Txt2Vid: Ultra-Low Bitrate Compression of Talking-Head Videos via Text

Video represents the majority of internet traffic today, driving a continual race between the generation of higher quality content, transmission of larger file sizes, and the development of network infrastructure. In addition, the recent COVID-19 pandemic fueled a surge in the use of video conferencing tools. Since videos take up considerable bandwidth ( ∼ 100 Kbps to a few Mbps), improved video compression can have a substantial impact on network performance for live and pre-recorded content, providing broader access to multimedia content worldwide. We present a novel video compression pipeline, called Txt2Vid, which dramatically reduces data transmission rates by compressing webcam videos ('talking-head videos') to a text transcript. The text is transmitted and decoded into a realistic reconstruction of the original video using recent advances in deep learning based voice cloning and lip syncing models. Our generative pipeline achieves two to three orders of magnitude reduction in the bitrate as compared to the standard audio-video codecs (encoders-decoders), while maintaining equivalent Quality-of-Experience based on a subjective evaluation by users ( n=242 ) in an online study. The Txt2Vid framework opens up the potential for creating novel applications such as enabling audio-video communication during poor internet connectivity, or in remote terrains with limited bandwidth. The code for this work is available at https://github.com/tpulkit/txt2vid.git. © 1983-2012 IEEE.

Low Serum Albumin at Admission Is Associated with Mortality among Inpatients with Cirrhosis: A Multi-National Experience

Background: MELD and Child-Pugh scores have traditionally been used as prognostic indicators in patients with cirrhosis. Albumin infusions in outpatients have been associated with improved outcomes, but not in transplant waitlisted patients or inpatients. This aim of this study was to assess whether low serum albumin (sAlb) on admission alone is a poor prognostic indicator among cirrhotic inpatients from a new multi-national cohort. Method(s): The CLEARED study is a global study that enrolled consecutive non-electively admitted inpatients without organ transplant or COVID-19 from 6 continents. Admission demographics, medical history, laboratory data, inpatient course, death/hospice transfer and mortality at 30 days post-discharge were recorded. Patients were divided into 3 groups: sAlb <28gm/L(A), sAlb >=28 but <35gm/L (B), and sAlb>=35gm/L (C) were compared. Multi-variable logistic regression was performed using inpatient mortality and overall 30-day mortality as outcomes. Result(s): 2429 patients were enrolled from 21 countries worldwide. The distribution was A:49%, B:39%, C:12%. Gp A patients were significantly younger (54yrs vs. 57yrs vs 58yrs p<0.0001) but with similar gender distribution, and higher MELD-Na score of 25 vs. 20 vs. 17 (p<0.0001). Gp A patients were more likely to have alcohol as etiology of cirrhosis (49% vs. 45% vs 38%, p=0.004), and were more likely to have either infection (27% vs. 18% vs. 13%, p<0.0001), HE (39% vs. 33% vs. 23%, p=0.005) or fluid related issues as a reason for admission (p<0.0001). More patients in Gp A received albumin infusion during their hospital stay (120gm vs. 100gm vs. 100gm p=0.0004), mostly for the indications of AKI (47% vs. 49% vs. 47%, p=0.79) and performance of large volume paracentesis (44% vs. 42% vs. 41%, p=0.80), followed by bacterial peritonitis indication (22% vs. 17% vs. 11%, p=0.01). Group A patients had longer hospital stays (9 days vs. 8 days vs. 7 days (p<0.001), but similar ICU transfer (23% vs. 22% vs. 20%, p=0.55). group A patients were more likely to die while inpatients (19% vs. 11% vs. 5%, p<0.0001), or by 30 days post-discharge (29% vs. 20% vs. 9%, p<0.0001). Table shows the admission variables associated with a poor outcome. Conclusion(s): Hypoalbuminemia is extremely common among admitted cirrhotic patients, with sAlb of <28gm/L occurring in almost half. Together with MELD-Na score and infection at admission, a low sAlb is associated with a poor outcome in these patients. Future studies will need to validate these findings and to assess whether albumin infusions will improve the outcome of these patients. (Figure Presented).

