Figure 1 compares the immunization rates for 3DTP and 3Hib in Louisiana. Yearly trends of the two vaccinations are similar and coverage rates range from 89.9% 3Hib, 1995 ; to 96.9% 3DTP, 1999 ; . Hib vaccination rates!

Consultant to consultant referrals deferred he NHS, at least in England, is to allow as many patients referred by GPs as currently afflicted by managerial possible to be seen. I know of many consultinterference in the referral of ants who have found out that their patients from one consultant to another and managers are being surreptitious about this also in the scheduling of follow-up appointactivity. I could give examples. ments in consultants' clinics. Similarly, some managers are unilatEach inpatient and outpatient in NHS erally deferring follow-up appointments hospitals with a few exceptions ; is under the beyond the review date the consultant care of a medically or dentally qualified condeemed clinically necessary when the sultant, who needs access to a number of patient was previously seen, again to release facilities so as to provide treatment and give capacity for new GP referrals. advice. These facilities include investigaConsultants should say loudly and tions, operating theatres, and the services of clearly that these activities are unacceptable. other professionals such as physiotherapists. They should remind the medical directors of Consultants also need to be able to get their NHS trusts of their ethical obligations opinions and interventions from other as doctors to do whatever they can to ensure consultants--from colleagues in their own that trust managers do not interfere hospital and sometimes by referring to a inappropriately with consultant to consultconsultant in another hospital. Access to this ant referrals or with the scheduling of facility is as fundamental as access to the follow-up appointments. others. When I receive a referral letter from a In the NHS, capacity for prompt referral fellow consultant I write on it "Routine, but from one consultant to another is often not to be deferred beyond lacking. Patients needing current routine list for GP such referrals often have to referrals" or, if appropriate, join waiting lists for clinics Managers are "Potential cancer patient-- to which general practition- being ers are also making refersame priority as GP referral rals. It is an accepted maxim surreptitious with potential cancer, " that patients on waiting lists about this activity before giving it to the bookare to be prioritised according clerk. Any consultants ing to clinical need. GP who encounter this type of referrals and consultant referrals should problem should ask that the issue be aired thus be joining the same queue, within any and resolved at a meeting of their trust or agreed system of clinical prioritisation. It hospital's medical staff committee, with the could even be argued that consultant medical director in attendance. referrals should take priority over new GP I would certainly agree that protocols referrals because the patient has already should be in place to ensure that each waited once to enter the system. My own consultant to consultant referral really is trust now intends to have separate queues needed for the referring consultant to be for the two types of referral--"separate but able to treat the patient. A patient presenting equal." I doubt this will work, however, with an acute chest infection who also has a because of variability in the number of chronic hip problem should go back to his urgent consultant referrals. Yet we will or her GP for the referral to an orthopaedic continue to have GPs being able to book clinic once the chest problem has been sucexercise electrocardiography through refercessfully cured. ral to our rapid access chest pain clinic faster To those colleagues and managers who than we physicians can get it done. point out that the flow of funds to their trust The government has been setting targets might be at risk if GP referrals are not on the longest time that patients referred by prioritised over consultant to consultant general practitioners should wait to see a referrals, I reply that it is surely unethical to consultant. The pay and promotion prosagree, solely for financial reasons, to the pects of some managers, even their tenure of deferring of one patient's treatment so that employment, can depend on these targets another can be treated more quickly. being achieved. The government trumpets If we fail to defend our professional and the meeting of these targets as a measure of ethical positions in these matters we will its success with the NHS. Consultant to conhave accepted the handing over of the maksultant referrals are neither measured nor ing of clinical decisions on our patients to counted for this purpose. Moreover, the lay managers, acting under the diktat of provision of funds to trusts is based on the politicians, and we will thus have become numbers of referrals by GPs, with consultant deprofessionalised. referrals generating no additional financial flow, even when a specialist centre receives a referral from another hospital. Michael Goodman consultant gastroenterologist, It is thus not surprising that some NHS Bury, Greater Manchester dr.m.goodman btinternet managers have been contriving to keep.

