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.

Getting priorities right

Very early in Jesus' ministry he was enjoying great success as a healer. It started with Simon Peter's mother-in-law. He had come to her house after synagogue where he had cast an evil spirit out of a man. After sunset, when the Sabbath had ended crowds of people appeared bringing their sick for healing. Mark tells us that the whole town had gathered at the door. I guess that had he stuck at it, he could have cured every disease in Galilee. And people would have been prepared to pay - not the poor, of course, he would have done those pro bono - there were plenty of rich people with nasty diseases, just as there are today.

I think of the plastic surgeons who see plainness or flat-chestedness as a disease, the liposuckers and stomach staplers who make a fine living out of other people's excess. It really is possible to make a very good living out of sickness.

The next day as the crowds began to gather Jesus was nowhere to be seen. You see, very early in the morning, while it was still dark, Jesus had got up, left the house and gone to a solitary place to pray. Peter went out to look for him and when he eventually located him I guess he was a bit cross. I wouldn't have been at all surprised if Peter had been going around drumming up business. "You should see the guy who's staying with us. He even healed my wife's mother."

"This is where you are. Everybody's waiting. They're all looking for you."

But Jesus knew his ministry in that place had finished. He said, "Let's go somewhere else. To the villages nearby, for instance. I might get a chance to preach there if all the sick have come to Capernaum. That's what I have come for, you know, to preach, not to heal."

I guess that the most common prayer is for healing. We all know someone who is sick. Whether it is a husband or wife, a mother or father, a son or daughter. Even if its only me. Of course, we want to pray for them, it is right that we should. I guess we would all like a miracle.

Now, miracles do happen; these extraordinary, supernatural events, when the cancer is there one minute and gone the next. But the point is that they are extraordinary. In Jesus's day they had almost become ordinary. Wherever he went he did miracles. Forgive me if I'm wrong, but that is not the case today. Dr Brand the famous surgeon to the lepers of India wrote that in all his long years of practise he had never seen one. In 42 years of practice I have never seen one. Dr May, a Christian GP of Southampton has investigated thousands of supposed healing miracles, but has never been able to substantiate one. We don't have to go as far as saying that miracles don't happen, just that miracles in this age, certainly where they can be tested for scientifically, are very rare indeed.

Why should that be so? Has God stopped caring for his people? In John's gospel miracles are called 'signs' by the author, and that is why there were so many around Jesus. The miracles authenticated Jesus' message, just as the staff turning to a snake was meant to authenticate Moses' message to Pharaoh.

For a while, miracles accompanied the message of the Apostles, again to authenticate that they were speaking with the voice of God, but by the end of the Acts of the Apostles the miracles had begun to peter out.

Jesus has not stopped caring for his people, but all along he has had a different agenda. Preaching not healing was his priority. What did he preach? "The kingdom of God is near. Repent and believe the good news. This message has been authenticated by the resurrection of Jesus and by the words of Scripture.

So continue to pray for me. By all means pray that I may be healed. Pray for my physicians that they make the right decisions. Pray for the nurses that they do their jobs correctly and kindly. Pray that my cancer will respond to the treatment. Pray for the scientists that they may discover more effective treatment. Pray for the pharmaceutical companies that they make the right investment decisions over which drugs will be invested in. Pray for the regulators that they do not hold back the regulation of effective drugs. But most of all pray that I might be useful in spreading the gospel to those who are perishing.

Diagnosing CLL

The diagnosis of CLL is easy, but the criteria for the diagnosis have recently changed. The first thing that is necessary is a raised lymphocyte count. Back in the days when I started in CLL you needed 15,000 lymphocytes per microlitre for the diagnosis. Gradually this was reduced, first to 10,000 and then to 5000. In fact the upper limit of normal for lymphocytes is either 3,500 or 4000, depending on which set of normal values you go by, so we might have suspected CLL even if the lymphocyte count were less than 5000.

The second requirement is the peculiar immunophenotype of CLL. The cells must be positive for CD5, CD19 and CD23, have low levels of surface immunoglobulin and CD79b and be FMC7 negative. There is actually a CLL scoring system that gives 1 point for each of these (except CD19 which is present on all B cells tumors). A score of 4 or 5 is required for the diagnosis of CLL. Very occasionally a true CLL will only score 3, but these really are exceptional cases that require an expert eye over them.

