Appraisal of potentially toxic metals contamination in protein supplements for muscle growth: A chemometric approach and associated human health risks.

BACKGROUND: The use of protein supplements by athletes has risen due to their effectiveness in meeting dietary needs. However, there is a growing concern about the presence of potentially toxic metals (PTMs. Al, Cr, Mn, Ni, Cu, Zn, Cd, and Pb) in these supplements. Consequently, it is crucial to evaluate the levels of these PTMs to ensure the safety of the supplements. METHODS: The objective of the current study was to assess the PTMs concentrations in protein supplements and examine any possible health hazards. Twenty-five samples of protein supplements were purchased from different pharmacies to screen them for metals. Inductively coupled plasma-optical emission spectrometry (ICP-OES) was utilized to analyze metal content. Additionally, chemometric methods such as Pearson's correlation coefficient (PCC), principal component analysis (PCA), and hierarchical cluster analysis (HCA) were employed to identify possible sources of PTMs contamination in protein supplements. RESULTS: Concentration ranges for PTMs were found as, Al (0.03-3.05 mg/kg), Cr (0.11-0.89 mg/kg), Mn (1.13-8.40 mg/kg), Ni (0.06-0.71 mg/kg), Cu (1.05-5.51 mg/kg), Zn (2.14-27.10 mg/kg), Cd (0.01-0.78 mg/kg), and Pb (0.06-0.57 mg/kg). The weekly intake of Cd exceeded the level of tolerable weekly intake (TWI) set by the European Food Safety Authority (EFSA). CONCLUSION: Athletes, bodybuilders, fitness enthusiasts, dieters, young adults and adolescents, and health-conscious individuals should be conscious of Cd concentration as it does not compliance the TWI set by EFSA. Target hazard quotient (THQ < 1), hazard index (HI < 1), margin of exposure (MOE ≥ 1), percentile permitted daily exposure (% PDE < 100), and cumulative cancer risk (CCR < 1 × 10-3) analyses revealed that there are no appreciable non-carcinogenic and carcinogenic health risks associated with the use of these products.

The dynamic nature of parenting practices: a qualitative enquiry of parenting adolescents during COVID-19.

Introduction: Parenting practices are known to be dynamic, evolving in response to various factors such as societal changes, cultural norms, and individual circumstances. Understanding the dynamic nature of parenting is essential for comprehending its influence on children's development. This study aimed to explore the adaptive nature of parenting practices amidst the backdrop of the COVID-19 pandemic, a global event that provided a unique context for examining these dynamics. Methods: In-depth semi-structured qualitative interviews were conducted with six heterogeneous couples who were parenting at least one adolescent during the pandemic. Attride-Sterling's thematic network analysis was employed to analyze the interview data. Results: Five global themes emerged from the data, namely, change in parenting style due to stressors, paternal versus maternal style of parenting, intergenerational transmission of parenting practices, child-centric parenting practices, positive parenting practices and evolving parent-child relationship during COVID-19. Discussion: The findings highlight the tendency of parents to adapt their parenting styles to meet the evolving needs of their children. Understanding these dynamics is crucial for supporting families during times of crisis. Future research should explore the long-term effects of these changes and effective strategies for promoting positive parent-child relationships.

GC-MS-based profiling and ameliorative potential of Carissa opaca Stapf ex Haines fruit against cardiac and testicular toxicity: An In vivo study.

