an army of priests ar-. As Melchizedek held the offices of king and priest and was so great that he blessed the patriarch Abraham, so will the Messiah hold both offices and be so great that Abraham and David—indeed, all of his people— are blessed in him.

In Old Testament Israel the offices of priest and king were kept distinct cf. But in the Messiah both offices will be combined cf. Zechariah He will be both king and priest forever. The context of Psalm implies that both offices are essential if the Mes-. And because he is both of these his battle itself is a priestly royal work, and just on this account his people fighting with him also wear priestly garments. After praising the LORD for enthroning the Messiah at his right hand, David proceeds to depict the suc- cessful warfare of the Messiah in five statements.

These kings are, therefore, earthly rulers who reject the au- thority of God and of his chosen king, the Messiah. These must be the same kings who are spoken of in Psalm where they are described as being in re- volt against the LORD and his Anointed. And as the Messiah is commanded in Psalm to break them with a rod of iron, so here in Psalm the Mes- siah is pictured as carrying out that command by striking through these kings and filling the battlefield with dead bodies.

Is it the judgment that will come at the last day? No, the context indicates that it is the judgment of the Lord that will fall upon rebellious kings and nations while the Messiah is enthroned at the right hand of God. It describes the wrath of the Messiah that is visited upon his enemies as he goes forth from Zion to make them his footstool.

Jeremiah ; Psalm ; Deuteronomy To depict the victory of the Messiah over his adver- saries, Psalm uses the image of a warrior who pauses to drink from a brook, and then arises refreshed to press the battle to a successful conclusion. As the cool drink renews the warrior, so will the Messiah be ever renewed and strengthened by the LORD as he goes forth to conquer. In its Old Testament context Psalm is a proph- ecy of the coming Messiah.

The emphasis of this Psalm is on the victorious reign of the Messiah from the right hand of God. He will be exalted to the throne of God and from that position he shall go forth with his people to fulfill the divine commission to rule in the midst of his enemies and extend his dominion to the four cor- ners of the earth. The purpose of his reign will not be achieved until all of his enemies are his footstool.

He must reign at the right hand of God until the victory is his. Christians are commit- ted to the final authority of Jesus and his Apostles for understanding and applying the Old Testament Scrip- tures. Therefore, if Christians are to know the full meaning and true fulfillment of Psalm , they must look to the New Testament and consider how the New Testament interprets and applies this messianic psalm. Psalm is perhaps the single most important Old Testament text for under- standing the person of Christ and the essential characteristics and sequence of his reign.

The goal here is to survey the quotations and allusions to Psalm found in the New Testament. We conduct this survey convinced that the New Testament indicates the precise way in which the teaching of Psalm on the victorious reign of the Messiah is fulfilled in Jesus Christ. The Use of Psalm in the New Testament I will consider the use of Psalm in the New Testament under five headings, which will illustrate its significance in the New Testament.

His enemies, the Jewish leaders, were offended by him, and at various times during the week they came to challenge his authority and sought to entrap him with difficult questions Mat- thew However, all their attempts to catch Jesus in his words failed miserably.

Having dealt with their trick questions, Jesus asked them a ques- tion of his own. Rather he was challenging their narrow concept of the Messiah. I will focus on the text of Matthew. Whose son is he? The problem was that the Jews were only thinking in terms of a political Messiah who would reestablish the throne of David in Jerusalem and lead Israel to military vic-. John Jesus then proceeds to quote Psalm to the Jews Matthew There the Messiah is rec- ognized as having a unique relationship, not to David, but to God, whose sovereignty He shares.

What that conception is he does not explicitly state, but the content of Psalm indi- cates that it involves a close relation to God himself, and includes the office not only of king, but of priest verse 4. It is a position of victory and dominion, but a victory and dominion conferred by the power of God. We may endorse the verdict of E. At this trial the Sanhedrin were seeking testi- mony against Jesus so that they might condemn him to death.

