Healthcare indicators associated with COVID-19 death rates in the European Union.

OBJECTIVES: Identification of environmental and hospital indicators that may influence coronavirus disease 2019 (COVID-19) mortality in different countries is essential for better management of this infectious disease. STUDY DESIGN: Correlation analysis between healthcare system indicators and COVID-19 mortality rate in Europe. METHODS: For each country in the European Union (EU), the date of the first diagnosed case and the crude death rate for COVID-19 were retrieved from the John Hopkins University website. These data were then combined with environmental, hospital and clinical indicators extracted from the European Health Information Gateway of the World Health Organization. RESULTS: The COVID-19 death rate in EU countries (mean 1.9 ± 0.8%) was inversely associated with the number of available general hospitals, physicians and nurses. Significant positive associations were also found with the rate of acute care bed occupancy, as well as with the proportion of population who were aged older than 65 years, overweight or who had cancer. Total healthcare expenditure, public sector health expenditure and the number of hospital and acute care beds did not influence COVID-19 death rate. CONCLUSIONS: Some common healthcare system inadequacies, such as limited numbers of general hospitals, physicians and nurses, in addition to high acute care bed occupancy, may be significant drivers of nationwide COVID-19 mortality rates in EU countries.

Systematic review and meta-analysis of the anatomical variants of the left colic artery.

AIM: To provide a comprehensive evidence-based assessment of the anatomical variations of the left colic artery (LCA). METHOD: A thorough systematic search of the literature up until 1 April 2019 was conducted on the electronic databases PubMed, SCOPUS and Web of Science (WOS) to identify studies eligible for inclusion. Data were extracted and pooled into a meta-analysis using the Metafor package in R. The primary outcomes of interest were the absence of the LCA and the anatomical variants of its origin. The secondary outcomes were the distance (mean ± SD) between the origin of the inferior mesenteric artery (OIMA) and the origin of the left colic artery (OLCA). RESULTS: A total of 19 studies (n = 2040 patients) were included. The pooled prevalence estimate (PPE) of LCA absence was 1.2% (95% CI 0.0-3.6%). Across participants with either a Type I or Type II LCA, the PPE of a Type I LCA was 49.0% (95% CI 40.2-57.8%). The PPE of a Type II LCA was therefore 51.0%. The pooled mean distance from the OIMA to the OLCA was 40.41 mm (95 CI% 38.69-42.12 mm). The pooled mean length of a Type I LCA was 39.12 mm (95% CI 36.70-41.53 mm) while the pooled mean length of a Type IIa and Type IIb LCA was 41.43 mm (95% CI 36.90-43.27 mm) and 39.64 mm (95% CI 37.68-41.59 mm), respectively. CONCLUSION: Although the absence of the LCA is a rare occurrence (PPE 1.2%), it may be associated with an important risk of anastomotic leakage as a result of insufficient vascularization of the proximal colonic conduit. It is also necessary to distinguish variants I and II of Latarjet, the frequency of which is identical, with division of the LCA being technically more straightforward in variant I of Latarjet. Surgeons should be aware that technical difficulties are likely to be more common with variant II of Latarjet, as LCA ligation may be more difficult due to its close proximity to the inferior mesenteric vein (IMV).

Sigmoid resection for diverticular disease - to ligate or to preserve the inferior mesenteric artery? Results of a systematic review and meta-analysis.

AIM: In colorectal cancer, ligation of the inferior mesenteric artery (IMA) is a standard surgical approach. In contrast, ligation of the IMA is not mandatory during treatment of diverticular disease. The object of this meta-analysis was to assess if preservation of the IMA reduces the risk of anastomotic leakage. METHOD: A search was performed up to August 2018 using the following electronic databases: MEDLINE/PubMed, ISI Web of Knowledge and Scopus. The measures of treatment effect utilized risk ratios for dichotomous variables with calculation of the 95% CI. Data analysis was performed using the meta-analysis software Review Manager 5.3. RESULTS: Eight studies met the inclusion criteria and were included in the meta-analysis: two randomized controlled trials (RCTs) and six non-RCTs with 2190 patients (IMA preservation 1353, ligation 837). The rate of anastomotic leakage was higher in the IMA ligation group (6%) than the IMA preservation group (2.4%), but this difference was not statistically significant [risk ratio (RR) 0.59, 95% CI 0.26-1.33, I2  = 55%]. The conversion to laparotomy was significantly lower in the IMA ligation group (5.1%) than in the IMA preservation group (9%) (RR 1.74, 95% CI 1.14-2.65, I2  = 0%). Regarding the other outcomes (anastomotic bleeding, bowel injury and splenic damage), no significant differences between the two techniques were observed. CONCLUSION: This meta-analysis failed to demonstrate a statistically significant difference in the anastomotic leakage rate when comparing IMA preservation with IMA ligation. Thus, to date there is insufficient evidence to recommend the IMA-preserving technique as mandatory in resection for left-sided colonic diverticular disease.

