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.

Keep on keeping on

I have seen the consultant surgeon this morning. Not very much new, I'm afraid. My main problems are colicky abdominal pains and diarrhea for which I am taking an anti-spasmodic and codeine phosphate. Th surgeon thinks these symptoms are caused by the mechanical effect of the presence of secondaries in the peritoneum and that the remedy is chemotherapy. I am seeing the medical oncologist this afternoon.

The special stains do not tell us anything new. They were negative for carcinoid, but even that is not helpful since the histology of adenocarcinoid can change to adenocarcinoma when it metastasizes, indeed such patients have a rather better prognosis. Although he thinks that the appendix is the most likely source of the tumor, he cannot be sure. The other option, large bowel, has been searched through very thoroughly on several occasions without finding a primary. The overwhelming majority of appendix tumors start life as carcinoid.

Were it not for the colic I would be very well. I have lost 14 pounds, but the weight loss has reversed and I have put on a couple of pounds since the nadir. My nutrition is important now, and the only restrictions on my diet are to avoid high residue products like peas and beans, sweet corn and cabbage, skins and pith.

I was encouraged when my friend George Stevenson brought me in a paper by Yan et al (Annals of Surgical Oncology 2008; 15:1440-6) which describes adenocarcinoid of the appendix that on peritoneal dissemination lacks the neuroendocrine component and appears as adenocarcinoma. Such patients have an improved survival over those who retain the carcinoid appearance, with a cumulative survival of 70% at 4 years and no further deaths thereafter.

This afternoon I saw the medical oncologist, Tamas Hickish. I will have a baseline CT next week with insertion of a Hickman like, starting chemotherapy at the end of next week of the beginning of the week afterwards.

Yesterday we watched the movie of 'The Kite Runner'. Although perhaps not as complete as the novel, it was a moving story and a rebuke to those who wish for an accommodation with the Taliban. These are appalling people who were quite justifiably deposed by George Bush and his allies. It is a common phenomenon found in the Western Democracies that they fail to complete the task that they embark on. They seem to lose heart when adversities stand in their way. Obama is talking about an exit strategy in Afghanistan. Will he be condemning millions of women to a second class life that includes no education, beheading for being raped, genital mutilation and forced marriage. Will the beard police return?

How this contrasts with the attitude of Christ who does not give up on us. "He who began a good work in you will carry it on to completion until the day of Christ Jesus" (Philippians 1:6).

I continue to receive messages of encouragement. From the Manabats in the Philippines and from Mary and Milena, two former colleagues of mine at the hospital whom I happened to meet in the corridor. Sometimes we despair when we have this diagnosis. When we know so many people are praying we wonder whether God is listening. Then he will send the chance meeting to encourage us and to let us know that he certainly is listening - so keep praying.

Strutting and fretting

One thing that surprised me about being in hospital was how little the doctors influenced what was going on. When I was in charge of the wards I had the distinct impression that I was running things. Of course, it may be very different in surgery, where surgeons are in essence doing the same thing repeatedly and the whole subject may be protocolized. Standard operating procedures (SOPs) are relatively easy to produce and follow when one case doesn't vary very much from the next. In contrast, hematology patients are very different from each other. About the only leukemia that is at all stereotyped is chronic myeloid leukemia, where an identical molecular lesion produces a very similar clinical condition, but my readers will mostly know how heterogeneous is CLL, and AML or MDS is even more so. Non-Hodgkin's lymphoma breaks down into over 40 separate conditions.

When I was running the hematology lab we majored on SOPs, but then we were doing full blood counts on 750+ samples a day and very few other tests. We even had an SOP for answering the telephone (Good morning, this is the Hematology Lab. How may we help you?). The benefit of SOPs is that relatively unskilled workers can be trained to do complex tasks accurately and reproducibly. The danger of SOPs is inflexibility.

