Changing Knowledge and Attitudes towards Bariatric Surgery in Primary Care: a 10-Year Cross-Sectional Survey.

BACKGROUND: Some 28% of the Scottish population suffer from obesity. Bariatric procedures per population carried out in England when compared to Scotland (NBSR 2018) are significantly higher. Primary care practitioners (PCP) influence equality of access to secondary care bariatrics and frequently manage post-operative bariatric patients. Examining changes in PCP knowledge and attitude could improve access to bariatric procedures in Scotland. METHODS: Following a sample pilot, all PCPs within three Scottish NHS health boards were emailed a questionnaire-based survey (2011; n = 902). A subsequent 10-year follow-up encompassed a greater scope of practice, additionally distributed to all PCPs in five further health boards (2021; n = 2049). RESULTS: Some 452 responses were achieved (2011, 230; 2021, 222). PCPs felt bariatric surgery offered a greater impact in both weight management and that of obesity-related diseases (p < .0001). More PCPs were aware of local bariatric surgical referral criteria (2011, 43%; 2021, 57% (p = .003)), and more made referrals (2011, 60%; 2021, 72% (p = .018)) but were less familiar with national bariatric surgical guidelines (2011, 70%; 2021, 48% (p < .001)). Comfort at managing post-operative bariatric surgical patients were unchanged (2011, 24%; 2021, 27% (p = .660)). Minimal progress through dietetic-lead weight management services, plus rejection of patients thought to be good candidates, was reasons for referral hesitancy. CONCLUSION: Over 10 years, PCPs were more aware of local referral criteria, making increased numbers of referrals. Knowledge deficits of national guidelines remain, and overwhelmingly PCPs do not feel comfortable looking after post-operative bariatric surgical patients. Further research into PCP educational needs, in addition to improving the primary to secondary care interface, is required.

8-0 polyglactin 910 suture in entropion repair: long term follow up and rates of recurrence.

OBJECTIVES: The choice of suture is an important consideration in entropion repair, with implications on wound strength, inflammation and scar formation. There is no consensus on the best suture material or gauge of suture at present. We aim to assess the long-term outcome of entropion repair using 8-0 polyglactin sutures, with specific focus on rates of recurrence, wound dehiscence, infection and scarring. METHODS: This retrospective case series included consecutive patients from two institutions (84 eyes) undergoing entropion repair using a subciliary incision and a lateral wedge resection. Patients were invited for follow up review and patient records were evaluated to assess for cosmetic and functional outcome, complications and patient satisfaction. RESULTS: The median follow-up time from surgery was 48 months (range 20-100). There were five cases of entropion recurrence (5.9%), taking place between 8 months to 4 years after surgery, two cases required further surgery, while three were conservatively treated. There was no wound dehiscence. Two cases (2.4%) of mild superficial wound infections occurred which were successfully treated with topical antibiotics, 1 case (1.2%) of mild lid notching, and 1 case (1.2%) of scarring were recorded. 97% of patients reported to be satisfied with the outcome of their surgery. CONCLUSIONS: The use of 8-0 polyglactin suture in entropion repair has resulted in good aesthetic and functional outcome in this case series, with low rates of recurrence, complications, and no case of wound dehiscence, suggesting this suture provides sufficient tensile strength to enable wound closure and healing.

Diplopia Following the Insertion of a Canalicular Bypass Tube: Etiology, Risk Factors, Management, and Outcomes.

PURPOSE: To report the etiology, management, and possible risk factors for diplopia after canalicular bypass surgery. METHODS: A multicenter retrospective, noncomparative case series of patients who developed diplopia following canalicular bypass surgery were assessed. RESULTS: Twenty-four cases of diplopia were identified across 12 institutions. Tubes were inserted as a primary procedure with external dacryocystorhinostomy (DCR) (1; 4%) or without DCR (10; 42%) or as a secondary procedure after external (8; 33%) or endonasal (5; 21%) DCR. Factors predisposing to local damage were noted in 17 (71%): these factors included preexisting autoimmune/inflammatory condition (7 cases), medial canthal tumor resection (5 cases), preoperative radiotherapy (2 cases), 2 drug treatments (topical and systemic), and 1 local surgery. Horizontal diplopia was due to restriction of abduction and first noted at a median of 3.5 months (mean: 17.8 months, range: 1 day to 112 months) and persisted in 23 (96%) cases with a mean restriction of -2, affecting primary gaze in 4 patients and activities of daily living in 13 (42%). Seventeen patients received various treatments: 10 were operated on resulting in cure in 1 and improvement in 9. A stable degree of diplopia persisted in all but one patient. CONCLUSIONS: Restriction of abduction causing horizontal diplopia is a rare complication with canalicular bypass surgery and a notably high proportion occurred after tube placement without DCR; carunculectomy was not ubiquitous. Although in some the diplopia may be improved with intervention, the chance of cure is low. This complication should probably be included during informed consent for canalicular bypass tubes.