I will say more about this when we talk about the differential diagnosis (that just means answering the question, "If it's not CLL, what else could it be?").

It is also necessary to demonstrate monoclonality. To be accurate, we don't actually demonstrate monoclonality, but instead take advantage of the fact that the immunoglobulin molecules can have one of two possible types of light chains, called kappa or lambda (those are just the Greek letters that stand for 'K' or 'L'). Normal B cell sometimes have kappa light chains and sometimes lambda light chains; usually the ration is 2 kappa for each lambda. Since CLL cells are derived from a single cells, in any individual all the CLL cells have a single light chain, either kappa or lambda.

The thing that has changed has been the threshold count. Instead of 5000 lymphocytes per microlitre, now you must have 5000 B-cells per microlitre. Since many cases of CLL have well in excess of 4000 T-cells per microlitre, this equates to a lymphocyte count of at least 8000 and sometimes as much as 15,000 per microlitre.

This all sounds like a circular route back to 1975. But the reason for the redefinition is clear. I have been saying for some time now that many cases of stage 0 CLL live out a normal life span and never require treatment - to label such patients as having leukemia is unnecessarily frightening. Especially since Andy Rawstron discovered monoclonal B cell lymphocytosis, which I will write about tomorrow.

Realized eschatology

The problem is realized eschatology. When I was a callow youth I rudely asked my landlord, a Church of England vicar, "Are you saved?" He replied, in words not his own and too deep for me at the time, "I have been saved, I am being saved, I will be saved."

In the first chapter of 1 Peter these words are played out. We have been saved. Verse 3 "In his great mercy he has given us new birth into a living hope through the resurrection of Jesus Christ from the dead."

We are being saved. Verse 6-7 "Though now for a little while you may have had to suffer grief in all kinds of trials. These have come so that your faith—of greater worth than gold, which perishes even though refined by fire—may be proved genuine."

We will be saved. Verses 7-9: "When Jesus Christ is revealed. Though you have not seen him, you love him; and even though you do not see him now, you believe in him and are filled with an inexpressible and glorious joy, for you are receiving the goal of your faith, the salvation of your souls."

Some Christians insist that since we have been saved we should enjoy the benefits of heaven now. We should never get ill, we should never have our children go off the rails, our parents should never become demented, we should have a nice house a nice job and live in a nice part of town. Unemployment, bankruptcy, sickness, divorce, cancer and paralysis are not for the Christian, or if they are then they are easily prayed away. Sorry folks, but life ain't like that, and if you think they are you are heading for disappointment. Sure, there are answers to prayer, but often the answer is no, my grace is sufficient for you.

Jesus' promise was that in this world you will have tribulation. Suffering is part of being a christian. In Romans 8:17 Paul writes "Now if we are children, then we are heirs—heirs of God and co-heirs with Christ, if indeed we share in his sufferings in order that we may also share in his glory."

We are tempted when we are hurt to think we have been abandoned by God, or that there is no God, or that we cannot be a real Christian, or that we are not one of the elect. On the contrary, when we suffer it is sure evidence that we are co-heirs with Christ. (Suffering because you have robbed a bank doesn't count - that is called punishment.)

But still we have the promise of glory, where he will wipe all tears from our eyes.

For such a time as this

Esther had won a beauty contest, married a king, and from her position of influence had uncovered a plot to kill all the Jews. She had a mentor, Mordecai, who told her, "You didn't get into this position by accident. Who knows but that you have come to Royal position for such a time as this." (Esther 4:14) And so she had. The task before her was to approach the king (very dangerous in those days) and expose the plot.

I don't suppose that Mr Bates relished having multiple myeloma and he must have been even more disappointed to die from it only six months later. He never even knew what it was all about, but I was sent to take a blood sample from him when he got the diagnosis. He took that opportunity to witness to me and invite me to his church. Perhaps he witnessed to many people, I don't know. He never knew it, but the Sunday after he died I visited his church for the first time and if he had not died I doubt that the preacher would have preached that particular sermon that led to my conversion. I hope Mr Bates was given the good news when he arrived in heaven. He may not have understood but his widow did and so did the members of the prayer group that had been praying about those whom he witnessed to.

