Swine Flu

Over-hyped? Justifyingly frightened? What should we make of it?

So far just a handful of cases apart from in Mexico, where the death rate is about 7% of those known to have been infected. Outside Mexico the illness has been pretty mild.

Influenza A is an unpleasant illness causing fever, headache, sweats, debility, backache, and features of a head cold. In the worst cases pneumonia develops and this can be either viral or a secondary bacterial. Deaths are pretty rare but they do occur. Historically, everyone fears another 'Spanish Flu' which killed many millions after the first world war.

Every year the common type of flu changes slightly so that a new vaccine is produced to give protection to the most vulnerable. Every dozen years there is a major change which results in a type of flu spreading around the world. I have had Asian flu in 1957, Hong Kong flu in 1968, and Russian flu in 1979. I spent 4 days in bed on each occasion and was so ill that there was no confusing it with a cold. For the past 30 years I have never had flu.

It appears that the new strain coming out of Mexico is so different from what went before that most people have no immunity, and therefore it will spread rapidly throughout the world. What seems strange so far is that it seems very virulent in Mexico and quite mild outside that country. However, we don't have enough information yet to make a judgement on how dangerous it is going to be.

It should be assumed that many people exposed to flu will suffer no symptoms, so the number infected in Mexico may be many more than the number tested positive. The deaths will be the same so the death rate is probably much less than 7%. The fact that only mild cases have been seen outside Mexico tells us nothing yet. If, say, only <1% of cases are fatal, we would have to have many more cases before our first death. Since all contacts are being tested we will get a poor picture of what is really going on. Many of these cases will be subclinical so the true incidence of flu will be difficult to estimate.

There is some evidence that it is the immune response that is lethal, so those with poor immune systems may be better off, but I would not want to rely on this.

What can one do? Obviously, avoiding crowded places, not traveling and avoiding anyone with an infection is wise advice, but I would not regard this as essential at the present. Wearing a mask works for about 30 minutes, but after that the mask becomes soggier enough to fail to protect. Most infection is cause by hand to hand contact so avoiding shaking hands is good advice. Wearing a mask may prevent you transferring flu from hand to face, but it should anyway be a discipline for people with poor immunity. The new strain seems susceptible to Tamiflu, so you should get hold of a supply if you think you have been exposed. there is plenty available to cover those who really are infected, but don't panic buy.

How to do church III - our leaders: priests.

Popes, Cardinals, Archbishops, Archimandrites, Bishops, Monsignors, Priests, Abbots, Abesses, Overseers, Elders, Presbyters, Canons, Deans, Deacons, Archdeacons, Pastors, Major-Generals, Over-Shepherds, Under-Shepherds, Monks, Friars, Brothers, Fathers, Mother-Superiors, Churchwardens, Vergers, Sacrestans, Reverends, Right-Reverends, Very-Reverends, Apostles, Patriarchs, Catholicoi, Primates, Vicars, Parsons, Padres, Sky-Pilots, Rectors, Suffragans, Chorbishops, Superintendents, Ministers, Teaching Elders, Territorial Commanders, Curates, Metropolitans, Moderators, Clerics, Prebendaries, Protodeacons, Hieromonks and Hierodeacons.

I have been amusing myself by trying to think up as many names for different clergy in the Christian Church. I expect my readers will be able to think of others. Leadership is important. There is only one leader of the Christian church and that is Jesus Christ. He is the Head of the Church, but He has called and appointed sub-leaders who have a local role in serving the church. As far as I can see there are only four terms that are used in the New Testament to describe those in leadership roles.

The first is 'Priest', the translation of the Greek word, hiereus. It refers to exclusively to priests who offer sacrifice, such as the priesthood of the Jewish Temple, or the priests of pagan gods. In Christian terms it refers only to Jesus Christ, as is made clear in the Letter to the Hebrews. It distinguishes between Jesus, a priest in the order of Melchizadek, 'a priest not on the basis of a regulation as to his ancestry (like the Aaronic priests), but on the basis of the power of an indestructable life' (Heb 7:16), and the Jewish priesthood 'appointed to offer both gifts and sacrifices' (Heb 8:3).

The Jewish priesthood had an elaborate system of offerings and sacrifices which are laid out in the first five books of the Bible. They were all from the tribe of Levi which is what is referred to in the Hebrews 7 passage ('not on the basis of ancestry'). But what they did was 'a copy and shadow of what is in heaven' (Heb 8:5), 'but the ministry Jesus has received is superior to theirs' (v6). The first Mosaic covenant (= agreement between God and man) which began with the passover and was extended through centuries of animal sacrifices was replaced. 'If there had been nothing wrong with that first covenant, no place would have been sought for another. But God found fault' (v7-8) and established a new covenant. 'By calling this covenant "new" he has made the first one obsolete' (v 13)

The old covenant relied on the regular sacrifice of animals - harking back to the animal sacrifice at the time of the Passover when the blood of a lamb smeared on the lintel was accepted as a 'substitute' for the first-born who was otherwise killed. 'Day after day every priest stands and performs his religious duties; again and again he offers the same sacrifices which can never take away sins' (Hen 10:11) but this new type of priest 'offered for all time one sacrifice for sins and sat down at the right hand of God' (v 12) his task completed. 'It is impossible for the blood of bulls and goats to take away sins' (Heb 10:4) but 'Christ is the mediator of a new covenant that those who are called may receive the promised eternal inheritance now that he has died as a ransom to set them free from the sins committed under the first covenant' (Heb 9:15). 'Just as man is destined to die once and after that to face judgement, so Christ was sacrificed once to take away the sins of many people' (Heb 9:27-28)

Therefore, the responsibility of a priest, to represent the people to God, to act as a mediator with sacrifices necessary to approach his holy presence, is obsolete. We have a great High Priest, even Jesus Christ out Lord, who sits at the right hand of the Most High, ever making intercession for us.

For any earthly priest (and I don't take exception to the name, merely the function) to presume to be that sort of priest is a rejection of the gospel. To talk about the communion service as if it were a re-enactment of the sacrifice of the cross, even for it having a similar efficacy seems to me something close to blasphemy. Sure it is a reminder of what Christ has done for us, and we ought always to be reminded, but the point of the cross is that it was a once and for all sacrifice. No more is required.

It was Martin Luther who rediscovered the priesthood of all believers. From I Timothy 2:5 we have "For there is one God and one mediator between God and men, the man Christ Jesus, who gave himself as a ransom for all men." and from I Peter 2:5: "You also, like living stones, are being built into a spiritual house to be a holy priesthood, offering spiritual sacrifices acceptable to God through Jesus Christ". and verse 9 "You are a chosen people. You are royal priests, a holy nation, God’s very own possession. As a result, you can show others the goodness of God, for he called you out of the darkness into his wonderful light".

We are all priests in that we have access to God through Jesus Christ, and we need no secondary mediator be it a dead saint, or Mary or some earthy priest.

Some churches retain the word 'priest', saying it is merely a translation of 'presbyteros'. There may be some etymological justification for this, but the argument is specious. Presbyteros means 'elder' (in medicine we have 'presbyopia' the condition that requires to need reading glasses as we get older). It will write about elders on another occasion.

Bad weekend

It has been a very poor weekend. I slept for most of yesterday and this morning I have had postural hypotension. I think I must try and persuade the docs that I don't need the large dose of steroids as part of the anti-emetic regimen. It causes such adverse fluid shifts that my metabolism is awry. Clearly, it was a good decision not to come to Niagara Falls, even though I did not know how it would turn out at the time. It was one of those decisions that I had no peace over. Interestingly, I was also invited to Athens, and that would have been a mistake, too.

I understand that Niagara went well, and I am very pleased about that.

I wanted to say something about marriage. My daughter is to be wed in October. I doubt that many men really understand how different women are from us. It is not just a matter of reverse parking or talking on the telephone for hours as it says in South Pacific. I first met my wife nearly 50 years ago and it is only now I begin to understand how blessed I have been with her. One tip for all intending to marry: Listen to her.

The centrality of the cross

Selina Hastings had a saying, "I thank God for the letter 'M'". She was referring to a passage in Paul's first letter to the Corinthians 1:26. "Brothers think of what you were when you were called. Not many of you were wise by human standards; not many were influential; not many were of noble birth."

For Selina Hastings was the daughter of the 2nd Earl of Ferrers (you were wondering where Jane Austen got the name from) and became the Countess of Huntington. Without the letter 'M' it would have read, "Not any were of noble birth." She was a great lady, the link between George Whitefield and the Methodists and the Clapham sect of evangelicals such as Wilberforce.

Paul was preaching on the futility of human endeavor and the centrality of the Cross. No-one should boast, he says (v29) unless he boast of the Lord, quoting Jeremiah 29:23-4. Despite this, Paul was rather given to boasting. In Philippians chapter 3 he boasts of his qualifications - his circumcision, his law-keeping, his zeal and his Jewishness; and in 2 Corinthians 11 he boasts of his sufferings. But in verse 30 of this chapter he comes back, "If I must boast I will boast of the things that show my weakness."

Forgive me then if I indulge in a little boasting - it is intended to show the futility of what the world chases after and the centrality of the cross.

Ask a child what he or she wants to be when they grow up and they often answer, "Famous". I have been famous. Not just as a hematologist, but locally I have even had a street named after me. Often they want to be on television. I have been on TV. I can't remember how many times, but enough not to care whether I am ever on again. Money? I have more than enough.

Hear what some of the ancients thought:

What is fame? An empty bubble.
Gold? A transient shining trouble.