Rial pH 7.35-7.45 ; and adequate oxygenation Po2 60 ; . Sodium and potassium concentrations were analyzed by flame photometry. A high-pressure liquid chromatography assay procedure21 was used to measure plasma concentrations of ODE and of 3methoxy O-desmethyl encainide MODE ; , which is another less potent encainide metabolite that is generated by ODE biotransformation.16-19, 22MODE concentrations were either below or just above the limits of assay detection 25 ng ml ; Encainide was not detected in these samples. Study design Eligible patients were treated with two sequential three-day courses days 1-3 and 8-10 ; consisting of 150 mg m 2 d of carboplatin in continuous infusion, associated with 100 mg m 2 d of etoposide given as an i.v.-infusion over one hour and 500 mg m 2 of cytarabine given i.v. every 12 hours as one-hour infusion. On day + 14, all patients had bone marrow aspirate BM ; to evaluate response and BM was subsequently repeated at weekly intervals to monitor hematopoietic recovery. All patients received prophylactic antibiotic treatment consisting of oral amphotericine-B and ciprofloxacine during the neutropenic phase without the addition of growth factors. Responding patients were considered eligible for allogenic or autoBMT. The BM for auto-BMT was harvested in all cases within 3 months after CR following the intensive treatment The conditioning regimen consisted of busulfan and cyclophosphamide for patients assigned to allo-BMT [15] and of the BCNU, cytarabine, etoposide and amsacrine combination BAVC ; for those submitted to auto-BMT [16]. The last and butorphanol.

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Busulfan is predominantly metabolized by conjugation with glutathione, both spontaneously and by glutathione s-transferase gst ; catalysis. CORRESPONDING AUTHOR: Department of Social and Preventive Dentistry Medical University of Bialystok ul. Akademicka 3, 15-089 Bialystok, Poland e-mail: helpdentamb tlen Received 23.03.2006 Accepted 30.03.2006 and carbenicillin.
Busulfan in the Treatment of Chronic Myelocytic Leukemia. The Effect of Long Term Intermittent Therapy and butorphanol. The following criteria applied: 1 ; first chronic phase of chronic myelogenous leukemia14; 2 ; first transplantation; 3 ; conditioning regimen: either busulfan cyclophosphamide15 or cyclophosphamide total body irradiation, as described15, 16; 4 ; age at transplantation, at least 18 years; and 5 ; available DNA. All patients received 4 doses of MTX intravenously, day 1, at 15 mg m, 2 and days 3, 6, and 11, at 10 mg m2 ; and cyclosporine as previously described15 ; for prevention of GVHD.2 All patients gave informed consent. The study was approved by the FHCRC Institutional Review Board. Data collection Data were abstracted by a single abstractor blinded to genotypes ; on previous interferon treatment, smoking, MTX administration, and, if applicable, MTX serum levels and leucovorin administration. Data from the patient database included: 1 ; conditioning regimen; 2 ; donor matching status; 3 ; demographics; 4 ; weight, height, and calculated body mass index and surface area; 5 ; platelet and granulocyte counts; 6 ; bilirubin and creatinine; and 7 ; survival status or day of last contact. Mucositis is a major toxicity associated with folate antagonists. The oral mucositis index OMI ; was developed17 to measure severity of oral mucosal changes; patients were examined every 2 to 3 days. Oral mucositis usually peaks between days 7 and 11 and resolves by days 18 to 21 after transplantation. We assessed mean scores on days 6 to 12 peak period ; and days 1 to 18 overall mucositis course ; . MTHFR genotyping Genotyping for the MTHFR C677T polymorphism was performed, 9 blinded to outcome measures; 10% blinded duplicate samples yielded 100% concordance. Genotypes were in Hardy-Weinberg equilibrium and carboplatin.

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