Fruit of Carissa opaca Stapf ex Haines (C. opaca) is a feed additive and is commonly used against cardiac dysfunction, fever, asthma, diarrhea, gastrointestinal ailments, and skin diseases. In this study, we aimed to evaluate the metabolic profile and antioxidant potential of C. opaca fruit against carbon tetrachloride (CCl4)-induced cardiotoxicity and testicular toxicity in rats. Gas Chromatoghraphy-Mass Spectrometry (GC-MS) analysis of C. opaca fruit for the identification of potential metabolic profile, followed by methanolic extract of C. opaca and its derived fractions including n-hexane, ethyl acetate, chloroform, butanol, and aqueous were used to assess the antioxidant potential of fruits. Ten groups of rats received different treatments and got evaluated for cardiac and testicular antioxidant enzymes, histological architecture, and serum hormonal levels. GC-MS analysis of methanolic extract of C. opaca fruit showed the presence of some bioactive metabolites like cyclodecane, diethyl 2,6-pyridine dicarboxylate, tetrahydro-geraniol, S-[2-[N, N-Dimethylamino]ethyl]morpoline, 2,3-Methylenedioxyphenol, alpha-d-Glucopyranoside, 5,10-Diethoxy-2,3,7,8-tetrahydro-1H, 6H-dipyrrolo [1,2-a; 1',2'-d] pyrazine and 1,3-Benzothiazol-2(3H)-one,3-(3,3-dimethyl-1-oxobutyl) that corresponds the medicinal properties of C. opaca fruit. Prepared fractions of C. opaca fruits mitigated the toxicity induced by CCl4 in the heart and testicular tissues of rats. Oxidative stress was caused by the inhibition of activities of glutathione and other antioxidant enzymes of the body, while on the other hand elevating the levels of nitrite and hydrogen peroxide. Treatment with C. opaca fruit extract normalized the levels of enzymes, reproductive hormones, and free radicals thus restoring the histopathological and enzymatic biomarkers towards the normal group. The study supports the indigenous use of fruits as an alternative medicine against cardiac dysfunction by providing scientific evidence of protection against CCl4-induced injuries, and it also concludes the antioxidant defensive role in testicular tissues.

Pleurospermum candollei Methanolic Extract Ameliorates CCl4-Induced Liver Injury by Modulating Oxidative Stress, Inflammatory, and Apoptotic Markers in Rats.

The main objective of this study was to investigate the hepatoprotective potency of the Pleurospermum candollei methanol extract against CCl4-induced liver damage in rats. HPLC technique was used to estimate the presence of polyphenols in the methanol extract of P. candollei (PCM), while proximate analysis revealed the presence of carbohydrates, lipids, and moisture in the extract. The antioxidant potential of PCM was evaluated by 2,2-diphenylpicrylhydrazyl (DPPH) and reducing power assay, which showed a high percentage of inhibition against free radicals. Hepatotoxicity was induced by carbon tetrachloride (CCl4). CCl4 administration reduced the activity of endogenous antioxidants, whereas it increased the production of nitrites and hydrogen peroxide (H2O2) in rats. Furthermore, the level of hepatic markers in serum was also elevated after CCl4 administration. Moreover, the expression of stress-related markers, proinflammatory mediators, and apoptotic genes was enhanced in CCl4-treated rats. Coadministration of PCM along with CCl4 in rats reduced the levels of free radicals and the above genes to normal levels. CCl4 administration caused histopathological alterations in liver tissues, while cotreatment with PCM mitigated liver injuries. These findings suggest that the methanol extract of P. candollei possesses antioxidant and anti-inflammatory properties and can prevent liver injury. Further pharmacological research will be helpful in determining the effectiveness of P. candollei in humans. Development of FDA-approved plant-based anti-inflammatory drugs can help treat patients and reduce the chances of toxicity.

Outcome, risk factors and therapeutic strategies in carbapenem-resistant Gram-negative bacteraemia from Pakistan.