Fame is a food that dead men eat –
I have no stomach for such meat.

Love of fame is the last thing that even learned men can bear to be parted from.

Young doctors long to be published. I have had so many papers published that sometimes I see papers ascribed to me that I can't even remember writing until I re-read them. It's no big deal. If I look back on my life, I might not have been born with a silver spoon in my mouth, but somehow I was born with a good brain. I don't reckon much on IQ tests as a measure of worth, but my father told me that when measured my IQ was 168. I was certainly good at passing exams and had a good memory. I went to schools that stretched me and taught me how to regard authority (skeptically). My experience at school gave me the confidence for public speaking and taught me how to write English. I have spoken to audiences of 5000 and write easily.

At University I met a huge range of people so that I now have a wide range of interests. I explored all sorts of philosophies of life from communism, through existentialism to the absurd. They all lead to despair. It seemed that everything the world desired was useless.

I have been wise in the ways of the world, but the ways of the world hold no attraction for me.

I remember sitting at dinner with a very clever colleague who chided me for believing the Bible. But why should I be surprised? To preach Christ crucified is a stumbling block to Jews and foolishness to Gentiles; but to those whom God has called Christ is the power of God and the wisdom of God.

All I have achieved with my life is pointless and worthless compared to this, except perhaps in this way: it is worth telling people to get their priorities right. From my experience I can say that the first priority in life is to get right with God. This is simply a question of believing Him when he says that if we confess our sins He is faithful and just to forgive us our sins and cleanse us from all unrighteousness. Nothing more. No trip to Jerusalem or Mecca, no special ritual, no special prayers, no masses of offerings.

Christ has done it all.

Being a doctor is a wonderful thing; a doctor can perhaps do more good in the world than anyone in any other profession. As a doctor, I have succeeded. My record is outstanding. The youngest attending in Bournemouth, a pioneer of plasma exchange, first to do idiotype vaccination in the world, first to do a blood stem cell transplant in Britain, a pioneer of monoclonal antibody therapy, one of the first in the world to use both Campath and ofatumumab, discoverer of IgVH genes as a prognostic indicator, pioneer in the UK of adjuvant treatment for solid tumors and one of the few holders of the Binet-Rai medal.

Not only that, I have served in the church. I ran the children’s Sunday school for 11 years and spent 20 years as deacon and elder in a large church. I gave up countless evenings to run the church well.

I hate to boast, but the thing is that if doing it could crack it, I have done it. Do you think that you could do ore than I?

But doing it can’t crack it. No matter how much I try I am incapable of meeting the pass mark. I need rescuing.

This morning I had an attack of postural hypotension. I was lying flat on the bathroom floor. I could not stand up. I knew how to stand up. I knew that I had to stand at the wash basin and shave, but every time I raised my head I fainted. Eventually, I had to admit that I couldn’t do it myself and call my wife. I lay there as she dressed me like a baby and maneuvered me back to bed.

As far as saving ourselves is concerned we are helpless.

That does not mean that we do nothing. We should do all we can, but not in an attempt to save ourselves, but in gratitude to the one who has saved us. For the love of Christ constrains us.

Not so good today

It seems that the day after the chemo ends is a poor day. I can't seem to think much and my concentration span is only about 15 minutes. I suppose some would call it 'chemo-brain'. On the other hand, I am coming down off a large dose of steroids, I only slept for 4 hours last night, I have retained water from the steroids and put on about 4 pounds, and my BP is up to 155/80. So maybe its just tiredness.

I was going to write something about 'The Oxford Murders' starring Elijah Wood and John Hurt, but apart from saying it was an enjoyable puzzle that I watched in 4 stages because of my chemo-brain I can't think of anything interesting. The reviews were mixed, but it was better than that. I think I'll keep it in my collection

The other thing I had in mind to write about was 'Winter in Madrid' by CJ Sampsom who writes the Henry VIII detective stories. I knew very little about the Spanish Civil War, so this was a good introduction and an interesting thriller. Worth a read.

CLL: differential diagnosis part II

B-PLL

B-PLL is a very rare disease and some people think that it doesn’t exist as a single entity. The picture shows what it looks like down the microscope and the definition says there have to be more than 55% prolymphocytes. It is said to be commoner in men and always associated with an enlarged spleen, usually without enlarged lymph nodes, and a very high white count. Immunophenotyping is uncertain. There seems to be confusion as to whether it is CD5 positive or not. In my experience all those cases that were CD5 positive also had the t(11;14) translocation, making them a blastic phase of mantle cell lymphoma. They all had a very bad prognosis. The other cases seem to be a hodge-podge of atypical B cell tumors. But none are transformations from CLL in my experience. I wouldn’t rule out that a transformed CLL with the t(14;19) might appear to be PLL, but I have never seen a case of this very rare tumor do this, and there is some reason to say that this is not really CLL at all.


Marginal zone lymphoma

There are several types of marginal zone lymphoma, but the one that is usually confused with CLL is splenic marginal zone lymphoma, SMZL (sometimes called splenic lymphoma with villous lymphocytes, SLVL). The picture shows why. Little projections are shown coming from the cell surface, particularly at the end where most of the cytoplasm is. However, these don't always show on many blood films and again it is the immunophenotyping that gives it away. SMZL is positive for the B cell markers, CD19, CD20, CD22, bright surface Ig and CD79b, and negative for the CLL markers CD5 and CD23. Of course there are always atypical cases that are weakly CD5 positive and even perhaps weakly CD23 positive, so these can be some confusion. Clinically, the patients have enlarged spleens without enlarged lymph nodes, and they usually have a very indolent disease which can be put into along term remission by splenectomy. Some patients have both CLL and SMZL together (don't ask me why) and careful immunophenotyping can recognise the two separate diseases.


Follicular lymphoma

A large proportion of follicular lymphoma patients have some minor involvement in teh blood. The number of cells seldom reaches the levels seen in CLL, and the disease is much more prominent in lymph nodes. The cells shown here have even less cytoplasm and the nucleus often shows a cleft (they are sometimes called 'baby-buttock cells). Despite the difference in shape to most CLL cells, cells with a cleaved nucleus can be seen in some cases (I had a patient with a very benign CLL whose clefted cells were very prominent throughout her disease). The majority of follicular lymphoma cells have the t(14:18) chromosomal translocation, but this can also be found in a small minority of true CLLs. The best distinction is again the immunophenotyping which shows the same pattern as in marginal zone lymphoma with the addition of positivity for CD10.



Polyclonal B cell lymphocytosis.

This is a very strange condition almost confined to female smokers. It is probably not a malignant condition, but I know of one unpublished case that underwent a Richter-like transformation. On the blood film the characteristic finding is of binucleate cells. Immunophenotyping shows that it is polyclonal with populations of cells staining for kappa and for lambda light chains.

Multiple tumors.

I have already mentioned that sometimes immunophenotyping can recognise two populations of B cells - one from a CLL clone and one from a marginal zone lymphoma clone. Even more frequently, two CLL clones may be detected. This can be picked up on immunophenotyping (especially if one stains with anti-kappa and one with anti-lambda, but sometimes this does not pick it up and one has to resort to immunoglobulin gene sequencing to demonstrate that two different heavy chain genes are being used. Sometimes Richter's transformation occurs in a B cell that was not part often original CLL clone. It is not clear whether this was in an entirely innocent B cells that was attacked by a virus in the immunocompromised patient, or from a minor clone of CLL cells that had not been previously detected.

CLL can occur with other tumors of B cell origin which may cause confusion. Myeloma, Waldenstrom's macroglobulinemia and Hodgkin's disease are well recognised associations.

In conclusion, immunophenotyping is an essential part of the diagnostic work-up, and no-one should be satisfied with a diagnosis of CLL just made by looking down the microscope.

CLL differential diagnosis

The diagnosis of CLL is easy. The cells are very characteristic on the blood film. They have dark staining nuclei that takes up most of the cell with a thin rim of cytoplasm surrounding. Very little nuclear detail can be seen and the cells are about the same side as normal lymphocytes - indeed it can be quite difficult to distinguish the leukemia cells from the normal lymphocytes that we know are there.

I have already written at length about MBL, but it comes into the differential diagnosis. The distinction is made on the B-cell count in the blood. If it equal to or greater than 5000 per microliter it is CLL; if it is less than 5000 per microliter it is MBL, unless there is evidence of lymph node enlargement, when the diagnosis is small lymphocytic lymphoma (SLL). It is easy enough to feel in the neck, armpits (ugh!) and groin (double ugh!) for lymph nodes, but the lymph nodes might be at the back of the tummy unreachable by the hand and only diagnosable by ultrasound or CT. Now MBL is hundreds of times commoner than CLL and you can't do a CT scan on every case of MBL on the remote prospect that it might be SLL, so one would only do this if there were some other reason to suspect SLL, like weight loss, fever, night sweats or severe fatigue.

The definitive diagnosis of CLL is by immunophenotyping. This is done with a flow cytometer which is able to measure how well certain antibodies react with the cells and therefore whether the cells have certain antigens on them.