Differences in Mortality Rates in Inpatients with Cirrhosis Depends on the Low, Middle or High Income Country Location: Multi-National Cleared Consortium Experience

Background: Although cirrhosis is a major cause of mortality worldwide, there could be disparities in outcomes. This needs a global consortium to study disparities in inpatient cirrhosis care Aim: Define the impact of location in prediction of outcomes in inpts with cirrhosis. Method(s): CLEARED prospectively enrolled non-electively admitted cirrhosis pts without COVID from all continents. To ensure equity, we allowed only 50 pts/site. Admission details, cirrhosis history, inpatient & 30-day course were recorded. World bank classification of low/low middle income (LMI), upper middle (UMI) & High income (HI) were used. Cirrhosis details, inpatient & 30-day outcomes were compared between groups. Multi-variable regression was performed using inpatient & 30-day mortality as outcomes. Result(s): 2758 pts from 21 countries from all continents, including Africa & Australia, were included.727 were L/LMI, 1050 UMI & 981 pts were from HICs. More men & younger pts were in LMI. Cirrhosis details: More pts in HI gp had 6M hospitalizations & infections, HE & ascites while prior variceal bleeding was higher in LMI . Prior HCC & transplant listings were lower in LMI but similar in UMI/HI. Alcohol & NASH was highest in HI. Viral hepatitis & cryptogenic were highest in UMI.Admissions: Admission MELD was highest in LMI. LMI pts were admitted more for GI Bleed, HE, & DILI, while anasarca & HBV flares were higher in UMI. Higher SBP (36% vs 24% vs 21% p<0.0001) & lowest skin/soft-tissue infections were in LMI (5% vs 5% vs 10% p=0.008);rest were similar. Nosocomial infections, driven by UTI were highest in LMI & HI pts (15% vs 14% vs 11% UMI, p=0.03). Admission diuretics, PPIs, Lactulose & statins were highest & antivirals lower in HI. SBP prophylaxis & rifaximin were highest in LMI pts. Outcome(s): More LMI pts needed ICU & had more organ failures (Fig B). Discharge MELD was highest in LMI. In-hospital mortality was highest & transplant lowest in LMI. This extended to 30-day mortality & transplant in LMI patients vs HI pts.Regression: In-hospital mortality was linked with age, infections, MELD & being in a LMI/UMI vs HIC while being on a transplant list, diabetes, & SBP prophylaxis were protective (Fig C). 30-day mortality predicted by age, ascites, HCC, discharge MELD, organ failures, LMI/UMI vs HIC but rifaximin was protective(Fig D). In-hospital transplant was higher with high MELD, admission rifaximin & listed pts &lower in LMI (OR 0.26) & UMI (OR 0.22) & age. 30-day transplant was higher in those with hyponatremia, ascites & HRS, on the list & on rifaximin and lower in LMI (OR 0.24) & UMI (OR 0.59) vs HI. Conclusion(s): In a global study of inpatients with cirrhosis, there were major differences in outcomes. Not being in a high-income country significantly increased the risk of inpatient and 30-day mortality independent of demographics, medications, in-hospital course, and cirrhosis severity likely due to disparities in access to transplant, which should be accounted for in global models. (Figure Presented).

Txt2Vid: Ultra-Low Bitrate Compression of Talking-Head Videos via Text

Video represents the majority of internet traffic today, driving a continual race between the generation of higher quality content, transmission of larger file sizes, and the development of network infrastructure. In addition, the recent COVID-19 pandemic fueled a surge in the use of video conferencing tools. Since videos take up considerable bandwidth (~100 Kbps to a few Mbps), improved video compression can have a substantial impact on network performance for live and pre-recorded content, providing broader access to multimedia content worldwide. We present a novel video compression pipeline, called Txt2Vid, which dramatically reduces data transmission rates by compressing webcam videos (“talking-head videos”) to a text transcript. The text is transmitted and decoded into a realistic reconstruction of the original video using recent advances in deep learning based voice cloning and lip syncing models. Our generative pipeline achieves two to three orders of magnitude reduction in the bitrate as compared to the standard audio-video codecs (encoders-decoders), while maintaining equivalent Quality-of-Experience based on a subjective evaluation by users (n = 242) in an online study. The Txt2Vid framework opens up the potential for creating novel applications such as enabling audio-video communication during poor internet connectivity, or in remote terrains with limited bandwidth. The code for this work is available at https://github.com/tpulkit/txt2vid.git. IEEE