In this response Jesus did claim to be the Messiah. The High Priest, clearly understanding this, condemned him to die on the charge of blasphemy Matthew In his reply to the High Priest, Jesus uses Psalm and Daniel in support of his messianic claim. Now that he has been condemned to die, Jesus enters that time of suffering which will ultimately lead to his triumph over death and his exaltation to the right hand of God. It is important to recognize that Jesus brings to- gether the messianic prophecies of Psalm and Daniel in Matthew In Psalm the LORD enthrones the Messiah at his right hand and grants him authority to rule the nations and to ex- tend his kingdom throughout the earth.

Consequently, Jesus now rules the na- tions from his throne on high. As Jesus di-. These same misguided notions are still held by Chris- tians who believe that fulfilling the Davidic Covenant demands that after Jesus returns he will rule as king over all nations from the throne of national Israel in Jerusalem. Peter then proceeds to prove that Jesus is the Messiah by pointing to the resurrection and ascen- sion of Jesus Acts Looking to Old Testament prophecy, Peter says that Jesus has been raised from the dead in fulfillment of Psalm , and has been exalted to the right hand of God in fulfillment of Psalm God fulfilled that promise when he raised Jesus from the dead and exalted him to his right hand Acts The temporal throne of David is to be reconstructed in Jerusalem.

Surely the throne of David was of no more impor- tance than David. The premillennialist by his peculiar interpretation mistakes the type for the antitype; he mistakes the shadow for the reality. David himself, though living in the Old Dispensa- tion, beheld the superior and exalted throne and wrote of it in Psalm The Apostle Peter refers to this Psalm in his sermon on the day of Pen- tecost Acts As a matter of fact there is not one passage in the New Testament which gives definite information of a personal reign of Christ upon a temporal throne in the material city of Jerusalem.

The context of this quotation is the superiority of the Son to angels. According to the writer of He- brews the exaltation of the Messiah in Psalm to the right hand of God proves the preeminence of the Son the Messiah to angels and raises him to a posi- tion of equality with God. An allusion to Psalm appears in Hebrews Thus the writer of Hebrews asserts that the exaltation of Christ to the right hand of God is proof of his deity. No mere man, no mere son of David, no angel could ever occupy such a high and glorious position.

Jesus Christ could because he is the Son of God. The New Testament writers make many clear allu- sions to Psalm in their repeated and emphatic teaching that Jesus Christ is now seated at the right hand of God. They confirm the fact that the ascension of Christ marked the time of his enthronement, and that he now rules over all as King and Lord of all cf. Mark ; Ephesians ; I Peter These al- lusions to Psalm also establish a definite. Acts ; Hebrews ; ; also Philippians Romans ; Hebrews ; In this chapter Paul vigorously re- futes the false teachers in Corinth who were denying the future bodily resurrection of the saints.

Paul then teaches that the bodily resurrection of Christ is the surety that all who believe in Christ will be raised at his return vv. The second sense is the meaning here. Therefore, Paul says that at the Second Coming Jesus Christ will deliver up to the Father his delegated sovereignty because he will have fulfilled the divine task entrusted to him. The Father has commissioned Christ to render powerless the enemies of God, and has granted him royal power and authority to fulfill that commission.

Paul says that the Second Coming will mark the fulfillment of that commission. According to Paul, Psalm reveals that the exaltation of Christ to the right hand of the Father gave him sovereign authority, and that the purpose of that grant of authority was for the defeat of all the enemies of truth and righteousness.

Finally, Paul saw in Psalm the promise that the Messiah would triumph over all of his enemies prior to his return—Paul believed that the victorious reign of Christ predicted in Psalm referred to this age. Only then does Christ hand over the kingdom to the Father. It was through his death on the cross that Christ struck the fatal blow against sin and the kingdom of darkness.

