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Lead (Pb) soil contamination in urban environments represents a considerable health risk for exposed populations, which often include environmental justice communities. In Philadelphia, Pennsylvania (PA), Pb pollution is a major concern primarily due to extensive historical Pb-smelting/processing activity and legacy use of Pb-based paints and leaded gasoline. The U.S. Environmental Protection Agency (USEPA) organized and/or compiled community-driven soil sampling campaigns to investigate Pb content in surface soils across Philadelphia. Using these data ( n = 1277), combined with our own dataset ( n = 1388), we explored the spatial distribution of Pb content in soils across the city using ArcGIS. While assessing Zone Improvement Plan (ZIP)-code level data, we found strong correlations between factors, such as the percentage of children with elevated blood lead levels (% EBLL) and % minority population as well as between % EBLL and % children in poverty. We developed a " Lead Index " that took demographics, median measured Pb-in-soil content, and % EBLLs into account to identify ZIP codes in need of further assessment. Our results will be used to help lower the Pb-exposure risk for vulnerable children living in disproportionately burdened communities.

The United States is experiencing an epidemic of nonmedical opioid use and opioid overdose-related deaths. As a result, there have been a number of public health interventions aimed at addressing this epidemic. However, these interventions fail to address care of individuals with opioid use disorder during hospitalizations and, therefore, miss a key opportunity for intervention. The role of hospitalists in managing hospitalized patients with opioid use disorder is not established. In this review, we discuss the inpatient management of individuals with opioid use disorder, including the treatment of withdrawal, benefits of medication-assisted treatment, and application of harm-reduction strategies. Journal of Hospital Medicine 2017;12:369-374., (© 2017 Society of Hospital Medicine.)

Background: Infective endocarditis is a serious infection, often resulting from injection drug use. Inpatient treatment regularly focuses on management of infection without attention to the underlying addiction. We aimed to determine the addiction interventions done in patients hospitalized with injection drug use-associated infective endocarditis., Methods: This is a retrospective review of patients hospitalized with injection drug use-associated infective endocarditis from January, 2004 through August, 2014 at a large academic tertiary care center in Boston, Massachusetts. For the initial and subsequent admissions, data were collected regarding addiction interventions, including consultation by social work, addiction clinical nurse and psychiatry, documentation of addiction in the discharge summary plan, plan for medication-assisted treatment and naloxone provision., Results: There were 102 patients admitted with injection drug use-associated infective endocarditis, 50 patients (49.0%) were readmitted and 28 (27.5%) patients had ongoing injection drug use at readmission. At initial admission, 86.4% of patients had social work consultation, 23.7% had addiction consultation, and 24.0% had psychiatry consultation. Addiction was mentioned in 55.9% of discharge summary plans, 7.8% of patients had a plan for medication-assisted treatment, and naloxone was never prescribed. Of 102 patients, 26 (25.5%) are deceased. The median age at death was 40.9 years (interquartile range 28.7-48.7)., Conclusions: We found that patients hospitalized with injection drug use-associated infective endocarditis had high rates of readmission, recurrent infective endocarditis and death. Despite this, addiction interventions were suboptimal. Improved addiction interventions are imperative in the treatment of injection drug use-associated infective endocarditis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Delirium is common in hospitalized patients and warrants early diagnosis and treatment. Often the evaluation of delirium includes head computed tomography imaging. However, in hospitalized medical patients, the yield of head computed tomography is unknown., Objective: To determine the diagnostic yield of head computed tomography when evaluating a hospitalized medical patient with delirium in the absence of a recent fall, head trauma, or new neurologic deficit., Design and Setting: Retrospective medical record review at a large academic medical center in Boston, Massachusetts., Participants: We reviewed all medical records for head computed tomography scans performed from January 2010 through November 2012 in patients on the general medicine or medical subspecialties units., Main Outcomes: A "positive" head computed tomography was defined as an intracranial process that could explain delirium. An "equivocal" head computed tomography was defined as the presence of a finding of unclear significance in relation to delirium., Results: There were 398 patients hospitalized for >24 hours who underwent head computed tomography for delirium. Two hundred twenty head computed tomography studies met eligibility criteria, with 6 (2.7%) positive and 4 (1.8%) equivocal results. All positive and equivocal findings resulted in change in management., Conclusions: The diagnostic yield of head computed tomography in determining the cause of delirium in hospitalized patients is low. Due to the low rate of positive findings, head imaging is unnecessary in the majority of cases of delirium. However, there may be a subset of high-risk individuals in which head imaging is indicated., (© 2014 Society of Hospital Medicine.)