The most important antigens are: CD19 - which is present on all B cells so it establishes that we are not dealing with a T cell tumor. Don't laugh, some cutaneous T cell tumors and even some T-PLLs can resemble CLL down the microscope and I have been fooled and so have many others.
CD5 - which is present on T cells and surprisingly on two types of B cell tumors: CLL and mantle cell lymphoma? So this is pretty good at separating CLL from most other B cell tumors.
CD23 - which is present on some B cells, but of B cell tumors it is pretty well confined to CLL. Unfortunately, it decays on storage so it isn't very good for going back to stored material that was frozen down before we knew about CD23.
Surface Ig - which is present on all B cells but strangely on CLL cells there is only about 10% of the normal amount. This is very helpful in distinguishing between CLL and mantle cell lymphoma where the surface Ig is if anything more than normal.
CD79a - this is one of the accessory molecules that attaches itself to surface Ig and forms part of the B cell receptor. Like surface Ig it is usually at a very low level on the surface and sometimes cannot be detected at all. This is quite unlike the situation in other B cell lymphomas, and especially in the case of mantle cell lymphoma.
CD20 - this is the rituximab target. This is less easy to detect on CLL cells than on other lymphomas, which may be why rituximab works less well in CLL than in other lymphomas. It is probably there all right, but we think that the lipid conformation of the cell membrane hides it.
FMC7 - this is part of the CD20 molecule and it is the part that is hidden in CLL so CLL cells are usually negative or very weak for FMC7.

Atypical CLL


This was originally a diagnosis made on the blood film. You can see from this picture that there are some larger cells with more cytoplasm here and that they have a pale circle in the nucleus (called a nucleolus). These are prolymphocytes. when there are a lot of these (over 15%) or a lot of other cells with notches in their nuclei (sometimes called baby bottom cells) the diagnosis was called atypical CLL. Nowadays, the term is usually applied if the flow cytometry result is not really typical. The surface Ig and CD79a might be a bit more obvious than usual or CD20 might be brighter and FMC7 moderately strong. CD5 might be a bit weak and sometimes CD22 comes up even though it is usually negative.

Atypical CLL is usually just CLL with slightly atypical markers. Often the reason is that the chromosomal pattern is trisomy 12 or del 11q. In these the prognosis belongs to the chromosomes. The most atypical patterns are seen with the very rare t(14;19) translocations.

CLL/PLL is another form of CLL but one that is much understood. The second picture shows what it looks like - so it is a kind of atypical CLL. In CLL you are allowed to have up to 15% prolymphocytes present. If there are between 15% and 55% then the diagnosis is CLL/PLL. More than 55% means a diagnosis of B-PLL (B-cell prolymphocytic leukemia)

Many people think that finding CLL/PLL means that the CLL is turning into PLL. This simply is not so. CLL never turns into PLL. So what does it mean if you find CLL/PLL? Contrary to the common perception, in the original study of 55 cases of CLL/PLL that defined the condition, half showed a stable picture without a progressive increase in prolymphocytes. The prognosis of this group was similar to that of stable CLL without prolymphocytes. In one third of cases the increase in prolymphocytes was unsustained and probably represented a reaction to an infection or vaccination. In only 18% was there a definite progression towards a more malignant phase of the disease. It is this last 18% in which the term 'prolymphocytoid' (not 'prolymphocytic') transformation can be applied. It is often associated with the acquisition of a malign chromosomal change like del 11q or del 17p.

Mantle cell lymphoma

This is a much more malignant disease than CLL and in this picture the cells look quite different. It is the other B-cell tumor that is CD5 positive, but the other markers are quite different and it has some special features of its own. It virtually always carries the chromosomal translocation t(11;14) which engineers the appearance of the protein cyclin D1 in the cell nucleus. About 80% of mantle cell lymphomas have tumor cells in the bone marrow and these often appear in the blood. Mantle cell lymphoma is a great mimic and the cells can look like CLL cells of PLL cells or even marginal zone lymphoma in the spleen. It is always important to investigate cases with atypical markers to se if they might not be mantle cell lymphoma cells. Interestingly some of the cases that resemble CLL are very indolent and may behave more like CLL than mantle cell lymphoma.

This is already a very long blog, so I will finish it off in a second post later today or tomorrow.

Budget

This from Seablogger

I’m reminded of a story I heard about one way the mob does business…they find a small businessman and “persuade” him to take a member as a “minority partner.” The partner proceeds to withdraw funds from the bank account, buy (and steal) inventory on credit, and generally loot the business, eventually leaving the proprietor with a bankrupted business and destroyed personal credit and reputation. Having pushed the limit on legitimate borrowing, is the US Government now using guile to loot the private savings and investments of even non-US investors?

Today Alistair Darling presents his UK budget for 2009/10. It comes the day after a warning from the IMF that the UK will have the hardest climb out of recession of any Western economy and the day after the retail price index went negative for the first time in 45 years.

It is hard to know how to interpret the financial position of the country. In one respect this is just another 'bubble' that has burst. In contrast to most of Europe, Britain has been a householding democracy. We showed our faith in the country by buying a bit of it. I noticed something was up when I took out buildings insurance on my house. The rebuild costs were far less than the market value of the house. Obviously someone was putting a high value on the land.

I wrote yesterday about £8 million houses in Sandbanks (pictured above). This is apparently the site of the fourth most expensive real estate in the world. England (as opposed to the UK) is the most densely populated country in Europe. Not only does everyone expect to own their own house, but a constant stream of immigrants form Eastern Europe, Iraq, Afghanistan, Somalia, India and Pakistan wants to own one to. Fine large houses from the twentieth century were being torn down and turned into one bedroom apartments. There was a lot of money to be made. Typically, a £400,000 house was demolished and an apartment block rebuilt at a building cost of £300,000. It would contain 14 apartments which retailed at £150,000 each. Do the sums. Who wouldn't want a piece of that? The banks offered 100% mortgages at 2% starting interest to rise to standard interest rates after 3 years. It looked like a good investment. You could get on the housing ladder, house prices could only rise, your salary would rise and in three years you could afford the higher interest rate and if you couldn't you could shop around for another fix.

The word 'fix' is a giveaway. It had become an addiction. the rising price of housing was a drug. People were bankrupting themselves to get a part of it. Legislation allowed the addicts to put their pension funds into housing. The elderly gave their life savings to their children to buy into the housing bubble. Unscrupulous bankers lent money to people who had no income. You can't buy a house on benefits no matter how generous they seem.

A secondary market in bad debts arose and there were plenty of suckers to buy them. The banks had a fail safe position. Nobody could contemplate bank failures - they remembered the great depression. Only the government could save the banks. The government has unlimited money. Wait a minute! The government has no money. It has a means of confiscating other people's money by taxation or by inflation or by devaluation of the currency.

People are not stupid. They may be short term stupid. Some of them are long term stupid. But you can't fool all of the people all of the time. I believe Bob Dylan said that(!) Harold Wilson, prime minister in the sixties and seventies, famously lied to us, "The pound in your pocket is not worth less." The pound has been devalued against the Euro and the dollar by about 25%. Now's the time to holiday in the UK.

It is predicted that the Budget will raise taxes and cut public spending. If that meant smaller government I would be all for it but it will probably mean cutting services and the services it will cut will not be the ones precious to the socialist heart.

Pensions will be hit since that will not really be felt for many years. The motorist will bear the brunt because it fits with the government's 'green' agenda. Speed limits will be reduced to save 'greenhouse gases'. There is no point in the government currying favor with the electorate even though an election is only 12 months away, since they are 19% behind in the opinion polls following the scurrilous e-mail scandal. They are now working towards the next election in 2015, trying to leave as big a mess as possible for the Tories to clean up. So the middle classes will be hit with tax rises.

That's one side of the argument. The conclusion is that the government should keep its nose out of business; it should let the market do its job. There were plenty of banks that did not buy into this reckless business model. If banks had failed depositors could have been protected (were protected up to a £50,000 maximum, and the warnings were there that investors should not have all their eggs in one basket) and these banks would have replaced the ones that failed. Some retailers like FW Woolworths in the UK have failed but, in truth, it was a shop that had lost its way and it deserved to fail. It lived on its history, but had nothing worthwhile to sell. Other retailers will move into its premesis and snap up its employees.

The Christian side of this argument says that Haggai (1:4-6) said it all "Is it a time for you yourselves to be living in your paneled houses, while this house remains a ruin? Now this is what the LORD Almighty says: "Give careful thought to your ways. You have planted much, but have harvested little. You eat, but never have enough. You drink, but never have your fill. You put on clothes, but are not warm. You earn wages, only to put them in a purse with holes in it."

The House of God in the UK remains a ruin. I'm not talking about run down church buildings. The church is the people, and the people have had their fill of hedonism. Now is the time to seek sounder values.

The other side of the argument says that it is all about confidence. When I was 17 I was a keen but not very skillful footballer. I played center back for the 2nd eleven. The school was divided into four houses, two named after bishops (Beaufort and Wykham - spelled without the 'e') and two after Victorian novelists (Dickens and Kingsley). I was in Kingsley house together with a few other intellectuals and physical weaklings. Seizing my chance, I stood for Sports captain (we had no members of the 1st eleven at either football or cricket nor the 1st fifteen at Rugby. Our hero was a 4 minute 20 second miler who had left school six years previously). I was not elected; instead they chose a red-haired skinny boy who had transferred from the Catholic school at 16 and as a consequence nothing bad was known about him.

The house football championship was a disaster. We were on the end of drubbings from Wykham and Beaufort and had to face Dickens who had the captain of the 1st eleven and several other stars in their team. To make up a team we had recruited 14 and 15 year-olds and some bookish types who played in spectacles. Predictably, at half time playing down the slope and with the wind at our backs we were losing 3-0.