Ephesians ; Philippians ; Psalm In addi- tion, this text in Hebrews establishes that the victorious. Thus, Jesus will not come to consum- mate his kingdom until his enemies lie prostrate at his feet. This establishes a close connection between Psalm and the Great Com- mission as recorded in Matthew This sovereign authority is his because of his exaltation to the right hand of God in fulfillment of Psalm The Great Commission also alludes to Psalm wherein the Messiah would have an army clothed in.

The Great Commission reveals that the Church is that army. Having been redeemed by his blood and filled with his Spirit, the Church goes into the world to subdue the rebellious nations by preach- ing, baptizing, and teaching. The Church is the agent of Christ in making his enemies his foot- stool, having a vital role in the fulfillment of Psalm Revelation identifies this army as the church, and the clothing of fine linen is said to be the righteous acts of the saints.

Hebrews refers extensively to Psalm as the writer explains the redemptive work of Christ Hebrews , 10; ; , 11, 15, 17, Hebrews pre- sents the saving work of Christ as the fulfillment of the Old Testament sacrificial system. Because Christ was holy, he offered the perfect sacrifice, and he has the power of an endless life Hebrews Thus, in Acts Peter alludes to Psalm and the messianic offices of king and priest, and also affirms that Christ fulfills both of these offices from the right hand of God.

The New Testament declares that Jesus fulfills the office of priest in Psalm by his death and endless life. The New Testament no- where directly quotes these verses. It appears, however, that Revelation alludes to Psalm be- cause so many parallels link the two passages.

Psalm The Messiah judges and makes Psalm Revelation , war in the day of his wrath. The Messiah judges Christ judges and Revelation and , makes war Christ in the judges treads theand treads winepress the of day winepress of the wrathofofthe his wrath. Psalm Psalm The kingsRevelation of the earth fight The kings of the against the Messiah.

The kings of the earth earth fight against fight against Christ. Revelation the Messiah. Revelation bodies. Christ is completely Revelation Christ is completely victorious. Revelation is describing the same mes- sianic victory as Psalm Therefore, as Psalm is a symbolic description of the victorious warfare of the Messiah that takes place during his reign at the right hand of God, so does Revelation depict the victorious warfare during this present age.

Commenting on Revelation , B. Warfield states:. It is a vivid picture of a complete victory, an entire conquest that we have here; and all the imagery of war and battle is employed to give it life. This is the symbol. The thing symbolized is obviously the com- plete victory of the Son of God over all the hosts of wickedness.

Only a single hint of this signification is afforded by the language, but that is enough. On two occasions we are told that the sword by which the victory is won proceeds out of the mouth of the con- queror verses 15 and We are not to think, as we read, of any literal war or manual fighting, therefore; the conquest is wrought by the spoken word—in short, by the preaching of the gospel.

In fine, we have before us here a picture of the victorious career of the gospel of Christ in the world. All the imagery of the dread battle and its hideous details are but to give us the impression of the completeness of the victory.

Therefore, all the details of Psalm need to be applied to the person and work of Christ. Each part of the psalm speaks directly of Christ and his kingdom. This great messianic psalm de- clares the victorious reign of Christ from the right hand of God. It instructs the Church to look for the triumph of Christ and his kingdom in this age, and challenges her to do her part in pressing forward the victory. Christ and his kingdom will, therefore, triumph in history and before his return at the end of the age.

And the second answer is that postmillennialists do not base their eschatology on the newspapers or the current state of the church; they base their eschatology on the word of God. However, as R. As an eschatology of victory, it will inspire men with the power of God, and, as with great saints of old, and the Puritans of yester- years, it will lead again and more enduringly to the.

Einwechter, Th. Portland, Ore. Cox, Amillennialism Today, Phillipsburg, N. Bahnsen and Kenneth L. However, all the available evidence suggests that these headings are both early and reliable. See Gleason L. Archer, Jr. James Anderson rep. Keil and F. Delitzsch rep. Laird Harris Chicago: Moody, , Hereinafter: TWOT. Thus, ac-. Cohen London: Soncino, , Kautzch, rev. Cowley, 2nd ed. Oxford: Oxford University Press, , Waltke and M.