How do absorbable sutures absorb? A prospective double-blind randomized clinical study of tissue reaction to polyglactin 910 sutures in human skin.

OBJECTIVE: To compare the tissue reaction produced by 2 gauges of implanted polyglactin 910(Vicryl) suture material in human skin. METHODS: A prospective, double masked, parallel randomized IRB approved clinical trial. Consecutive patients with involutional entropion and horizontal eyelid laxity were randomly allocated to 5/0 or 7/0 gauge test suture groups. Symptoms were alleviated during the wait for definitive surgery by placement of eyelid everting sutures. After 28 days, surgical entropion correction including eyelid wedge excision was achieved. Histological analysis was carried out, masked to the suture gauge used, on the excised eyelid containing one of the temporary everting sutures. Both patient and analyst were masked to the suture group. The four primary outcome measurements were granuloma outer diameter, central cellular diameter, giant cell number and area of fibrous coat and a statistical comparison made between suture gauge groups. RESULTS: 21 patients were allocated to each group, and histological analysis was possible in 36 patients. Significant suture-related granulomatous inflammatory reactions were found in all specimens. Medians of the measurements for 5/0 and 7/0 gauge sutures, respectively, were 0.855 mm versus 0.387 mm granuloma outer diameter (p = 0.0001); 0.464 mm versus 0.250 mm central cellular element diameter (p = 0.0003); 0.194 mm(2) versus 0.053 mm(2) fibrous coat area (p = 0.0009) and 0.8 versus 1.2 giant cell number (p = 0.7511). CONCLUSIONS: Polyglycolic acid sutures elicit a significant foreign body inflammatory response proportional to suture gauge. This reaction may be minimized by early suture removal. The study validates a novel and ethical approach to the examination of human skin response to implanted suture material.

Lymphocytic infiltration and enlargement of the lacrimal glands: a new subtype of primary Sjögren's syndrome?

PURPOSE: To review the clinical, radiologic, serologic, histopathologic, immunohistochemical, and molecular genetic features of patients having Sjögren's syndrome (SS) with lacrimal gland enlargement. DESIGN: Retrospective case series review. PARTICIPANTS: Fourteen patients histopathologically diagnosed with SS with lacrimal enlargement. Twenty-three age- and gender-matched controls were used for comparison on radiologic analysis. METHODS: Clinical and serologic data were determined directly or by chart review. Computed tomography images from patients were compared with those from the control group. Histopathologic sections were reviewed and graded using the Chisholm-Mason scale, and quantitative immunohistochemical analysis was applied. MAIN OUTCOME MEASURES: Clinically, patients were assessed for age, gender, onset, symptoms and signs, systemic features, treatment, and outcome. Existing histologic specimens were reviewed according to the Chisholm-Mason scale, and then the percentages of plasma cells containing immunoglobulin (Ig) A, IgG, and IgM were determined. Imaging was assessed for lacrimal gland thickness, prolapse, density, and margin contour; extraocular muscle size; orbital tissue displacement; and proptosis. RESULTS: Clinical and histopathological data fulfilled the revised American-European criteria for primary SS in 79% of patients. Compared with other large series of primary SS patients, similarities were found with age, xerophthalmia, parotidomegaly, and articular involvement. Differences included a lower incidence of autoantibodies, xerostomia, and extraglandular features and a higher male-to-female ratio. In almost all patients (93%), the percentage of plasma cells positive for IgA was less than 70%, consistent with SS. Compared with controls, the lacrimal glands were enlarged significantly (P<0.0001) and prolapsed (P<0.001). Involved glands had blurred margins (P<0.007), caused displacement of adjacent tissues (P = 0.03), and were associated with hyperdense fat (P = 0.007). Lymphocytic infiltration of orbital fat was present in all patients for whom fat biopsy results were available. Three patients had monoclonal infiltrates, and 1 patient experienced subsequent extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue type, 4 years after presentation. CONCLUSIONS: The criteria used to diagnose primary SS are controversial, but both diagnostic and quantitative immunohistochemical criteria suggest that these patients, with lacrimal gland enlargement resulting from lymphocytic infiltration, represent a new subtype of primary SS. This is clinically important in view of the increased risk of lymphoma associated with SS, compared with idiopathic nonspecific lacrimal inflammation.