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Fluoroquinolone-nonsusceptible Streptococcus pyogenes has rapidly emerged in several countries. The aim of this study was to survey the epidemiology and molecular characteristics of fluoroquinolone-nonsusceptible S . pyogenes in Taiwan. A total of 350 consecutive S . pyogenes isolates were collected between January 2005 and December 2012, including 152 (43.4%) invasive and 198 (56.6%) noninvasive isolates. Thirty-nine isolates (11.1%) of S . pyogenes were nonsusceptible to fluoroquinolones, including one emm 1/ST28, 4 emm 4/ST39, 33 emm 12/ST36, and 1 emm 87/ST62. Of all the isolates, emm 12 (50%) demonstrated the highest prevalence of fluoroquinolone nonsusceptibility. Alterations of Ser79Phe and Ala12Val in ParC were the most frequently mutations in fluoroquinolone-nonsusceptible S . pyogenes isolates. There were no amino acid substitutions in GyrB, and 1 emm 87 isolate exhibited 3 nonsynonymous mutations in ParE. Our study reveals the emergence of fluoroquinolone-nonsusceptible S . pyogenes emm 12/ST36 in Taiwan. Regular surveillance of fluoroquinolone susceptibility in S . pyogenes is suggested. [ABSTRACT FROM AUTHOR]

Background: The association between enterovirus infections in children and risk of leukaemia is unclear. We aimed to assess the risk of leukaemia after enterovirus infection in children.Methods: We did a nationwide retrospective cohort study by analysing data from the National Health Insurance Research Database (NHIRD) in Taiwan. Children with enterovirus infections aged younger than 18 years were identified. With use of computer-generated random numbers, children not infected with enterovirus were randomly selected and frequency matched (1:1) with children infected with enterovirus by sex, age, urbanisation level, parental occupation, and index year of enterovirus infection. We only included children with complete baseline data for age and sex and who had at least three clinic visits with the diagnosis of enterovirus infection. The diagnosis date of the first clinic visit for the enterovirus infection was defined as the index date for initiation of follow-up person-year measurement and participants. All study patients were followed up until they developed leukaemia, were lost to follow-up, withdrew from the NHI programme, or until the end of the study without leukaemia (censored). Our primary endpoint was a diagnosis of leukaemia during follow-up.Findings: Insurance claims data for 3 054 336 children younger than 18 years were randomly selected from all insured children in the NHIRD. We identified 282 360 children infected with enterovirus and 282 355 children not infected with enterovirus between Jan 1, 2000, and Dec 31, 2007. The incidence density rates of leukaemia were 3·26 per 100 000 person-years for the enterovirus-infected and 5·84 per 100 000 person-years for the non-enterovirus-infected cohorts. The risk of leukaemia was significantly lower in the enterovirus-infected cohort than in the non-enterovirus-infected cohort (adjusted subhazard ratio [SHR] 0·44, 95% CI 0·31-0·60; p<0·0001). Children infected with enterovirus have a reduced risk of both lymphocytic leukaemia (adjusted SHR 0·44, 0·30-0·65; p<0·0001) and acute myeloid leukaemia (adjusted SHR 0·40, 0·17-0·97; p=0·04). Herpangina and hand-foot-and-mouth disease were the main diseases associated with the reduced risk of leukaemia.Interpretation: The association between enterovirus infection and the reduced risk of developing leukaemia supports Greaves' delayed infection hypothesis for the cause of childhood leukaemia. [ABSTRACT FROM AUTHOR]

Abstract: Background: Group A Streptococcal (GAS) necrotizing fasciitis is a critical emergency. Patients with necrotizing fasciitis principally present to emergency departments (EDs), but most studies are focused on hospitalized patients. Objective: An ED patient-based retrospective study was conducted to investigate the clinical characteristics, associated factors, and outcomes of GAS necrotizing fasciitis in the ED. Methods: Patients visiting the ED from January 2005 through December 2011 with the diagnosis of GAS necrotizing fasciitis were enrolled. All patients with the diagnosis of noninvasive skin and soft-tissue infections caused by GAS were included as the control group. Results: During the study period, 75 patients with GAS necrotizing fasciitis were identified. Males accounted for 84% of patients. The most prevalent underlying disease was diabetes mellitus (45.3%). Bullae were recognized in 37.3% of patients. One third of cases were complicated by bacteremia. Polymicrobial infections were found in 30.7% of patients. Overall mortality rate for GAS necrotizing fasciitis was 16%. Patients aged >60 years with diabetes mellitus, liver cirrhosis, and gout were considerably more likely to have GAS necrotizing fasciitis than noninvasive infections. Patients presenting with bacteremia, shock, duration of symptoms/signs <5 days, low white blood cell count, low platelet count, and prolonged prothrombin time were associated with increased mortality. Surgery is a significantly negative factor for mortality of patients with GAS necrotizing fasciitis (odds ratio = 0.16; 95% confidence interval 0.002−0.16; p < 0.001). Conclusions: A better understanding of the associated factors and initiation of adequate treatments will allow for improved survival after GAS necrotizing fasciitis. [Copyright &y& Elsevier]