Background: Carbapenem-resistant Gram-negative (CRGN) bacteraemia has high mortality and limited therapeutic options. We assessed the risk factors and outcome of CRGN bacteraemia treated with limited options. Methods: A prospective cohort study done at a tertiary care hospital in Pakistan, from October 2021 to August 2022. All patients >18 years with CRGN bacteraemia were assessed for demographics, source, risk factors and treatment received. Outcome was assessed as bacterial clearance and all-cause mortality at Day 14 of bacteraemia. Results: We included 175 patients. Median age was 45 years (IQR 30-58) and the majority of our patients were on haemodialysis (75%). We found 14 day mortality in 26.8% of our patients; in addition, microbiological clearance was achieved in 95%. The central line (49.7%) was the most common source and Klebsiella spp. (47%) the most common organism. On multivariate analysis, risk factors for mortality were Foley's catheter [aOR 2.7 (95% CI 1.1-6.5)], mechanical ventilation [aOR 5.1 (95% CI 1.6-15.8)] and Pitt bacteraemia score >4 [aOR 3.48 (95% CI 1.1-10.5)]. Source control was a significant protective factor [aOR 0.251 (95% CI 0.09-0.6)]. The majority received a colistin-based regimen with no difference in mortality between monotherapy and combination therapy. Conclusions: Our cohort of CRGN bacteraemia is unique, comprising younger patients mostly on haemodialysis with a central line as the source of bacteraemia and we have found 14 day mortality of 27%. Colistin with various combinations can be an effective option in patients with renal failure having prompt source control.

Forensic Age Estimation of Individuals from Computed Tomography Analysis of Medial Clavicular Epiphysis in Pakistani Population.

OBJECTIVE: To determine the association of chronological age through ossification of the medial clavicular epiphysis using computed tomography (CT) scan. STUDY DESIGN: An Observational study. Place and Duration of the Study: Dow Institute of Radiology, Dow University Hospital, Karachi, Pakistan, from February 2021 till October 2021. METHODOLOGY: Subjects aged 10-35 years of either gender reported without any clavicular trauma or fracture, no known chronic illness or malignancy, or no congenital bony abnormalities, or any prior surgical intervention to the sterno-clavicular region were included. The fusion of maturity of medial clavicular epiphyses was evaluated on either side by using the five-stage classification system reported by Schmeling. RESULTS: Of 200 patients, a significant increase in the age of the patients was observed with respect to the increase in the stages (p <0.001). When stratified on the basis of gender, a significant increase in age was also observed with respect to the increase in stages (p <0.001). Stage 4 was observed in majority of the patients, i.e., 81 (40.5%), followed by stages 2 and 3 in 35 (17.5%) each, stage 5 in 32 (16%), while stage 1 was observed in 17 (8.5%) patients. An insignificant difference of age was observed with respect to the gender of the patients (p= 0.472, 95% CI -2.91 - 1.35). CONCLUSION: The fusion of the medial clavicular epiphysis showed a considerable degree of variability. Fused clavicles at stage 4 could be observed at age 22 years or less in males while at 21 years or less in females. KEY WORDS: Age estimation, Schmeling method, Medial clavicular epiphysis, Computed tomography.

Jasminum humile (Linn) ameliorates CCl4-induced oxidative stress by regulating ER stress, inflammatory, and fibrosis markers in rats.

Jasminum humile (Linn) is highly valued for its medicinal properties. The pulp and decoction made from its leaves are effective for skin diseases. Juice prepared from roots is used against ringworm illness. Our current study aims to illustrate the non-toxicity and protective potential of methanol extract of Jasminum humile (JHM) against CCl4-induced oxidative stress in the liver of rats. Qualitative phytochemical screening, total flavonoids (TFC), and total phenolic content (TPC) assays were performed with JHM. The toxicity of the plant was estimated by treating female rats at different JHM doses while to assess anti-inflammatory potential of plant nine groups of male rats (six rats/group) received different treatments such as: CCl4 only (1 ml/kg mixed with olive oil in a ratio of 3:7), silymarin (200 mg/kg) + CCl4, different doses of JHM alone at a ratio of 1:2:4, and JHM (at a ratio of 1:2:4) + CCl4, and were examined for different antioxidant enzymes, serum markers, and histological changes, while mRNA expression of stress, inflammatory and fibrosis markers were assessed by real-time polymerase chain reaction analysis. Different phytochemicals were found in JHM. A high amount of total phenolic and flavonoid content was found (89.71 ± 2.79 mg RE/g and 124.77 ± 2.41 mg GAE/g) in the methanolic extract of the plant. Non-toxicity of JHM was revealed even at higher doses of JHM. Normal levels of serum markers in blood serum and antioxidant enzymes in tissue homogenates were found after co-administration of JHM along with CCl4. However, CCl4 treatment caused oxidative stress in the liver by enhancing the levels of stress and inflammatory markers and reducing antioxidant enzyme levels, while JHM treatment showed significant (P < 0.05) downregulation was in mRNA expression of those markers. Investigation of mechanism of specific signaling pathways related to apoptosis and clinical trials to assess safety and efficacy of optimal dosage of Jasminum humile will be helpful to develop FDA-approved drug.