I don't remember what I said at half-time. Something about the other side not being Supermen. Something about how they would be complacent with such a large lead. Something about believing in ourselves. Something about a good little one beating a slow and over-confident big one. Something about opportunities. I only know that somehow the team played the second half with confidence. They played for each other. They remembered what they could do and forgot what they couldn't. We scored 5 goals in the second half, uphill and against the wind. The following week I was picked for the 1st eleven.

It was all fake, of course; we weren't a better football team than Dickens, any more that Bournemouth were a better football team than Manchester United when they knocked them out of the FA Cup in the 1980s. It is all about confidence.

This was how we escaped from the great depression. In Germany in the 1920s the currency was so devalued that you needed a wheelbarrow to carry home your wages in banknotes, and if you were robbed on the way home they would steal the wheelbarrow. Hitler restored confidence with oratory and military adventures. He got the German people believing in themselves after the calamitous defeat of the Great War and the punitive reparations of Versailles. He picked on a common enemy - the Jews - and united the people. In the States Roosevelt restored confidence in America, first by public works (which were not universally popular) but most importantly by the wartime expenditure. He created the Military-Industrial Complex which survived the Second World War by choosing another common enemy, communism. After Reagan there was no peace dividend. New enemies were discovered, Militant Islam and Greenhouse Gases.

Keynesian economics bought into this idea of confidence. Someone has to have it. Banks have to be confident enough to lend; industrialists have to be confident enough to borrow to invest and employ, consumers have to be confident enough to buy, retailers have to be confident enough to expand, consumers have to be confident enough to invest and so the cycle rotates. When everyone's confidence fails, government has to supply the fake confidence. It helps to have a great orator. Hitler, Churchill, Clinton and Blair all had that ability - so does Obama (in that respect Bush and Brown are and were disasters). They also need a compliant media and the blogosphere is a threat to that. We are not being surreptitiously fed propaganda by 'government sources'; we have to think for ourselves.

The Christian response to this side of the argument is that the real sufferers from the recession are the poor in Africa and Asia who have stopped growing food for home consumption and instead have been producing flowers for the rich man's wife, kiwi fruits for his low-calorie breakfast and fair trade coffee for his sore conscience. The rich man has been salving his conscience by cutting down on air freight greenhouse gases and tightening his belt because charity begins at home. And didn't Jesus say something about the poor being always with you. So the left-leaning Christian says spend, spend, spend, but direct your spending to the poor and needy.

As I said at the beginning of this lengthy piece I am ambivalent about what to do. In truth, I have been little affected by the recession. I have always thought that the inflated price put on my house was a joke. I paid £25,000 for it, which today wouldn't even buy a beach hut. For a while I seemed to be a paper dollar millionaire, though without a millionaire's life style. I have never spent all my income, and although my investments have gone down through the stock exchange fall, they are still probably worth more than I paid for them. My pension is large enough for me not to worry about money ever again. I don't believe that the left hand should know what the right hand is doing with donations so I will say nothing about this. Construe that as you will.

I am concerned about my grandchildren, but they all seem to be talented and they should make their way in the world, but Mr Darling's budget may well affect them. I would like to trust that he knows what he is doing, but the middle verse in the whole Bible (Psalm 118:8) says "It is better to take refuge in the LORD than to trust in man." (even a darling man). Incidentally, for those who like coincidences, 1188 is exactly the number of chapters in the Bible.

Course 2

The first day of my second round of chemotherapy. Already I have the cold-induced pins and needles. At dinner tonight I had to run the cutlery under the hot tap or eat with gloves on. I couldn't manage my apple juice - it made my tongue go numb.

I spend the two hours of the infusion listening to downloaded radio programs on my iPod, but I still have a backlog of over 40 programs to listen to. I kept getting interrupted as former colleagues came visiting.

This morning the surgeon I first worked for as an intern came to visit. He is about 78 now and has problems with angina and diabetes. We had an hour of happy reminiscing.

Blogging is difficult under the influence of dexamethasone so I'm off to watch the Liverpool v Arsenal match on the TV.

Later: just the match to watch on Dexamethasone. 8 goals and a 4-4 tie. Liverpool's title shot looks gone. If they win their remaining 5 matches, Manchester United will have to lose two of their remaining seven for Liverpool to triumph and even then they will have to outscore United. Stll United have still to play Arsenal and both play the open attacking football that leads to high scoring results. The also have to play Arsenal twice in the European Cup so they will be very familiar with their game.

Getting Stronger

Today I had my pre-chemo check-up for my second round which begins tomorrow. I am six weeks out from surgery and everything is going well. The side effects were tolerable - a little constipation, a little diarrhea, a little cold-induced pins and needles, some small mouth ulcers. If it gets no worse than that I shall consider myself blessed. Of course, I was not ill before all this started and I am not quite as well as before the operation, but I am back to 95%.

I have been able to drive, to mow the lawn and do a little weeding and today I went for a walk. Living on the coast as we do we have always enjoyed trips to the beach (10 minutes away) though, in truth, we have not taken as much advantage of our proximity as we might have. Work has always seemed too demanding. Today we decided to explore somewhere we have never been.

Bournemouth occupies the eastern side of south-facing Poole Bay. Today we decided to explore the far-western edge of the bay. The bay extends for seven miles and the beach is sandy all the way (unlike that of our rival, Brighton, which is stony). At the far eastern end is Hengistbury Head, a Roman hill fort, which is wonderfully windy and great for flying kites. As one moves westward the sandstone cliffs climb to about 70 feet above the beach. The beach can be reached by a series of zig-zag footpaths or by the cliff lifts, for those who can't manage the climb.

There are also a series of chines. These are small streams that have carved steep-sided valleys that also form walks down to the beach. The largest of these is the Bourne stream itself which is only about five feet wide and inches deep. It runs through the center of Bournemouth through a series of beautiful gardens, beginning at Coy Pond, about a mile or two inland.

About halfway round the bay, Bournemouth merges into Poole. There is great rivalry between the two. Bournemouth is relatively recently established in 1812 (even younger than America) whereas Poole has been a settlement for 2500 years. Poole is also the home of the Bournemouth Symphony Orchestra and the main campus of Bournemouth University. However, Poole has a population of 138,000 and Bournemouth is larger with 168,000. The whole conurbation is just short of half a million and is known as the Bournemouth urban area.

Anyway, we explored the Poole end for a change, something we haven't done in the 37 years we have lived in this area. The beach is wider down there and the sand finer so that walking on the beach for an hour tested the healing of my abdominal wound. The houses that abut the beach are among the most expensive in the world. You could easily pay £8 million for one, even in the recession. Finally we reached the end of the beach and the mouth of Poole harbor. A chain ferry operates across the mouth of the harbor, taking cars and passengers across to Shell Bay, but we turned back to walk alongside the harbor, a vast expanse of a playground for sailing dinghies, windsurfers and gin palaces.

Immediately ahead of us was Brownsea Island, one of the last habitats for the native red squirrel, but we must leave a trip there for when I have more energy. It was a balmy day with hazy sunshine and by the time we returned to the car I was quite warm. Back home I found an interesting TV program available on the net. It was called The Narnia Code and dealt with a new CS Lewis discovery. Watch it if you can.

I re-start treatment at 2pm tomorrow.

One church or many?

In my last post on how to do church I stressed that New Testament writers always used the Greek word ekklesia to mean a local church rather than the universal church. I have been challenged on that, so here is the article from the New Bible Dictionary (IVP) that I was quoting from:

"Although we often speak of these congregations collectively as the New Testament Church or the Early Church, no New Testament writer uses ekklesia in this collective way. An ekklesia was a meeting or assembly. Its commonest use was for the public assembly of citizens duly summoned, which was a feature of all the cities outside Judea where the gospel was planted (eg Acts 19:39). Ekklesia was also used among the Jews (LXX) for the 'congregation of Israel' which was constituted at Sinai and assembled before the LORD at annual feasts in the persons of its representative males (Acts 7:38). Whether the Christian use of ekklesia was first adopted from Gentile or Jewish usages, it certainly implied 'meting' rather than 'organization' or 'society'. Locality was essential to its character. The local ekklesia was not thought of as part of some world wide ekklesia, which would have been a contradiction in terms. The reference in the best texts of Acts 9:31 to the church 'throughout all Judea and Galilee and Samaria' is not an exception. Since this verse concludes the pericope (that's a technical term for a short passage of Scripture read in public worship so why they don't use 'passage' is beyond me; obfuscation for the sake of it) describing the scattering of the Jerusalem church (Acts 8:1) it seems right to take ekklesia here to be the Jerusalem church so spread as to occupy the territory of 'the ancient ekklesia which had its home in the whole land of Israel' (the quote is from Hort: The Christian Ekklesia)".

"While there might be as many churches as there are cities or even households, yet the New Testament recognized only one ekklesia without finding it necessary to explain the relationship between the one and the many. The one was not an amalgamation or a federation of the many. It was a 'heavenly' reality belonging not to the form of this world but to the realm of resurrection glory where Christ is exulted at the right hand of God. (Eph 1:20-23, Heb 2:12 and 12:23) (ie the 'locality' is heaven). Yet since the local ekklesia was gathered together in Christ's name and had Him in its midst it tasted the power of the age to come and was the first fruits of that eschatological ekklesia. So the local church was called 'the church of God which he has purchased with His own blood (Acts 20:28)."