Abstract: Endometriosis is defined as the presence of ectopic foci of endometrial tissue outside the uterine cavity. Many patients are asymptomatic, but others present protean symptoms, including headache, cyclic hemoptysis, pleural effusion, and ascites depending on the endometrial implantation sites. Although massive ascites has been reported as a manifestation of endometriosis, hypovolemic shock is unusual. We report a case of endometriosis presenting as shock and bloody ascites to show that endometriosis can result in acute abdomen with shock. A 29-year-old female presented to our Emergency Department (ED) complaining of light-headedness and palpitations. Examination suggested hypovolemic shock. Ultrasonography revealed massive ascites and paracentesis showed bloody ascites. Exploratory laparoscopy showed endometriosis over the left broad ligament. After fluid resuscitation and electrocauterization of the endometriosis, the patient''s condition stabilized, and she was discharged 5 days after admission. This case is presented to raise awareness that endometriosis can present with hypovolemic shock. [Copyright &y& Elsevier]

Summary: Objective: To identify the differences in clinical characteristics between acute Q fever and scrub typhus in southern Taiwan. Methods: A prospective observational study was conducted in which serological tests for acute Q fever and scrub typhus were performed simultaneously regardless of which disease was suspected clinically. From April 2004 to December 2007, 80 and 40 cases of serologically confirmed acute Q fever and scrub typhus, respectively, were identified and included in the study for comparison. Results: By univariate analysis, being male (p <0.001) and having an alanine aminotransferase (ALT) >88U/l (p =0.015) were more common in acute Q fever, whereas residence or travel in a mountainous region or offshore island of Taiwan (p <0.001), skin rash (p <0.001), eschar (p <0.001), lymphadenopathy (p =0.04), leukocytosis (p =0.002), and pulmonary involvement on chest X-ray (p =0.003) were more common in scrub typhus. In the multivariate analysis, being male (odds ratio (OR) 10.883, 95% confidence interval (CI) 2.079–56.441, p =0.005) was an independent characteristic of acute Q fever, while residence or travel in a mountainous region or offshore island (OR 0.073, 95% CI 0.019–0.275, p <0.001) and skin rash (OR 0.152, 95% CI 0.024–0.945, p =0.043) were independent characteristics of scrub typhus. The response to doxycycline treatment was not different. Conclusions: In southern Taiwan, sex, area of residence, travel history, and physical examination are important in the differentiation of acute Q fever from scrub typhus. [Copyright &y& Elsevier]

Abstract: Background: Acute appendicitis continues to be a condition at high risk for missed and delayed diagnosis. It characteristically presents with right lower quadrant pain after vague epigastric or periumbilical discomfort. Left-sided appendicitis is an atypical presentation and has been reported rarely. The majority of these cases have been described to be associated with congenital midgut malrotation, situs inversus, or an extremely long appendix. We report a case of left-sided acute appendicitis occurring in a patient with a redundant and hypermobile ascending colon. Objectives: To alert emergency physicians to an anatomical anomaly that could delay the diagnosis of appendicitis. Case Report: A 50-year-old man presented with fever and left lower abdominal pain. Physical examination revealed local tenderness over the left lower quadrant. Abdominal computed tomography scan revealed a redundant, floating, ascending colon and inflammatory appendix adhering to the descending colon over the left lower abdomen. Exploratory laparotomy was performed and perforated appendicitis with turbid ascites was found during the surgery. Appendectomy was performed and the patient recovered uneventfully. Conclusion: This case is presented to increase awareness among emergency physicians of this anatomical variant and atypical presentation of appendicitis. [Copyright &y& Elsevier]