MED1 Deficiency in Macrophages Aggravates Isoproterenol-Induced Cardiac Fibrosis in Mice.

Mediator 1 (MED1), a key subunit of the mediator complex, interacts with various nuclear receptors and functions in lipid metabolism and energy homeostasis. Dilated cardiomyopathy-related ventricular dilatation and heart failure have been reported in mice with cardiomyocyte-specific Med1 deficiency. However, the contribution of macrophage-specific MED1 in cardiac remodeling remains unclear. In this study, macrophage-specific Med1 knockout (Med1ΔMac) mice were generated and exposed to isoproterenol (ISO) to induce cardiac fibrosis; these mice showed aggravated cardiac fibrosis compared with Med1fl/fl mice. The levels of expression of marker genes for myofibroblast transdifferentiation [α-smooth muscle actin (SMA)] and of profibrotic genes, including Col1a1, Col3a1, Postn, Mmp2, Timp1, and Fn1, were significantly increased in the cardiac tissues of Med1ΔMac mice with ISO-induced myocardial fibrosis. In particular, the transforming growth factor (TGF)-ß-Smad2/3 signaling pathway was activated. In bone marrow-derived and peritoneal macrophages, Med1 deficiency was also associated with elevated levels of expression of proinflammatory genes, including Il6, Tnfa, and Il1b. These findings indicate that macrophage-specific MED1 deficiency may aggravate ISO-induced cardiac fibrosis via the regulation of the TGF-ß-SMAD2/3 pathway, and the underlying mechanism may involve MED1 deficiency triggering the activation of inflammatory cytokines in macrophages, which in turn may stimulate phenotypic switch of cardiac fibroblasts and accelerate cardiac fibrosis. Thus, MED1 is a potential therapeutic target for cardiac fibrosis.

Microbial toxins in fermented foods: health implications and analytical techniques for detection.

Recently, demand for fermented foods has increased due to their improved nutritional value, taste, and health-promoting properties. Worldwide consumption of these products is increasing. Fermented foods are generally safe for human consumption. However, some toxins, primarily biogenic amines (putrescine, phenylethylamine, histamine, tyramine, and cadaverine), mycotoxins (fumonisins, aflatoxins, ochratoxin A, zearalenone, and trichothecenes), and bacterial toxins (endotoxins, enterotoxins, and emetic toxins) can be produced as a result of using an inappropriate starter culture, processing conditions, and improper storage. These toxins can cause a multitude of foodborne illnesses and can lead to cardiovascular aberration and adverse gastrointestinal symptoms. Analytical techniques are in use for the detection of toxins in fermented foods for monitoring and control purposes. These include culture, chromatographic, immunoassays, and nano sensor-based techniques. These detection techniques can be used during the production process and along the food chain. On an industrial scale, HPLC is widely used for sensitive quantification of toxins in fermented foods. Recently, biosensor and nano sensor-based techniques have gained popularity due to accuracy, time efficiency, and simultaneous detection of multiple toxins. Other strategic methods being investigated for the removal of toxins from fermented foods include the use of specific starter cultures for bio-preservation, aflatoxin-binding, and biogenic amine-degradation agents that may help to appropriately manage the food safety concerns associated with fermented foods.

