SARS-CoV-2 Testing and Patient Waiting Times in the Emergency Department.

Aim Emergency Departments (EDs) were impacted early in the coronavirus disease 2019 (COVID-19) pandemic, with high attendance numbers. EDs relied upon SARS-CoV-2 reverse-transcriptase polymerase chain reaction (RT-PCR) tests to triage patients and facilitate admission to appropriate wards, meaning positive patients were isolated as early as possible. In October 2020, we introduced a 24-hour SARS-CoV-2 testing service. We examined the impact of this on patient experience times (PETs) in the ED, and on healthcare-associated (HA) COVID-19 infections. Methods Data on PETs before and after the introduction of 24-hour testing were available from the ED. HA COVID-19 infections were reported weekly to the Health Services Executive as a key performance indicator. Results Mean PET prior to the pandemic was 20 hours and dropped to 10 and 13 hours respectively in the first and second wave. A surge in case numbers and ED attendances during the third wave was not reflected in a rise in PETs, with a mean PET of 11 hours, significantly below pre-pandemic levels. HA-COVID-19 infections remained stable between wave one and three (83 v 92). Conclusion The introduction of 24-hour SARS-CoV-2 testing in our ED contributed to a reduction in PETs, facilitated appropriate patient placement at ward level, and kept HA-COVID-19 infections at acceptably low levels.

A comparison of the efficiency of ELISA and selected primer sets to detect Norovirus isolates in southern Ireland over a four-year period (2002-2006): variation in detection rates and evidence for continuing predominance of NoV GII.4 genotype.

Norovirus (NoV) gastroenteritis occurs in all age groups and is the most common cause of gastroenteritis in the community. However, detection methods and rates vary widely, and few data are available to compare these, particularly in Ireland. Detection of noroviruses through antigen and molecular-based strategies was carried out on 135 suspected NoV-positive samples, collected over the course of three NoV outbreaks, from 2002 to 2006, in the southern region of Ireland. A commercially available ELISA and a panel of six primer sets were evaluated to determine their suitability for NoV detection in Irish clinical samples. The key findings of this study were the detection of both GGI and GGII noroviruses by ELISA, but the detection of only GGII noroviruses by RT-PCR. In addition to this, a variation in the levels of detection from 9.4 % to 17.3 % was observed for conventional PCR assays, while a detection rate of 46.3 % was observed for the real-time PCR assay. A proportion (17.8 %) of samples were found to be negative by all detection strategies, suggesting the possibility of reporting false positives for these samples or low-copy positives that do not often repeat. Sequencing information from selected samples also revealed nucleotide polymorphisms, compromising efficient primer binding in the case of one primer pairing. Phylogenetic analysis of the partial polymerase gene identified NoV GII.4 as the dominant genotype, in accordance with previous NoV studies in Ireland. Investigating the NoV diversity of the circulating strains and the dynamics of strain replacement is important to better assess the efficacy of future NoV vaccines and to facilitate the early detection of changes in circulating NoV strains.

Changing profile of rotavirus in Ireland: predominance of P[8] and emergence of P[6] and P[9] in mixed infections.

Six hundred and thirty three fecal specimens were collected from patients under 6 years, suffering from non-bacterial, putative viral gastroenteritis in the south of Ireland, between 2003 and 2006. Following laboratory identification of rotavirus as the aetiological agent in 558 specimens, reverse transcriptase polymerase chain reaction was employed to amplify the VP7 and VP4 gene segments of 249 and 245 samples, respectively. G and P typing was subsequently carried out on these amplicons. G1 (65.1%), and G3 (16.1%) were found to be the most prevalent circulating G types over the course of the study. Both G2 (1.2%) and G9 (3.6%), were also found to be circulating, however, these types were less frequently detected. Mixed G type infections were found to account for 41 samples (14%). P typing was carried out on 245 samples. P[8] was the most commonly detected P type over the course of the study (93.5%). Both P[6] and P[9], which had not previously been detected in the Irish population, were detected during this investigation. P[6] was detected in both single and mixed P type infections, while P[9] was detected as part of mixed infections only. The key findings of this study were the emergence of P[6] and P[9] as epidemiologically important rotavirus strains in the Irish population. The profile of rotavirus is changing continuously in Ireland, and continued surveillance of the circulating strains is needed to detect the appearance of new strains, or new variants which could escape immune protection induced by an outdated vaccine.

