Assessment of liver fibrosis markers in people with rheumatoid arthritis on methotrexate.

BACKGROUND: Up to 3% of methotrexate (MTX)-treated rheumatoid arthritis (RA) patients might develop liver fibrosis or cirrhosis, requiring effective screening algorithms. AIMS: To assess the utility of non-invasive liver fibrosis assessment in RA patients on MTX. METHODS: Fifty-six patients were recruited from rheumatology outpatient clinics in a public tertiary centre from July 2017 to October 2018. Clinical data was collected. Screening for hepatic fibrosis was performed using transient elastography (TE), aminoaspartate transaminase to platelet ratio index (APRI), Hepascore and Fibrosis-4 index (FIB-4). Those with suspected significant liver fibrosis based on these screening tests were assessed by a hepatologist. RESULTS: Twenty-seven patients were suspected to have liver fibrosis on screening, including 10/56 (18%) by TE, 20/56 (36%) by Hepascore, 2/56 by APRI (4%) and 1/56 by FIB-4 (2%). Of these 27 patients, 11 were reviewed by a hepatologist and one diagnosed with significant liver fibrosis. TE, but not APRI, Hepascore or FIB-4, was found to have 100% sensitivity and 84% specificity (P = 0.029) for hepatologist-diagnosed liver fibrosis. CONCLUSION: Liver fibrosis develops in a minority of MTX-treated RA patients. The present study suggests that TE is a more sensitive screening test than APRI, FIB-4 or Hepascore in the identification of people with RA at risk of hepatic fibrosis.

Bronchiolitis versus bronchopneumonia: navigating antibiotic use within the LRTI spectrum.

Bronchiolitis, a common reason for infant hospitalisation in South Africa (SA), is caused by viral pathogens. Bronchiolitis is typically an illness of mild to moderate severity that occurs in well-nourished children. Hospitalised SA infants frequently have severe disease and/or coexisting medical conditions, and these cases of bronchiolitis may have bacterial co-infection that requires antibiotic therapy. However, the existence of widespread antimicrobial resistance in SA warrants the judicious use of antibiotics. This commentary describes: (i) common clinical pitfalls leading to an incorrect diagnosis of bronchopneumonia; and (ii) considerations for antibiotic therapy in hospitalised infants with bronchiolitis. If antibiotics are prescribed, the indication for their use should be clearly stated, and antibiotic therapy must be stopped promptly if investigations indicate that bacterial co-infection is unlikely. Until more robust data emerge, we recommend a pragmatic management strategy to inform antibiotic use in hospitalised SA infants with bronchiolitis in whom bacterial co-infection is suspected.

Emerging organic contaminants in the River Ganga and key tributaries in the middle Gangetic Plain, India: Characterization, distribution & controls.

The presence and distribution of emerging organic contaminants (EOCs) in freshwater environments is a key issue in India and globally, particularly due to ecotoxicological and potential antimicrobial resistance concerns. Here we have investigated the composition and spatial distribution of EOCs in surface water along a ∼500 km segment of the iconic River Ganges (Ganga) and key tributaries in the middle Gangetic Plain of Northern India. Using a broad screening approach, in 11 surface water samples, we identified 51 EOCs, comprising of pharmaceuticals, agrochemicals, lifestyle and industrial chemicals. Whilst the majority of EOCs detected were a mixture of pharmaceuticals and agrochemicals, lifestyle chemicals (and particularly sucralose) occurred at the highest concentrations. Ten of the EOCs detected are priority compounds (e.g. sulfamethoxazole, diuron, atrazine, chlorpyrifos, perfluorooctane sulfonate (PFOS), perfluorobutane sulfonate, thiamethoxam, imidacloprid, clothianidin and diclofenac). In almost 50% of water samples, sulfamethoxazole concentrations exceeded predicted no-effect concentrations (PNECs) for ecological toxicity. A significant downstream reduction in EOCs was observed along the River Ganga between Varanasi (Uttar Pradesh) and Begusarai (Bihar), likely reflecting dilution effects associated with three major tributaries, all with considerably lower EOC concentrations than the main Ganga channel. Sorption and/or redox controls were observed for some compounds (e.g. clopidol), as well as a relatively high degree of mixing of EOCs within the river. We discuss the environmental relevance of the persistence of several parent compounds (notably atrazine, carbamazepine, metribuzin and fipronil) and associated transformation products. Associations between EOCs and other hydrochemical parameters including excitation emission matrix (EEM) fluorescence indicated positive, significant, and compound-specific correlations between EOCs and tryptophan-, fulvic- and humic-like fluorescence. This study expands the baseline characterization of EOCs in Indian surface water and contributes to an improved understanding of the potential sources and controls on EOC distribution in the River Ganga and other large river systems.