Association of spectral Doppler cardiac activity in the lower limb veins and echocardiographic findings in patients with tricuspid regurgitation.

Objective: To determine the association between spectral Doppler cardiac activity in the lower limb veins and echocardiographic findings in patients with tricuspid regurgitation. Material and methods: A cross-sectional analysis was performed in the Gilani Ultrasound Center over a period of 13 months. The total study sample comprised 400 subjects. All individuals referred for abdominal ultrasound having cardiac activities in external iliac vein, popliteal and posterior tibial vein, individuals having normal venous Doppler ultrasound, both genders and all ages, were included, and unwilling and non-cooperative patients were excluded from the study. Results: Out of 400 individuals, 200 showed cardiac activity in the lower limb veins on Doppler vascular ultrasound, while 200 did not show cardiac activity. On echocardiography, 204 individuals were diagnosed with tricuspid regurgitation, and 196 individuals had a competent tricuspid valve. According to the independent sample t-test the mean difference in the posterior tibial vein was 25.54 (95% CI: 24.09; 26.98), while the mean difference in the iliac vein was 2.34 (95% CI: 0.64; 4.03) among normal and tricuspid regurgitation. Conclusion: A correlation was found between the cardiac activities in the lower limb veins and tricuspid regurgitation.Objective: To determine the association between spectral Doppler cardiac activity in the lower limb veins and echocardiographic findings in patients with tricuspid regurgitation. Material and methods: A cross-sectional analysis was performed in the Gilani Ultrasound Center over a period of 13 months. The total study sample comprised 400 subjects. All individuals referred for abdominal ultrasound having cardiac activities in external iliac vein, popliteal and posterior tibial vein, individuals having normal venous Doppler ultrasound, both genders and all ages, were included, and unwilling and non-cooperative patients were excluded from the study. Results: Out of 400 individuals, 200 showed cardiac activity in the lower limb veins on Doppler vascular ultrasound, while 200 did not show cardiac activity. On echocardiography, 204 individuals were diagnosed with tricuspid regurgitation, and 196 individuals had a competent tricuspid valve. According to the independent sample t-test the mean difference in the posterior tibial vein was 25.54 (95% CI: 24.09; 26.98), while the mean difference in the iliac vein was 2.34 (95% CI: 0.64; 4.03) among normal and tricuspid regurgitation. Conclusion: A correlation was found between the cardiac activities in the lower limb veins and tricuspid regurgitation.

Ultrasonographic Features Associated with Diffuse Hepatosteatosis among Diabetic Obese and Normal Body Mass Index Patients.

BACKGROUND: The purpose of the study is to evaluate and compare the changes associated with hepatosteatosis in diabetic obese versus diabetic normal-weight patients through ultrasonography. It is estimated that with the prevalence of about 30%-75% of obese individuals accordingto the body mass index (BMI) criteria are at increase risk of developing simple fatty live. Besides obesity, diabetes mellitus is also considered to be one of the important causes of hepatosteatosis. METHODS: This prospective study was conducted in February 2015-December 2015 on a group of 181 diabetic patients, including 65 males and 116 females with an age range of 40-80 years. The patients were divided into two diabetic groups: those having a BMI ≥30 kg/m2 were included in the obese group (n = 116) and those with a BMI of 18.5-25 kg/m2 were included in the normal BMI group (n = 65). Ultrasound machine Esaote MyLab 50 equipped with a 3.5-5 MHz curvilinear multifrequency transducer was used to scan the liver. Independent samples t-test was performed to compare the liver span in the two groups. Chi-square tests were applied to compare the frequencies of fatty changes, border, and surface characteristics. RESULTS: The presence of fatty changes among obese groups was statistically significant in the diabetic obese group compared to the normal-weight individuals with P < 0.0001. Similarly, hepatic spans were found to be significantly greater in the diabetic obese group than the diabetic normal BMI group on independent samples t-test with P < 0.0001. Females were seen to develop hepatosteatosis more frequently compared to males in all diabetic individuals with P = 0.02. CONCLUSION: It is concluded that diabetic obese patients are more prone to develop hepatosteatosis as compared to normal BMI diabetic individuals.