I think that what the author was keen to emphasize was the error of Rome, which talks about one church based in Rome that has branches everywhere. The church is not like Wal-Mart with a headquarters somewhere in Bentonville, Arkansas and branches everywhere. He is stressing the autonomy of the local church against this. He sees our membership of a single universal church as a heavenly truth - an eschatological certainty - which may be realized in a spiritual sense now; we are all part of one body, but does not become a reality until the second coming. As far as I can see, where the reference is not confined to a local church, our membership of one body always relates to our relationship to Christ - who is in fact in heaven. We have a closeness to our brothers and sisters in Christ who are in other localities, but that relationship is through Christ, not in any earthly hierarchy. We relate to our brothers and sisters in Canterbury because we are all adopted into the family of God, not because the Archbishop of Canterbury has a lordship or oversight over all Christians in England.

Revelation: 1 Peter 1:10-12

An old man in the sky with a beard? A sort of electric force? A statue with a lot of arms? A cow? We all see God in our different ways, and what else could you expect?
I was having lunch with the boss of the local radio station. "To my mind, the statement 'God is love' totally sums up the Christian religion," he said, "as long as we love each other we'll all go to heaven."

"Do you love pedophiles?" I asked.

"Be reasonable," he replied.

His idea of love was mere soppiness, a warm cuddly feeling that he felt for his mother and his girlfriend.

Another acquaintance asked me whether Christians believed in reincarnation. Others have told me that Jesus has usurped control of the universe from the Old Testament God of wrath and justice. How are we to know anything about God? There are only two ways; we can either guess or God could reveal himself to us.

You could make an educated guess. That's what philosophers do. Some think that Plato got quite close to the real thing by his educated guess, though others, including myself, would not want to trust Plato's ideas with their lives.

In 1 Peter 1:10-12 the apostle lets us into the secret of exactly how he knows about the salvation of our souls. In a word it is by revelation (v 12).

First it was the prophets (v 10) who revealed the truth. We are apt to think of the prophets as Isaiah, Jeremiah, Ezekiel and the rest, but of course there are prophets in the books of Law, the history books and the books of wisdom literature. When Jesus is talking to the two on the road to Emmaus he explained to them what was written about him in Scripture beginning with Moses and all the prophets. Some of the most important prophesies are from the Psalms (eg Ps 22). We are given a hint here of how the prophets came by their information. They certainly searched with the greatest of care (v 10), but it was the Spirit of Christ within them (ie the Holy Spirit) that was doing the pointing and the predicting (v 11).

Here we have a universal explanation of the inspiration of Scripture. The writing was done by the individual authors: Moses, Samuel, Isaiah and the rest, but the Bible is the Word of God. How can it be both? Because the Spirit is within (predicting and pointing) but the writer is still searching for the right words with the greatest of care.

It is not clear that the prophets knew exactly the significance of what they were writing. However, they did know that they were writing for us, not just for themselves (v 12).

What the prophets were writing about was made clear when the gospel was preached (v 12). The preaching of the gospel was also the work of the Holy Spirit (v 12). So we have it: both the Old and New Testaments written by men inspired by the Holy Spirit.

What else can we need. If you want to know about God go to the book written by God. Both are about Christ who is the image of the invisible God. Begin with Jesus; read the Old Testament through Jesus shaped spectacles.

It is important not to add anything. The Apocrypha is not the inspired word of God. Sure there are some fine things in it, but there are fine things in Charles Dickens - neither is Holy Writ. Don't rely on the Magisterium. The Church Fathers and Popes from Gregory the Great to Rick Warren are just men. Weigh what they say in the light of Scripture.

It is important not to take anything away. A group of Jesus scholars are trying to find the real Jesus. They have been through Mark's gospel and tried to determine which of the sayings are the true sayings of Jesus. Only one story remains after their butchering - the parable of the mustard seed. And only 76% of them agree on that!

However, I do not stress these points to embarrass Catholics or liberals. Evangelicals often add to Scripture. You've heard about the pastor who was disciplined by his Elders for taking the youth group to the swimming pool? Mixed bathing! Or the Preaching Elder who was carpeted for skating across the loch to get to the kirk when the roads had been made impassable by snow. After hearing his defence the other Elders said, "Weeell, as long as ye didna enjoy the skating."

We are apt to take away also. There are passages that we avoid preaching on (I have only ever heard one sermon on Ezekiel). Sadly many churches prefer to sing songs rather than listen to sermons. Eighty minute 'worship' services with five minute homilies have become increasingly common.

The Quakers used to talk of Scripture as 'the outer light'. Sadly, they have come to prefer 'the inner light' which they take to mean the Holy Spirit within yet is often personal whim or prejudice. The Bible instructs us to test the spirit. He can only be tested against Scripture.

What a privilege it is to have the word of God in our hands. WE no longer have to guess.

How should we do church?

Today I want to start an extended series on how we do church. I know I have other series going on like the one on vitamins and the one on explaining CLL to patients, but I have always had the sort of mind that likes to have many balls in the air.

The impetus comes from ‘The Briefing’ this month. It begins: Some years ago an elderly relative visited our church. She was a churchgoer herself – of a rather traditional kind. Afterwards, I asked her whether she had enjoyed church that morning – at which point, she looked straight at me with characteristic bluntness, “This is not a real church”.

I dare say there would be many who visit our church who would say that ours is not a real church. We don’t have a prayer book or liturgy. We don’t use the organ. Most of the hymns were written in the past 30 years. The prayers are extempore. We don’t have communion at every service. We don’t have a common cup. We don’t have vestments. The Pastor is often tie-less and jacketless. But when I look in the Bible I don’t find any of that.

At the time of the early church they did not have church buildings, and although there are little conglomerations of words that may have had liturgical significance, we really don’t know how they were used. It is probably deliberate that we don’t have clear instructions in Scripture on how we should conduct our services. It is such a contrast to the Old Testament where the Israelites were given instructions in the minutest detail. Remember how poor old Uzzah reached out and steadied the ark of God when the oxen stumbled (2 Samuel 6:6-7) and the Lord struck him dead for his irreverent act.

But we are given few instructions on how to worship God under the new covenant. WE are told that God will pour out His Spirit on all people. Our sons and daughters will prophesy, our old men will dream dreams and our young men see visions (Joel 2:28), and that indeed has happened, but specific instructions on how large a church should be, in what order we should do things, whether we should have a long or short or no sermon, how many hymns (if any), what musical instruments we should use (if any), how we should baptize people, who should pray and for how long, what form the communion service should take, and what we should wear are just not given

Scripture is not silent on church, but there is an open-endedness that has led to different denominations doing different things down the ages. I think we should recognize that many of the things that we do are simply human tradition, no doubt based on a Biblical principle, but they represent a church’s response to the cultural problems and conditions of the time, and quite honestly, many of these traditions are quite archaic and alienating from our own culture. The Salvation Army uniform is quaint, redolent with history, and serves to identify its members, but it isn’t exactly cutting edge twenty-first century. I would not dream of adopting it as a norm for any new church I was planting.

So, let’s start. I think that we can all agree that the ‘church’ is nothing to do with either a building or a denomination. It stands for the gathered local community of Christians; all those who have been gathered together to worship him in a particular place. The other sense of the universal church – all those who have ever trusted Jesus to stand in their stead at the judgement seat – both those alive now and those who have gone to glory, does not seem to be a New Testament usage.

Why have a ‘church’? Because it is a community of believers who worship together and help each other to grow closer to our Savior, who are His witness to our generation, and who need each other for mutual encouragement, support and sustenance.

As the weeks go on I will examine some of the things that we do in church and ask whether these are biblical, necessary, culturally relevant and helpful, and whether we could do things better.

Evil crouching near.

They are like a lion hungry for prey, like a great lion crouching in cover.

This verse from Psalm 17 expresses David's great fear of his enemies around him. It reminds me of a line in a Graham Kendrick hymn: 'evil crouching near'.

David's cry like Job's goes up to God, "Why is this happening to me? What have I done to deserve this?"

He can see no reason in it. His prayer "does not rise from deceitful lips," verse 1.

Examine his heart and "you will find nothing," verse 3.

He has kept himself "from the ways of the violent," verse 4.

He has always followed God's path; he's not a backslider, verse 5.

We know this doesn't mean that he is sinless for surely all have sinned and fallen short of the glory of God (Romans 3:23). But just as Job's comforters can find no wickedness in Job to justify his terrible suffering, and just as Paul can declare himself "as for legalistic righteousness; faultless" (Philippians 3:6) without claiming to be sinless, so David here is appealing to the justice of God.

"Am I not your chosen and anointed king? Am I not in a covenantal relationship with you? Am I not the apple of your eye?" (verse 8).

So it is that a Christian who finds himself suffering feels like calling out to God, "Why?"

It's easy to talk about God's will and to say, "That's God's business." Isn't that what the book of Job tells us? Job wanted to confront God and ask him why he had to suffer like that. God grants him an audience but he doesn't give him an answer. Instead, he poses a question, "Where were you when I laid the earth's foundation?" In other words what gives you the right to question how I run my world? You, Job, who don't even know when the mountain goats give birth; would you question my choices? And of course Job acquiesces. "I am unworthy - how can I reply to you?"

Job ends, "I despise myself and repent in dust and ashes."

And yet, and yet - we would not be human if we did not rail against the slings and arrows.

David cries out to God and asks the Lord to vindicate him, to strike down his enemies, to save him from such men. He wants to hide in the shadow of his wings. So we may cry out to God in our pain and suffering. We too are the apple of his eye. He has loved us so much that he gave his one and only son to die for us, that we might not perish but have everlasting life. He has sent his Holy Spirit to dwell within us. He has promised that he will not just forget our sins but will dis-remember them - not just an act of forgetfulness, but a positive action not to hold them against us. He has clothed us in the righteousness of Christ, so that when he looks at us it is as if he saw his beloved son. He has made us heirs - co-heirs with Christ.