When disaster falls upon us we are often perplexed as to why. What have I ever done to deserve this? What sort of God are you to bring this upon me? Is there a God at all? The questions slip easily onto out lips. But we do have a God who cares and his main priority is to save souls from Hell. He is not willing that any should perish, but that all should turn from their wicked ways and live. It is certain that unless the Lord returns we shall all fall sick and die.

The sheriff surrounded by superior weaponry is apt to say, "You may kill me, but I'll certainly take some of you with me."

I'm going to heaven, but I hope to take some of you with me.

CLL is a tumor of ? cells

There are lots of different types of white blood cells and any one of them can turn leukemic. Back in the 1840s Rudolf Virchow didn't know this. Even now looking back we don't know what sort of leukemia his patient had. Actually, Rudolf was the first to describe leukemia. He was beaten to the punch by John Hughes Bennett, an Englishman working in Scotland, who published six weeks before Virchow. We don't know what sort of leukemia his patient had either. It wasn't until Paul Erlich learnt how to stain cells on a blood film that it became possible to distinguish different types of white cells.

The distinction between the two chronic leukemias was easily made, but the acute leukemias still looked very similar and it was many years before they could be distinguished using specially developed stains.

The abnormal cell in CLL is a small round cell containing a round nucleus that occupies most of its bulk, and a thin rim of unremarkable cytoplasm. The nucleus stains a uniform dark blue color with no visible features. Apart from saying it was a small lymphocyte there was not much more to be said, and even as late as the 1950s nobody was sure about what lymphocytes were there for. It gradually emerged that they were part of the immune system and by the 1970s it was clear that there were two major types. All lymphocytes are apparently made in the bone marrow, but many of them need further processing in the thymus, an organ in the front of the chest that is prominent in children but shrinks as a person ages. Such cells are called T-cells. Most of the rest of the lymphocytes need a different type of processing. In chickens this is done in an organ near the cloaca called the Bursa of Fabricius. Consequently, such cells were called B-cells.

Humans and other mammals don't have this organ and a lot of time was spent looking for a 'bursa-equivalent'. In the end they decided that all the processing of B cells takes place in bone marrow, which, luckily, also begins with a 'b'.

As time has gone by we have developed more and more sophisticated means of distinguishing one type of cell from another. The most useful technique involves staining with labelled monoclonal antibodies. This has been given the posh name of immunocytochemistry. The various monoclonal antibody targets have been given numbers preceded by the letters 'CD' which stands for 'clusters of differentiation'. Your probably no better off for knowing that.

CLL cells are B cells, but they have an unusual CD signature. They turn out to stain positively for CD5, CD19 and CD23. All B cells have immunoglobulin molecules on their surface, but CLL cells have only about one tenth of the normal amount. There are two other molecules that CLL cells have less than the normal amounts of: CD20 and CD79b. With such a distinctive signature you'd think it would be easy to find the exact normal cell that CLL is derived from. Unfortunately, there isn't one. At one time many people thought it was equivalent to the B1 cell in the mouse, but that cell lives in the peritoneal cavity of the mouse and there isn't really a human equivalent. Other suggestions have been memory B cells and marginal zone B cells, but in truth the peculiar CLL signature is not the same as that of any other cell that we have discovered.

The lifetime achievement award

It's been one of those Spring days when the sea mist rolls in and the sun is just to weak to disperse it. While the rest of the country has been bathed in sunshine with temperatures reaching as high as 61, here in Bournemouth it has been rather cool. Earlier in the week we had sat in the garden sunning ourselves, watching the birds and admiring the first tulips, but today I wore an anorak on a short trip to the post office. I have felt like the sun; too weak to disperse anything. This is in part a reaction to the Hickman line which left me bruised and aching around the neck and in part a reaction to flucloxacillin given to prevent wound infection. It has given me heartburn. This afternoon I slept for 90 minutes in an armchair.