Sonographic Evaluation of Urolithiasis Formation with Positive Family History in the Population of Lahore.

BACKGROUND: The purpose of the research is to know the sonographic evaluation of urolithiasis formation with positive family history in population of Lahore because urolithiasis is a major problem in Pakistan. According to a survey in 1985-1987 the incidence rate reaches to 8.3/100,000 individuals in the Punjab. In Pakistan, urolithiasis is the sixth major cause of surgery. The study was conducted to rule out the role of positive family history in people suffering from urolithiasis. MATERIALS AND METHODS: This was an observational cross-sectional study conducted at the Radiology department of the University of Lahore teaching hospital and Gilani Ultrasound center-Afro-Asian Institute, Lahore, Pakistan. A total of 125 patients were included in the study which were diagnosed with urolithiasis and individuals with any other abnormality were excluded from the study. The duration of the study was from January 2017 to April 2017. Data were tabulated and analyzed using SPSS version 24. The data were reported using descriptive and inferential statistics. The quantitative variable like age was assessed using mean standard deviation and standard errors. The qualitative variables like gender were reported using percentages and frequencies. RESULTS: Urolithiasis is commonly seen in the males (77 individuals out of 125) as compared to females (48 individuals out of 125) and mid pole of right kidney is the most common site of the renal stones deposition (13.6%), and the relationship of father is mostly seen as familial history (39.2%). CONCLUSION: It is concluded that positive family history is the major predisposing factor in urolithiasis and one of the cause in the development of stones in the urinary tract or in other words people who have a history of urolithiasis in blood relations have more tendency of stone formation in any part of their lives. Its positive aspect is that we can do a screening in blood relations, especially whose parents or family members diagnosed with stones and can do preventive measures for that. Moreover, its negative aspect is that there are several causes of the stone formation in the urinary tract.

Environmental risk modelling and potential sand fly vectors of cutaneous leishmaniasis in Chitral district: a leishmanial focal point of mount Tirich Mir, Pakistan.

OBJECTIVE: To provide baseline information about suspected vectors and the incidence, distribution and an active zone of transmission for cutaneous leishmaniasis (CL) in Chitral, Pakistan, using GIS tools; and to investigate the role of environmental factors in the disease dynamics. METHOD: Two surveys in 2014 and 2016 as a basis for choropleth and environmental risk mapping. RESULTS: A total of 769 captured specimens yielded 14 Phlebotomus and six Sergentomyia species including two potential vectors of CL, i.e. Phlebotomus papatasi and Phlebotomus sergenti. P. papatasi (71%) was dominant, followed by P. sergenti (18%). A choropleth map generated in Arcmap 10.1 based on 1560 CL case reports displayed maximum prevalence (0.92-2.5%) in Ayun, Broz, Charun, Chitral 1 and 2 and Darosh 1 and 2 union councils. An environmental risk map constructed by MaxEnt 3.3.3 defined an active zone of transmission based on leishmaniasis occurrence records (n = 315). The analysis of variable contribution in MaxEnt indicates significance of elevation (54.4%), population density (23.3%) and land use/land cover (6.6%) in CL disease dynamics. CONCLUSION: The probability of CL increases (0.6-1 on logistic scale) in severely deforested areas, in lowland valleys and in regions with high-population density.

Endobronchial Ultrasound Guided Transbronchial Needle Aspiration (EBUS-TBNA) for Diagnosis of Mediastinal and Hilar Masses.