The surgery ward ran efficiently on a cadre of trained nurses and health care assistants (HCAs). There were some things that only nurses could do, like give injections, dole out pills and attach and detach intravenous pumps, but for most of the traditional nursing duties, like making beds, emptying bed-pans and giving bed-baths, the nurses and HCAs were interchangeable. Obviously, the use of HCAs to replace nurses is a cost saving. Many of the HCAs were from Eastern Europe or other foreign countries (though their English was always excellent) but, then, my nurses were also likely to be foreign (Indian, Chinese,) and their training was equally as good as those who were locally trained.

Many of my readers will know the Tom Stoppard play 'Rosencrantz and Guildenstern are dead'. For those who don't the author takes two minor characters from Hamlet and builds a play around them. They spend most of the play discussing the absurdities of life and death, the paradox of freedom and inevitability, of freewill and predestination. Mostly it is a two-hander, but at times the whole Shakespeare play rushes on to the stage and performs their bit of Elizabethan drama before exiting stage left, leaving the two alone, perplexed and totally misconstruing what has just happened.

The consultant ward round is like that. Of course, Hamlet is the main thing and Rozencrantz and Guildenstern mere strolling players in comparison. The great and important decisions are taken by the consultant and his retinue, while we patients are blown about by the forces of destiny.

Everything boxed and coxed, categorized and acted out word perfect without prompting makes for an efficient service where errors of omission do not occur. As long as the out of the ordinary does not come along.

The problem with this inflexibility arose over my drip. The houseman (now called a Foundation year one) has the task of writing up the intravenous fluids for the next 24 hours. At the beginning of March the F1s have only been employed for a couple of weeks and have difficulty in getting their routine work done in the day. In my day you stayed until the work was complete, but today the European Working Time Directive insists that you leave on time. Overstay the 5pm deadline and you get a ticket. Do it twice and you receive a reprimand. Habitual offenders may have to repeat the year.

There is a back up position, though. At night there is an F1 available to cover the whole hospital. Of course, this person does not know the individual patients and apart from catching up on the work left left over from the day she (and these days it is usually a she) has to deal with emergencies as they arise, so it wasn't until 2am that she got around to writing up my fluid chart. By which time the drip had been stopped for two hours and the cannula had clotted. In the old days the nurse in charge of the ward have put up a bag of whatever had gone before rather than let a drip stop, but today a nurse does not have that discretion. She has to obey orders precisely and if nothing is prescribed nothing can be given.

The F1 was very nervous as she tried to resite the cannula, and she failed. She summoned Night Sister and she failed twice. A more senior doctor was called for and she failed three times. Eventually an anesthesiologist was called and she got in first time - but it was the seventh attempt.

The next time I needed a new drip I insisted on an anesthesiologist first time. He turned out to be an old colleague whom I had only met over the telephone. He remembered that I had once done him a favor, and he certainly did one for me.

Pain relief.

We expect it to be painful when someone slices your tummy open. I remember seeing a war film once where the soldiers hit the ground when showered with machine gun bullets. After the shooting stopped the sergeant told his men to start moving out, only to be greeted by one of his men asking, "What shall I do with these?" as the camera panned down to his abdomen where he held several coils of intestine in his hand. The very thought makes many people squirm, but it is just what an abdominal operation involves.

Naturally, some form of pain relief is necessary, and the best form is an epidural which stops the messages from nerve to brain, for although it seems as though we feel the pain in our tummy, in reality it is the brain that really does the feeling. Almost all other forms of pain relief involve impairing the function of the brain, sometimes so much that we are rendered unconscious.

It is also true that most forms of pain relief have serious side effects. Morphine and other opiates induce nausea and vomiting, suppress the cough reflex, slow down the bowel causing constipation and in large doses suppress the respiratory center causing one to stop breathing. The non-steroidal anti-inflmmatories can cause mucosal ulceration and depending whether they are cox-1 or cox-2 inhibitors affect the clotting mechanisms, either by leading to bleeding (cox-1) or thrombotic (cox-2). The one drug that is pretty free of side effect is acetaminophen (paracetamol), but overdoses (greater than 15 g or 30 tablets) are fatal, causing liver damage. Standard hospital guidelines allow a safety margin and require anti-poisoning measures after 24 tablets, but strangely the maximum permitted therapeutic dose in hospital in 8 tablets.