To catch 153 fish and not break your nets is a lifetime achievement. It has often occurred to me that when you achieve some great feat it must be difficult to produce a follow on. After Bob Beamon's great leap in the Mexico Olympics that beat the World Long Jump record by about 3 feet, what was left for him to do? Steve Redgrave won gold medals in 5 successive Olympic Games in the rowing; from here his life must be all downhill. Did Pete Samprass get bored with winning Grand Slam events? Will Tiger Woods have a life after golf?

When I won the Binet-Rai medal for my work on IgVH genes in CLL it was the summit of my career. I would never produce anything that important again. For me everything would be a downward slope.

So, Peter, your lifetime best catch has been achieved, what do you do next?

The disciple whom Jesus loved (presumably John, though Ben Witherington III thinks it was the risen Lazarus), said to Peter, "It is the Lord."

As soon as Simon Peter heard him say it, he wrapped his outer garment around him and jumped into the water to go to him. He left his lifetime achievement behind and rushed to Jesus.

There is a scene at the end of Schindler's List where Oscar Schindler realises that though he has connived at rescuing over a thousand Jews, he could have done more. He tears off his ring, "That will buy two more," he says in desperation.

At the end of our lives we are all frustrated that we could have done more, but without trying to boast (forgive me if it sounds like boasting) I'm not sure how I could have done more with my life. I could have done it differently - spent more time with my family, avoided certain vanities, given more to the needy and so on, but a life is a whole and what I did in one area was dependent of what I did in others. No, it's not that. But I still feel that my task is unfinished.

I have friends who have spent their latter years in the poorest part of Malawi. They tell me how non-existent the medical services are there. I know that even my limited general skills and absent surgical skills would help in a place like that, and I have thought of possibly spending a few weeks or months out there. I fear my illness has put a stop to that idea. I applied to serve on a government committee on standards in public life, but that door has also closed. I have a feeling now that if the Lord spares me it will be to serve him in some undisclosed way. Before my operation I was in rude health and I expect to be so again. So my prayer is, "Jesus show me how I too may feed your lambs."

What is leukemia?

I am in the process of writing a chapter on CLL for a new textbook and I thought I would take the opportunity to write a guide to CLL for patients and their carers alongside. This has been a long term ambition of mine. I will publish each section on my blog as it is written, and then when it is finished I will endeavor to get the whole thing published as a booklet.

Let us start with the question, “What is leukemia?”

Literally, it means “white blood” and the name was coined in 1846 by Rudolf Virchow, the famous German physician and politician. It means that there is an excess of white blood cells in the blood. Now, there are lots of reasons for having too many white cells in the blood, the most common being an infection. White cells are principally there to fight infections and when you have an infection the usual thing is for the body to make more white cells to combat it. However, in a leukemia the cells are growing spontaneously without stimulation. Moreover, they all derive from single cell that has lost part of its control mechanism. The word “monoclonal” describes it – it simply means that all the cells of the leukemia have the same grandparent. Virchow himself taught the then novel concept that every living cell derives from another similar cell.

(As an aside I must tell you a funny story about Virchow. It is said that Otto von Bismarck, the German Chancellor, challenged Virchow to a duel. Virchow, as the challenged party had the choice of weapons and he chose two sausages, one of which had been inoculated with cholera. Bismarck is said to have called off the duel at once.)

Simply put there are four types of leukemia, two myeloid and two lymphoid, and two acute and two chronic; thus: acute myeloid leukemia, chronic myeloid leukemia, acute lymphoid leukemia and chronic lymphoid leukemia. The acute leukemias are usually called “blastic” and the chronic leukaemias “cytic”; hence: acute myeloblastic leukemia, chronic lymphocytic leukemia and so on. Of course, this is a gross oversimplification and there are many subdivisions. The latest WHO manual describes 62 different types of leukemia.

Chronic lymphocytic leukemia (CLL) is the commonest of them (at least in Europe and North America). But to make things more complicated CLL is also classified amongst the lymphomas, so what is a lymphoma?

A lymphoma is a tumor of lymphocytes. The word ‘tumor’ is a bit misleading. Originally it meant a swelling, so if you knocked you head and raised a lump, it could be called a tumor on your head, and in Victorian times it probably was. Gradually, though, words change their meanings and ‘tumor’ now means the same as the lay-term ‘growth’ or the medical euphemism ‘neoplasm’. Such growths can be benign, but most of the tumors we talk about are malignant, so the stark term ‘cancer’ is another synonym. A lymphoma can be thought of as a cancer of the lymph glands – though for several reasons even this can be misleading.

