Ictal asystole: a diagnostic and management conundrum.

We report two cases of adults presenting with transient loss of consciousness (TLoC) followed by a rapid recovery. Careful history taking revealed a stereotyped prodrome of déjà vu, raising the possibility of these events being focal seizures rather than syncope. The patients were commenced on antiepileptic drugs (AEDs) at the same time as having cardiac monitoring organised. This confirmed asystole during the seizure symptoms, resulting in TLoC. It was assumed that the cardiac arrhythmia explained the entire picture, a permanent pacemaker (PPM) was inserted, and the AEDs were withdrawn in one patient and not commenced in the other. However, they both subsequently presented with worsening seizures, including generalised tonic-clonic seizures, despite a functioning pacemaker. The seizures improved on restarting AEDs. The cases illustrate the diagnostic and management difficulties of patients presenting with ictal asystole, a condition that requires input from various medical specialities. There is no strong evidence base for the management of ictal asystole, but we favour a combined approach of AEDs and PPM insertion.

A pilot study into locating the bad bugs in a busy intensive care unit.

BACKGROUND: The persistence of multidrug-resistant organisms (MDROs) within an intensive care unit (ICU) possibly contained within dry surface biofilms, remains a perplexing confounder and is a threat to patient safety. Identification of residential locations of MDRO within the ICU is an intervention for which new scientific approaches may assist in finding potential MDRO reservoirs. METHOD: This study investigated a new approach to sampling using a more aggressive environmental swabbing technique of high-touch objects (HTOs) and surfaces, aided by 2 commercially available adenosine triphosphate (ATP) bioluminometers. RESULTS: A total of 13 individual MDRO locations identified in this pilot study. The use of ATP bioluminometers was significantly associated with the identification of 12 of the 13 individual MDRO locations. The MDRO recovery and readings from the 2 ATP bioluminometers were not significantly correlated with distinct cutoffs for each ATP device, and there was no correlation between the 2 ATP devices. CONCLUSION: The specific MDRO locations were not limited to the immediate patient surroundings or to any specific HTO or type of surface. The use of ATP testing helped rapidly identify the soiled locations for MDRO sampling. The greatest density of positive MDRO locations was around and within the clinical staff work station.

Seizure classification key to epilepsy management.

The diagnosis of epilepsy carries significant implications for physical, psychosocial and financial wellbeing as well as a small but significant increased risk of mortality. The diagnosis is often incorrect, potentially in up to 20% of cases, so should be revisited if seizures are not responding to treatment. Evidence indicates that misdiagnosis is significantly more common among nonspecialists. SIGN recommends that the diagnosis of epilepsy should be made by an epilepsy specialist, ideally in the setting of a dedicated first seizure or epilepsy clinic. An incorrect diagnosis of epilepsy can be harmful. There is an exhaustive list of epilepsy mimics that can result in misdiagnosis and expose patients to unnecessary treatment with antiepileptic drugs. Diagnosis relies primarily on the history. Investigations can support the diagnosis but cannot make it in isolation, and negative investigation findings are common in epilepsy. Brain imaging will be undertaken in most patients with epilepsy, but is not routinely required in those with a definite diagnosis of genetic generalised epilepsy. The EEG has limitations and can sometimes cloud rather than clarify the diagnostic picture. Distinguishing between a genetic generalised epilepsy and a focal epilepsy is vital as this influences investigation, treatment and prognosis. Generally medication should not be started following a single seizure except in specific circumstances or in cases where the risk of recurrence is high.

Wastewater treatment by a modular, domestic-scale reedbed system for safe horticultural irrigation.

The aim of the study was to assess the sequential treatment performance of a commercial, domestic-scale modular reedbed system intended to provide safe horticultural irrigation water. Previously only mechanical treatment systems involving forced aeration with subsequent disinfection, usually by tablet-chlorination, had been accredited in Australia. The modular design of the hybrid, subsurface-flow reedbed system offered 5 control points where monitoring and management of the treatment train could be carried out. Ten chemical parameters (chemical and biochemical oxygen demand, total organic carbon, total Kjeldahl nitrogen, ammonia nitrogen, nitrite nitrogen, nitrate nitrogen, total nitrogen, dissolved oxygen percentage saturation and suspended solids) and 4 microbial parameters (total coliform, Escherichia coli, enterococci and Clostridium perfringens) reached satisfactory levels as a result of the treatment process. Health requirements for safe horticultural irrigation were met by the outlet of the second reedbed, providing a high level of treatment-backup capacity in terms of the remaining 2 reedbeds. This suggested that chlorination was a redundant backup precaution in treating irrigation water to the acceptable regional guideline level for all horticultural uses, including the spray irrigation of salad crops eaten raw.

The perennial problem of variability in adenosine triphosphate (ATP) tests for hygiene monitoring within healthcare settings.