For a theological justification of this exegetical method, see O. Feinberg, ed. Matthew rep. But this passage is also very problematic for the amillennialist. He is perfectly able to accom- plish this from the right hand of God. Warfield 1. He has a number of things, in themselves of value, to say about it; but he appears to find most satisfaction in the suggestion that although Christ by his expiatory death has bought for his people some things—and these the most important things—which he has not bought for all men, yet there are some most desirable things also which he has bought for all men.

This, however, is certainly not what John says. Its sins have been as really and fully expiated as those of the Chris- tians John was addressing, and as his own. We do not know what John means, he says; we lack the necessary information to en-. But difficulties remain. And John! Perhaps it is, on the other hand, the missionary instinct of the Church, which declares here that no limits are to be set to the spread of salvation over the whole world—in contrast to the Gnostic confinement of it to certain gifted indi- viduals.

We can form many conjectures; we can reach no assurance. In something of the same way, the world-wide extension of the people of God may be thought to be brought into contrast by John with the local churches he is addressing; and his purpose may be supposed to be to remind these local churches that they have no monopoly of the gospel.

Christ is no local Savior, and all,. When the assumptions on which this view of the passage is founded are scrutinized, however, they can- not be said particularly to commend themselves. This is already apparent from his identifying himself with them in these affirmations. He appears, on the contrary, to be reminding them of universal Christian privileges, in which they and he shared precisely for the reason that they were univer- sally Christian.

Why should the Apostle with such emphasis—why should he at all— assure his readers that the privileges they enjoyed as Christians—in common with him be- cause they were both Christians—were also enjoyed by all other Christians—by all other Christians through- out the whole world? Would it not be a matter of course, scarcely calling for such explicit assertion, that other Christians like themselves enjoyed the benefits of the expiatory death of their Lord? That was pre- cisely what it was to be a Christian.

That carries with it, of course, that in some sense our Lord is declared to have made propitiation not only for the sins of be- lievers, thought of by John as actually such, but also for mankind at large. It may seem, then, the simplest thing just to recognize that John here repre- sents Christ as by his atoning death expiating all the sins of all mankind—all of them without exception.

This is the line of exposition which is taken, for in- stance, by Bernhard Weiss. John speaks of this expiation as a great benefit brought to the world by Christ, or, to put it in its true light, as the great benefit, in comparison with which no other benefit deserves consideration. Yet it would puzzle us to point out of what benefit it is to the world.

The world, to all appearance, re- mains precisely as it was before. It is very clear that the world was not conceived by John as a redeemed world. We are not to love it, nor the things in it. We are rather to renounce it, as an inimical power. Is not the rejection of Jesus as our propitiation a sin? And if it is a sin, is it not like other sins, covered by the death of Christ? And surely it would be very odd if the sin of rejection of the Redeemer were the only condemning sin, in a world the vast major- ity of the dwellers in which have never heard of this Redeemer, and nevertheless perish.

On what ground do they perish, all their sins having been expiated? This is the view presented by B. Westcott also, according to whom Christ is ad- vocate exclusively for Christians, while he is a propitiation for the whole world. His propitiatory death on earth was for all men; his advocacy in heaven is for those only who believe in him. No support is given this elaborate construction by John; and our present passage is enough to shatter the foun-.

But it is based on it not as if it bore merely an accidental relation to it, and might or might not, at will, follow on it; but as its natural and indeed neces- sary issue. The efficacy of the advocacy rests on that of the propitiation, not the efficacy of the propitiation on that of the advocacy. The propitiation accordingly not merely lays a foun- dation for a saving operation, to follow or not follow as circumstances may determine.

It itself saves. It is idle to talk of expounding this passage until we are ready to recognize that according to its express as-. In declar- ing that Jesus Christ is a propitiation for the whole world, John certainly does not mean to assert that Christ has made expiation for all the sins of every indi- vidual man who has come or will come into being, from the beginning of the race in Adam to its end at the last day.