Assessing groundwater salinity across Africa.

In Africa groundwater is the principal source of drinking water (https://washdata.org/) and has significant potential to improve food production as a source of irrigation water. Although volumes of stored groundwater are high when compared to surface water, not all the available groundwater is suitable for irrigation. One of the principal factors that limit the development of groundwater is salinity, but quantitative evidence regarding the scale of salinization in Africa has been lacking. This paper presents an initial analysis of the extent of groundwater salinization in Africa, bringing together groundwater salinity data (n = 12,255) from across the continent. In our dataset c.80% of the samples have electrical conductivity values less than 2000 µS/cm. Samples with high conductivity values of more than 2000 µS/cm are restricted to limited geological and climatic environments. The data reveals salinity does not affect the water security status of most countries in Africa. However, salinity compounds water insecurity issues in arid low groundwater recharge environments. The paper discusses the role of anthropogenic processes such as river valley water resources development, extensive groundwater pumping, inter-basin groundwater transfer, and irrigation in altering the salinity of groundwater bodies. The paper further elucidates the origin of groundwater salinity by critically reviewing the natural and human-induced factors that control the salinization of the various groundwater bodies across Africa. Existing case studies reveal several causes of salinization, including i) human-induced salinization, ii) climate and hydrological change-induced paleo groundwater salinity, iii) rock dissolution, and iv), saltwater encroachment.

Emerging organic contaminants in groundwater under a rapidly developing city (Patna) in northern India dominated by high concentrations of lifestyle chemicals.

Aquatic pollution from emerging organic contaminants (EOCs) is of key environmental importance in India and globally, particularly due to concerns of antimicrobial resistance, ecotoxicity and drinking water supply vulnerability. Here, using a broad screening approach, we characterize the composition and distribution of EOCs in groundwater in the Gangetic Plain around Patna (Bihar), as an exemplar of a rapidly developing urban area in northern India. A total of 73 EOCs were detected in 51 samples, typically at ng.L-1 to low µg.L-1 concentrations, relating to medical and veterinary, agrochemical, industrial and lifestyle usage. Concentrations were often dominated by the lifestyle chemical and artificial sweetener sucralose. Seventeen identified EOCs are flagged as priority compounds by the European Commission, World Health Organisation and/or World Organisation for Animal Health: namely, herbicides diuron and atrazine; insecticides imidacloprid, thiamethoxam, clothianidin and acetamiprid; the surfactant perfluorooctane sulfonate (and related perfluorobutane sulfonate, perfluorohexane sulfonate, perfluorooctanoic acid and perfluoropentane sulfonate); and medical/veterinary compounds sulfamethoxazole, sulfanilamide, dapson, sulfathiazole, sulfamethazine and diclofenac. The spatial distribution of EOCs varies widely, with concentrations declining with depth, consistent with a strong dominant vertical flow control. Groundwater EOC concentrations in Patna were found to peak within ∼10 km distance from the River Ganges, indicating mainly urban inputs with some local pollution hotspots. A heterogeneous relationship between EOCs and population density likely reflects confounding factors including varying input types and controls (e.g. spatial, temporal), wastewater treatment infrastructure and groundwater abstraction. Strong seasonal agreement in EOC concentrations was observed. Co-existence of limited transformation products with associated parent compounds indicate active microbial degradation processes. This study characterizes key controls on the distribution of groundwater EOCs across the urban to rural transition near Patna, as a rapidly developing Indian city, and contributes to the wider understanding of the vulnerability of shallow groundwater to surface-derived contamination in similar environments.

High school coaches' assessments, intentions to use, and use of a concussion prevention toolkit: Centers for Disease Control and Prevention's heads up: concussion in high school sports.