OBJECTIVE: To investigate the reliability of commercial ATP bioluminometers and to document precision and variability measurements using known and quantitated standard materials. METHODS: Four commercially branded ATP bioluminometers and their consumables were subjected to a series of controlled studies with quantitated materials in multiple repetitions of dilution series. The individual dilutions were applied directly to ATP swabs. To assess precision and reproducibility, each dilution step was tested in triplicate or quadruplicate and the RLU reading from each test point was recorded. Results across the multiple dilution series were normalized using the coefficient of variation. RESULTS: The results for pure ATP and bacterial ATP from suspensions of Staphylococcus epidermidis and Pseudomonas aeruginosa are presented graphically. The data indicate that precision and reproducibility are poor across all brands tested. Standard deviation was as high as 50% of the mean for all brands, and in the field users are not provided any indication of this level of imprecision. CONCLUSIONS: The variability of commercial ATP bioluminometers and their consumables is unacceptably high with the current technical configuration. The advantage of speed of response is undermined by instrument imprecision expressed in the numerical scale of relative light units (RLU).

Failure analysis in the identification of synergies between cleaning monitoring methods.

BACKGROUND: The 4 monitoring methods used to manage the quality assurance of cleaning outcomes within health care settings are visual inspection, microbial recovery, fluorescent marker assessment, and rapid ATP bioluminometry. These methods each generate different types of information, presenting a challenge to the successful integration of monitoring results. A systematic approach to safety and quality control can be used to interrogate the known qualities of cleaning monitoring methods and provide a prospective management tool for infection control professionals. We investigated the use of failure mode and effects analysis (FMEA) for measuring failure risk arising through each cleaning monitoring method. METHODS: FMEA uses existing data in a structured risk assessment tool that identifies weaknesses in products or processes. Our FMEA approach used the literature and a small experienced team to construct a series of analyses to investigate the cleaning monitoring methods in a way that minimized identified failure risks. RESULTS: FMEA applied to each of the cleaning monitoring methods revealed failure modes for each. The combined use of cleaning monitoring methods in sequence is preferable to their use in isolation. CONCLUSIONS: When these 4 cleaning monitoring methods are used in combination in a logical sequence, the failure modes noted for any 1 can be complemented by the strengths of the alternatives, thereby circumventing the risk of failure of any individual cleaning monitoring method.

Regrowth of enterococci indicator in an open recycled-water impoundment.

The purpose of the research was to assess the potential for enterococci faecal-indicator to regrow in recycled water while under environmentally-open storage. Regrowth would result in false-positive indicator results with possible downgrading, rejection or over-chlorination of recycled water. The research setting was the main 93-megalitre storage impoundment of the Hawkesbury Water Recycling Scheme in Sydney's North West, receiving tertiary treated (chlorinated) effluent from the Richmond sewage treatment plant. The water is used to irrigate horticultural food crops, pasture for dairy cattle, sheep, deer and horses, and for the maintenance of lawns and sports fields. Highly significant positive relationships were noted in multivariate analysis between indicator counts and the growth factors atmospheric temperature and UV254 unfiltered as proxy for total organic carbon (p=0.001 and 0.003 respectively). Nitrate and phosphate did not show significant relationships suggesting that these nutrients may not be growth-limiting at levels found in recycled water. Rainfall and wild duck presence did not appear to have an impact on enterococcal growth in the study. The overall predictive power of the regression model was shown to be highly significant (p=0.001). These findings will assist in recycled water monitoring and the revision of guidelines, with potential for the reduction of the chlorination by-product burden on the environment. A formula derived for the relationship between the indicator and atmospheric temperature could be used in food-production and climate-change modelling.

Rapid health-risk assessment of effluent irrigation on an Australian university campus.

Rapid health-risk assessment of chlorinated sewage-effluent irrigation of lawns, fields and crops adjacent to populated areas at the University of Western Sydney was carried out in response to warnings from the supplying authority of deteriorating bacteriological quality of the water. Irrigation with low-quality effluent offered potential for the contamination of a range of foodstuffs and the exposure of staff, students and visitors. The need for early investigation was emphasised by eutrophication presenting as sudden algal bloom in one of the campus dams and an odour suggestive of anaerobic proteolysis on irrigation. No baseline data existed regarding improvement or deterioration in water quality with passage through the dams, or relating to potential for direct or indirect exposure. The assessment design incorporated three methodologies to generate biophysical, environmental and social data. Environmental and social data were used to augment short-term data for biophysical indicators in the estimation of risk. Where required qualitative information was converted to quantitative data using categorical ranking tables, and risk evaluation was carried out using ranked risk and uncertainty values. Results for biophysical indicators showed a steady improvement in water quality with passage through campus dams, emphasising a need to regard the impoundments as part of a treatment chain, rather than as passive storage units. Effluent quality at most irrigation sites marginally exceeded regional action thresholds for relevant crop types, suggesting a need for risk management through revised irrigation practice, system design, distribution management and risk communication. Problems requiring urgent intervention included the concentration of contaminants of bovine faecal origin in one dam as the result of a closed loop within the reticulation. Also of concern was the exposure of certain most susceptible individuals including crèche children who visited pasture land and orchards where irrigated oranges were collected, and potentially immunocompromised or mentally challenged adults in a work-opportunity gardening scheme. Despite its limitations, rapid risk assessment enabled identification and proactive management of major risk factors, promoted risk communication and awareness, and laid the foundation for ongoing risk surveillance.