OBJECTIVE: To determine the sensitivity, specificity, negative and positive predictive values, and diagnostic accuracy of Endobronchial Ultrasound Guided Transbronchial Needle Aspiration (EBUS-TBNA). STUDY DESIGN: Across-sectional validation study. PLACE AND DURATION OF STUDY: Department of Histopathology, Army Medical College, in collaboration with Department of Pulmonology, Military Hospital Rawalpindi, from March 2014 to March 2015. METHODOLOGY: Cases of EBUS-TBNAcomprised of both TBNAs and cell block/biopsy of the same patients. Diagnosis was made on the TBNAslides and cell block/biopsy material. Taking biopsy/cell block as the gold standard, the data was analysed to calculate the sensitivity, specificity, negative and positive predictive values, and diagnostic accuracy of EBUSTBNA. RESULTS: The sensitivity of EBUS-TBNAwas found to be 96.5%; whereas, specificity and positive predictive values were 100%. The negative predictive value was calculated at 50%. Diagnostic accuracy of the procedure was found to be 96.67%. CONCLUSION: EBUS-TBNA is a sensitive and a specific test and is accurate in diagnosing mediastinal and hilar pathologies.

DREEM on: validation of the Dundee Ready Education Environment Measure in Pakistan.

OBJECTIVES: To validate DREEM in medical education environment of Punjab, Pakistan. METHODS: The DREEM questionnaire was anonymously collected from Final year Baccalaureate of Medicine; Baccalaureate of Surgery students in the private and public medical colleges affiliated with the University of Health Sciences, Lahore. Data was analyzed using Principal Component Analysis with Varimax Rotation. RESULTS: The response rate was 84.14 %. The average DREEM score was 125. Confirmatory and Exploratory Factor Analysis was applied under the conditions of eigenvalues >1 and loadings > or = 0.3. In CONFIRMATORY FACTOR ANALYSIS, Five components were extracted accounting for 40.10% of variance and in EXPLORATORY FACTOR ANALYSIS, Ten components were extracted accounting for 52.33% of variance. Total 50 items had internal consistency reliability of 0.91 (Cronbach's Alpha). The value of Spearman-Brown was 0.868 showing the reliability of the analysis. In both analyses the subscales produced were sensible but the mismatch from the original was largely due to the English-Pakistan contextual and cultural differences. CONCLUSION: DREEM is a generic instrument that will do well with regional modifications to suit individual, contextual and cultural settings.

Coverage to curb the emerging HIV epidemic among injecting drug users in Pakistan: delivering prevention services where most needed.

BACKGROUND: HIV Surveillance data from IDUs is suggestive of an escalating epidemic in major cities of Pakistan. The relatively widespread presence and interlinking of IDU and high-risk sexual networks, combined with low levels of HIV knowledge and prevention methods, indicate that there is potential for a rapid spread of HIV to other high-risk groups and its further expansion to general population through bridging groups. METHODS: We reviewed Second Generation Surveillance data which provides mapping, biological and behavioural information from IDUs in eight major cities across Pakistan. Geographic mapping provided information about the location and size of the population, which was followed by a behavioural survey, conducted with a representative sample of 2432 IDUs. In addition, blood samples were also obtained which were tested for HIV. RESULTS: Despite availability of syringe and needle exchange programmes in larger cities, drug users continued to reuse syringes (78.1%), injected in groups (73.3%) where extensive sharing of needle and injecting paraphernalia took place (50%). 12.6% of the respondents reported to having sexual relationships with female sex workers and 14.7% had sex with males in the past 6 months. 65% never used condoms. In addition 5.3% reported exchange of sex for money and drugs. Fairly low levels of coverage were reported from most of the cities. CONCLUSION: Despite an existing nationwide harm reduction programme, increasing rates of HIV infection among IDUs underscore the need to identify gaps in the existing prevention strategy. Data available on coverage shows that effective harm reduction activities are unable to reach a substantial number of IDUs to actually avert or delay the emerging IDUs epidemic. There is an urgent need to expand coverage, and to integrate harm reduction in the mainstream of public health.