Molecular characterisation and analysis of bovine rotavirus strains circulating in Ireland 2002-2004.

One hundred and two faecal samples were collected from calves diagnosed with rotavirus infection, in the southern region of Ireland, from 2002 to 2004. Ninety one percent (n=93) were confirmed positive for rotavirus, using latex agglutination and enzyme linked immunosorbent assay (ELISA) methods. Determination of the G- and P-types was carried out using nested reverse transcriptase polymerase chain reaction (nRT-PCR). G6 was the most prevalent genotype, accounting for 80.6% (75/93), G10 accounted for 6.5% (6/93) and G6G10 mixed types accounted for 9.7% (9/93) of the collection. Rotavirus in three of the samples (3.2%) could not be characterised with any of the five G-specific primers used in this study. A subset of the positive samples (n=54) was examined for their P-type specificities, P[5] and P[11] accounted for 77.8% (42/54), and 9.3% (5/54), respectively. One P[1] genotype (1.9%) was found in the collection. P[5] and P[11] mixed genotypes accounted for 11% (6/54) of the study. The genotypes corresponded to the UK-like strain (G6P[5]) 57.4%, KN4-like strain (G6[P11]) 7.4%, B223-like strain (G10P[11]) and NCDV-like strain (G6P[1]) 1.9% each. The unusual combination of G10P[5] accounted for 7.4%, with mixed infections G6+G10P[5] and G6P[5]+P[11] representing 13% and 11%, respectively. This is the first time that the G- and P-types of bovine rotaviruses (BRVs) have been determined in Ireland, and this study contributes to a better understanding of the epidemiology of such viruses circulating in Ireland.

Emergence of G3 and G9 rotavirus and increased incidence of mixed infections in the southern region of Ireland 2001-2004.

Two hundred and thirty fecal specimens were collected from children (up to 5 years of age) admitted with suspected rotaviral gastroenteritis at four Irish hospitals (Cork University Hospital, Mercy Hospital, Cork, Waterford Regional Hospital, and Kerry General Hospital) in the southern region of Ireland, between 2001 and 2004. Following laboratory confirmation of the aetiological agent, the rotavirus G-type was determined in all positive samples by reverse transcriptase-polymerase chain reaction (RT-PCR). The distribution of the G-types (n=230) over the 3 year period was G1 (31%), G9 (21.8%), G3 (8.7%), G4 (6.5%), and G2 (3.5%). There were many mixed infections which accounted for 28.5% of the collection. G9 emerged as the most prevalent G type (30.1%) in 2001-2002, whilst G3 first emerged in 2002-2003 and accounted for 15.8% of the collection. Notably, G2 strains were present at a very low frequency (3.5%) during 2001-2004, compared to an earlier study (1997-1999), where they accounted for 28.5% of the specimens. A smaller subset of the study collection was similarly P-typed (n=139). P[8]-type was identified as the most prevalent P-type, accounting for 97.4% (n=186), while P[4] accounted for just 2.6% (n=5) of the collection. The low frequency of P[4] coincided with the decrease in G2 strains in circulation. The key finding in this study was the emergence of G3- and G9-serotypes as epidemiologically important rotavirus strains since 1999, and the low prevalence of the previously common G2 strains in Ireland. The profile of rotavirus is changing continuously in Ireland and the implications for a successful vaccination program are discussed.

Deep venous thrombophlebitis following aortoiliac reconstructive surgery.

One hundred patients undergoing elective aortic surgery were scanned prospectively for development of deep venous thrombosis (DVT). The incidence of DVT in this population was 13%. Eleven patients showed only calf vein thrombosis on venography, whereas two had occlusive iliofemoral thrombus. The correlation between venous Doppler ultrasound and venography was 80%. More importantly, Doppler examination correctly identified both patients with occlusive thrombus. Fibrinogen scanning was associated with a false-positive rate of 31%. Only one patient suffered a nonfatal pulmonary embolus. Fibrinogen scanning has an unacceptably high false-positive rate; however, Doppler ultrasound will identify significant occlusive thrombus without a high false-positive rate. The low incidence of pulmonary emboli does not warrant such definitive measures as prophylactic vena caval interruption.