John means only, he says, that Christ is a Savior with abiding power for the whole human era; all through the ages he is mighty to save, though he saves only his own. He knew of those not of his own time who were saved; he knew of children of the devil in his own day.

There is a protensive element in his con- ception of the world. It is however of its protension in the future rather than in the past that he is thinking. He sees the world not only lying on every side of him in space, but very especially as stretching out before him in time. The contrast between it and the little flock of Christians includes thus a contrast of times. The interpretation of our passage has suffered seri- ously from a mechanical treatment of its language.

We must permit to John the flexibility customary among men in the handling of human speech. He is certainly intending to present Christ as a world-wide Savior by whom nothing less than the world is saved; but it does not follow that he means to affirm that therefore no single man of all who ever live in the world is omitted. It belongs therefore distinctly to his mission that he should take away the sin of the world.

He came into the world because of love of the world, in order that he might save the world, and he actually saves the world. Where the expositors have gone astray is in not perceiving that this salvation of the world was not conceived by John—any more than the salvation of the individual—accomplishing itself all at once.

Jesus came to save the world, and the world will through him be saved; at the end of the day he will have a saved world to present to his father. From that point of view he is the Savior of the world. And there- fore he proclaims Jesus the Savior of the world and declares him a propitiation for the whole world.

He is a universalist; he teaches the salvation of the whole world. He teaches the salvation of the world through a process; it may be— it has proved to be—a long process; but it is a process which shall reach its goal.

And what his declaration is, at its core, is thus only another of those numerous —prophecies, shall we say? But he is not willing to stop there. His glad. We are but the beginnings: the salvation of the world is the end. And it is not this only, but that, that Christ has purchased with his precious blood.

For Jesus Christ is the Savior not of a little flock merely, but of the world itself: and the end to which all things are working to- gether is nothing other than a saved world. He authored scores of articles and numerous books. Meeter, ed. Warfield contains ten volumes of his selected writings.

For instance, Colin G. Consequently, he is opposed to the popular doctrine of the imminent return of Christ. If Christianity is the final religion, the church is still in its infancy. Two thousand years are as two days. Agony, Irony, and the Postmillennialist by Kenneth L.

T HE eschatological debate between amillennialists and postmillennialists in the reformed camp has been taking a new turn of late. Whereas amillennialists of the recent past e. Gaffin, Strimple, and White3 are pressing the basic soteriological revelation.

Though both amillennialists and postmillennialists largely agree with Geerhardus Vos on the eschatological nature of salvation and the redemptive-historical structure of history,4 the differ- ences between our visions remain. As I indicate elsewhere5 the particular nature of this pessimism must be understood as presented in the debate.

Obviously, all evangelical perspectives are ultimately optimistic: the righteous will be eternally. For instance, R. He opens with scholarly citations highlighting the moral decline our culture is enduring. Over all, he presents an accurate portrayal of my postmillennial writings and those of Bahnsen and North. He urges considering more closely the victory of the church in addition to that of Christ. He suggests that the church victoriously reigns with Christ as she faith- fully endures her earthly trials White, , , He does not discount Strimple or Gaffin, but transforms the negative argument into a positive one, while correcting some deficiencies in Strimple White, , Unfortunately, as this factor of the debate illustrates, postmillennialism is the easiest eschatological option to misconstrue.

In this regard I must note up front that postmillennialists do not assert: 1 universalism not all will be saved at any point in history ; 2 perfectionism the saved are never perfect on earth ; or 3 satisfactionism we do not prefer earthly dominion over consummational glory. Of course, just as White confesses that space constraints prohibit his fuller interaction and explication White, , , , so must I. This is not only due to the broad theological implications of the debate, but also my fighting a battle on two fronts: the emphases of both Gaffin-Strimple and White.