Since normally the required dose for pain relief is 2 tablets every 4 hours, this leaves anyone who is kept awake by pain with nowhere to go in the middle of the night. This happened to me. My pain was adequately controlled by paracetamol, but at 4 in the morning I needed another dose. The nurse informed me that I was not allowed any more paracetamol for another hour, but I could have some morphine.

I didn't blame the nurse, she was only obeying her instructions, but I do blame whoever wrote the instructions. It was not a local decision it is a central NHS decision. The maximal allowable dose is just one third of the toxic dose - even when there is a built in safety margin - and did I mention that there is a perfectly adequate antidote for paracetamol?

Had I been at home I could have taken paracetamol with impunity. As it was I suffered for another hour.

Torture

I'm not sure about waterboarding. They say it is very effective in extracting information and that although it induces a feeling of impending drowning, it leaves no marks and damages no tissue. Watching Jack Bauer on '24' torture traitors with a tazer does not seem immediately preferable. Yet scores of Westerns and cops and robbers movies have shown the 'good' guys beating a confession or information out of a villain.

It is a difficult dilemma. To stand up for human rights is a fine thing, but who would not have looked the other way if a CIA agent had been able to obtain information by torture that would have prevented 9/11? And if you think you would have stopped the torture consider whether you would have done so if your wife or son was one of the intended victims.

The whole question of what rights criminals retain is a difficult one, and even more so in the case of those detained who are presumed innocent until proved guilty or those detained on the basis of evidence that would not be admissible in a court of law.

Strange as it may seem, the law is there to protect the guilty as well as the innocent. Suppose you run over a child in a Malaysian village and kill him. A colleague of mine who served in the RAF during the Malayan crisis of the 1950s was told that on no account under such circumstances should he stop the car and get out; if he did so he would be torn limb from limb by the villagers, because there was no law there. Such a driver might well deserve punishment, but he might be entirely blameless; mob law admits no such nuances.

I don't know whether anyone has considered as a means of torturing, the injection of a drug that induces severe abdominal colic and diarrhea, but I would imagine it to be an effective means of extracting information. The past weekend was truly terrible. I was screaming with agony as the colic hit me. Had someone offered me an injection that would stop it in return for a confession, I would have given up the crown jewels. I would have confessed to anything from treason to pedophilia if they would only make it stop. I would have offered to have an arm or leg amputated rather than continue in such pain.

The real problem with torture is that you can't rely on the answer.

There is such a remedy for colic; it is called mebeverine, and since I have been taking it I am back to normal making a slow recovery from surgery. I have so far lost 15 pounds and am not yet eating properly, but I no longer have wound pain.

Proverbs 3:11-12 says "My son, do not despise the LORD's discipline and do not resent his rebuke, because the LORD disciplines those he loves, as a father the son he delights in.

I'm not sure what lesson the Lord is teaching me, but perhaps it is not to rely on my own wisdom, and not to be too proud the ask for advice. They say of a doctor who treats himself that he has a fool for a patient and a quack for a physician. My wife, who is non-medical, was urging mebeverine (colofac) on me for some hours before I accepted it and I only did that after I had managed to contact my surgeon's colleague (the surgeon was out of town) and he had agreed with my wife's prescription. What a vicious sin pride is.

Nasogastric tubes

As a medical student I had to insert a gastric tube to measure my own gastric acidity. I remember it as one of miserable days of my life. On that occasion I had to pass it via the mouth and it was only down for three hours. Following my two pint vomit they decided to insert one transnasaly.

At the age of 16 I played at center half for the school second XI. On one occasion I was about to head the ball over my own crossbar to concede a corner from a high cross, when our goalkeeper, Roger Millward, rushed out and in attempting to punch the football, punched me in the nose. When I came too my nose was broken, and this is why inserting a nasogastric tube was very painful, even though the nurse inserting it was Nurse Nightingale and extremely skillful with it.

