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Factors associated with structural racism, disenfranchisement, poverty, and other persistent sources of inequity are associated with vulnerability and exposure to environmental hazards. Social, demographic, and environmental factors associated with vulnerability to environmental hazards have been used by many researchers to produce indexes of hazard vulnerability. In preparation for a climate change health risk assessment for Washington state, we compared methods and results from six indexes designed to support environmental health risk assessment. Production of these indexes varies in the number of variables considered, calculation complexity, and exposure of local causal pathways. Results for these indexes are generally very similar, especially at the highest decile of vulnerability, the exception being the Environmental Health Disparities index, the only one to consider hazard exposure. Some indexes used methods that hide causal pathways. Those that exposed causal pathways limited model structure. Results indicate that simpler indexes may be more appropriate for use in decision support tools as they require less overhead for data updates and scenario analysis and that other methodologies may provide a more useful framework for index generation.

SARS-CoV-2 leading to COVID-19 is a global pandemic, the likes of which have been unprecedented in our lifetime, with many presentations, unknown complications, and few effective treatment options. The most common organ affected by COVID-19 is the lungs, but another well-known effect of COVID-19 infection is thromboembolic phenomena. In this case, a patient previously infected with SARSCoV-2 developed chest pain radiating to the back, shortness of breath, and marked hypertension and was diagnosed with an acute ST-segment elevation myocardial infarction (STEMI) complicated by a moderate pericardial effusion which led to a cardiac tamponade. The patient had all three of the components of Beck's Triad: muffled heart sounds, jugular venous distention, and hypotension as well as a narrow pulse pressure and had COVID-19 induced myocarditis resulting in a pericardial effusion and tamponade physiology. This COVID-19 associated pericardial effusion has, to our knowledge, been reported only six times in the literature and this presentation was unique because the patient was in the subacute phase with COVID-19, had a cardiac tamponade, and had a thrombosed stent during the catheterization despite being on long term apixaban. The patient underwent emergency percutaneous coronary intervention (PCI) with two stents and was transferred to the intensive care unit where he was noted to have worsening hypotension despite aggressive vasopressor support. Ultimately, despite an emergent bedside pericardiocentesis, the patient succumbed to complications of COVID-19 infection. To our knowledge, there have only been six reported cases in the literature of COVID-19 associated pericardial effusions, and four had cardiac tamponade. It is imperative that clinicians be wary of, and educated about, the less common effects of COVID-19 infection even after the acute phase has passed, which include a persistent prothrombotic state. © Journal of Emergency and Critical Care Medicine. All rights reserved.

Purpose This study aims to evaluate home-hospital implications for facility management (FM) and, in particular, ED crowding. Home-hospital programs, in which select patients receive hospital-level care at home, can extend hospital facility capacity. Emergency department (ED) crowding, a sensitive hospital capacity indicator, is associated with unsafe operations and reduced quality of care. Design/methodology/approach The impact of a home-hospital program on crowding was analyzed with a discrete-event simulation model using one month of historical data from a case hospital. Time ED patients waited for inpatient beds was the primary endpoint. Five scenarios with different levels of patient suitability for home-hospital were each run 30 times. Differences were evaluated using paired t-tests. Findings Implementing home-hospital reduced ED crowding by up to 3 per cent. Additionally, the simulation yielded insights regarding advantages and limitations of various home-hospital arrangements, suggested which hospital types may be the best candidates for home-hospital and highlighted the role of bed-cleaning turnaround times and environmental services staffing schedules in operations. Research limitations/implications This research examined home-hospital and crowding at one hospital. Developing a model that accounts for all hospital types requires significant data and many hospital partnerships but could allow for more informed decisions regarding implementation of such programs. Social implications This research has implications for ensuring access to ED care, an important source of acute care generally and particularly for the underserved. Originality/value This research systematically evaluates home-hospital’s impact on ED crowding. Simulation modeling resulted in analytical results and allowed for evaluation of what-if scenarios providing recommendations for hospital FMs on their role in decreasing ED boarding.

