On-road Driving Performance of Patients With Bilateral Moderate and Advanced Glaucoma.

PURPOSE: To compare on-road driving performance of patients with moderate or advanced glaucoma to controls and evaluate factors associated with unsafe driving. DESIGN: Case-control pilot study. METHODS: A consecutive sample of 21 patients with bilateral moderate or advanced glaucoma from Washington University, St Louis, Missouri and 38 community-dwelling controls were enrolled. Participants, aged 55-90 years, underwent a comprehensive clinical evaluation by a trained occupational therapist and an on-road driving evaluation by a masked driver rehabilitation specialist. Overall driving performance of pass vs marginal/fail and number of wheel and/or brake interventions were recorded. RESULTS: Fifty-two percent of glaucoma participants scored a marginal/fail compared to 21% of controls (odds ratio [OR], 4.1; 95% CI, 1.30-13.14; P = .02). Glaucoma participants had a higher risk of wheel interventions than controls (OR, 4.67; 95% CI, 1.03-21.17; P = .046). There were no differences detected between glaucoma participants who scored a pass vs marginal/fail for visual field mean deviation of the better (P = .62) or worse (P = .88) eye, binocular distance (P = .15) or near (P = .23) visual acuity, contrast sensitivity (P = .28), or glare (P = .88). However, glaucoma participants with a marginal/fail score performed worse on Trail Making Tests A (P = .03) and B (P = .05), right-sided Jamar grip strength (P = .02), Rapid Pace Walk (P = .03), Braking Response Time (P = .03), and identifying traffic signs (P = .05). CONCLUSIONS: Patients with bilateral moderate or advanced glaucoma are at risk for unsafe driving-particularly those with impairments on psychometric and mobility tests. A comprehensive clinical assessment and on-road driving evaluation is recommended to effectively evaluate driving safety of these patients.

Clinical predictors of operative complexity in laparoscopic ventral hernia repair: a prospective study.

BACKGROUND: Because of uncertainties about the complexity of laparoscopic ventral hernia repair for varying patient populations, surgeons may be reluctant to perform this procedure. This study aimed to delineate the risk factors that can be identified in the preoperative setting predictive of longer operative times and complexity in laparoscopic ventral hernia repair. METHODS: Patient demographics including body mass index (BMI), comorbidities, previous laparoscopic and open surgical procedures, ventral hernia repairs, and hernia characteristics (defect size and location, adhesions, incarceration) were recorded prospectively. Data are given as mean +/- standard deviation. Times (min) required for abdominal access, adhesiolysis, and mesh placement as well as the total operative time were recorded during each case as outcome measures of operative difficulty. Univariate analyses were performed with the t-test or the Mann-Whitney U test as well as multivariate analyses using the stepwise analysis of covariance model to determine demographic and clinical variables influencing operative times. RESULT: The study enrolled 180 patients (78 men and 102 women) with a mean age of 54.8 +/- 12.2 years and a mean BMI of 33.3 +/- 13.0 kg/m(2). Multivariate analysis demonstrated significantly longer (p < 0.05) adhesiolysis and total operative times for patients with prior ventral hernia repairs, suprapubic hernia, bowel adhesion to the abdominal wall or hernia sac, and larger hernia defect. The total operative time also was increased (p < 0.05) with incarcerated hernia contents. Mesh placement time was increased (p < 0.05) with incarcerated hernia contents, suprapubic hernia location, hernias requiring larger mesh for repair, and decreased postgraduate year of the surgical assistant. The time required to obtain abdominal access was longer (p < 0.05) with a greater BMI and a higher American Society of Anesthesiology (ASA) classification. The operative times were not increased with a history of peritonitis, diabetes, immunosuppression, cancer, or with higher numbers of previous open or laparoscopic surgeries. CONCLUSIONS: At least 10 preoperatively identifiable patient variables, either alone or in combination, are predictive of prolonged operative times during laparoscopic ventral hernia repair and may be used as surrogates to determine the complexity of a minimally invasive approach.