There are even more types of lymphomas than there are leukemias. The WHO handbook lists 84! Some of them are as rare as toads with wooden legs, but CLL is one of the commonest. When viewed as a lymphoma, CLL is often called small lymphocytic lymphoma, SLL. You would only use the term clinically if there was no increase in lymphocytes in the peripheral blood, but one or more lymph glands is enlarged. Other than this there is no difference between CLL and SLL; by every other criterion they are the same disease.

I need to clear up a few more misconceptions in this first section. I have used the term “lymph gland” because that is what they are often called, but strictly speaking they are not glands at all. When you have a sore throat your doctor may say to you “Your glands are up.” So it isn’t only the lay-public that engages in this fiction. A better term is “lymph node”.

The lymphoid system is spread throughout the body and is represented mainly by the bone marrow, the thymus, the spleen and the lymph nodes, (although there are important local systems in the gut - especially the appendix - and in the skin). Its purpose is defense against intruders, chiefly various types of germs. You don’t keep your defense forces at home in their barracks; you send them out on patrol. Similarly, lymphocytes are sent wandering all over the body; there is hardly a tissue where you would be unlikely to encounter a lymphocyte. Sometimes they do their patrolling along the main highways – arteries and veins – but they also have access to special routes, what you might think of as highways restricted for military use. These small lymph vessels are called “lymphatics”. Set along the lymphatics are little way-stations where the lymphocytes rest and recuperate, communicate with other cells and take instruction. These are the lymph nodes.

We also need to distinguish between the terms “benign” and “malignant”. A malignant growth is one outside the bounds of control. Normally a cell grows according to a specific stimulus and dies when given a different stimulation. It sticks with its fellows. A pancreas cell doesn’t suddenly take off to see what it would be like to live in the lung. It is restricted by tissue planes – a live cell grows up to the capsule of the liver, but it doesn’t breach it. A benign tumor may grow in an out of control way, but it doesn’t breach boundaries. However, a malignant cell accepts no restrictions. It invades into other tissues and goes walkabout to settle in other organs – this is called metastasis. Once it has spread it is still the original tumor, so if a breast cancer spreads to the liver it is still secondary breast cancer in the liver, not liver cancer,

Is CLL a benign or malignant tumor? That’s a difficult one. In that is only goes where lymphocytes normally go, it may be thought benign, but it does cross tissue boundaries to some degree. There are other types of cancer which come somewhere in the middle between benign and malignant; basal cell carcinoma is one. It certainly invades locally (its other name is rodent ulcer) but it seldom metastasizes.

Tomorrow we’ll think about where the CLL cell comes from.

Mother love

Janette Mercer, 49, was yesterday given a three-year sentence for obstructing the police. Her son Sean murdered 11-year old Rhys Jones as he walked through a car park in Liverpool. In a way it was an accident, he was actually trying to kill someone else; Rhys was an innocent bystander. The police had CCTV evidence of a young man riding away from the scene of the crime on a distinctive mountain bike. Mrs Mercer lied to the police saying that Sean's bike was quite different. Eventually the bike was found dumped at the edge of town and was traced to Sean by DNA evidence. The Daily Mail tells us that Mrs Mercer was working as a prostitute during her son's trial.

She was not the only one sent to prison over the cover-up. The parents of another gang member also lied and they were gaoled.

It is clear that there was an subculture of crime and disdain for the law in that part of Liverpool, but notwithstanding that, it set me thinking about how far one should or would go to protect one's children. I would be interested in what any readers think. A verse to ponder on comes from Isaiah 49:15: "Can a mother forget the baby at her breast and have no compassion on the child she has borne? Though she may forget, I will not forget you!"

Hickman line inserted

Today I had my Hickman line inserted. We first started inserting these about 25 years ago. The idea is that we have long term access to a central vein so that the injected drugs will not damage small blood vessels and multiple injections are not necessary. The risk of leaving a line in so long (up to 6 months in my case) is that it will become infected. To avoid this a tunnel is made so that the line emerges from the skin some distance from where it enters the vein.