I have taught generations of students that the word 'retch' is pronounced 'reach' and not 'wretch', but they will not learn. The presence of a tube at the back of the throat stimulated the gag reflex and causes retching. Many surgeons, Dr Fozard included, are not keen on the use of nasogastric tubes post-operatively, but when gastric stasis leads to vomiting, there is very little choice. The usual practice is to spigot the tube and wait until the stomach is clearly emptying before removing the tube as soon as possible. In my case the stasis was prolonged and the tube was down for several days. Eventually Dr Fozard took the decision to pull it up and immediately I felt better.

When I was about 14 I rapidly expanded my vocabulary and began to use long words instead of short ones. I would say 'commence' instead of 'start' or 'begin' and 'velocity' instead of 'speed'. I discovered the word 'recuperate' which for some reason I believed was a posh word for 'to belch'. I remember writing an essay at school in which I used 'recuperate' several times with this meaning. I couldn't understand why the boys in the class were laughing.

After abdominal surgery the first sign of recovery is the downward passage of wind. The nurses come round every morning and discretely ask, "Any wind?"

I see now that as a teenager I got thinks upside down. 'To recuperate' doesn't mean 'to belch', it means 'to fart'.

How it was in hospital

This is a chance to get off my chest the experience of the past two weeks while it is still fresh in my mind. The first thing I have to say is that I have never known such kindness and care as that I received from the nursing staff at my hospital.

I was admitted to the Royal Bournemouth Hospital early on the morning of my operation. This is the hospital that I worked at for my entire career. When I was first appointed in 1974 it was Victorian Establishment that had just 'growed like Topsy', with major developments in 1911, 1927, 1936, 1968, 1982 and 1986. The building that I originally worked in was demolished in 1993 and the new hospital built on the edge of the city opened in two phases in 1988 and 1992. It is a bright, airy, modern hospital that seems to have seen continual improvement since it opened. I was the first Medical Director of the new hospital.

The colorectal surgery department has an enviable reputation for high quality outcomes and low mortality and morbidity, a tribute to the meticulous planning and forethought of the head of department Dr Basil Fozard (you will see some of his innovations later). Dr Fozard has been at Bournemouth for about 12 years, having completed his training at the Mayo Clinic. I had already been pre-clerked before admission; so on the morning of the operation I knew precisely what awaited me as I sat and read in the day-room. I was able to walk to the operating theater suite. The anesthetist inserted a pink cannula in my wrist and injected a few drops of Hypnoval. He then sat me up to insert an epidural into my back and that's the last thing that I remember until I woke up in recovery. The surgeon came in and told me his findings, but I was still under the Hypnoval and I was in no fit state to fully understand.

My wife and daughter came in to visit me in the evening and here they encountered the first problem. It is now apparently the case that relatives can be given no information by the staff unless the patient has expressedly said that they might. There was therefore no-ne able to impart the news to them when they arrived, and it was I, in my drugged state, who blurted out the diagnosis. It was a terrible shock that they had not been expecting.

The rule has come in as an instruction from above because some patients have complained about their relatives being told. I have always thought that that was an unreasonable attitude to take unless there was some sort of estrangement involved. I have encountered husbands who wished to protect their wives from the news, but I have always countered that view by saying, "You have spent the past x years in the closest relationship it is possible to have, do you really intend to spend whatever time you have left telling lies to each other?"

The best person to break bad news is not the patient, but the doctor in charge, if he or she knows the job. He can speak from a position of knowledge, not only of the pathology, but also of how people react. He has an eye for the physiological reactions that accompany shock and is prepared with acts of comfort from a hand held to a cup of warm sweet tea.

To my mind the new rule is just one more of the vicious consequences of unthinking pandering to PC.