Why then does it hurt so much? Why do I have this dreadful diagnosis hanging over me? Why am I being poisoned with chemicals? Why am I laying myself open to infection?

I know all the answers - but I still hurt!

The most famous villanelle in English poetry is by Dylan Thomas. The repeated lines are "Do not go gentle into that dark night." and "Rage, rage against the dying of the light." I quote them with approval. They were written by an alcoholic, womanizing atheist; why should I do so?

Thomas was right to rage against death. It is not part of God's plan but part of the curse that we live under. Christ has defeated death; but we are not yet free of it, that part of our salvation is yet to come. When Jesus approached Jerusalem he wept over the death and destruction he knew was to come. When he stood over the grave of Lazarus he wept, even though he knew he would raise him from death.

Of course, we must all accept death but we enter death acknowledging that it is already a defeated foe, and we don't have to like it; it is still a foe.

For those who have an incurable disease let me give this advice: don't be afraid to hate it. I have spent my life fighting cancer; I won't stop now. One former mentor told me, "It is a disease with no redeeming feature." He was right. When you are given the diagnosis, don't be afraid to weep. Cry out to God as David did, as Job did, even as Jesus did on the cross. If necessary use groans that words cannot express (Romans 8:26).

These are your real feelings. If you think you have to put on a brave face you will alienate yourself from your spouse, who will be feeling wretched and wondering how you can face this with equanimity when he or she is so distraught. Honesty between you will break down.

The psalm ends "And I—in righteousness I will see your face; when I awake, I will be satisfied with seeing your likeness.

That is how it ends.

The Damned United

After success as Tony Blair and David Frost, Michael Sheen can now be seen masquerading as football manager, Brian Clough, in the film, "The Damned United". I haven't seen the film but I have read the book by David Peace.

Brian Clough was a 2nd division footballer and a goal scoring machine. Playing for North-Eastern clubs, Middlesborough and Sunderland, he scored at the rate of nearly a goal a game, but his career ended at 29 with a torn anterior cruciate ligament.

He found his way into football management, first at Hartlepools, the bottom club in the football league, then at Derby County - a midlands no-hoper team that he took the top of the 1st division, then with Brighton, another never-been-there outfit, and then on to Leeds United, the most successful team in Britain for the past 15 years.

Clough's recipe for success was pass, run, play for each other, never argue with officials, never criticise referees, never commit fouls, play football as it should be on the ground. One of his sayings was "If God had meant football to be played in the air, he would have put grass in the clouds."

But Clough didn't believe in God. He didn't believe in luck. He believed in Brian Howard Clough and fair play.

Leeds United played football in a quite different way. They were good, but they were hard. They sought out their opponents weaknesses and played on them. They fouled, they niggled, they feigned injury, they time-wasted, they bullied referees; they cheated. Their long term manager, Don Revie, was a meticulous planner, superstitious, and a whinger. He always had an excuse if thing went wrong. It was never him or his team that erred; it was always bad luck, or a blind referee, or the fans or fixture congestion, or the opposition cheating.

Clough and Revie were diametric opposites. Clough was arrogant, outgoing, conceited, often drunk, emotional, unreliable, brilliantly inspiring and a fast talker. Revie was taciturn,, unsmiling, introverted, tight-lipped, religious (in a superstitious way), punctual, regulated and tongue-tied. They did not get on.

Then there were the owners. In the 1970s football cubs were owned by a Board of Directors - usually self-made working class successes. These men had made their money form scrap metal or haulage, they were butchers or owned a fleet of taxicabs. They were often local politicians for how better to get those lucrative contracts than sitting on the council that awarded them. Local graft was the rule not the exception. The well known and irreverent footballer, Len Shackleton, wrote his own autobiography, rather than have a journalist to write it for him. He had one chapter entitled, "What the average football director knows about football". The chapter consisted of blank pages.

As you might imagine Clough did not get on with directors. He found himself dismissed from Derby County and while settled with lowly Brighton was approached by Leeds United. He broke his contract went to Leeds and told the players there to chuck their trophies and medals in a bin, since they'd only won them by cheating. The players, the fans, the directors, and the old manager all hated him and he hated them. He lasted 44 days before being canned.

5 years later he had taken Nottingham Forest, in the next door town to Derby, to the first division championship and twice to become Champions of Europe.

In 2004 he died of cancer having already had a liver transplant for alcoholic cirrhosis.

The novel is a strange one; a impressionistic fiction based on fact. It offended a lot of people, but was critically acclaimed. If the picture that it paints of football is an accurate one, then it is a horrible world. The footballers are foul-mouthed, heavy smokers, drinkers and lechers. Their on-the-pitch behavior is cynical and fraudulent. At one point in the novel Clough the socialist/atheist opines that there must be a heaven because the world he lives in is surely hell. I'd agree with that.

MBL: what does it mean for you?

The quite different criterion for diagnosing CLL - namely a B lymphocyte count of 5000/mictrolitre will make a big impact on how we see CLL. For a start, 10 years ago I suggested that the average survival for stage A CLL with mutated IgVH genes was 25 years. It is quite clear that some, perhaps many, of these patients would now be reclassified as MBL, so that those that weren't would have a corresponding worse prognosis.

I have just done a rough and ready analysis on 52 patients (34 mutated, 18 unmutated) who had stage 0 disease with an absolute lymphocyte count greater than 15,000/microlitre (who therefore pretty certainly did not have MBL), and the median survival for the mutated cases was 191 months (16 years) and for the unmutated cases 124 months (10 years). The numbers are not sufficient for this to be statistically significant, but I have no doubt that when I do accumulate enough numbers there will be enough. If I censor the deaths unrelated to CLL, then the difference is highly significant with no CLL deaths in the mutated group, while the average survival for the unmutated group stays at 10 years.

Looking at it the other way using stage 0 patients with a lymphocyte count of less than 15,000 per microlitre which will include most of the MBLs, there were 88 mutated and 41 unmutated. The average survival for the mutated group is 254 months (26 years) and for the unmutated group, 115 months (10 years) - again this is highly significant. Censoring deaths unrelated to CLL we have median survivals of 135 months (13 years) for the unmutated group and just 2 late CLL-related deaths in the mutated group.

Another way of examining the dataset is to look at the likelihood of needing treatment for CLL. Here again using my rough and ready calculation, if you have MBL it is far better to be mutated with only 25% needing treatment by 15 years, whereas in the unmutated group the median time to needing treatment is just under 7 years.

One caveat on this analysis: this does not apply to all MBLs. This is a very difficulty analysis to do because it requires MBLs to be picked up off the street and followed prospectively for many years. What I am talking about here are patients who would have been diagnosed as stage 0 CLL under the old criteria, but are now recategorized as MBL under the new criteria.

We don't do God.

I really didn't like her. She was loud-mouthed with foul language; her sexually flagrant behavior on reality TV was offensive to me. She was uneducated and ignorant. She hurled racist insults at other cast members. My best thoughts for her were to ignore her. When she turned out to have terminal cancer, derived from a sexually-transmitted disease, I felt, "Well, what can you expect?"

Yet she had a great public following. She was news, albeit handled by a great publicity machine. You could perhaps find extenuating circumstances; a doctor I know looked after her father, a heroin addict recently discharged from prison and infected with hepatitis C when he came into hospital with his muscles dissolving because he had been lying inert on them for days.

But I found the sermon preached at her funeral when she died. I quote a slightly edited version.

"Reality's a word that's often been linked to her: a star, possibly the greatest star of what we call reality TV. But we know, don't we, that her life was far from free of some of the harsher realities of life. She had her fair share, possibly more than her fair share, of life's hardships. But as we've seen, particularly over the past months, she's inspired so many with her courage in fighting cancer and her dignity in facing death."

"There's one thing we don't expect to find as we come to bury this vibrant 27 year old mother, daughter, wife and friend - HOPE. Even when we're faced with the harsh reality of death, hope is what is offered by the Christian faith, the Christian faith into which she herself was baptised just four weeks ago today. And that hope is not found in the rules or rituals of an ancient religion, but in a living person, Jesus Christ, whose name she wasn't afraid to take on her lips: not as a swear word but as the name of the person she wanted her children to get to know for themselves."

"I know that she liked reading the gospel of Luke in the New Testament; it's the one that highlights God's love for unlikely people. She will have read there how Jesus welcomed those who weren't particularly religious, and how Jesus spent time with people like herself: down to earth people whose lives, like hers, were at times flawed and difficult, but whose lives were precious to God. And she will have read there, in Luke's gospel, of Jesus bringing the hope that we all need. She discovered that turning to Jesus brought comfort and peace for herself and her children. She discovered it late on, but she discovered it in time. Why not discover it for yourselves now?"

"You see, we don't have all the answers to our questions of suffering and pain. But we do have Jesus who shares what we're going through, and who shows infinite compassion and care. We don't have the guarantee of a pain-free life, but we do have Jesus, who can walk with us through illness, grief and anything else life may throw at us. We don't have a way of finally escaping death, but we do have Jesus, who died for us and then defeated death itself at Easter, giving us hope of life beyond the grave. And that life is not just a continuation of what we have now, but a life that is finally free from sickness, from pain, from grief, and from all that spoils our lives and our world here. How true are her words that heaven is a place where sick people go to be made well, because heaven is where we finally meet face to face Jesus, the greatest healer of all, who alone is able to make our broken lives whole."