This study evaluated school coaches' perceptions, assessments, and use of a toolkit to prevent and manage concussions among school athletes. A computer-assisted telephone survey was conducted with a stratified, random sample of high school coaches (n = 497; response rate = 39.3%; cooperation rate = 81.5%) from five states. Most reported that they had used or planned to use kit materials. Most (81%) in schools with a written plan for preventing and managing concussions indicated that the toolkit could be used to improve it and 96% of coaches in schools without a plan indicated that the kit could be used to develop one. Most assessed the kit as visually appealing, easy to use, and containing appropriate content. There were no significant differences among coaches with differing professional experience or for sports with different injury rates. Among those with other concussion-prevention materials, most indicated greater satisfaction with the toolkit.

Going blank: factors contributing to interruptions to nurses' work and related outcomes.

AIM: To examine interruptions to nurses' work, the systems issues related to these and the associated outcomes. BACKGROUND: While some research has described the role interruptions play in medication errors, work is needed to examine specific factors in the nursing work environment that cause interruptions and to assess the impact of these on nurses' work and patient outcomes. METHODS: The present study utilized a mixed method design that involved work observation to detect nursing interruptions in the workplace followed by focus groups with a subsample of nurses. RESULTS: A total of 13,025 interruptions were observed. Equal numbers of these took place on medical and surgical units. The predominant source of interruptions was members of the health team, who interrupted more frequently on medical units. CONCLUSIONS: Differences in the type of patient and the care needs between medical and surgical units may be a contributing factor to these findings. As members of the health team were among the leading source of interruptions, an interdisciplinary team-based approach to changing the organization and design of work should be explored. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse leaders should examine ways in which nurses' work can benefit from system improvements to reduce interruptions that lead to patient safety issues such as treatment delays and loss of concentration.

Cystic fibrosis in black African children in South Africa: a case control study.

BACKGROUND: Cystic fibrosis (CF) is described more commonly in Caucasian populations in whom p.Phe508del is the most common mutation. There is a paucity of data of CF in black African children. The aim of this study was to describe and compare the presentation and outcomes of black African children with CF to those with p.Phe508del genotype. METHODS: A retrospective case-controlled study was conducted from January 2000 - March 2018 of children with CF attending two CF centres in South Africa. Presentation, genotype, nutrition and pulmonary function outcomes of black African children were compared to matched controls with the p.Phe508del mutation. RESULTS: Thirty-four black African children (cases) with median age of diagnosis (5.5 months, IQR 2.0-15.0) were matched to 34 controls. Among cases, 3120+1G->A CFTR mutation was most commonly identified; homozygous n=22 (64.7%) and heterozygous=7(20.5%). Compared to controls, cases at diagnosis were more malnourished and fewer presented with neonatal bowel obstruction [cases n=2 (5.9%) vs. controls n=10 (29.4%); p = 0.03]. Nutrition and pulmonary function (FEV1 in children ≥ 6 years) outcomes and changes over time from ages 3-16 years were similar in both groups; median FEV1 z-score at age 6,10 and 14 years was -0.9 (±1.5), -1.8 (±2.0) and -1.8 (±1.9) respectively for all patients. Deaths were recorded in three cases (8.8%) and one control (2.9%) (p = 0.6). CONCLUSION: Black African children with CF were more malnourished at diagnosis, and fewer presented with neonatal bowel obstruction. Cases and controls had comparable nutritional, pulmonary function and early mortality outcomes.

Tracking changes in the occurrence and source of pharmaceuticals within the River Thames, UK; from source to sea.

There is a growing interest in the occurrence and sources of pharmaceutical substances in the environment. This paper reports the first detailed transect of pharmaceutical occurrence along the River Thames, UK, from source to sea, undertaken during a period of high flow in 2016. In 37 samples a total of 41 pharmaceuticals and 2 lifestyle compounds (cocaine and sucralose) were detected. Total concentration of pharmaceuticals ranged from 0.0012 µg/l to 10.24 µg/l with a median of 2.6 µg/l. Sucralose concentrations varied from <0.01 to 5.9 µg/l with a median concentration of 1.93 µg/l and was detected in every sample except the groundwater-dominated sources of the Thames. Antimicrobials, including those on the surface water watch list (erythromycin, clarithromycin and azithromycin) were detected in every site downstream of the Thames source. Diclofenac, recently on the surface water watch list, was detected in 97% of Thames samples and above the proposed EQS of 0.1 µg/l in 12 samples. Distinct increases in concentration and number of pharmaceuticals were found downstream of the Oxford, Mogdon and Hogsmill wastewater treatment works (WWTW) but were more subdued downstream of the Crossness and Beckton WWTW due to the tidal nature of the Thames and combined sewer outflows. Sucralose was found to be an excellent tracer of wastewaters (treated and untreated) and can be used as a proxy for many pharmaceuticals. Paracetamol and ibuprofen were tracers of untreated wastewater inputs to the Thames due to their high biodegradation within WWTWs.

