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Introduction: Loaded ruck marching is a common training and operational task for many members of the military. It is known to cause fatigue, affect soldier readiness, and can lead to traumatic and overuse injuries. Quantifying the gait changes that occur over the course of a loaded ruck march may provide a better understanding of injury mechanisms and potentially allow for development of individualized injury-prevention training programs. This study examined the change in soldiers' gait patterns over the course of a loaded ruck march in order to examine the correlation between fatigue and kinematic parameters. Fatigue is a subjective term that may encompass factors such as energy expenditure, muscle exhaustion, and cognitive engagement. Since it can be difficult to quantify, the current study makes the broad assumption that fatigue increases in some (potentially nonlinear) fashion during a loaded ruck march., Method: Three platoons of soldiers participated in a field training exercise with inertial measurement sensors placed on their chests and ankles to record gait parameters throughout a 7-mile ruck march. The effects of fatigue on stride length, stride width, ankle yaw, and torso lean (anterior-posterior [AP] and side-to-side [SS]) were compared using one-way repeated measure analyses of variance., Results: In comparing the first and last quarters of the ruck march, stride length decreased, stride width increased, stride width variability increased, AP torso lean variability increased, and SS torso lean variability increased., Conclusion: Although they do not describe a direct relationship to injury, these results can inform enhanced approaches to quantify and predict soldier fatigue and more reliably prevent future injury., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Inappropriate and excessive antimicrobial prescribing can lead to antimicrobial resistance. Antimicrobial Stewardship (AMS) principles are not well established in general practice in Australia despite the relatively high rate of community antimicrobial prescribing. Few interventions have been implemented that have resulted in a significant reduction or improvement in antimicrobial prescribing by General Practitioners (GPs). This study was therefore conducted to assess the impact of a novel GP educational intervention on the appropriateness of antimicrobial prescriptions as well as GP compliance with antimicrobial prescription guidelines., Methods: In 2018, a simple GP educational intervention was rolled out in a large clinic with the aim of improving antimicrobial prescribing. It included face-to-face education sessions with GPs on AMS principles, antimicrobial resistance, current prescribing guidelines and microbiological testing. An antibiotic appropriateness audit on prescribing practice before and after the educational intervention was conducted. Data were summarised using percentages and compared across time points using Chi-squared tests and Poisson regression (results reported as risk ratios (RR) with 95% confidence intervals (CI))., Results: Data from 376 and 369 prescriptions in July 2016 and July 2018, respectively, were extracted. There were significant improvements in appropriate antimicrobial selection (73.9% vs 92.8%, RR = 1.26; 95% CI = 1.18-1.34), appropriate duration (53.1% vs 87.7%, RR = 1.65; 95% CI = 1.49-1.83) and compliance with guidelines (42.2% vs 58.5%, RR = 1.39, 95% CI = 1.19-1.61) post- intervention. Documentation of antimicrobial duration directions, patient follow-up as well as patient weight significantly increased after the intervention (p < 0.001). There was significant reduction in; prescriptions without a listed indication for antimicrobial therapy, prescriptions without appropriate accompanying microbiological tests and the provision of unnecessary repeat prescriptions (p < 0.001). Inappropriate antimicrobial prescriptions observed pre-intervention for medical termination of pregnancy ceased post-intervention., Conclusions: Auditing GP antimicrobial prescriptions identified prescribing practices inconsistent with Australian guidelines. However, implementation of a simple education program led to significantly improved antimicrobial prescribing by GPs. These findings indicate the important role of AMS and continued antimicrobial education within general practice.