And in this the recent amillennial textbook by Cornelis Venema concurs. Thus, this suffering argument suggests to the amillennialist the impossibility of the large scale elimi- nation of suffering demanded in the postmillennial scheme. How shall the postmillennialist respond?

I would urge the following for clarifying both our reformed interpretation of Scripture and our accurate under- standing of postmillennialism. Scripture is occasional and historical. That is, we must always recognize that it speaks to real people in their original settings. Is that a universal ecclesiastical expectation for all times, or an occasional assertion for those times? Surely the latter. Historically, the early church to whom the apostles wrote found herself in the throes of a rapidly expand- ing and increasingly deepening persecution.

Consequently, warnings of persecutional suffering ap- ply to the original recipients in a direct and relevant way. We misconstrue them if we universalize them so as to require the continued persecution of the church. Persecution is serious external oppression. As we reflect on this point in the debate we must bear in mind a vitally important matter: The only kind of suf- fering that contradicts postmillennialism is suffering rooted in dangerous external threats and oppression especially when designed to suppress or punish the Christian faith.

And were these conditions to continue until the end, postmillennialism could not be true. We know from our experience that Christianity can exist in a large-scale, long-lasting external peace from persecutional suffering. Persecution does not always prevail. Remember- ing the form of persecution highlighted in point I.

Is Strimple suffering in a way proving his point? Are the publish- ers of The Westminster Theological Journal? Corporate personality may account for some statements of persecutional suffering. Their struggles should be remembered e. The persecutional suffering in much of church history, then, is a persecution of the body of Christ and a source of sorrow even when the body finally comes to peace in.

The Coliseum is, as it were, our Wailing Wall. Suffering is broader than external oppression and compatible with postmillennialism. As I indi- cated in my introduction, postmillennialists can affirm suffering-with-Christ as a basic element of our Christian experience even up to the end—when we carefully reflect on the biblical requirements of the suffering argument.

Whereas bap- tism is fuller than that, in that it represents union with Christ in all that he does, not just his death and resur- rection. But there are others: a We suffer as fallen creatures enduring physical weakness in this age. We are even too weak to pray as we ought, so the Spirit who resurrects intercedes for us But when we properly analyze the suf- fering argument, postmillennialists are not confronted with an insurmountable wall.

For postmillennialism does not expect the elimination of mortality this side of the resurrection. And so these sufferings due to mortality will continue even at the height of the advance of the gospel. Ephesians ; James ; Titus As regenerate, spiritually semi-eschatological resurrected believers, we abhor the sinful tendencies present in ourselves and in others. Paul was torn as he struggled to please God Romans Who will set me free from the body of this death?

The Christian, in fact, lives in two worlds simultaneously, and so long as this is so he lives in a state of tension. Matthew Romans ; Colossians Christ is an example of suffering for us. We dis- cover further evidence of the broad nature of suffering in Christ, our model of suffering.

His suffering was not limited to external oppression by rebellious man. Rather, his entire state of humiliation was by defini- tion a state of suffering in which he endured mundane, creaturely pains and sorrows.

He wearied John , hungered Matthew , and sorrowed John —apart from persecution. Our union with Christ in his suffering involves all of these mundane things, not just matters of external assault and trial. And these forms of suffering are com- patible with the postmillennial hope.

Suffering is contrasted with eternal glory. Philippians II Corinthians For indeed in this house we groan, longing to be clothed with our dwell- ing from heaven. Earthly suffering involves times of prosperity as well as times of adversity. Nevertheless, his enhancements deserve addi- tional contemplation.

Before I begin I must quickly dispatch an erroneous charge he brings against the postmillennialist. Much of. This cannot possibly be dismissed as an irrelevancy. This charge is a sample of an all too frequent tendency to argumentative overstatement. But we do not be- lieve that experiencing persecution in all times is a necessary condition of her victory, or else she cannot be victorious now in America nor will she be victori- ous in heaven. Postmillennialists necessarily highlight this distinctive difference between our view and the other evangelical eschatological options: our expectation that external persecution must gradually fade away.

