BackgroundMistreatment or belittlement of medical students either by faculty or fellow students has often been reported. Perception of mistreatment has also been associated with increased degree of psychological morbidity. There is a lack of such studies being conducted amongst the medical students of Pakistan. The aim of this study was to determine the prevalence and forms of perceived mistreatment and presence of mental health morbidity in a private medical school in Pakistan. Also, any association between mental health morbidity and mistreatment was to be identified.MethodsA cross sectional study was carried out on medical students from Aga Khan University Hospital, Karachi, Pakistan during the period of June–September 2007. A self administered questionnaire, adapted from Frank et al and Baldwin et al was distributed to a total of 350 students. The questionnaire consisted of three parts: the first dealing with the demographics of the population, the second concerning the various forms of mistreatment, while the third assessed the mental health of students using the General Health Questionnaire 12(GHQ12). Descriptive statistics were performed. The Chi-square test and Fisher's exact tests were applied.ResultsA total of 350 students were approached out of which 232 completed the questionnaire giving a response rate of 66.2%. Mistreatment was reported by 62.5% (145/232) of the respondents. Of these, 69.7% (83/145) were males and 54.9% (62/145) were females. There was a significant relationship between gender, year division, stress at medical school and possible use of drugs/alcohol and reported mistreatment but no statistical relationship was seen with psychiatric morbidity. The overall prevalence of psychological morbidity was 34.8% (77/221).ConclusionThis study suggests high prevalence of perceived mistreatment and psychological morbidity among Pakistani medical students. However, no association was found between these two aspects of medical student education. There is a need to bring about changes to make the medical education environment conducive to learning. Increased student feedback, support systems and guidance about progress throughout the year and the provision of adequate learning resources may provide help with resolving both of these issues.

Introduction Systemic Sclerosis (SSc) is a systemic autoimmune disease characterized by severe and often progressive cutaneous, pulmonary, cardiac and gastrointestinal tract fibrosis, cellular and humoral immunologic alterations, and pronounced fibroproliferative vasculopathy. There is no effective SSc disease modifying therapy. Patients with rapidly progressive SSc have poor prognosis with frequent disability and very high mortality. Areas Covered This paper reviews currently available therapeutic approaches for rapidly progressive SSc and discuss novel drugs under study for SSc disease modification. Expert Opinion The extent, severity, and rate of progression of SSc skin and internal organ involvement determines the optimal therapeutic interventions for SSc. Cyclophosphamide for progressive SSc-associated interstitial lung disease and mycophenolate for rapidly progressive cutaneous involvement have shown effectiveness. Methotrexate has been used for less severe skin progression and for patients unable to tolerate mycophenolate. Rituximab was shown to induce improvement in SSc-cutaneous and lung involvement. Autologous bone marrow transplantation is reserved for selected cases in whom poor survival risk outweighs the high mortality rate of the procedure. Novel agents capable of modulating fibrotic and inflammatory pathways involved in SSc pathogenesis, including tocilizumab, pirfenidone, tyrosine kinase inhibitors, lipid lysophosphatidic acid 1, and NOX4 inhibitors are currently under development for the treatment of rapidly progressive SSc.

Methods We aimed to review the management of patients with decompensated liver disease in the first 24 h after admission to hospital. This was a region-wide audit including all Trusts in the Northern Deanery. An audit proforma was designed and data collected on consecutive admissions over a 3 month period.Results 139 patients were included in the study; 69% male, median age 54 years (range 26-86 years). ARLD was the cause of liver disease in 88%. The median MELD score was 19 (range 6-39) and 88% had Child-Pugh Grade B or C disease. The commonest reasons for admission were ascites (28%), GI bleeding (21%), encephalopathy (19%) and jaundice (16%).There was a 9% mortality rate during the admission and average length of stay was 15 days.82 patients had clinical ascites; 62% had a diagnostic tap within 24 h of admission, 21% waited >24 h and 17% did not have a diagnostic tap. 18% had spontaneous bacterial peritonitis (SBP).Previous alcohol history was only documented in 43% but current daily consumption was documented in 81%. Of patients with documented current alcohol excess, 92% received pabrinex and 94% were started on CIWA.99% had their renal function checked on admission. 26% had renal impairment; 28% of whom did not have all their nephrotoxins stopped. Hyponatraemia (sodium <125 mmol/L) was present in 9%; 42% of whom did not have diuretics stopped.27 (19%) patients had known or suspected variceal bleeding. 19% did not receive terlipressin and 30% did not receive vitamin K. 67% of patients had an upper GI endoscopy within 12 h of admission, and 78% within 24 h.Hepatic encephalopathy was present in 32% of patients and lactulose commenced in 98%.17% of patients were not seen by a consultant (any speciality) within 12 h of admission, 7% were not seen by a gastroenterology or hepatology consultant within 72 h of admission and 39% were not seen within 24 h. Conclusion There are clear deficiencies in the acute management of patients with decompensated liver disease across the Northern region in keeping with the findings of the NCEPOD report. The findings of this audit will be shared across the region and we are instituting a 'care bundle' to focus on the key management of these patients and guide clinicians to improve patient care. We will re-audit to assess the impact of the 'care bundle' on patient care.

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