"Her baptism symbolised that she had made a choice, a choice that we can - that we must - all make: to trust in the Jesus that we find, not only in Luke's gospel, but in the whole of the Bible. I had the privilege last week of being able to see the Bible she read from. She underlined one chapter more fully than any other. It's one of the most momentous passages of the whole Bible. and it's actually in the Old Testament, in a book of the Bible called Isaiah and chapter 53. The words were written 700 years before Jesus, but speak of him and describe exactly what He came to do. They're words that lie at the heart of the Christian faith and describe the events of Good Friday that Christians will remember this coming week. Here are some of the words that she underlined:

All of us were like sheep that were lost,

Each of us going his own way.

But the Lord made the punishment fall on him,

The punishment all of us deserve.

"These words explain that it is possible to be confident about heaven, even though our lives are flawed. You see none of us - not you, not me, not her - can stand before a holy God with lives free from mistakes, from faults, from things that we regret. As these verses that she underlined tell us, we don't have perfect lives. But we do have Jesus, who opened heaven's doors: not for great achievers, not for those who think they are better than others, but for people like her, who simply reach out to Jesus and trust in him, even when all else seems hopeless."

"To me, the fact these verses are underlined means that she understood this incredible good news about Jesus. It means that she has only completed the first chapter of a life that continues in his loving presence. It means that when the last column inches have been written about her unforgettable life, then that in no way is the end of her story."

Alistair Campbell, Tony Blair's spin-doctor famously said, "We don't do God." For the past many years God has ben sidelined from public life. Priests are portrayed on television as wimps or buffoons, the public face of religion is compromising or asinine, or even worse positively scary. The press loves to build people up so as to be able to tear them down. I was encouraged, therefore, this Easter that individuals were prepared to stand up for their faith and not be ashamed.

AN Wilson is an author, journalist, pundit and member of the chattering classes. In yesterday's Daily Mail he, too, came out of the closet. In an article that again I reproduce in a slightly edited version, he says:


"For much of my life, I, too, have been one of those who did not believe. It was in my young manhood that I began to wonder how much of the Easter story I accepted, and in my 30s I lost any religious belief whatsoever. Like many people who lost faith, I felt anger with myself for having been 'conned' by such a story. I began to rail against Christianity, and wrote a book, entitled Jesus, which endeavoured to establish that he had been no more than a messianic prophet who had well and truly failed, and died."

"Why did I, along with so many others, become so dismissive of Christianity?
Like most educated people in Britain and Northern Europe (I was born in 1950), I have grown up in a culture that is overwhelmingly secular and anti-religious. The universities, broadcasters and media generally are not merely non-religious, they are positively anti. To my shame, I believe it was this that made me lose faith and heart in my youth. It felt so uncool to be religious. With the mentality of a child in the playground, I felt at some visceral level that being religious was unsexy, like having spots or wearing specs."

"This playground attitude accounts for much of the attitude towards Christianity that you pick up, say, from the alternative comedians, and the casual light blasphemy of jokes on TV or radio. The vast majority of media pundits and intelligentsia in Britain are unbelievers, many of them quite fervent in their hatred of religion itself. In this world they ignore all the benign aspects of religion and see it purely as a sinister agent of control, especially over women.
One suspects this is how it is viewed in most liberal circles, in university common rooms, at the BBC and, perhaps above all, sadly, by the bishops of the Church of England, who despite their episcopal regalia, nourish few discernible beliefs that could be distinguished from the liberalism of the age."

"For ten or 15 of my middle years, I, too, was one of the mockers. But, as time passed, I found myself going back to church, although at first only as a fellow traveller with the believers, not as one who shared the faith that Jesus had truly risen from the grave. Some time over the past five or six years - I could not tell you exactly when - I found that I had changed."

"My own return to faith has surprised no one more than myself. Why did I return to it? Partially, perhaps it is no more than the confidence I have gained with age.
Rather than being cowed by them, I relish the notion that, by asserting a belief in the risen Christ, I am defying all the liberal clever-clogs on the block: cutting-edge novelists; foul-mouthed, self-satisfied TV presenters and the smug, tieless architects of so much television output. But there is more to it than that. My belief has come about in large measure because of the lives and examples of people I have known - not the famous, not saints, but friends and relations who have lived, and faced death, in the light of the Resurrection story, or in the quiet acceptance that they have a future after they die."

"The Easter story answers their questions about the spiritual aspects of humanity. It changes people's lives because it helps us understand that we, like Jesus, are born as spiritual beings. Every inner prompting of conscience, every glimmering sense of beauty, every response we make to music, every experience we have of love - whether of physical love, sexual love, family love or the love of friends - and every experience of bereavement, reminds us of this fact about ourselves."

"Ah, say the rationalists. But no one can possibly rise again after death, for that is beyond the realm of scientific possibility. And it is true to say that no one can ever prove - nor, indeed, disprove - the existence of an after-life or God, or answer the conundrums of honest doubters (how does a loving God allow an earthquake in Italy?)"

"Easter does not answer such questions by clever-clever logic. Nor is it irrational. On the contrary, it meets our reason and our hearts together, for it addresses the whole person. In the past, I have questioned its veracity and suggested that it should not be taken literally. But the more I read the Easter story, the better it seems to fit and apply to the human condition. That, too, is why I now believe in it. Easter confronts us with a historical event set in time. We are faced with a story of an empty tomb, of a small group of men and women who were at one stage hiding for their lives and at the next were brave enough to face the full judicial persecution of the Roman Empire and proclaim their belief in a risen Christ.
Historians of Roman and Jewish law have argued at length about the details of Jesus's trial - and just how historical the Gospel accounts are."

"Anyone who believes in the truth must heed the fine points that such scholars unearth. But at this distance of time, there is never going to be historical evidence one way or the other that could dissolve or sustain faith. Of course, only hard evidence will satisfy the secularists, but over time and after repeated readings of the story, I've been convinced without it. And in contrast to those ephemeral pundits of today, I have as my companions in belief such Christians as Dostoevsky, T. S. Eliot, Samuel Johnson and all the saints, known and unknown, throughout the ages. When that great saint Thomas More, Chancellor of England, was on trial for his life for daring to defy Henry VIII, one of his prosecutors asked him if it did not worry him that he was standing out against all the bishops of England."

"He replied: 'My lord, for one bishop of your opinion, I have a hundred saints of mine.'"

"Now, I think of that exchange and of his bravery in proclaiming his faith. Our bishops and theologians, frightened as they have been by the pounding of secularist guns, need that kind of bravery more than ever. Sadly, they have all but accepted that only stupid people actually believe in Christianity, and that the few intelligent people left in the churches are there only for the music or believe it all in some symbolic or contorted way which, when examined, turns out not to be belief after all. As a matter of fact, I am sure the opposite is the case and that materialist atheism is not merely an arid creed, but totally irrational.
Materialist atheism says we are just a collection of chemicals. It has no answer whatsoever to the question of how we should be capable of love or heroism or poetry if we are simply animated pieces of meat. The Resurrection, which proclaims that matter and spirit are mysteriously conjoined, is the ultimate key to who we are. It confronts us with an extraordinarily haunting story."

"J. S. Bach believed the story, and set it to music. Most of the greatest writers and thinkers of the past 1,500 years have believed it. But an even stronger argument is the way that Christian faith transforms individual lives - the lives of the men and women with whom you mingle on a daily basis, the man, woman or child next to you in church each Sunday morning."

My final example is Paul Moore. He was a banker, hardly anyone's favorite profession these days. He was head of regulatory affairs at Halifax Bank of Scotland (HBOS). He was a bit of a hero. In 2004 he warned the bank against lending to people with no means of repaying the debt and against the unregulated investment in toxic assets. His protests were brushed aside and the chief financial officer even refused to minute them. Despite this he continued to protest and the CEO eventually dismissed him, replacing him with a man with no experience in banking regulation.

He was devastated. When he phoned his wife she replied, "Perhaps this is all part of God's wider plan for your life."

You see he was a Christian, though not boasting about it, just living quietly and getting on with his life. On suing for unfair dismissal he was offered a large financial settlement and a gagging order. He wrestled with his conscience and, perhaps wrongly, took the money. God is a God of second chances. When the financial crisis broke he was given another opportunity to tell his story. Now, despite the gagging order he told the House of Commons Select Committee the whole truth about why the public needed to spend 28 billion pounds to bail out HBOS, who the culpable executives were and why Sir James Crosby, former CEO of HBOS was no fit person to run the financial services authority (FSA).

This morning on a BBC radio news program, Paul Moore gave his testimony. He told how his faith allowed him to cope with this crisis in his life. He is not a socialist; he believes in capitalism. But he also believes in honesty and telling the truth, a capacity sadly absent from the high echelons of power, whether political or financial.

So this Easter Day I am pleased to report that a TV reality star, member of the chattering classes and a banker have all declared their love of the Lord Jesus. More importantly, Jesus has shown that anyone can be saved.

What to do when you don't feel well.

The last few days have seen me rather below par. I have been tired and had abdominal discomfort, though no real pain. My appetite has been poor and I've lost a few pounds. However, this is nothing like the chemotherapy side effects that I have inflicted on others.

To pass the time I have been reading. I recommend the following:

The Reed Stephens novels. These are written by fantasy writer Stephen Donaldson. Normally he writes epics about Thomas Covenant, Unbeliever, battling with Lord Foul, but between times he throws off a Chandler-esq thriller. It is light entertainment, but fast moving.