The role of two noninvasive tests in deep venous thrombosis.

A prospective study was performed to evaluate the accuracy and usefulness of two noninvasive modalities, Doppler ultrasonography and segmental air plethysmography, in the detection of deep vein thrombosis. Over a two-year period, 211 limbs were studied among 167 patients, and the results were compared with venography. Doppler ultrasonography was found to be very accurate in detecting above-knee thrombi (sensitivity: 92.4%, specificity: 90.7%) while plethysmography was found to be much less accurate (sensitivity: 77.3%, specificity: 62.4%). The results were also assessed according to the mode of patient presentation. Doppler ultrasonography was found to be very useful in symptomatic out-patients, because of the lower incidence of calf thrombi, and less accurate in symptomatic inpatients and in high risk in-patients being screened. The clinical usefulness of noninvasive detection of venous thrombosis is discussed with regard to the incidence of disease and the site of thrombosis in different patient groups under study, and recommendations are made based on these results.

Anatomic localization of atherosclerotic lesions by hemodynamic tests.

Use of noninvasive tests to assess the severity of lower-extremity occlusive lesions is generally accepted. To evaluate the effectiveness of noninvasive vascular-laboratory tests in locating atherosclerotic lesions, the results of hemodynamic studies in 100 patients were reviewed by both skilled observers and a vascular computer, and compared with angiograms. The results of the comparison suggest a remarkable sensitivity of the vascular-laboratory tests in locating significant arterial obstructions, and underscore that the great predictive value of a negative results gives the physician reliable information on the patency of a given arterial segment. Computer interpretation proved less accurate than that of the vascular-laboratory personnel.

The value of electrocardiogram monitoring during treadmill testing for peripheral vascular disease.

In evaluating the arterial hemodynamics of the lower extremities in patients with peripheral vascular disease, the treadmill exercise test offers useful information concerning the peripheral circulation. The addition of electrocardiographic (EKG) monitoring during the treadmill examination provides a method of estimating the effectiveness of coronary circulation. In three groups of patients studied, the results demonstrated that EKG monitoring during the treadmill exercise test will reveal previously unsuspected arrhythmias and ischemia. Thus the safety of the patient is enhanced. In patients followed through the operative period, there was a high correlation between exercise-induced EKG changes and perioperative cardiac problems. The value of EKG monitoring during treadmill testing is clear and offers predictive information to the surgeon contemplating a revascularization procedure.

Noninvasive evaluation of asymptomatic carotid bruits.

Proper clinical management of a patient found to have an asymptomatic carotid bruit continues to be controversial, with wide differences of opinion concerning the advisability of angiography and surgery. A noninvasive cerebrovascular evaluation is described, which combines three separate but complimentary procedures: ocular pneumoplethysmography (OPPG), carotid audiofrequency analysis (CAA), and cerebral Doppler analysis. Such studies are particularly helpful in evaluating patients with an asymptomatic carotid bruit. The reliability and effectiveness of this approach was evaluated in a series of 165 consecutive patients with an asymptomatic bruit. Angiography was recommended in patients with positive results (42%) and safely withheld in those with negative findings (58%). There were two false-positive results and only one known false-negative interpretation.

Hemodynamic studies of the audiofrequency analysis of carotid bruits.

The contribution of carotid audiofrequency analysis to the noninvasive diagnosis of carotid arterial lesions requires clarification. Carotid arterial stenoses were simulated in the dog and the following measurements were made: proximal and distal arterial pressure, blood flow, percent area reduction, and carotid audiofrequency analysis. A 40% area reduction produced a systolic bruit but no interference with flow or pressure. A 60% area reduction produced a pansystolic bruit and a reduction in peak systolic flow (precritical stenosis). A 70% area reduction produced a systolic bruit that extended into diastole, a reduction in mean blood flow, and an increased pressure gradient (critical stenosis). At total occlusion, there was no recordable heart sound or bruit. Carotid audiofrequency analysis can establish the hemodynamic importance of a carotid artery lesion and it is an essential component of any noninvasive examination.