The major consequence of bowel surgery is paralytic ileus. This means the bowel stops its onward contractions (peristalsis) and just hangs about idly loitering. This always happens, especially if the bowel has been much handled (as when searching for a small primary). Post-operative treatment is aimed at making the period of ileus as short as possible. For many years morphine has been the mainstay of control of post-operative pain relief. However, morphine makes you constipated. Indeed, morphine alone can cause a paralytic ileus. Therefore, for Dr Fozard, the policy for pain relief is to use epidural anesthesia.

The problem for me was that the epidural only worked on the left side and the right was still painful. It happens occasionally and when it does the problem is more difficult. There was some Fentayl in the epidural to keep me in a haze, but I needed a PCA pump (patient controlled analgesia) to supplement this. This is a pump that delivers 1 mg of morphine at the press of a button, but then shuts out the patient for 5 minutes befor any more can be delivered. It is very effective, but the most immediate effect of morphine is nausea and vomiting. Generally, we offer an anti-emetic with morphine, but the choice is limited. Metaclopramide is a prokinetic agent that stimulates onward movement - possibly dangerous when the bowel has been resected and then rejoined, and ondansetron is constipating. Cyclizine is effective, but very sedating. As a result I had the morphine neat. This caused me severe spasm of the gullet.

Esophageal spasm produces a pain like angina, but can be relieved in the same way with glyceryl trinitrate, either under the tongue or as a spray. The new young doctor and I worked this out by Googling in the small hours of the morning, so she arranged to get a spray from the CCU. I tried it with instant pain relief. Then I vomited a couple of pints of brown fluid. What had been happening was that the body had contrived its own anti-emetic by constricting the gullet so hard it hurt. As soon as that was released - upchuck.

The response was to put down a naso-gastric tube and tomorrow I will tell you about that.

A great comfort to me throughout the period of hospitalization were the visits of Dr John Falkner Lee. John is a retired general practitioner. He and I were baptized on the same day in 1975 at Lansdowne Baptist Church. He is about 20 years older than I and shortly about to enter hospital to have one of his hip replacements replaced. Please pray for him. We were deacons together, elders together and always very close. For the past several years he has been on the staff of the hospital as Pastoral Visitor. On one of his visits he read to me from Zephaniah chapter 3.

The LORD has taken away your punishment; he has turned back your enemy. The LORD, the King of Israel, is with you; never again will you fear any harm. On that day they will say to Jerusalem, "Do not fear, O Zion; do not let your hands hang limp. The LORD your God is with you, he is mighty to save. He will take great delight in you, he will quiet you with his love, he will rejoice over you with singing."

Notice all those 'wills'; there is no 'might' in God, except that He is ‘might’y to save.

Home from hospital

I want to thank all those who have sent their good wishes, prayers and kind thoughts over the past couple of weeks.

It has been longer than I expected to fire up my computer again, and I am afraid that the news is not as good as I had hoped. Apparently I have cancer of the appendix that has spread sufficiently for me to need chemotherapy. The disease is not in my liver and the largest lymph nodes were removed

I returned from hospital today and I need some time of convalescence.

The histology came back as well differentiated adenocarcinoma that is CEA positive. There were some goblet cells, however, and it would still be compatible with goblet cell carcinoid, a very rare tumor with only 600 cases in the medical literature. but it will require special stains to distinguish (Chromogranin A). I will also need to know whether the k-ras gene is mutated in order to know whether the new EDGFR receptor monoclonal antibodies will be helpful.

I suppose the most optimistic factors and that I was really very well before the surgery, that the liver is not involved and that the CT in February was almost identical with the one in September.

This all suggests that the disease in very indolent (not another 'good' cancer!).

I have yet to be given a final diagnosis and the prognosis is still uncertain.

I will write later about various aspects of this experience, but I just want to say for now that the most comforting element of the whole episode was to recite to myself, "Thou wilt keep him in perfect peace, whose mind is stayed on thee: because he trusteth in thee" (Isaiah 26:3). Strange how the old King James version comes to me in times of need.