IMPLEMENTING A CIRRHOSIS ORDER SET: A QUALITATIVE ANALYSIS OF PROVIDER-IDENTIFIED BARRIERS AND FACILITATORS

Background: Cirrhosis is the leading cause of mortality and morbidity in individuals with gastrointestinal disease. Multiple care gaps exist for hospitalized patients with cirrhosis, resulting in high rates of re-hospitalization (e.g. 44% at 90 days in Alberta). The Cirrhosis Care Alberta (CCAB) is a 4-year multi-component pragmatic trial with an aim to reduce acute-care utilization by implementing an electronic order set and supporting education across eight hospital sites in Alberta. Aims: As part of the pre-implementation evaluation, this qualitative study analyzed data from provider focus groups to identify barriers and facilitators to implementation. Methods: We conducted focus groups at eight hospital sites with a total of 54 healthcare providers (3-12 per site). A semi-structured interview guide based upon constructs of the Consolidated Framework for Implementation Research (CFIR) and Normalization Process Theory (NPT) frameworks was used to guide the focus groups. Focus groups were recorded and transcribed verbatim. Data was analyzed thematically and inductively. Results: Five major themes emerged across all eight sites: (i) understanding past implementation experiences, (ii) resource challenges, (iii) competing priorities among healthcare providers, (iv) system challenges, and (v) urban versus rural differences. Site-specific barriers included perceived lack of patient flow, time restraints, and concerns about the quality and quantity of past implementation interventions. Facilitators included passionate project champions, and an ample feedback process. Conclusions: Focus groups were useful for identifying pre-implementation barriers and facilitators of an electronic orders set. Findings from this study are being refined to address the influence of COVID-19, and the data will be used to inform the intervention roll-out at each of the sites.

Needs Assessment for Physical Activity Information During COVID-19 Among a Nationally Representative Sample of Parents and Children Ages 6-17 in the United States: A Cross-sectional Study

Background: The COVID-19 pandemic presented novel barriers to physical activity engagement for children and their families. Identifying what resources parents and children are interested in receiving can support efforts to mitigate the negative impact of the pandemic on youth physical activity behavior. This study aimed to identify physical activity-related information needs during the COVID-19 pandemic among a nationally representative sample of parents of children ages 6-10 and parent-child dyads of children ages 11-17. Methods: A crosssectional survey was conducted by a market research company (YouGov) in October-November 2020. Weighted percentages and corresponding 95% confidence intervals were calculated for information needs around physical activity, overall and by parent and child demographics. Parents were asked about their interest in information about helping their family be physically active during the pandemic, and children were asked about their own interest in information about being physically active. Results: Final analytic sample was 1000 parents (55.4% female;74.7% White;74.0% non-Hispanic);500 children ages 11-17 (52.1% male;77.6% White;77.4% non-Hispanic). Over 40% of parents and children were interested in information about being active during the pandemic [41.9% (95% CI: 38.9%-45.5%) and 41.5% (95% CI: 36.5%-46.7%), respectively]. Parents were more likely to be interested in information if they worked from home compared to outside the home [53.3% (95% CI: 43.3%-63.0%) versus 22.0% (95% CI: 14.9%-31.3%), respectively];had children attending school remotely compared to in-person [47.3% (95% CI: 40.2%-54.5%) versus 27.5% (95% CI: 19.6%-37.1%), respectively];and lived in a big city (66.5%;95% CI: 54.5%-76.7%) compared to a suburban area (42.5%;95% CI: 34.2%-51.2%), small town (34.6%;95% CI: 22.8%-48.8%), or rural area (34.1%;95% CI: 22.8%-47.6%). Children most interested were those who did not have resources for online activity engagement (65.3%;95% CI: 51.8%-76.7%), and those worried about their safety (55.2%;95% CI: 44.4%-65.6%) or getting infected with COVID-19 (57.8%;95% CI: 49.5%-65.6%). Children were also more likely to be interested in information if their parents worked full-time compared to not working [48.6% (95% CI: 41.7%-55.6%) versus 31.5% (95% CI:24.1%-39.9%), respectively], and lived in big city compared to a rural area [57.2% (95% CI: 45.3%-68.3%) versus 27.8% (95% CI: 17.8%-40.7%)]. Conclusion: Families most interested in physical activity-related resources were those whose organized activity opportunities may have been disrupted by the pandemic. Identifying felt needs is an important step in developing tailored interventions that effectively and sustainably support families in promoting activity among youth. Behavioral interventions oriented around increasing youth physical activity should provide guidance that resonates with families and accounts for setting-specific constraints and stressors.