We used to use them in patients with acute leukemia, where we easily used up peripheral veins with multiple punctures, and where infections were very likely. They were very successful. In those days we used to insert them blind, judging where they should go from measuring so far from the middle of the collar bone. Nowadays, the line inserted under X-ray control, although at a hospital not far from here they still put them in blindly.

You can be sedated for the whole procedure, but sedation is for wimps. My line was put in by a colleague I trusted who worked with me for more than ten years. He was very effective and I now have a double lumen Hickman protruding from my chest wall.

Being a patient is a matter of trust. I trust Terry who inserted the line, and Basil who did the operation as well as Tamas who will give the chemotherapy. I trust them because I know them. How much harder it would have been to put my trust in strangers.

There is a story of a man who fell over a cliff edge, but as he was crashing down 100 feet to the beach below, he grabbed hold of a branch a dozen feet from the top.

He called out, "Is anybody there?" There was no-one there, the clifftop seemed deserted.

He cried out again,"Help!, Help! Is anyone up there?"

Suddenly a deep voice sounded as if from the sky, "I am here."

"Who are you? Can you save me?"

"It is I, God, I can save you. Please don't worry. All you need to to is let go of that branch and I will catch you in my arms and bear you up."

The man, clinging to his branch, pondered on this. At last he spoke, "Is anyone else up there?"

You see he wasn't able to trust God, because he didn't know him.

If the times are good now, take time to know him better so that you will be able to trust him in the hard times.

The BBC

What do you think of the BBC? There is a whole website devoted to picking holes in its daily output and certainly some of the barbs are true. The BBC news and current affairs output is consistently pro-Palestinian, anti-Israel; pro-Europe, anti-American; pro-left, anti-right; pro-global warming, anti-warming sceptics; pro-Muslim, anti-Christian; pro-Republican, anti-Loyalist; pro-multiculturalism, anti-British; pro-gay/Lesbian/transsexual, anti-conservative life style; pro-EU, anti-UKIP. Recent documents released under the 30-year rule have demonstrated that the BBC played a significant part in the undermining of the Shah of Iran and in hastening the Khomeni revolution. Even when the British electorate so keenly wants to get rid of Gordon Brown and the whole of Nu-Labor, the BBC persists on trying to make the ruling party look good while trying to besmirch the Conservative Party.

However, I have noticed that even Alan Sullivan over at Fresh Bilge, whose conservatism doesn't differ much from my own, often turns to the BBC for news items that are simply not carried by the American media.

There are some things that the BBC does exceedingly well. I might mention period drama such as the recent 'Cranford', 'Bleak House' and 'Little Dorrit'. The output of the Wild-life center at Bristol is also impressive. The photography of documentaries like 'Blue Planet' and 'Alien Empire' presented by David Attenborough is worth getting Blu-ray for. (The effect is spoiled by the specious pro-evolution commentaries). The output of the main television channels is junk, of course, but that is true for most television anyway. Radio programs are better and downloadable as podcasts. I recommend looking at their selection.

This morning my son sent me a link to a series of articles on statistics by Michael Blastland that are worth a second look. They are a remedy for all the hype you read in the newspapers and watch on the news. Take this remarkable fact. Headline figures for GDP are usually wrong. The true state of the economy is not established for three years, when the tax returns are analyzed. In the UK the first figure is almost always too pessimistic whereas in the USA it is mostly over-optimistic. A recession is defined by two three month periods when there is negative growth (or shrinkage) in the economy. Who knows, when the final figures come in we may not even be in a recession.

There is a great deal of hype surrounding the current economic circumstances. Reading Micahel Blandford will probably set your mind at rest over all sorts of stuff you see in the newspapers. Statistics matter, but don't trust anyone other than a statistician making an argument from them. All politicians are liars, they can't help themselves. Journalists prefer a story to the truth. Salesmen want a sale. Businessmen want a profit.

The other thing the BBC does is "The Archers". Giving up "The Archers" is like giving up smoking. You can go for years without them, then just a single puff and you're hooked again.

