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Effect of wortmannin and methazolamide on AE1 exocytosis in the colon. To. 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.

A. de Alarcn. Hospital Universitario Virgen del Roco, Seville, Spain Q fever is a worldwide zoonosis caused by Coxiella burnetii, a small gram-negative microorganism that grows exclusively in the phagolysosomes of eukaryotic cells. It was originally described by Derrick in Queensland Australia ; , as an acute febrile illness among abattoir workers, and since 1945 the disease has been reported from every part of the world. Coxiella burnetii has been found in feces, urine and the placenta of infected cats, sheep and goats, that are the main sources that can spread the infection to humans through the inhalation of spores, but it is of note that in nearly 50% of cases of Q fever no identifiable infection source is detected. Cases may be sporadic or in outbreaks, with a large number of individuals being affected in a short period. Clinic polymorphism is a main feature of Q fever. Subclinic forms, acute febrile illness generally with hepatic alteration ; , atypical pneumonia and chronic forms ie. endocarditis ; have been reported, and diferences in clinical presentation are described according to the geographic location. Uncommon manifestations of acute Q fever include pericarditis and or myocarditis, hemolytic anemia, thyroiditis, pancreatitis, medistinal lymphadenopathy, orchiepididimitis, erythema nodosum and neurologycal diseases. Endocarditis is the major form nearly 75% ; of chronic Q fever and it is diagnosed almost exclusively in patients with previous valvular disease or when an immunosuppressive condition is present. Isolation of C. burnetii from biopsy specimens ie a cardiac valve ; is possible with cell-cultures and by genomic amplification. However, serology complement fixation, indirect immunofluorescence or ELISA ; is the most commonly tool for diagnosis in daily practice, although in subacute and chronic forms diagnostic criteria to phase I antigens can overlap. Treatment in acute forms is well established and a short course of doxycycline 6-12 days ; is enough for a complete curation. However, in chronic endocarditis antibiotic combinations have demonstrated a better outcome. Doxycycline with either rifampin, co-trimoxazole or quinolones have been used with good results and, today, surgical valve replacement and methimazole.

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