Background: Laboratory testing is the single highest-volume medical activity and drives clinical decision-making across medicine. However, the overall landscape of inappropriate testing, which is thought to be dominated by repeat testing, is unclear. Systematic differences in initial vs. repeat testing, measurement criteria, and other factors would suggest new priorities for improving laboratory testing., Methods: A multi-database systematic review was performed on published studies from 1997-2012 using strict inclusion and exclusion criteria. Over- vs. underutilization, initial vs. repeat testing, low- vs. high-volume testing, subjective vs. objective appropriateness criteria, and restrictive vs. permissive appropriateness criteria, among other factors, were assessed., Results: Overall mean rates of over- and underutilization were 20.6% (95% CI 16.2-24.9%) and 44.8% (95% CI 33.8-55.8%). Overutilization during initial testing (43.9%; 95% CI 35.4-52.5%) was six times higher than during repeat testing (7.4%; 95% CI 2.5-12.3%; P for stratum difference <0.001). Overutilization of low-volume tests (32.2%; 95% CI 25.0-39.4%) was three times that of high-volume tests (10.2%; 95% CI 2.6-17.7%; P<0.001). Overutilization measured according to restrictive criteria (44.2%; 95% CI 36.8-51.6%) was three times higher than for permissive criteria (12.0%; 95% CI 8.0-16.0%; P<0.001). Overutilization measured using subjective criteria (29.0%; 95% CI 21.9-36.1%) was nearly twice as high as for objective criteria (16.1%; 95% CI 11.0-21.2%; P = 0.004). Together, these factors explained over half (54%) of the overall variability in overutilization. There were no statistically significant differences between studies from the United States vs. elsewhere (P = 0.38) or among chemistry, hematology, microbiology, and molecular tests (P = 0.05-0.65) and no robust statistically significant trends over time., Conclusions: The landscape of overutilization varies systematically by clinical setting (initial vs. repeat), test volume, and measurement criteria. Underutilization is also widespread, but understudied. Expanding the current focus on reducing repeat testing to include ordering the right test during initial evaluation may lead to fewer errors and better care.

Background: Serum folate levels are commonly ordered for multiple indications in the inpatient and emergency department settings. Since mandatory folic acid fortification in 1998, there has been a decreasing prevalence of folate deficiency in the United States., Objective: Our objective was to determine the indications, rate of deficiency, charge and cost per deficient result, and change in management per deficient result in serum folate testing in inpatients and emergency department patients., Design: Retrospective analysis of all inpatient and emergency department serum folate tests., Methods: We analyzed all inpatient and emergency department serum folate tests performed over a 12-month period. We reviewed the charts of 250 patients and all low-normal or deficient serum folate levels to determine indications, comorbidities, and change in management based on result. Charge and cost analyses were performed., Setting/patients: All inpatient and emergency department patients with a serum folate test performed at a major medical center in Boston, Massachusetts., Results: A total of 2093 serum folate tests were performed in 1944 patients with 2 deficient levels. The most common indications were anemia without macrocytosis and anemia with macrocytosis. The amount charged per deficient result was $158,022. The cost to the hospital per deficient result was less than $2093., Conclusions: In folic acid fortified countries, serum folate testing has low utility and poor cost effectiveness for all indications in inpatients and emergency department patients., (Copyright © 2012 Society of Hospital Medicine.)

Pulmonary zygomycosis is an uncommon infection that occurs mostly in immunocompromised patients. We report the case of a 75-year-old man with myelodysplastic syndrome, treated with lenalidomide for 3 months, who developed respiratory failure and a rapidly progressive left upper lobe consolidation. An extensive workup was unrevealing of the etiology, and the patient expired. A full autopsy was declined, but an in situ post-mortem transbronchial lung biopsy revealed pulmonary zygomycosis. This unique case illustrates the potential risks of lenalidomide therapy in patients with myelodysplastic syndrome and the difficulties in diagnosing pulmonary zygomycosis. To our knowledge this is the first report of a diagnostic in situ post-mortem transbronchial lung biopsy.

Calmodulin (CaM) is the primary calcium sensor in eukaryotes. Calcium binds cooperatively to pairs of EF-hand motifs in each domain (N and C). This allows CaM to regulate cellular processes via calcium-dependent interactions with a variety of proteins, including ion channels. One neuronal target is NaV1.2, voltage-dependent sodium channel type II, to which CaM binds via an IQ motif within the NaV1.2 C-terminal tail (residues 1901-1938) [Mori, M., et al. (2000) Biochemistry 39, 1316-1323]. Here we report on the use of circular dichroism, fluorescein emission, and fluorescence anisotropy to study the interaction between CaM and NaV1.2 at varying calcium concentrations. At 1 mM MgCl2, both full-length CaM (CaM1-148) and a C-domain fragment (CaM76-148) exhibit tight (nanomolar) calcium-independent binding to the NaV1.2 IQ motif, whereas an N-domain fragment of CaM (CaM1-80) binds weakly, regardless of calcium concentration. Equilibrium calcium titrations of CaM at several concentrations of the NaV1.2 IQ peptide showed that the peptide reduced the calcium affinity of the CaM C-domain sites (III and IV) without affecting the N-domain sites (I and II) significantly. This leads us to propose that the CaM C-domain mediates constitutive binding to the NaV1.2 peptide, but that interaction then distorts calcium-binding sites III and IV, thereby reducing their affinity for calcium. This contrasts with the CaM-binding domains of voltage-dependent Ca2+ channels, kinases, and phosphatases, which increase the calcium binding affinity of the C-domain of CaM.