Asymptomatic catheter-related venous thrombosis in a child with cystic fibrosis: When to treat?

The use of central venous catheters (CVCs) in patients with cystic fibrosis is associated with an increased incidence of right atrial thrombosis. Practically, the management of CVC-related right atrial thrombosis presents a challenge as there are no clinical trials or systematic reviews in pediatric patients with cystic fibrosis. We describe a case of a 5-year-old child who presented with a CVC-related infection due to Candida parapsilosis. Echocardiogram revealed the presence of an incidental thrombus, measuring 1.4 cm × 0.4 cm, at the tip of the catheter, adherent to the right atrial wall and discrete from the tricuspid valve leaflets. Imaging was performed at monthly intervals and showed spontaneous resolution of the thrombus after six months. Follow-up blood cultures were negative, and the course of the patient was uneventful.

A baseline assessment of emerging organic contaminants in New Zealand groundwater.

Emerging organic contaminants (EOCs) are manufactured compounds, used for a range of purposes, that are a rising concern for freshwater quality, human and aquatic health. Their occurrence in groundwater has been demonstrated in several international surveys. We conducted the first baseline survey on EOC occurrence in New Zealand groundwater, using a wide-screening approach (723 compounds) and a novel stratified to mean residence time (MRT) randomised design to inform future monitoring. A total of 61 sites were sampled: 51 baseline sites from the State of the Environment (SOE) network in the Waikato region and 10 targeted sites located in the vicinity of known EOC sources for comparison. EOCs were detected at 91% of the baseline sites at concentrations ranging from 0.1 to 11,000 ng·L-1. Multiple groups of EOCs were encountered: pesticides (48 compounds), pharmaceuticals (11), industrial (10), preservatives/food additives (3) and personal care products (1). Similar diversity and concentration range of EOCs were observed at the targeted sites, with the addition of drugs of abuse and life-style compounds. EOC detections occurred across young (1-11 yrs. MRT), intermediate (11-50 yrs. MRT) and old (50-250 yrs. MRT) groundwaters with higher concentrations and more types of EOCs detected at sites in the youngest age category. Concentrations of the 73 compounds detected at baseline sites were comparable to those found in overseas groundwaters with 28 compounds measured at concentrations greater than the EU maximum admissible concentration for pesticides. We used the survey results to: review current pesticide monitoring; propose complementary monitoring; identify potential EOC groundwater tracers and identify compounds for which cost-effective national laboratory capability is needed. The Waikato survey results demonstrated ubiquitous occurrence of unmonitored, unregulated EOCs in groundwater and limitations in using targeted approaches to establish monitoring.

Communities of practice: creating opportunities to enhance quality of care and safe practices.

A Communities of Practice (CoPs) approach was used to enhance interprofessional practice in seven clinical sites across Alberta. Participating staff were free to decide the area of practice to focus on and the actions to be implemented. All practice changes implemented by the CoPs related to either improving communications (e.g., introduction of joint care meetings) or information transfer (e.g., streamlining of admission and discharge processes). The practice changes contributed to more effective communication of information and more effective transitions of patients between providers, hence potentially reducing errors. The present study demonstrates that CoPs can enhance interprofessional communication and patient safety in traditional care delivery units. In contrast to more structured safety initiatives, sites were able to choose their area of focus. This ensures buy-in and enhances sustainability, making CoPs an interesting option for patient safety initiatives.

A comparison between raw and predicted mortality in a paediatric intensive care unit in South Africa.