THE CHAIR STAND TEST IS A RELIABLE FRAILTY METRIC FOR PREDICTING WAITLIST MORBIDITY AND MORTALITY IN PATIENTS WITH CIRRHOSIS

Background Frailty is defined as a clinical state of increased vulnerability to health and age associated stressors. The liver frailty index (LFI), composed of grip strength, chair stand and balance testing, is an accepted predictor of morbidity and mortality in cirrhosis. With the need for COVID-19 related social distancing, many appointments are being carried out virtually. The chair stand subcomponent of the LFI has the potential to be evaluated virtually, with a high reliability as compared to in-person testing noted in other disease populations. Objective To determine if the chair stand test is an independent predictor of morbidity and mortality in patients with cirrhosis. Methods 822 adult patients with cirrhosis were prospectively enrolled from five centers (3 in Canada, 1 in the United States, and 1 in India). Inclusion criteria included adult patients with cirrhosis. 787 of these patients completed a chair stand test at baseline, measured as the time (seconds) a patient takes to rise from sitting with their arms folded across their chest five times (measured in-person). The times were divided into 3 categories: >15 seconds, between 10 and 15 seconds, and <10 seconds. Patients who could not complete 5 chair stands were classified in the >15 seconds category. Primary outcome was all-cause mortality. Secondary outcome was unplanned all-cause hospital admission. Fine-Gray proportional hazard regression models were used to evaluate the association between the chair stand time and the outcomes. We adjusted for baseline age, sex, and MELD score and accounted for liver transplantation as a competing risk. Cumulative incidence functions were used to create a graphical representation of the survival analysis. Results Patients were divided into three groups: group 1, <10 seconds (n = 276);group 2, 10-15 seconds (n = 290);and group 3, >15 seconds (n = 221). Mortality was increased in group 3 in comparison to group 1 (HR 3.21, 95% CI: 2.16-4.78, p<0.001). Similarly, the hazard of non-elective hospitalizations was higher in group 3 in comparison to group 1 (HR 2.24, 95% CI: 1.73-2.91, p<0.001). Overall, patients with chair stand times greater than 15 seconds had increased all-cause mortality (HR 2.78, 95% CI 2.01-3.83, p<0.001) and non-elective hospitalizations (HR 1.84, 95% CI 1.48-2.29, p<0.001) when compared to patients with times less than 15 seconds. Conclusion A time to complete 5 chair stands of >15 seconds predicts morbidity and mortality in patients with cirrhosis. This test shows promise as a frailty measure that could be evaluated over a virtual platform. (Figure Presented)

THE CHAIR STAND TEST IS A RELIABLE FRAILTY METRIC FOR PREDICTING WAITLIST MORBIDITY AND MORTALITY IN PATIENTS WITH CIRRHOSIS

