Technology, Training, and Task Shifting at the World's Largest Mass Gathering in 2025: An Opportunity for Antibiotic Stewardship in India.

The role of antibiotic overuse in intensifying selection pressures and contributing to the emergence of antimicrobial resistance is well established. The Kumbh Mela, a religious festival that occurs in 4 Indian cities of spiritual significance, is the world's largest mass gathering, attracting over 80 million pilgrims in 2013. Digital syndromic surveillance from the 2013 and 2015 Melas demonstrated a consistent pattern of antibiotic overuse, with an antibiotic prescribing rate of up to 31% for all patient encounters. As preparations for the 2025 Kumbh Mela begin, task shifting, point-of-care diagnostic and digital tools, robust clinician training, and community awareness can promote the restrained and evidence-based use of antibiotics, minimizing the potential for the emergence of antimicrobial resistance at the world's largest mass gathering.

Diabetes as a risk factor for incident peripheral arterial disease in women compared to men: a systematic review and meta-analysis.

AIMS/HYPOTHESIS: Previous meta-analyses have suggested that diabetes confers a greater excess risk of coronary heart disease, stroke, vascular dementia, and heart failure in women compared to men. While the underlying mechanism that explains such greater excess risk is unknown, in the current meta-analysis we hypothesized that we would find a similar sex difference in the relationship between diabetes and peripheral arterial disease (PAD). METHODS: PubMed MEDLINE, the Cochrane Database of Systematic Reviews, and Embase were systematically searched for prospective population-based cohort studies, with no restriction on publication date, language, or country. We included studies that reported the relative risk (RR), and its variability, for incident PAD associated with diabetes in both sexes. We excluded studies that did not adjust at least for age, and in which participants had pre-existing PAD. In cases where sex-specific results were not reported, study authors were contacted. Random-effects meta-analyses with inverse variance weighting were used to obtain summary sex-specific RRs and the women: men ratio of RRs for PAD. The Newcastle-Ottawa scale was used to assess study quality. RESULTS: Data from seven cohorts, totalling 2071,260 participants (49.8% women), were included. The relative risk for incident PAD associated with diabetes compared with no diabetes was 1.96 (95% CI 1.29-2.63) in women and 1.84 (95% CI 1.29-2.86) in men, after adjusting for potential confounders. The multiple-adjusted RR ratio was 1.05 (95% CI 0.90-1.22), with virtually no heterogeneity between studies (I2 = 0%). All studies scored 6-8, on the Newcastle-Ottawa scale of 0-9, indicating good quality. Eleven of the 12 studies that met review inclusion criteria did not report sex-specific relative risk, and these data were collected through direct correspondence with the study authors. CONCLUSION/INTERPRETATION: Consistent with other studies, we found evidence that diabetes is an independent risk factor for PAD. However, in contrast to similar studies of other types of cardiovascular disease, we did not find evidence that diabetes confers a greater excess risk in women compared to men for PAD. More research is needed to explain this sex differential between PAD and other forms of CVD, in the sequelae of diabetes. In addition, we found that very few studies reported the sex-specific relative risk for the association between diabetes and PAD, adding to existing evidence for the need for improved reporting of sex-disaggregated results in cardiovascular disease research.

Post-migration follow-up of migrants identified to be at increased risk of developing tuberculosis at pre-migration screening: a systematic review and meta-analysis.

BACKGROUND: Post-migration follow-up of migrants considered at increased risk of developing tuberculosis based on pre-migration screening abnormalities (high-risk migrants) is implemented in several low-incidence countries. We aimed to determine the rate of tuberculosis in this population to inform cross-border tuberculosis control policies. METHODS: We searched MEDLINE and Embase (since inception to Jan 12, 2017) for studies evaluating post-migration follow-up of high-risk migrants. Outcomes evaluated were the number of tuberculosis cases occurring post-migration, expressed as the tuberculosis incidence per 100 000 person-years of follow-up, as cumulative incidence of tuberculosis per 100 000 persons, and the cumulative incidence of tuberculosis at the first post-migration follow-up visit. Random-effects models were used to summarise outcomes across studies. FINDINGS: We identified 20 publications (describing 23 study cohorts) reporting the pre-migration screening outcomes of 8 355 030 migrants processed between Jan 1, 1981, and May 1, 2014, with 222 375 high-risk migrants identified. The pooled cumulative incidence of tuberculosis post-migration in our study population from 22 cohorts was 2794 per 100 000 persons (95% CI 2179-3409; I2=99%). The pooled cumulative incidence of tuberculosis at the first follow-up visit from ten cohorts was 3284 per 100 000 persons (95% CI 2173-4395; I2=99%). The pooled tuberculosis incidence from 15 cohorts was 1249 per 100 000 person-years of follow-up (95% CI 924-1574; I2=98%). INTERPRETATION: The high rate of tuberculosis in high-risk migrants suggests that tuberculosis control measures in this population, including more sensitive pre-migration screening, preventive treatment of latent tuberculosis infection, or post-migration follow-up, are potentially effective cross-border tuberculosis control strategies in low-incidence countries. FUNDING: Australian National Health and Medical Research Council.

Itch Management: Physical Approaches (UV Phototherapy, Acupuncture).

BACKGROUND: Physical therapies refer to non-medical treatment strategies, including surgery, cryotherapy, UV phototherapy, and acupuncture. Most physical approaches are inappropriate in the context of itch. UV phototherapy and acupuncture may be effective in the management of itch. METHODS: A literature search was performed using MEDLINE and EMBASE. Bibliographies were reviewed for relevant articles. RESULTS: Narrowband UVB (311-313 nm) and UVA1 (340-400 nm) are equally effective in managing atopic dermatitis and associated itch. The efficacy of broadband UVB in reducing uraemic itch has been demonstrated in a series of randomised controlled trials, but more recent studies have failed to reproduce these results. Non-randomised, uncontrolled studies and case series suggest that UV is effective in managing itch associated with cholestasis, chronic urticaria, prurigo, cutaneous T-cell lymphoma, aquagenic itch, and scleroderma. UV phototherapy is well tolerated, and no significant relationship between UVB therapy and skin cancer has been found. Experimentally, acupuncture has been shown to reduce allergen-related itch, although this finding has been limited by the small number of studies, inconsistency in agreement on acupuncture sites and study design, small sample sizes, and limited follow-up. CONCLUSIONS: UV phototherapy is an effective treatment for itch associated with atopic dermatitis. UVB may be effective in managing itch associated with end-stage kidney disease, cholestasis, chronic urticaria, prurigo, cutaneous T-cell lymphoma, aquagenic itch, and scleroderma. Phototherapy should be combined with standard first-line therapies. Insufficient evidence exists to justify acupuncture as a physical therapy for itch. Further well-designed studies are required to establish the effectiveness of physical therapies in managing itch.