OBJECTIVE: Paediatric intensive care resources are limited in sub-Saharan Africa. The mortality rate in a combined Paediatric/Neonatal Intensive Care Unit in Johannesburg, South Africa was almost double that in a dedicated paediatric intensive care unit in the same country. This study aimed to compare the raw mortality rate with that predicted with the Paediatric Index of Mortality (version 3), by doing a retrospective analysis of an existing database. RESULTS: A total of 530 patients admitted to the intensive care unit between 1 January 2015 and 31 December 2017 were included. The raw mortality rate was 27.1% and the predicted mortality rate was 27.0% (p = 0.971). Cardiac arrest during ICU admission (p < 0.001), non-reactive pupils (0.035), inotropic support (p < 0.001) and renal disease (p = 0.002) were all associated with an increased risk of mortality. These findings indicate that the high mortality rate is due to the severity of illness in the patients that are admitted. It also indicates that the quality of care delivered is acceptable.

Development of the four-item Letter and Shape Drawing test (LSD-4): A brief bedside test of visuospatial function.

Conventional bedside tests of visuospatial function such as the Clock Drawing (CDT) and Intersecting Pentagons (IPT) lack consistency in delivery and interpretation. We compared performance on a novel test of visuospatial ability - the LSD - with the IPT, CDT and MMSE in 180 acute elderly medical inpatients [mean age 79.7±7.1 (range 62-96); 91 females (50.6%)]. 124 (69%) scored ≤23 on the MMSE; 60 with mild (score 18-23) and 64 with severe (score ≤17) impairment. 78 (43%) scored ≥6 on the CDT, while for the IPT, 87 (47%) scored ≥4. The CDT and IPT agreed on the classification of 138 patients (77%) with modest-strong agreement with the MMSE categories. Correlation between the LSD and visuospatial tests was high. A four-item version of the LSD incorporating items 1,10,12,15 had high correlation with the LSD-15 and strong association with MMSE categories. The LSD-4 provides a brief and easily interpreted bedside test of visuospatial function that has high coverage of elderly patients with neurocognitive impairment, good agreement with conventional tests of visuospatial ability and favourable ability to identify significant cognitive impairment. [181 words].

The Letter and Shape Drawing (LSD) test: An efficient and systematised approach to testing of visuospatial function.

The automation and systemisation of the next generation of cognitive assessment approaches have the potential to change how clinicians assess and interact with patients. This may be especially pertinent in the case of delirium, as current methods often rely on the subjective opinion of clinicians and specialists, with potential for the condition to be overlooked or misdiagnosed. Currently, one of the most commonly used tests, is the clock-drawing test, which has relatively wide appeal as a cognitive screening instrument due to its clinical utility and psychometric properties. However, there are a number of inconsistencies associated with its use and interpretation. In this paper, we describe a new assessment methodology that we have developed, facilitated by the advances in tablet technology. In trials, our "Letter and Shape Drawing (LSD)" tool, involving both an automated scoring capability and a simpler user interaction, has demonstrated correlation with other conventional cognitive test methods although some optimisation requirements remain.

The bronchiolitis season is upon us--recommendations for the management and prevention of acute viral bronchiolitis.

Despite being so common, bronchiolitis remains poorly diagnosed and managed. This article is intended as an update on issues pertaining to this condition.

Perceived Barriers to and Facilitators of Patient-to-Provider E-Mail in the Management of Diabetes Care.

OBJECTIVES: 1) to describe current utilization of e-mail in the clinical care of patients with diabetes; and 2) to identify barriers to and facilitators of the adoption of e-mail in diabetes care. METHODS: Participants included diabetes care providers, including 9 physicians and 7 allied health professionals (AHPs). Participation involved, first, completing a self-administered survey to evaluate the use of e-mail within diabetes-related clinical practice. Second, focus group discussions were conducted with diabetes care providers using semistructured interviews to collect data about their perceptions of using e-mail to exchange information with patients diagnosed with diabetes. Patients' perspectives on the use of e-communication with their care providers was also proposed on the basis of the discussions. RESULTS: Significant differences were found between physicians and AHPs concerning questions that were related to the use of e-mail and the amount of time spent using e-mail to communicate to patients. There was perceived function and value to the use of e-mail among AHPs, while few physicians used e-mail routinely and were uncertain about its potential in improving care. Five themes, including barriers, benefits, risks, safeguards and compensation, were developed from the focus group interviews. CONCLUSIONS: Currently, most of the physicians surveyed do not e-mail patients directly; however, AHPs frequently use e-mail in diabetes care and find this tool valuable. Variation in practices regarding clinical e-mail across care disciplines suggest that appropriate policy with guidelines for e-mail and e-communication within the health care system may improve uptake of clinical e-mail and perhaps, by extension, improve efficiency and access in diabetes care.

