Several readers nailed this one – valproic acid (Depakote). Valproic acid does cause hyperammonemia
This syndrome can occur with overdoses, but can also occur on apparently stable dosing.
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High Value Cost Conscious Care does not just represent a slogan. HVCCC represents an attitude. We at ACP believe that physicians can help decrease health care costs. We see waste in the system and will do our best to decrease the waste.
Yesterday I tweeted - Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care bit.ly/yIjyP4 via @addthis – must read!
Please read this article. This represents a real attempt to provide practical guidelines (with a small g) on ways to avoid unnecessary testing. This article is just the beginning.
We physicians have a responsibility to the nation to decrease costs when doing so has no negative impact on health care. We must look carefully at eliminating unnecessary testing, drugs and procedures.
From this article I particularly like these quotes:
Finally, it is important to note that the true cost of a test includes not only the cost of the test itself but also the downstream costs incurred because the test was performed (5). For example, an exercise stress test in an asymptomatic patient may result in a false-positive finding that leads to cardiac catheterization, with its attendant costs and risks, but with no proven benefit. Thus, a seemingly inexpensive test can result in substantial costs because of subsequent testing, treatment, or follow-up. In assessing the costs of a diagnostic test, we must consider these downstream costs and savings.
Because of this article's importance, the Annals of Internal Medicine has made the text and the pdf free online!
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Patient admitted after apparent overdose. Patient does not respond to verbal stimuli or tactile stimulation. Patient has known schizophrenia.
Exam comatose, VS T 99, P 80, R 18, BP 130/80
Otherwise exam is unremarkable
Labs
| 143 | 103 | 22 | 82 |
| 3.9 | 23 | 1.0 | 9.6 |
WBC 7.9
Hgb 12.9/ Hct 37.1
Plt 194
NH3 28
4 hours later
Labs
| 147 | 107 | 16 | 135 |
| 4.0 | 22 | 0.8 | 10.3 |
ABG on room air
pH 7.45
pCO2 29
pO2 126
HCO3 20
NH3 98
Can you guess what the overdose included?
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First, a disclaimer – I am biased. I have spent 30 years thinking, researching and writing about adult pharyngitis. My success in that field has stunned me. Of course I will overemphasize all arguments in favor of my opinion and poo-poo those in opposition.
The advocates of the rapid strep test make these assumptions:
- We should treat group A strep pharyngitis with antibiotics (preferably a penicillin or a cephalosporin).
- No other cause of pharyngitis deserves antibiotics.
- We should avoid antibiotics in all other pharyngitis as that increases the probability of antibiotic resistance.
They implicitly seem to assume that pre-adolescent pharyngitis studies apply to adolescents and young adults (older adults get pharyngitis much less commonly).
They also generally believe the manufacturers claim that the sensitivity of the rapid strep test is > 90%.
We recently laid out the case for other bacterial causes in adolescents and young adults.1 In that article, we present the evidence that both group C streptococcal pharyngitis and Fusobacterium necrophorum pharyngitis were relatively frequent and worth treating in adolescents and young adults. These infections rarely occur in pre-adolescents!
Experts generally assume that the rapid test has a sensitivity of greater than 90%. They believe this because most papers in the literature result from industry sponsored studies in which the staff members are carefully trained. Two recent studies challenge that belief2,3. In the first study, one in a family medicine training program, they observed a sensitivity of only 75%. That study also confirmed the importance of non-group A streptococcal pharyngitis. The second paper from Turkey found a sensitivity of only 65%.
The assumptions for recommending the rapid test only strategy are suspect in my mind. But then I am biased. But I have shared some data to support my opinion.
REFERENCES
1. Mitchell MS, Sorrentino A, Centor RM. Adolescent pharyngitis: a review of bacterial causes. Clinical Pediatrics 2011;50(12):1091–1095.
2. Tiemstra J, Miranda RLF. Role of non-group a streptococci in acute pharyngitis. Journal of the American Board of Family Medicine : JABFM 2009;22(6):663–669.
3. Gurol Y, Akan H, Izbirak G, et al. The sensitivity and the specifity of rapid antigen test in streptococcal upper respiratory tract infections. International Journal of Pediatric Otorhinolaryngology 2010;74(6):591–593.
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