The Suspicions of Mr Whicher by Kate Summerscale. This is a non fiction account of a famous 1860 murder at Road Hill House in Wiltshire. A 3-year old was snatched from his bed and found with his throat cut in an outside privee. The first professional detectives from Scotland Yard were called in and quickly solved the case, but could not secure a conviction. Many years later a suspect confessed, but received life imprisonment rather than the gallows.

The story takes in the development of the fictional detective, and involves Wilkie Collins and Charles Dickens. The background social history of Victorian England is fascinating.

I have also watched some movies: two Jack Lemmon films: The Out of Towners and The Front Page and a Douglas Sirk movie, Me and My Gal. Six more Douglas Sirks to watch.

Darkness at Noon.

Are you afraid of the dark? It is a natural fear. Psalm 91:5 tells us that we will not fear the terror of the night, nor the pestilence that stalks in darkness, if we dwell in the shelter of the most high God.

But what are we to make of the darkness that came over the whole land from the sixth hour to the ninth hour of the day of Christ's crucifixion? Some say it was an eclipse of the sun, but Passover is held at the time of the full moon when the moon is in the wrong position to eclipse the sun. Some say it was a merely local phenomenon due to heavy storm clouds, but the Bible says "the sun stopped shining."

The lyrics of the old Spiritual, "Were you there when they crucified my Lord?" go on to ask "Were you there when the sun refused to shine?" and they have been pinched by the likes of Led Zeppelin and Richard Hawley as pop song words. Even so this wasn't a darkness caused by simply a withdrawing of the sun's light in appropriate homage to what was happening on the cross. This was not a passive darkness; it was active and terrifying.

Darkness was one of the Mosaic plagues brought upon Egypt, the last plague before the death of the firstborn. "Stretch out your hand towards the sky so that darkness will spread over Egypt - darkness that can be felt." This is the plague that made Pharaoh declare to Moses, "Get out of my sight! Make sure you do not appear before me again!" as the Egyptian ruler despised his last chance of salvation.

We look forward to the day of the Lord, when Christ shall return bringing with him the glorious dead, when we shall rise and meet him in the air, when the trumpets shall sound and the angels shall sing; but wait! For some it will be terrifying.

Hear what Amos says, "In that day," declares the Sovereign LORD, "I will make the sun go down at noon and darken the earth in broad daylight."

Joel chapter 2 pictures this day as a day of wrath with the Lord at the head of a mighty army of destruction drawn up for battle. "For the day of the LORD is coming. It is close at hand; a day of darkness and gloom, a day of clouds and blackness."

"Before them the earth shakes, the sky trembles, the sun and moon are darkened, and the stars no longer shine." "The day of the LORD is great. It is dreadful. Who can endure it?"

Zephaniah 1:15 describes it as "That day will be a day of wrath, a day of distress and anguish, a day of trouble and ruin, a day of darkness and gloom, a day of clouds and blackness."

I am a fantasy and science fiction fan, partly because I see in many religious overtones - in Tolkien and CS Lewis they are very obvious. Another writer, whose name is more associated with horror, but often writes in much the same genre is Stephen King. The film, "The Green Mile" starring Tom Hanks is adapted from King's book of the same name. In it a huge black man, John Coffey (played by Michael Clarke Duncan) who is unjustly on death row for rapes and murders committed by someone else. Apart from being afraid of the dark, Coffey has a supernatural gift of healing, in which he seems to suck the badness out of the victim. It makes him suffer when he does this and he eventually discharges the evil as a swarm of black flies.

This is of course a picture of Christ, signalled by Coffey's initials, JC.

The darkness at the cross is a picture of the wrath of God being heaped on the tortured Jesus. We are the beneficiaries of this sacrifice. It is not our physical healing, but our spiritual health that is being rectified. We receive his righteousness as he receives our punishment.

When I was teaching Sunday school I used to do a small science experiment. I put an iron nail in a flask of copper sulphate. When you do this, the iron replaces the copper in the solution, forming ferrous sulphate and the red copper is deposited in the surface of the nail. I used to say that this was a picture of substitutionary atonement; the blue sin was removed from the solution by the red 'blood' on the nail.

The equation for the reaction being:
Fe + CuSO4 = Cu + FeSO4

II Corinthians 5:21 puts it better: "God made him who had no sin to be sin for us, so that in him we might become the righteousness of God."

MBL with the characteristics of indolent CLL

We have known for many years that many people (about 6% of the over-60s) have a monoclonal protein in their serum, reminiscent of multiple myeloma, but without any of the malignant features of myeloma, and that about 1% a year of these turn into myeloma. The condition is known as monoclonal gammopathy of undetermined significance (MGUS). So it should not have been a surprise that a similar situation might exist for CLL. Still, nobody was expecting it when Andy Rawstron of Leeds published a paper in 2002 entitled "Monoclonal B lymphocytes with the characteristics of "indolent" chronic lymphocytic leukemia are present in 3.5% of adults with normal blood counts". 3.5% is about 1000 times commoner than CLL!

What they did was examine the dregs in the bottles of blood taken for routine CBCs from 910 outpatients at Leeds over the age of 40. They used 4-color flow cytometry testing for CD19/CD5/CD79b/CD20 expression, which detects the typical immunophenotype of CLL. In a subsequent paper they showed that in people with a family history of CLL there is an even higher prevalence of 13.5%.

There was some scepticism as to whether this really could be how CLL starts, but a subsequent longitudinal study demonstrated that of 185 subjects diagnosed as MBL from patients who presented with a lymphocyte count of greater than 4000 per microlitre, 28% developed progressive lymphocytosis when followed up for a median of 6.9 years (range 0.2- 11.5). There was little risk of progression for those with a B cells count of less than 1900 per microlitre. Of the 51 subjects with progressive lymphocytosis, further evidence of progressive CLL, predominantly lymphadenopathy, developed in 28, and 13 of these 51 subjects eventually required chemotherapy, starting a median of 4 years after the initial diagnosis.

The estimated rate of progression to CLL requiring treatment among subjects MBL presenting with lymphocytosis was 1.1% per year - about the same as those with MGUS progressing to myeloma. There were 62 deaths among the 185, but only 4 were due to CLL. Only age and non-CLL related anemia were prognostic factors, confirmation that these were deaths unrelated to CLL. None of the factors assessed — including age, sex, hemoglobin level, total lymphocyte count, T-cell count, B-cell count, and B-cell CD38 expression — predicted an increased risk of disease progression or the requirement for treatment. Unfortunately, not enough cases had IgVH genes tested to allow this to be evaluated as a prognostic factor. We do know that 87% of patients with MBL have mutated IgVH genes, which goes along with the idea that this is a very benign syndrome.

It even seems that progression from MBL is the usual way that CLL starts. A study from the NCI and Milano had available 77,000 blood samples among whom they found 45 cases of CLL for whom there was a previous blood sample stored. In 44 of these there was evidence of an MBL clone in the earlier specimen. Again most patients had mutated IgVH genes and most commonly used the V3-23 and V4-34 genes that are most commonly seen in mutated CLL.

Of course the vast majority of individuals with MBL will never develop CLL and there will be a few unlucky ones who will develop it despite having a B cell count of less than 1900 per microlitre, but this will be rare. What is clear is that we need to look again at stage A0 CLL and make the distinction between those with MBL and CLL.

First chemotherapy

Chemotherapy comes in all sorts of guises. The sort you get for abdominal cancer is very different from what you get for CLL.

The ‘chlorambucil’ of GI malignancies is 5-fluorouracil. How it works is this: DNA has four bases – adenine, cytosine, guanine and thymidine, RNA is very similar but instead of thymidine it has uracil. The body’s only source of thymidine in to make it from uracil. The idea is to feed the body modified uracil, with a fluorine atom stuck on so that when it is converted to thymidine, the stuck on fluorine prevents the DNA from replicating and therefore the cancer cell cannot divide.

The enzyme that does the conversion is called thymidine synthetase and the co-enzyme for the reaction is folinic acid. The idea is that giving excess folinic acid forces the reaction down this pathway and enhances the effect. Clinical trials have shown that this cheap vitamin greatly improves the performance of the drug.

The second drug is oxaliplatin which is one of a series of platinum compounds discovered when researchers tried passing an electric current through cancer cells in tissue culture. They found that the cancer cells died around the platinum electrodes. One of these drugs was developed by a boy in my class at school when he was doing his PhD. He is now a professor at Princeton. He was always cleverer than I.

This combination has some strange side effects. As well as marrow suppression, which is very common with all chemotherapy it can cause diarrhea and vomiting, but there are medicines to prevent these. The really strange thing is cold induced pins and needles. This means no cold drinks or going to the fridge. Even getting a clean shirt from the drawer can trigger it – put it in the airing cupboard first.

This in fact is the only side effect that I have had – it is disconcerting rather than unpleasant.

The other interesting thing is how the 5-fluorouracil is delivered. It is pumped in at a constant rate over 46 hours by a pump with no moving parts. The drug is contained in a thick walled balloon with a slow puncture, which deflates in exactly 46 hours. Very clever these Americans.

The pump is disconnected tomorrow and restarts in two weeks. The other noticeable change in me is the effect of one of the anti-sickness pills. Dexamethasone is a very strong steroid drug used for all sorts of anti-cancer effects, but also to prevent vomiting. It made me as high as a kite. I didn’t dare blog yesterday when under its full influence. Goodness knows what I said to my pastor when he came to visit, Garrulous isn’t in it.