Dyspnea Associated with Ticagrelor

Ticagrelor is an antiplatelet medication that is commonly used for a number of cardiovascular conditions.  Its mechanism is similar to that of antiplatelet medications clopidogrel and prasugrel in that it inhibits P2Y12 ADP receptors on platelets, preventing platelet activation and aggregation.  Ticagrelor is different from clopidogrel and prasugrel in that it binds reversibly to the receptor and, importantly, it is administered as the active compound.  This contrasts with clopidogrel and prasugrel which require metabolic activation by CYP450 enzymes and are therefore susceptible to drug interactions and altered activation in those with polymorphic CYP450 phenotypes (clopidogrel requires two CYP450 enzyme steps for

Intrapleural tPA and dornase alfa for pleural infection

A 48 year old male is admitted to the hospital after experiencing a fever and malaise for several days.  He states that he has some shortness of breath and chest pain when he coughs.  Imaging of the chest reveals a large loculated effusion and empyema in the right lower lung.  The decision is made to place a chest tube (thoracostomy) and drain the fluid.  The pleural fluid returns with a pH of 7.18, a glucose of 55 mg/dL, and a lactate of 1,150 units/L.  Initial drainage was 200 mL in the first 24 hours, contained pus, and had a putrid odor.  Cultures are pending.  In addition to drainage and appropriate antibiotic therapy, what else can be done to manage this patient?

Legionnaires' disease - reliability of urine antigen testing

A 58 year old male patient presents to the emergency room with shortness of breath for the last few days.  He also complains of chills, a cough, myalgia, and diarrhea.  His notable findings include WBC = 14 k/uL, Scr = 1.2 mg/dL, BUN = 27 mg/dL, BP = 132/76 mm Hg, RR = 30 breaths/minute, Tmax = 38.5⁰C, and O2sat = 92% on room air.  His chest x-ray reveals a patchy infiltrate suggestive of pneumonia.  Upon further questioning, the patient tells you he lives across the street from an apartment building where several people recently were diagnosed with Legionnaires' disease.  He has no recent exposure to any health care settings, has taken no antibiotics, was not recently incarcerated, is not immunocompromised, and has not recently traveled.  Can we use urine antigen testing to help guide our treatment of this patient's pneumonia?

Risk of hyperglycemia from glucocorticoids

A 65 year old patient with COPD sees his primary care provider for worsening shortness of breath over the past week.  His current medications include tiotropium and albuterol.  He has no other significant past medical history but has a family history of diabetes.  His current labs include a fasting plasma glucose of 96 mg/dL, HbA1c of 6.1%, Scr = 0.8 mg/dL.  His primary care provider determines that the patient is having a COPD exacerbation and is opting to initiate a 5 day course of prednisone 40 mg orally daily (click here for more on a 5 days course versus longer steroid courses for COPD exacerbations).  What are some of the risk factors, the time-course, and the mechanism for developing hyperglycemia in a situation like this?

Use of cephalosporins in penicillin-allergic patients

Let's start with a patient case.  A 71 year old patient arrives to the emergency room complaining of shortness of breath and sputum production that has worsened from when it started about three days ago.  She has a past medical history of diabetes mellitus type 2, myasthenia gravis, and atrial fibrillation and is taking metformin, pyridostigmine, prednisone, warfarin, and sotalol.  Her BP = 132/88, HR = 78, RR = 24, and T = 37.5 C and CXR reveals a left lower lobe infiltrate.  The diagnosis of pneumonia is made and as you begin to type orders for your standard ceftriaxone/azithromycin combination, you note that the patient has a penicillin allergy.  What is the risk of continuing this antibiotic regimen given the patient's allergy?

Is levalbuterol (Xopenex) more effective than albuterol?

The choice between levalbuterol and albuterol continues to be an area of contention for outpatients, in the emergency department, and those admitted into the hospital. Here is a brief explanation of the difference between the two products.