Early severe neutropenia and thrombocytopenia identifies the highest risk cases of severe meningococcal disease.

OBJECTIVE: To determine the performance of established predictors of mortality in pediatric acute meningococcal disease (MD) in a contemporary population and to develop a simple predictive score that will not vary with observer. DESIGN: Prospective study for development set and mixed retrospective and prospective study for validation set. Setting and PATIENTS: A total of 227 patients with clinical meningococcal disease who were referred to three multidisciplinary pediatric intensive care units from 1993 to 1999. Early deaths before transfer to pediatric intensive care unit and deaths from cerebral herniation were included in the analysis. MEASUREMENTS AND MAIN RESULTS: The product of platelet and neutrophil counts at presentation (PN product) predicts mortality from meningococcal disease better than either count alone and at least as well as established severity scores. The Glasgow Meningococcal Septicaemia Prognostic Score and Malley scores performed poorly in these populations. The positive predictive value (PPV) for a Glasgow meningococcal septicemia prognostic score of >/=8/15 was 17.5% (16 of 91; 95% CI = 9%-25%), significantly lower than published estimates of 30%-74%, (p <.01). The PPV for death (or amputation) with a Malley score of 3/3 was 50% (12 of 24; 29%-71%), significantly lower than the published value of 100% (p <.001). The PN product appears to be a useful predictor. For a PN product of <40, PPV = 82% (9 of 11), specificity = 99% (195 of 197), and sensitivity = 73% (23 of 30). The performance of this score was greatest in younger children <5 yrs of age in whom clinical cerebral herniation was not seen as a cause of death (0 of 21 deaths at <5 yrs of age; 4 of 9 deaths at >/=5 yrs of age). CONCLUSION: Established scores significantly overestimate the occurrence of adverse outcomes in meningococcal disease. This may reflect improved resuscitation and outcome or variability in the application of these scores. The PN product achieves similar prediction to the scores currently in use and is independent of the observer. Factors that reflect the extent of the inflammatory response rather than the care before presentation are becoming increasingly important.

Where and to what extent is prevention of low birth weight possible?

Law birth weight (LBW), due to shortened gestation and/or inadequate fetal growth. is the major determinant of infant mortality and morbidity. Despite improvements in infant mortality, them has been no reduction in LBW rates. The authors examined the relationship between 33 maternal characteristics and the increased risks of preterm (PT) delivery or small-for-gestational-age (SGA) births in 76,444 Alberta women 1994-1997. PT was associated with preexisting medical conditions, obstetrical history, and pregnancy complications. Modifiable factors such as advanced maternal age contributed only 11% to the overall PT risk. SGA births were associated with several modifiable factors, including low prepregnancy weight, maternal age, smoking, drinking, and drug dependency. These contributed to 29% and 31% of PTand term SGA births. Smoking remains an important target for intervention, having contributed to 8% of PT births and about 24% of SGA births. SGA appears to be more amenable to prevention than PT delivery.

Fitness-to-practise policies in Australian medical schools--are they fit for purpose?

OBJECTIVES: To describe current use and possible effects of Australian medical school fitness-to-practise policies (FTPPs), and to define and benchmark FTPP best practice. DESIGN, SETTING AND PARTICIPANTS: A questionnaire-based study of Australian medical schools was conducted in August 2009. MAIN OUTCOME MEASURES: Use of FTPPs by medical schools; criteria used in FTPPs; remediation processes; numbers of students excluded for professional misconduct, reasons for exclusion, and year of study at time of exclusion. RESULTS: The questionnaire was completed by 15 of 19 medical schools to which it was sent, and 12 schools reported using an FTPP. There was wide variation in the FTPP criteria used by individual schools, and use of an FTPP appeared to be independent of medical student registration with state medical boards and type of course entry. There were no apparent differences in medical student exclusion rates between schools with FTPPs and those without. The most common reason for exclusion was persistent inappropriate attitude or behaviour, including poor attendance, and most exclusions occurred by the third year of study. CONCLUSIONS: Most Australian medical schools use FTPPs, but these policies are variable and lack proven effectiveness. The variations in the numbers of students excluded by the different medical schools for unprofessional behaviour suggest discrepancies in the medical schools' abilities to detect and manage students with problems in this area. Previous calls to develop a nationally consistent approach to the management of poorly behaving students should be addressed.