Since the emergence of the coronavirus disease 2019 in December, 155 countries have reported cases of COVID-19, including sustained community transmission in several countries, such as China, Italy, and Iran. As of March 21, 2020, there have been 275 434 cases confirmed globally, including 11 399 deaths. 1 While the situation in China has improved, many countries continue to struggle with escalating case numbers and strained health care systems that are threatened to be overwhelmed by the pandemic.One of the World Health Organization's strategic priorities is to limit human-to-human transmission, including secondary infections among health care workers, which was a key feature of the severe acute respiratory syndrome (SARS) epidemic in 2003 and accounted for one-fifth of all cases globally. Although SARS and COVID-19 are both transmitted by droplets, it is now clear that the infectivity and extent of spread of COVID-19 will far exceed that of SARS.Despite the lower mortality rate in COVID-19 compared with SARS (2.3% vs 11%), a notable fraction of infected people (9.8%-15.2%) require invasive mechanical ventilation or extracorporeal membrane oxygenation. [2][3][4] In an epidemic setting, intensive care units (ICUs) will quickly reach capacity. Patients with prolonged ventilation may require tracheostomy to optimize weaning from ventilatory support. Unsurprisingly, open tracheostomy was the most common surgical procedure performed on infected patients during the SARS outbreak. 5,6 We performed a literature review of tracheostomies during the SARS epidemic consisting of a PubMed search with the terms SARS and tracheostomy, from which 3 case series (Table ) and 2 case reports were available for review. [5][6][7][8][9] Drawing from these experiences as well as our own contingency plans for SARS and COVID-19 outbreaks, we wish to highlight several important perioperative considerations when planning for open tracheostomy in an infected patient during the COVID-19 pandemic.First, it cannot be overemphasized that barrier precautions are of critical importance. Standard personal protective equipment (PPE) is essential. This comprises an N95 mask, surgical cap, goggles, surgical gown, and gloves. Of the published cases of tracheostomies performed in Singapore, Hong Kong, and Canada during the SARS outbreak, in addition to standard PPE, all 5 health care institutions further used enhanced PPE measures ranging from face shields to powered airpurifying respirators (PAPRs).

Objective The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. Data Sources Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. Review Methods The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. Conclusions Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. Implications for Practice Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

ImportanceHearing loss is associated with cognitive decline. However, it is unclear if hearing restorative devices may have a beneficial effect on cognition.ObjectiveTo evaluate the associations of hearing aids and cochlear implants with cognitive decline and dementia.Data SourcesPubMed, Embase, and Cochrane databases for studies published from inception to July 23, 2021.Study SelectionRandomized clinical trials or observational studies published as full-length articles in peer-reviewed journals relating to the effect of hearing interventions on cognitive function, cognitive decline, cognitive impairment, and dementia in patients with hearing loss.Data Extraction and SynthesisThe review was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) reporting guidelines. Two authors independently searched the PubMed, Embase, and Cochrane databases for studies relating to the effect of hearing interventions on cognitive decline and dementia in patients with hearing loss.Main Outcomes and MeasuresMaximally adjusted hazard ratios (HRs) were used for dichotomous outcomes and ratio of means for continuous outcomes. Sources of heterogeneity were investigated using sensitivity and subgroup analyses, and publication bias was assessed using visual inspection, the Egger test, and trim and fill.ResultsA total of 3243 studies were screened; 31 studies (25 observational studies, 6 trials) with 137 484 participants were included, of which 19 (15 observational studies, 4 trials) were included in quantitative analyses. Meta-analysis of 8 studies, which had 126 903 participants, had a follow-up duration ranging from 2 to 25 years, and studied long-term associations between hearing aid use and cognitive decline, showed significantly lower hazards of any cognitive decline among hearing aid users compared with participants with uncorrected hearing loss (HR, 0.81; 95% CI, 0.76-0.87; I2 = 0%). Additionally, meta-analysis of 11 studies with 568 participants studying the association between hearing restoration and short-term cognitive test score changes revealed a 3% improvement in short-term cognitive test scores after the use of hearing aids (ratio of means, 1.03; 95% CI, 1.02-1.04, I2 = 0%).Conclusions and RelevanceIn this meta-analysis, the usage of hearing restorative devices by participants with hearing loss was associated with a 19% decrease in hazards of long-term cognitive decline. Furthermore, usage of these devices was significantly associated with a 3% improvement in cognitive test scores that assessed general cognition in the short term. A cognitive benefit of hearing restorative devices should be further investigated in randomized trials.

Miniature batteries are easily available in our domestic environment, powering many electronic devices and toys. Despite improvement in the safety standards, children are able to remove the batteries from these devices. These batteries pose a hazard to children, as they are small and easily inserted into the nose or ears or even swallowed. We describe 6 children who inserted button batteries into their noses. Four of these insertions resulted in septal perforations. The mechanisms and management of button battery injury are discussed. We emphasize the need for urgent removal of a battery from the nose to prevent long-term complications.