Timing of tracheostomy in patients with COVID-19 has attracted substantial attention. Initial guidelines recommended delaying or avoiding tracheostomy due to the potential for particle aerosolization and theoretical risk to providers. However, early tracheostomy could improve patient outcomes and alleviate resource shortages. This study compares outcomes in a diverse population of hospitalized COVID-19 patients who underwent tracheostomy either "early" (within 14 d of intubation) or "late" (more than 14 d after intubation).DESIGN: International multi-institute retrospective cohort study. SETTING:Thirteen hospitals in Bolivia, Brazil, Spain, and the United States.

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T he protection of healthcare workers is vitally important during the coronavirus pandemic. 1 In addition to delays in availability of vaccines for low-and middle-income country (LMIC) providers, 2 there are ongoing deficits in COVID-19 mitigation and provider protection efforts, particularly with respect to personal protective equipment (PPE). 3 Pandemic-related supply chain disruptions have resulted in severe shortages of PPE, including gloves, masks, and eye protection used routinely in patient care by surgical and anesthetic providers. Furthermore, continued development and implementation of policies and procedures for the safe donning, doffing, and use of PPE is essential. This includes protocols for managing COVID-19þ patients on the wards and in the operating theatre. We conducted a global survey of surgical facilities and perioperative providers to assess the availability of materials and safety processes, including provider training, for preventing transmission of SARS-CoV-2 in the perioperative setting.An online facility-level survey was distributed to contacts of Lifebox, Smile Train, and Jhpiego who work at partner hospitals. A second online survey aimed at individual providers was disseminated widely through our networks and via social media. Both surveys were translated into 9 languages (English, Bahasa, French, Spanish, Khmer, Hindi, Mandarin, Portuguese, Vietnamese), to align with common organization partner languages. Responses were collected in October 2020 and all data were anonymized. Participation was voluntary, ethical approval was obtained, and data were analyzed using Stata v.15.1. Primary outcomes of interest were provider-reported PPE availability and self-purchasing, COVID-19 related training and protocol usage, and surgical facility COVID-19 testing, viral filter and pulse oximeter availability as reported by a senior level single facility respondent.A total of 230 facility and 507 provider surveys, representing 52 LMICs, were included in the analysis. Provider and facility surveys were similar in regional, hospital type, and hospital level distribution. We stratified data by income classification, grouping low-and lower-middle income countries (LIC/L-MICs) as compared to upper-middle income countries (UMICs) to better elucidate where the largest gaps in training and material resources were located.Providers in LIC/L-MICs reported less training in COVID-19 protocols for the operating room (51.2% vs 81.8%), PPE donning and doffing (67.2% vs 86.4%), and COVID-19 surgical patient checklist (40.0% vs 59.8%) than those in UMICs (Table 1). Actual use of protocols followed the same pattern, with LIC/L-MIC providers reporting less COVID-19 protocol implementation (48.5% vs 78.8%).In LIC/L-MICs, providers did not have routine access to N95s (37.1%), surgical masks (29.1%), gloves (21.6%), or eye protection (30.9%). Shortages were present but less severe in UMICs. Clinicians also reported reusing PPE; some were reusing PPE without decontamination (7.7% in LIC/L-MICs vs 6.8% in UMICs). Other prov...

Background Although folate deficiency is linked to adverse health effects, limited data exist characterizing the problem in rural settings. This study determined the prevalence of folate deficiency and anemia in rural adults in the Haitian Central Plateau using combined laboratory methods. Methods Dried blood spots (DBSs) and hemoglobin measurements were collected from adult men and women selected by cluster random sampling in Haiti’s Central Plateau. DBSs were analyzed for folate using a microbiological assay. Hemoglobin levels were determined using both a HemoCue photometer and the sodium lauryl sulfate microplate method. Red cell folate (RCF) levels were determined by normalizing DBS folate to hemoglobin. Results Of the 197 subjects assessed for hemoglobin, 11.4% of males and 21.0% of females were anemic (male: hemoglobin<12 g/dL; female: hemoglobin<11 g/dL). Of the 173 subjects assessed for RCF, 27.9% of men and 14.9% of women were folate deficient (RCF<340 nmol/L). Among reproductive-age women, 83.6% had RCF levels associated with a risk of neural tube defects of >14 per 10 000 live births (RCF≤699 nmol/L). Conclusions Adults in the Haitian Central Plateau suffer from high rates of anemia and folate deficiency, putting the population at elevated risk for disease. DBSs and microbiological assay make folate evaluation feasible, even in low-resource regions.

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