Background Frailty is defined as a clinical state of increased vulnerability to health and age associated stressors. The liver frailty index (LFI), composed of grip strength, chair stand and balance testing, is an accepted predictor of morbidity and mortality in cirrhosis. With the need for COVID-19 related social distancing, many appointments are being carried out virtually. The chair stand subcomponent of the LFI has the potential to be evaluated virtually, with a high reliability as compared to in-person testing noted in other disease populations. Aims To determine if the chair stand test is an independent predictor of morbidity and mortality in patients with cirrhosis. Methods 822 adult patients with cirrhosis were prospectively enrolled from five centers (3 in Canada, 1 in the United States, and 1 in India). Inclusion criteria included adult patients with cirrhosis. 787 of these patients completed a chair stand test at baseline, measured as the time (seconds) a patient takes to rise from sitting with their arms folded across their chest five times (measured in-person). The times were divided into 3 categories: >15 seconds, between 10 and 15 seconds, and <10 seconds. Patients who could not complete 5 chair stands were classified in the >15 seconds category. Primary outcome was all-cause mortality. Secondary outcome was unplanned all-cause hospital admission. Fine-Gray proportional hazard regression models were used to evaluate the association between the chair stand time and the outcomes. We adjusted for baseline age, sex, and MELD score and accounted for liver transplantation as a competing risk. Cumulative incidence functions were used to create a graphical representation of the survival analysis. Results Patients were divided into three groups: group 1, <10 seconds (n = 276);group 2, 10–15 seconds (n = 290);and group 3, >15 seconds (n = 221). Mortality was increased in group 3 in comparison to group 1 (HR 3.21, 95% CI: 2.16–4.78, p<0.001). Similarly, the hazard of non-elective hospitalizations was higher in group 3 in comparison to group 1 (HR 2.24, 95% CI: 1.73–2.91, p<0.001). Overall, patients with chair stand times greater than 15 seconds had increased all-cause mortality (HR 2.78, 95% CI 2.01–3.83, p<0.001) and non-elective hospitalizations (HR 1.84, 95% CI 1.48–2.29, p<0.001) when compared to patients with times less than 15 seconds. Conclusions A time to complete 5 chair stands of >15 seconds predicts morbidity and mortality in patients with cirrhosis. This test shows promise as a frailty measure that could be evaluated over a virtual platform. Funding Agencies None

Functional capacity in cirrhosis is predicted by additive impact of covert hepatic encephalopathy and frailty in a multi-center outpatient cohort

Background: Daily functional capacity is a major determinant of outcomes in patients with chronic medical conditions. Given that it can be affected by disease-specific factors as well as physical and cognitive impairment, it may be of increasing relevance in patients with cirrhosis given the changing demographics and increasing co-existing conditions including HE and physical frailty. An integrated multi-site approach combining cirrhosis-related factors, comorbidities, cognitive function, and frailty metrics is needed. Aim: To determine the integrated effect of frailty and CHE on functional capacity in outpatients with cirrhosis. Methods: NACSELD-3 (North American Consortium for the Study of End-Stage Liver Disease) is a new cohort of outpatients with cirrhosis recruited from 11 centers across North America. We enrolled pts able to consent, without HIV/illicit drug use or current alcohol misuse. Demographics, cirrhosis severity/history, comorbidities, medications were recorded. DASI (Duke Activity Status Index, Low=worse), studies that assess functional capacity, Liver frailty index instruments (LFI, high=worse) & EncephalApp Stroop (High time=worse) were administered. Norms were used to classify pts as having CHE on EncephalApp & frailty on LFI. Pts divided into having none, either or both CHE & frailty. Regression analyses were performed for DASI using all clinical variables collected. Results: Demographics: 220 patients (61.7±10.6 yrs, 74% men, 76% White, 6% Latinx) were enrolled;EncephalApp & LFI were complete in 182 pts (redgreen color blindness, logistic issues or COVID restrictions) Cirrhosis details: Major etiologies were 37% alcohol, 26% NAFLD, 17% HCV and 10% HCV+alcohol. Mean MELD was 13.9±8.5, 36% had prior HE, and 19% had difficult to control ascites. Mean Charlson comorbidity index was 5.1±2.2 Cognition, frailty and DASI: EncephalApp total was 184.2±55.6 seconds and 148 (64%) pts had CHE. Mean LFI score was 3.89±0.63 and 37 (16%) were deemed frail. 49 (27%) had neither CHE nor frailty, 104 (58%) had either CHE or Frailty , and 26 (15%) had both (Fig A). EncephalApp & LFI were positively correlated (r=0.36, p<0.001) and both were correlated with DASI (EncephalApp r=-0.33, LFI r=-0.27, both p<0.001). DASI was lower with both CHE & Frailty (Fig B). Regression: Variables associated with lower DASI (poor capacity) were higher MELD score (T-value -2.1, p=0.03), higher CCI (T-value -3.6, p<0.0001) and being frail+CHE versus either or none (T-value -2.6, p=0.01). No interaction between LFI and EncephalApp was seen. Conclusion: In this multi-center experience combined frailty and covert hepatic encephalopathy and cirrhosis-unrelated comorbidities significantly add to MELD score in predicting functional capacity in outpatients with cirrhosis.

