Key Points Question Does COVID-19 convalescent plasma (CCP), compared with placebo, improve the clinical status of hospitalized patients with COVID-19 requiring noninvasive supplemental oxygen? Findings In this randomized clinical trial including 941 patients, based on the World Health Organization 11-point Ordinal Scale for Clinical Improvement, CCP did not benefit 468 participants randomized to CCP compared with 473 randomized to placebo from April 2020 to March 2021. However, in exploratory analyses, CCP appeared to benefit those enrolled from April to June 2020, the period when most participants received high-titer CCP and were not receiving remdesivir and corticosteroids at randomization. Meaning In this trial, CCP did not meet prespecified outcomes for efficacy, but high-titer CCP may have benefited hospitalized patients with COVID-19 early in the pandemic when other treatments were not in use, suggesting a heterogenous treatment effect over time.

Blastomycosis is a fungal infection caused by Blastomyces dermatitidis, helicus, percursus, emzantsi, silverae, and gilchristi, herein referred to as Blastomyces spp. 1 Another member of the Blastomyces genus, B parvus, does not cause classical blastomycosis infection but rather a granulomatous pulmonary disease named adiaspiromycosis. The dimorphic fungus is endemic to the Ohio, Mississippi, and Saint Lawrence River areas of North America and classically causes pulmonary disease, although other organ systems may be involved. 1 Organ transplant recipients are at particular risk for Blastomyces infection due to pharmacologic immunosuppression. Despite this, blastomycosis remains uncommon relative to other fungal infections, such as coccidioidomycosis and histoplasmosis in this patient population. 2 We sought to better characterize the spectrum of blastomycosis infection among solid organ transplant (SOT) recipients to aid in the identification, treatment, and outcomes of blastomycosis. Herein, we report 30 cases of blastomycosis in SOT recipients treated at a large academic medical center in Southern Wisconsin.

A 58-year-old male was presented with an ST-elevation inferior myocardial infarction. Emergency medical services administered 325 mg of aspirin and sublingual nitroglycerin en route to the emergency room. In the emergency room, the patient received 600 mg of clopidogrel and a heparin bolus. Coronary angiography revealed complete occlusion of the distal right coronary artery with thrombus. Intravenous eptifibatide was given at the start of the percutaneous coronary intervention (PCI). Intravascular ultrasound demonstrated significant soft atheroma and ruptured plaque in the distal right coronary artery at the crux. A drug-eluting stent was deployed with an excellent angio-graphic result. Postintervention, the patient's chest pain and ECG demonstrated complete resolution of the previous ischemic changes. Approximately 11 hours after being treated in the emergency room, the patient developed recurrent chest pain. He was restarted on eptifibatide and heparin, and repeat coronary angiography demonstrated total occlusion at the origin of the right coronary artery stent (Figure 1). Thrombectomy was performed, removing huge amounts of atherothrombotic material (Figure 2). Intravascular ultra-sound did not demonstrate stent edge dissection or stent malapposition. A drug-eluting stent with 1-mm overlap with the distal edge of the previous stent was deployed. The patient was felt to have failed clopidogrel therapy and was transitioned to pra-sugrel therapy. The patient was screened for genetic variants in CYP2C19, the gene encoding the cytochrome P450 enzyme CYP2C19 that metabolizes clopidogrel. Clopidogrel is a prodrug and is metabolized by CYP2C19 into active thiol metabolites by a 2-step oxidative biotransforma-tion process. Only the active metabolite of clopidogrel targets the P2Y12 receptor for ADP on platelets. The most common LOF variant alleles are CYP2C19*2 and *3 alleles that result in nonfunctional proteins. The haplotype CYP2C19*2 comprises the variant rs4244285, which is a synonymous single-nucleotide polymorphism affecting the amino acid residue proline at position 227 in exon 5. Although guanine substitution by adenine does not change the proline amino acid, it creates an aberrant splice site, resulting in a premature stop codon. 2 The single-nucleotide polymorphism rs4986893 (G636A) comprising the CYP2C19*3 haplotype results in guanine substitution by adenine and substitution of the TGG codon that encodes tryptophan by TGA, a stop codon in exon 4 resulting in a truncated nonfunctional protein. 3 The minor allele frequency of CYP2C19*2 varies as per ethnic group, being most prevalent in East Asians (29%) and with approximately equal frequency in both the subjects of African (15%) and European (15%) origin. 1 CYP2C19*3 is rare in subjects of European and African ancestry (minor allele frequency <1%); however, it is more common in East Asians (minor allele frequency ≈9%). CYP2C19*2 and *3 account for ≥99% of the LOF alleles in a multiethnic population 1 CYP2C19 Genotype and Clopidogrel Pharmacokinetics LOF all...

AAIM is the largest academically focused specialty organization representing departments of internal medicine at medical schools and teaching hospitals in the United States and Canada. As a consortium of five organizations, AAIM represents department chairs and chiefs; clerkship, residency, and fellowship program directors; division chiefs; and academic and business administrators as well as other faculty and staff in departments of internal medicine and their divisions.

A facilitated reflective practice intervention increased hospitalist participation and awareness in the mission to reduce readmissions and this intervention resulted in a nonsignificant trend in readmission reduction.