London

Today was my day at a major London Teaching Hospital. Practically the whole team had decamped to America with management consultants to inspect the transplant set-ups at Dana Farber and the Hutch. So it was rather lonely there.

One particularly difficult case was a patient with ATLL, the strange and intractible T-cell leukemia caused by the HTLV-1 virus. She was Jamacian and an illegal immigrant, but she had been in the UK for 17 years and had a son who was a student in College. The leukemia was in her brain and she has perhaps 6 months to live. She could go home, but she has given up her lodgings since she has been in hospital. Social Services, who have the responsibility of finding the homeless somewhere to live don't want to know. Two adjacent areas each claim that she is the responsibility of the other. My suggestion was to contact the Pastor of her local church and ask them to care for her for her last few months, on the Christian principle of "I was a stranger and you took me in." Failing that I suggested that they contact the MP in whose constituency the hospital is and who also happens to be a Government Minister, and complain that a valuable transplant bed in the biggest marrow transplant center in the UK is being blocked by an illegal immigrant that nobody wants to own.

Another problem was a 59 year old patient with CLL who had been in hospital for nearly a year since his low intensity mini-transplant. His problem was chronic graft versus host disease. He receives phototherapy for his skin GVHD and this is improving but he still has diarrhea and abnormal liver function. On large doses of steroids to control his GVHD his CMV had reactivated and for this he takes gancyclovir. I asked how common was severe GVHD in the mini-transplants. The answer was 15% unless they also need donor lymphocyte infusions, when it rises to 30%.

Apparently the patient looks like Gollum from Lord of the Rings. For light relief, I informed the meeting that Andy Serkis, who plays Gollum, also played Bill Sykes in the BBC's early Oliver Twist and the gorilla in King Kong. "That was before he had his marrow transplant," opined some wag.

I also learned that once you have had Hepatitis B, the virus remains in your liver for life, ready to be awakened by immunosuppression. I caught Hepatitis B from a needle stick injury when I was a Fellow. Another good reason why I don't ever want a bone marrow transplant. Or fludarabine.

For relief from the doom and gloom I picked up this story from the Internet:
A man came across a striking brass rat in an antique store and decided it would look great on his desk. He paid $100 for it but was surprised when the proprietor insisted it was non-returnable. He said, "It's been returned twice already, and I don't want to see it again." Leaving the store, the man saw a couple of rats scurrying around the corner; several more were near his car. As he drove, rats appeared from the gutters and side streets until he was nearly overwhelmed. In panic, he threw the brass rat over a bridge railing into a river, and witnessed the army of live rats follow into the depths. The man hurried back to the store, but the owner cut him short, saying, "Look, I told you there would be no returns." The man quickly replied, " Oh no, that's fine. I was just wondering if you had a brass lawyer."