Development of a point-of-care mortality risk score for hospitalized COVID-19 patients

Rationale: While several COVID-19-specific mortality risk scores exist, they lack the ease of use given their dependence on online calculators and algorithms. Objectives: The objectives of this study were (1) to design, validate, and calibrate a simple, easy-to-use mortality risk score in a hospitalized COVID-19 population. Methods: Multi-hospital health system in New York City. Patients (n=4840) with laboratory-confirmed SARS-CoV2 infection who were admitted between March 1 and April 28, 2020. Gray's K-sample test for the cumulative incidence of a competing risk was used to assess and rank 48 different variables' associations with mortality. Candidate variables were added to the composite score using DeLong's test to evaluate their effect on predictive performance (AUC) of in-hospital mortality. Final AUCs for the new score, SOFA, qSOFA, and CURB-65 were assessed on an independent test set. Results: Of 48 variables investigated, 36 (75%) displayed significant (p<0.05 by Gray's test) associations with mortality. The variables selected for the final score were (1) oxygen support level, (2) troponin, (3) blood urea nitrogen, (4) lymphocyte percentage, (5) Glasgow Coma Score, and (6) age. The new score, COBALT, outperforms SOFA, qSOFA, and CURB-65 at predicting mortality in this COVID-19 population: AUCs for initial, maximum, and mean COBALT scores were 0.81, 0.91, and 0.92, compared to 0.77, 0.87, and 0.87 for SOFA. Conclusions: The COBALT score provides a point-of-care tool to estimate mortality in hospitalized COVID-19 patients with superior performance to SOFA and other scores currently in widespread use.

Cardiovascular disease and severe hypoxemia are associated with higher rates of non-invasive respiratory support failure in COVID-19 pneumonia