Extranodal natural killer (NK-)/T cell lymphoma, nasal type (ENKL), 1 is a rare disease that often mimics rheumatological and infectious conditions and can therefore be difficult to diagnose. The authors present a case of a 55-year-old Vietnamese woman who was misdiagnosed with severe atrophic rhinitis and chronic sinus osteitis. Over a period of 8 months from initial referral, she underwent multiple biopsies and was treated with various antimicrobial regimens until the histopathological diagnosis of ENKL was finally made. Her presentation was complicated by bacterial dacrocystitis, preseptal cellulitis and a retrobulbar extraconal phlegmon requiring surgical drainage. She also subsequently developed a naso-oral fistula on treatment. This case highlights the importance of repeated biopsies, in particular from non-necrotic regions of the sinonasal tract when a patient does not respond to therapy and clinical suspicion of neoplastic pathology remains. This is the first case of ENKL to describe significant orbital complication., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Reports of Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (KPC-Kp) in Australia were previously uncommon, with cases imported sporadically by travellers from higher prevalence countries., Aim: The study institution reported the first outbreak of KPC-Kp in Australia. The aim of this study was to identify risk factors for KPC-Kp colonization and infection using a matched case-control study., Methods: The study included all hospitalized patients with KPC-Kp colonization or infection from January 2012 to September 2015., Findings: Thirty-four cases of KPC-producing Enterobacteriaceae (including 31 KPC-Kp cases) were matched with 136 controls. Variables associated with KPC-Kp acquisition included: length of hospital stay >28 days in the past 12 months, prior vancomycin-resistant enterococci (VRE) colonization, central venous catheter (CVC), gastrointestinal disease and invasive procedures. Exposure to broad-spectrum antibiotics was also found to be a significant risk factor. In the multi-variate analysis, three factors independently associated with KPC-Kp acquisition were length of hospital stay >28 days in the past 12 months [odds ratio (OR) 23.6, 95% confidence interval (CI) 4.9-113.3], presence of a CVC (OR 15.4, 95% CI 2.7-86.9), and prior VRE colonization (OR 6.0, 95% CI 1.6-23.2). Very few patients had a history of overseas travel., Conclusion: This study demonstrates that patients with prolonged hospital exposure are more likely to acquire KPC-Kp in the setting of a local outbreak, and suggests that risk factors for KPC-Kp acquisition may be shared with those for VRE colonization. Local screening strategies targeting overseas travellers would likely miss many cases. The results of this study will help to inform screening policies for carbapenemase-producing Enterobacteriaceae., (Copyright © 2017 The Healthcare Infection Society. All rights reserved.)

β-Adrenergic receptors (β-ARs) promote brown adipose tissue (BAT) thermogenesis by mobilizing fatty acids and inducing the expression of oxidative genes. β-AR activation increases the expression of oxidative genes by elevating cAMP, but whether lipolytic products can modulate gene expression is not known. This study examined the role that adipose triglyceride lipase (ATGL) and hormone-sensitive lipase (HSL) plays in the induction of gene expression. Activation of brown adipocytes by β-AR agonism or 8-bromo-cyclic AMP increased the expression of PGC1α, PDK4, PPARα, uncoupling protein 1 (UCP1), and neuron-derived orphan receptor-1 (NOR-1), and concurrent inhibition of HSL reduced the induction of PGC1α, PDK4, PPARα, and UCP1 but not NOR-1. Similar results were observed in the BAT of mice following pharmacological or genetic inhibition of HSL and in brown adipocytes with stable knockdown of ATGL. Conversely, treatments that increase endogenous fatty acids elevated the expression of oxidative genes. Pharmacological antagonism and siRNA knockdown indicate that PPARα and PPARδ modulate the induction of oxidative genes by β-AR agonism. Using a live cell fluorescent reporter assay of PPAR activation, we demonstrated that ligands for PPARα and -δ, but not PPARγ, were rapidly generated at the lipid droplet surface and could transcriptionally activate PPARα and -δ. Knockdown of ATGL reduced cAMP-mediated induction of genes involved in fatty acid oxidation and oxidative phosphorylation. Consequently, ATGL knockdown reduced maximal oxidation of fatty acids, but not pyruvate, in response to cAMP stimulation. Overall, the results indicate that lipolytic products can activate PPARα and PPARδ in brown adipocytes, thereby expanding the oxidative capacity to match enhanced fatty acid supply.