Background: Studies have reported mixed findings regarding timing of antibiotic delivery in patients admitted for pneumonia and clinical outcomes. We hypothesized that there is no association between the time to antibiotics and the hospital length of stay (LOS) for patients admitted from the emergency department (ED) to the hospital for pneumonia.Objective: To compare the hospital LOS of patients admitted from the ED to the hospital for pneumonia based on the interval between ED arrival and first dose of antibiotics categorized to four hours or less, four to six hours, and greater than six hours.Methods: We conducted a retrospective chart review at a single inner city ED on patients who had admitting and discharge diagnoses of pneumonia and received antibiotics in the ED over a 17 month period. Using structured abstraction sheets, a trained reviewer identified cases and abstracted data on hospital LOS, time of arrival to first antibiotic dose, admission bed type, and other patient factors.The primary outcome was hospital LOS. Data were analyzed using descriptive statistics, ANOVA, and linear regression.Results: Nine hundred ninety ninecases were identified and541 met inclusion criteria. Four hundred eighty three (89%) were African American, 240 (44%) were female, the average age was 52 years old (SD 15), and 186 (34%) were HIV positive.There was no significant difference in LOS based on time to antibiotics. Controlling for patient factors including pneumonia type (community or health care associated) did not result in a significant difference in LOS across the time to antibiotic categories.Conclusions: In this population of pneumonia patients admitted to the hospital from the ED, time to first antibiotic dose was not significantly correlated with hospital LOS. Controlling for demographics and disease severity did not affect the observed relationship.

In 1999, 1.5 million Asians were infected with HIV (compared to 5.6 million people worldwide).2 The epidemic, spurred by the sex industry and intravenous drug use in south east Asia, is tragically concentrated among the young: 50% of the 6.5 million living with the infection worldwide are under 25.3 There is great cause for concern, but also vast potential for change and, until there is a vaccine, prevention is the key. Thailand's example offers proof that prevention efforts in many Asian countries can meet with success if they are well conceived and applied. As in Thailand, youth is a key factor in combating the epidemic for the rest of south east Asia.

Recurrent heat waves, already a concern in rapidly growing and urbanizing South Asia, will very likely worsen in a warming world. Coordinated adaptation efforts can reduce heat’s adverse health impacts, however. To address this concern in Ahmedabad (Gujarat, India), a coalition has been formed to develop an evidence-based heat preparedness plan and early warning system. This paper describes the group and initial steps in the plan’s development and implementation. Evidence accumulation included extensive literature review, analysis of local temperature and mortality data, surveys with heat-vulnerable populations, focus groups with health care professionals, and expert consultation. The findings and recommendations were encapsulated in policy briefs for key government agencies, health care professionals, outdoor workers, and slum communities, and synthesized in the heat preparedness plan. A 7-day probabilistic weather forecast was also developed and is used to trigger the plan in advance of dangerous heat waves. The pilot plan was implemented in 2013, and public outreach was done through training workshops, hoardings/billboards, pamphlets, and print advertisements. Evaluation activities and continuous improvement efforts are ongoing, along with plans to explore the program’s scalability to other Indian cities, as Ahmedabad is the first South Asian city to address heat-health threats comprehensively.

Wellbore designs and completions can positively impact long-term production in directional wells, but many directionally drilled wells are designed today without regard for future pump applications. Communication between drilling, completion, and production teams is often poor, and this negatively impacts the ability to produce in liquid-rich multiphase environments. This situation is especially true as the well matures. Early collaboration between these groups is imperative to maximize production options. Without such cooperation, many directional wells are designed without future pump success in mind. Consequently, electrical submersible pumping systems (ESPs) are excluded as a viable artificial lift solution in a majority of directionally drilled wells. ESP technology advances have made ESPs viable in many multiphase liquid-rich wells. Ignoring current ESP capabilities ultimately diminishes production over the life of some wells. Many of these directional wells flow naturally, but liquid loading reduces production without artificial lift. ESPs can be the most productive method for reducing reservoir pressure and optimizing production, and they should be considered when designing a wellbore. The Mississippian Lime in Oklahoma and Kansas (though not a shale play) has many similar attributes of a liquid-rich shale. This paper includes a case study from the Mississippian play for a horizontal drilling plan and completion technique aimed at optimizing pump performance. "Pump-friendly" fundamentals for wellbore design and geometry are presented. This paper concludes that increased awareness and implementation of a few basic principles will pay huge early dividends as the well matures.