RATIONALE Acute hypoxemic respiratory failure (AHRF) is the major complication of coronavirus disease 2019 (COVID-19), yet optimal respiratory support strategies are uncertain. We aimed to describe outcomes with highflow oxygen delivered through nasal cannula (HFNC) and non-invasive positive pressure ventilation (NIPPV) in COVID-19 AHRF and identify individual factors associated with non-invasive respiratory support failure. METHODS We conducted a retrospective cohort study of hospitalized adults with COVID-19 within a large academic health system in New York City early in the pandemic to describe outcomes with HFNC and NIPPV. Patients were categorized into the HFNC cohort if they received HFNC but not NIPPV, whereas the NIPPV cohort included patients who received NIPPV with or without HFNC. We described rates of HFNC and NIPPV success, defined as live discharge without endotracheal intubation (ETI). Further, using Fine-Gray sub-distribution hazard models, we identified demographic and patient characteristics associated with HFNC and NIPPV failure, defined as the need for ETI and/or in-hospital mortality. RESULTS Of the 331 patients in the HFNC cohort, 154 (46.5%) patients were successfully discharged without requiring ETI. Of the 177 (53.5%) who experienced HFNC failure, 100 (56.5%) required ETI and 135 (76.3%) patients ultimately died. Among the 747 patients in the NIPPV cohort, 167 (22.4%) patients were successfully discharged without requiring ETI, and 8 (1.1%) were censored. Of the 572 (76.6%) patients who failed NIPPV, 338 (59.1%) required ETI and 497 (86.9%) ultimately died. In adjusted models, significantly increased risk of HFNC and NIPPV failure was observed among patients with co-morbid cardiovascular disease (sub-distribution hazard ratio (sHR) 1.82;95% confidence interval (CI), 1.17-2.83 and sHR 1.40;95% CI 1.06-1.84, respectively). Conversely, a higher oxygen saturation to fraction of inspired oxygen ratio (SpO2/FiO2) at HFNC and NIPPV initiation was associated with reduced risk of failure (sHR, 0.32;95% CI 0.19-0.54, and sHR 0.34;95% CI 0.21-0.55, respectively). CONCLUSIONS A subset of patients with COVID-19 AHRF was effectively managed with non-invasive respiratory modalities and achieved successful hospital discharge without requiring ETI. Notably, patients with co-morbid cardiovascular disease and more severe hypoxemia experienced lower success rates with both HFNC and NIPPV. Identification of specific patient factors may help inform more selective use of non-invasive respiratory strategies, and allow for a more personalized approach to the management of COVID-19 AHRF in pandemic settings.

Mount sinai hospital institute for critical care medicine COVID-19 pandemic policies and procedures

INTRODUCTION: COVID-19 2020 pandemic with New York City (NYC) as the epicenter necessitated an unprecedented increase in critical care capacity and development of institutional guidelines for care. We describe our drastic increased ICU capacity and how we created and disseminated our guidelines. We hope our experiences help others manage their COVID-19 peaks. METHODS: Mount Sinai Hospital System includes a medical school and eight campuses, the largest being Mount Sinai Hospital (MSH). Since 2013, MSH had system-wide staffing models, cross credentialed staff, and combined leadership. MSH has and Institute for Critical Care Medicine (ICCM) that includes seven adult ICUs, 45 critical care faculty, rapid response team (RRT), vascular access team (VAS), difficult airway team (DART), patient safety quality team (PSQ), clinical research team, and post-ICU recovery clinic. ICCM coordinated COVID-19 critical care response within MSHS. ICCM, Emergency Medicine, Anesthesiology, and Infection Prevention helped develop systemwide guidelines on our COVID-19 website accessible to all hospital employees. RESULTS: MSH expanded from 1139-beds, 104 ICU beds, to 1453 beds, 235 ICU beds during the COVID-19 peak. CONCLUSIONS: MSH's response to COVID-19 surge by expanding critical care bed capacity from 104 to over 200 ICU beds required teamwork across disciplines. We developed new guidelines for airway management, cardiac arrest, anticoagulation, vascular access, and proning that helped streamline workflow and accommodate the surge in critically ill patients. Non-ICU services and staff were deployed to augment the critical care work force and open new critical care units by leveraging a tiered staffing model. This approach to rapidly expanding bed availability and staffing across the system was made possible by the collaboration between ICCM, emergency department, anesthesia department, and infection prevention, and helped to provide the best care for our patients and saved lives.