Three visitors

This morning we had three visitors to our front lawn, the very same lawn that played host to the green woodpecker a few weeks ago. Three Mallards came visiting. The female duck in her dowdy brown and white tweeds simply squatted on the hoar-covered grass while her attendant drakes stood guard duty around her. They marched in step around her like guards in full dress uniform. Their heads covered in bottle green sheen contrasting with their yellow bills, their thin white dog collars separating these green helmets from the russet breastplates. The main body of their uniforms was a pleasant grey – the light grey of a fine-tailored suit – but a black back stripe separated left from right, like the black cross on the back of the donkey that carried our Lord into Jerusalem.

If you have ever been to Athens and seen the National Guard on parade outside the Presidential Palace you will know what I mean when I liken their gait to a formal parade march. No-one would use this walk as a means of transportation. It is a formal march, without the menace of German or Russian goose-steps. Each step is performance that takes months of coaching. The movement is emphasized by the orange webbed galoshes that each of them wears. As they turn you notice that they both have black curly tail feathers, just two or three, protruding at the rear of no possible use, as if to demonstrate that this whole performance is just that. It is just for show.

The dowdy little princess that they are protecting takes no notice. She has her own thoughts and as if she has had enough of sitting on the cold grass. She gets up and waddles off mid performance. They continue their marching, slipping their heads forward in a jerk that precedes every step, even though I am now the only witness, then suddenly both fly off in a rush and flurry like jets launched from an aircraft carrier.

In thirty years of watching that lawn I have never seen Mallards (nor woodpeckers) before. Is it because I have never really watched before, too busy, too distracted? Or is this some special way the Lord is blessing me? Encouraging me that He is really there?

Whatever, I am certainly feeling better. The cramps are largely gone and are no longer so painful. I have put on another couple of pounds and am eating pretty normally.

Chemotherapy should begin this week or next. Things are moving.

Dream the impossible dream

A Chinese man was given a copy of the Sermon on the Mount. After reading it he exclaimed, "But if everyone lived like this there would be universal peace in the world!"

Even atheists agree that it is the most perfect recipe for peace and harmony. It is perhaps Jesus's greatest claim to fame as a great teacher. He is universally acclaimed as a great philosopher.

But the point of the Sermon on the Mount is not to show us how we ought to live. Indeed it is quite the opposite. It is a sermon that shows us how it is impossible to live.

Expressions like "Love your enemies" and "Turn the other cheek" are hedged around with provisos by Pastors as they are translated into more achievable recipes for living.

But Jesus states quite plainly that He has not come to abolish the Law and the Prophets. Not one iota of the Law will pass away. He says that your righteousness must exceed that of the Pharisees and the teachers of the Law else you have no hope of entering the Kingdom of Heaven.

He then goes on to reinforce the Law, making it even more stringent. When Jesus equates being angry with your brother with murder and looking at a woman with lust in your heart, even if you do nothing about it, with adultery, he is raising the bar to such a level that no-one can clear it. Look, he says, sin in so serious that you had better gouge your eyes out than look at porn and better to cut your hand off than use it to fiddle your expenses.

He is equally hard on divorce or swearing. As for retaliation when you are put upon; you are to accept persecution and make yourself vulnerable for more.

Quite frankly, these are just not humanly achievable standards. And if they were Jesus would just raise the bar even higher. These are standards that are meant to bring us down, be we ever so high. Even what we would regard as our acts of righteousness: giving to the needy, fasting and prayer are tainted with hypocrisy.

What can be done then?

In Matt 7:7 we are told to ask and to seek and to knock. This way we will find the answer, it will be given to us and the door to heaven will be opened. We need to stop relying on ourselves, on our own efforts, on our own righteousness. God has provided the answer in the death of Jesus on the cross and His resurrection from the dead. First we need to humble ourselves and recognise our need for a savior, for unless we feel the need why would we ever ask? Then we need to ask. Then we will receive.

Isn't that all too easy? No, for as Jesus says, Not everyone who says to me, 'Lord, Lord,' will enter the kingdom of Heaven.

Haven't you met those people who will take anything on offer. They would rather spend their afternoons cutting out coupons to pay the grocery bill than work for a living. Those who accept lifts to church just to save the gas in the tank, who sign on for free lunches when they have food enough in their fridge. Often you find people who are just the opposite, people who are too proud to accept charity.