Is it possible to identify the inguinal nerves during hernioplasty? A systematic review of the literature and meta-analysis of cadaveric and surgical studies.

PURPOSE: Patients who undergo inguinal hernioplasty may suffer from persistent postoperative pain due to inguinal nerve injuries. The aim of this systematic review and meta-analysis was to provide comprehensive data on the prevalence (identification rates), anatomical characteristics, and ethnic variations of the ilioinguinal (IIN), the iliohypogastric (IHN) and the genital branch of the genitofemoral (GNF) nerves. METHODS: The systematic literature search was conducted using the PubMed, Scopus and Web of Science databases. RESULTS: A total of 26 articles (5265 half-body examinations) were included in this study. The identification rate of the IIN was 94.4% (95% CI 89.5-97.9) using a random-effects model. Unweighted multiple regression analysis showed that study sample size (ß = - 0.74, p = .036) was the only statistically significant predictor of lower prevalence. The identification rates of the IHN and GNF was 86.7% (95% CI 78.3%-93.3%) and 69.1% (95% CI 53.1%-83.0%) using a random-effects model, respectively. For those outcomes, a visual analysis of funnel and Doi plots indicated irregularity and provided evidence that larger studies tended to have lower identification rates. In terms of the synthesis of anatomical reference points, there was a large and statistically significant amount of heterogeneity for most outcomes. CONCLUSIONS: The identification rates of the inguinal nerves in our study were lower than reported in literature. The lowest was found for GNF, suggesting that this nerve was the most difficult to identify. Knowledge regarding the anatomy of the inguinal nerves can facilitate their proper identification and reduce the risk of iatrogenic injury and postoperative pain.

The variable origin of the lateral circumflex femoral artery: a meta-analysis and proposal for a new classification system.

The lateral circumflex femoral artery (LCFA) is responsible for vascularisation of the head and neck of the femur, greater trochanter, vastus lateralis and the knee. The origin of the LCFA has been reported to vary significantly throughout the literature, with numerous branching patterns described and variable distances to the mid-inguinal point reported. The aim of this study was to determine the estimated population prevalence and pooled means of these anatomical characteristics, and review their associated clinical relevance. A search of the major electronic databases was performed to identify all articles reporting data on the origin of the lateral circumflex femoral artery and its distance to the mid-inguinal point. Additionally, an extensive search of the references of all relevant articles was performed. All data on origin, branching, and distance to mid-inguinal point was extracted and pooled into a meta-analysis. A total of 26 articles (n = 3731 lower limbs) were included in the meta-analysis. Lateral circumflex femoral artery most commonly originates from the deep femoral artery with a pooled prevalence of 76.1% (95% confidence interval 69.4-79.3). The deep femoral artery-derived lateral circumflex femoral artery was found to originate with a mean pooled distance of 51.06 mm (95% confidence interval 44.61-57.51 mm) from the mid-inguinal point. Subgroup analysis of both gender and limb side data were consistent with these findings. Due to variability in the lateral circumflex femoral artery's origin and distance to mid-inguinal point, anatomical knowledge is crucial for clinicians to avoid iatrogenic injuries when performing procedures in the femoral region, and thus radiographic assessment prior to surgery is recommended. Lastly, we propose a new classification system for origin of the lateral circumflex femoral artery.

The surgical anatomy of the lateral femoral cutaneous nerve in the inguinal region: a meta-analysis.

PURPOSE: Several variations in the anatomy and injury of the lateral femoral cutaneous nerve (LFCN) have been studied since 1885. The aim of our study was to analyze the available data on the LFCN and find a true prevalence to help in the planning and execution of surgical procedures in the area of the pelvis, namely inguinal hernia repair. METHODS: A search of the major medical databases was performed for LFCN anatomy. The anatomical data were collected and analyzed. RESULTS: Twenty-four studies (n = 1,720) were included. The most common pattern of the LFCN exiting the pelvis was medial to the Sartorius as a single branch. When it exited in this pattern, it did so on average 1.90 cm medial to the anterior superior iliac spine (ASIS). CONCLUSIONS: The LFCN and its variations are important to consider especially during inguinal hernia repair, abdominoplasty, and iliac bone grafting. We suggest maintaining a distance of 3 cm or more from the ASIS when operating to prevent injury to the LFCN.

Laparoscopic decompression as treatment for median arcuate ligament syndrome.

Median arcuate ligament syndrome (MALS) is a rare disorder due to coeliac trunk compression by the median arcuate ligament, resulting in coeliac artery stenosis characterised by chronic, recurrent abdominal pain. Patients with MALS are often middle-aged females presenting with a triad of postprandial epigastric pain, weight loss and abdominal bruit. It is a diagnosis of exclusion and confirmed by computed tomography or magnetic resonance imaging. Laparoscopic or open surgical decompression are the only treatment options in MALS. We present two cases of MALS treated by laparoscopic decompression as well as a literature review on this treatment.