Nature contact and children's health: A systematic review

Background: Daily outdoor play for children has been encouraged by the American Academy of Pediatrics,which has long recognized the importance of play for promoting children's health and social-emotionaldevelopment. The COVID-19 related school closures and activity restrictions have highlighted potentialinequities in opportunities for children to play outdoors. There is increasing evidence, of varying quality, thatoutdoor environments containing elements of nature may offer benets for children's health that comespecically from the nature contact experienced. However, one barrier to increasing support for naturecontact from the health care community has been the lack of systematically and rigorously reviewedaccessible evidence on this topic. Objective: Our goal was to conduct a systematic review to evaluate andaggregate the evidence regarding the impacts of nature contact on children's health and well-being. Methods:We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines forsystematic reviews. The database search was conducted using PubMed, CINAHL, PsychInfo, ERIC, Scopus, andWeb of Science in June 2018. In all searches, the rst element included nature terms (exposure occurring birth to 18 years) and the second element included child health outcome terms (physical, mental, andcognitive/learning outcomes). Studies that focused only on outdoor time or play, without nature elements,were excluded. Two reviewers evaluated each study and reached consensus for: 1) review inclusion;2)determination of nature exposure category;and 3) quality assessment using the Mixed Methods AppraisalTool (MMAT). The MMAT is a reliable and valid quality assessment metric;a summary score ≥ 80% wasconsidered high quality. Results: Of the 8756 studies initially identied, 163 were included in the review. Moststudies included were observational (n=159) and examined the presence of natural environments (greenspace) around residential or school locations (n=89). Our quality assessment suggested that several high-quality studies were present within each nature exposure category. We categorized studies into one of thefollowing types of nature exposure: green space/park proximity to home (n=74, 83% high quality), green spaceactivity (n=27, 37% high quality), green space/park proximity to school (n=14, 93% high quality), wildernessexposure (n=11, 9% high quality), gardening (n=6;25% high quality), greening intervention (n=5, 40% highquality), outdoor classroom (n=5, 0% high quality), and nature walks (n=2, 0% high quality), and other (n=19,27% high quality). Studies focused on a range of outcomes including physical health (n=111, 68%), mentalhealth (n=36;22%), and cognitive/learning outcomes (n=16, 10%). Conclusions: Our systematic reviewsummarizes literature available regarding the impact of nature exposure on health outcomes in children, withan emphasis on high quality studies. Ultimately, we seek to make this evidence accessible to pediatricians tobase clinical recommendations, develop health-promoting programs and policies, and guide future research.

A dynamic relationship between crude oil price and Indian equity market: an empirical study with special reference to Indian benchmark index Sensex

Purpose: The purpose of the study is to investigate the long-run and short-run dynamic relationship between crude oil prices and the movement of Sensex for the period of 2000–2018. Design/methodology/approach: The study uses the augmented Dickey–Fuller test for the presence of unit root, Johansen cointegration test for estimating the cointegration among the variables. Further, in the case of no cointegration found, the study employed the vector autoregression (VAR) model to estimate the long-run relationship and the Granger causality/Wald test for short-run relationship. The study also conducted tests for the prerequisites of the model: serial correlation, heteroskedasticity and normality of data. Findings: The study found that both the variables, crude oil prices and Sensex are integrated of order 1, that is, I (1), and there is no cointegration between them. Further, the results proliferated from the VAR model unfold the marked effect of previous month crude oil prices (lag 1) on the movement of Indian stock market represented by Sensex considered as the benchmark index. Furthermore, VAR–Granger causality/block exogeneity Wald tests results indicated that there is a causal relationship between the crude oil prices and Sensex under the VAR environment. The model does not have any serial correlation and heteroskedasticity indicating toward the unbiased and robust estimates. Research limitations/implications: The study is conducted till the year 2018, and data for the present period (post-2018) is excluded due to ongoing trade issues between the USA and oil-exporting countries such as Iran. The current COVID-19 outbreak has also put serious issues. Due to limited time and availability of standardized data, researchers have considered Sensex as equity index only, but for more generalized research outcome few other equity indexes could have been taken for study. Originality/value: The study is completely original in nature and is an extensive study of the relationship between the crude oil price and Indian stock market with reference to causality between the variables. © 2020, Emerald Publishing Limited.

COVID-19 and women: An obstetrician's perspective

In the era of COVID-19, pregnant patients have genuine concerns regarding their own health and the health of the unborn. It is difficult to provide standard protocols due to extremely limited data. The recommendations and guidelines are being frequently revised as we learn more about the disease.