George Bernard Shaw once said something to the tune of "Christianity is a beggar's charter. I'll pay my own debts."

It is true that the default position for a Christian is service, but when we are in need we need to be able to accept charity - the word in the KJV of 1 Cor 13 that is translated 'love' in modern versions. We are never in greater need than in our need of a savior. We should always accept that charisma. He will know us as His own when we do the will of the Father. The strange thing is that once we have put our trust in Jesus his standards don't seem so impossible. Oh, we won't get the pass mark of 100%, but we have this constant forgiveness of our falling short. His ideals seem more achievable because we have the Holy Spirit working within. It is a lifelong plan of approximating ourselves to Jesus with our setbacks met with encouragement rather than disparagement.

Well enough to work

Today I felt well enough to do some work so I wrote a book review for the New England Journal of Medicine. Here it is.

Chronic Lymphocytic Leukemia. Edited by Susan O’Brien and John G Gribben 301 pp. New York, Informa Healthcare.2008. ISBN-13: 978-1-4200-6895-5

Chronic lymphocytic leukemia (CLL) is a fast changing field. There can be few hematologists who still see it as the boring condition that I was brought up on. A new understanding of the nature of the disease, better delineation of its limits and more effective treatments that have supplanted chlorambucil, the fifty-year old stand-by, have all attracted the interest of serious scientists and high-flying physicians. This volume, largely written by the generation that came after me, presents an effective summary of the state of play in 2008, but, make no mistake, other books on this topic will surely follow since there are many questions as unanswered now as when I first took an interest in the disease some forty years ago.

The normal-cell equivalent that the leukemia derives from is still unknown. Analogies with the mouse have often been misleading and any particular candidate-cell has no more justification for its status than any other, save for the enthusiasm of those who espouse it. The recent understanding that a quarter of patients with CLL have B-cell receptors shaped according to a small number of stereotypes, suggests a common antigenic stimulus, but raises further questions as to how an immune response can be transformed into malignant growth.

If we think back to 1975, when Kanti Rai introduced his staging system, to diagnose CLL you needed a lymphocyte count of 15,000 /microlitre. As immunophenotyping became secure, the threshold reduced to 5000 /microlitre, but this resulted in many people being diagnosed with the condition whose clinical features and outcome were most un-leukemia-like. The latest guidelines from the International Workshop on CLL require in excess of 5000 /microlitre of monoclonal B lymphocytes for the diagnosis – if there are fewer then the diagnosis of monoclonal B lymphocytosis (MBL) is made. Although this largely restores the position of 1975, the figure of 5000 is quite arbitrary and the exact relationship between CLL and MBL is a matter of ongoing research. Furthermore, much of the current understanding of CLL reflects experience with a threshold of 5000 lymphocytes; this will have to be reviewed with the new threshold.

Other unsolved puzzles include why immunity against infectious agents diminishes while immune attacks against self increase and why the disease transforms to an aggressive form sometimes derived from tumor cells but sometimes from apparently uninvolved normal B cells.

In January last year we were informed by a commercial website that the German CLL Study Group CLL8 trial had fulfilled its primary endpoint at the first interim analysis. Although the results of this trial have still to be published in a peer-reviewed journal, it was immediately clear to the cognoscenti that adding rituximab to the combination of fludarabine and cyclophosphamide improved significantly progression-free survival. This result is a vindication for doctors at the MD Anderson Cancer Center in Houston, Texas who have eschewed randomized clinical trials in this area and instead have pursued a series of Phase II studies relying on historical comparisons. It should raise questions for regulators who have insisted on Simon-pure studies before approving new drugs. Most patients and many US physicians have been convinced of the value of the fludarabine, cyclophosphamide and rituximab combination even though until now there has been no formal proof of its superiority. Even now there is no evidence that this combination improves overall survival, but surely this will come as the German study matures.

John Byrd’s remarkable chapter lists 107 agents in early stage trials for the treatment of CLL. Simple arithmetic tells us that patients do not have enough time for conventional trial progression to deliver the best of these to the clinic.