We no more dismiss suffering by not emphasizing it in our writings than Paul dismisses the resurrection of the unbeliever by never mentioning it in his writings. Redemptive Irony White reminds us of the startling means by which God effects his will and blesses his people: He does so by. Ironic victory is biblical. White has presented a clear, concise, and helpful summary of the principle which I as a postmillennialist appreciate. I agree with his argument—until he draws wrong conclusions. Ironic victory is postmillennial.

The Jewish Messianic fervor expected a conquer- ing Messiah to overthrow the pagan world e. Whereas in history Satan employs the sword against the church in history, the sword of the Spirit will win the victory—also in history. Ironic victory is historical. Note that: the ser-. The craftiest creature became the ac- cursed creature—in history. The woman desired to rule her husband, but was ruled by him—in history. Man from the dust wanted to be like God, but was brought back to the dust—in history.

The serpent sought the woman as his ally, but she became the mother of the righteous conqueror—in history. It appears that the serpent sought the destruction of the human race—and won! Surely this is not the irony God intends. Ironic victory is admitted. But ironically! Therefore, faithfully enduring in the world is the exercise of our present victory in Christ.

In response I would note: a. Endurance is obvious in the trials of oppression. Those Christians who faithfully endured the per- secutions of the first and later centuries were indeed victorious. But, as I will show, this is not the only way in which we exercise victory. Endurance is historical in the Book of Revela- tion. And his pre- sentation is almost totally based on G.

I would argue that we must understand Revelation as an occasional epistle, a letter to historical churches. He is alerting them to the very important truth that Chris- tian victory is not one-dimensional, that Christian victory can and often does—and in their case will— require victory through enduring fearsome persecution.

Revelation is not a moving picture of all of Christian history, but a snapshot of its beginning; it does not prophesy a state of perpetual persecution, but ministers in a circumstance of particular tribula- tion hence Revelation , 3; , The early beleaguered, confused, and tempted Chris- tians had to understand that though the kingdom of Almighty God was indeed present e.

Revelation is steeling first century Christians for their very real trials, encouraging them to endurance as a form of earthly victory which leads to heavenly glory. Endurance is constant in the experiences of life. As I noted above I. Persecution is not the only arena for victory.

Certainly her vic- torious perseverance is more obvious in the crucible of oppression, but it is not the more remarkable, for defeat lurks in every corner of life. Such an understanding of victory-through-suffering- apart-from-persecution leaves the door open for postmillennialism, when the fires of persecution cf. Endurance is overstated in the discussion of eschatology. As glorious and necessary a factor of vic- tory as is perseverance through persecution, the troubling fact is: amillennialists are prone to overstate.

Do we not have victory when safely beyond the raging fires of per- secution? Are any American church communities living victoriously, though free from the lash of the persecutor? Was it not a shameful failure for them to fall into sin, irrespective of the crush of oppression I Corinthians ? But it certainly is not true that the biblical message of suffering and persever- ance contradicts the postmillennial hope. Postmillennialists whole- heartedly agree that the faithful church weathering the storms of persecution is victorious.

Postmillennialists unashamedly confess the reality that our state prior to the resurrection is one of suffering. Barker and W. Robert Godfrey, eds. Robert B. Hereinafter I will simply cite their last names with page references for documentation. See my chap- ter elsewhere in the present book. I was relieved to see that R. Fowler White does not bring such charges against postmillennialists see note 5 in his article.

World Tyler, Tex. As a postmillennialist I frequently find myself in agony over the widespread misinterpretations of my eschatological system. Gaffin and I recently engaged in a public, formal debate in Elkton, Maryland April 26, The video of the debate is available from me at www. But in employing the suffering argument as they do, amillennialists are re- ferring to persecutional suffering. Nor should it suggest my blindness to the genuine suffering of Christians in many places in the world still today.

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