scholarly journals Hallux Interphalangeal Arthrodesis Following First Metatarsophalangeal Arthrodesis

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0048
Author(s):  
Songwut Thitiboonsuwan ◽  
Joseph Kavolus ◽  
James Nunley
Keyword(s):  
Median Time ◽  
Bone Healing ◽  
Rate Ratio ◽  
Standard Treatment ◽  
Statistical Data ◽  
Risk Difference ◽  
Multivariable Regression ◽  
Interphalangeal Arthrodesis ◽  
Radiographic Union

Category: Midfoot/Forefoot Introduction/Purpose: Hallux interphalangeal (IP) arthritis can occur after first metatarsophalangeal (MTP) arthrodesis. IP Arthrodesis is a standard treatment, but in the setting of prior MTP surgery there will be increased stress on the IP joint and decrease local blood supply. These may result in diminished potential for bone healing. This investigation seeks to assess the outcomes of hallux IP arthrodesis after first MTP arthrodesis. Methods: Charts were retrospectively reviewed for patients who underwent interphalangeal arthrodesis between 1/1/2007 and 4/3/2017 and who had a minimum of 12-weeks of follow-up. We compared patients with and without prior ipsilateral first MTP arthrodesis. Charts were reviewed for clinical and radiographic union. Outcomes of interest were nonunion, complications, time to union and speed of union. Statistical data were analyzed by multivariable regression. Results: There were 42 patients whose median follow-up was nine (range, 3-135) months. Median time from previous first MTP arthrodesis until IP arthrodesis was 54 months. Six nonunions (35.3%) occurred in 17 patients with prior first MTP arthrodesis. Only two nonunions (8.0%) occurred in 25 patients with isolated IP arthrodesis. The multivariable risk difference of nonunion was 53.3% (P = .001). Prior first MTP arthrodesis also was more likely to have complications (52.9% vs. 24.0%, respectively). The multivariable risk difference of complications was 35.7% (P = .082). The speed of bone healing was statistically significant, with a multivariable rate ratio of 0.21 (P = .012). Conclusion: Prior first MTP arthrodesis resulted in 4.8 times slower bone healing for IP arthrodesis. The numbers needed to harm was two patients for nonunion and three patients for any complication.

Hallux Interphalangeal Arthrodesis Following First Metatarsophalangeal Arthrodesis

2018 ◽  
Vol 39 (10) ◽  
pp. 1178-1182 ◽  
Author(s):  
Songwut Thitiboonsuwan ◽  
Joseph J. Kavolus ◽  
James A. Nunley
Keyword(s):  
Comparative Study ◽  
Median Time ◽  
Bone Healing ◽  
Rate Ratio ◽  
Standard Treatment ◽  
Risk Difference ◽  
Level Of Evidence ◽  
Interphalangeal Arthrodesis ◽  
Retrospective Comparative Study

Background: Hallux interphalangeal (IP) arthritis can occur after first metatarsophalangeal (MTP) arthrodesis. IP arthrodesis is a standard treatment, but in the setting of prior MTP surgery there will be increased stress on the IP joint. This may result in diminished potential for bone healing. This investigation assessed the outcomes of hallux IP arthrodesis after first MTP arthrodesis. Methods: Charts were retrospectively reviewed for patients who underwent interphalangeal arthrodesis between January 1, 2007, and April 3, 2017, and who had a minimum of 12 weeks of follow-up. We compared patients with and without prior ipsilateral first MTP arthrodesis. There were 42 patients whose median follow-up was 9 (range, 3-135) months. Results: Median time from previous first MTP arthrodesis until IP arthrodesis was 54 months. Six nonunions (35.3%) occurred in 17 patients with prior first MTP arthrodesis. Only 2 nonunions (8.0%) occurred in 25 patients with isolated IP arthrodesis. The multivariable risk difference of nonunion was 53.3% ( P = .001). Prior first MTP arthrodesis also was more likely to have complications (52.9% vs 24.0%, respectively). The multivariable risk difference of complications was 35.7% ( P = .082). The speed of bone healing was significantly different, with a multivariable rate ratio of 0.21 ( P = .012). Conclusion Prior first MTP arthrodesis resulted in 4.8 times slower bone healing for IP arthrodesis. It increased the risks of nonunion and any other complications. Level of Evidence: Level III, retrospective comparative study.

Gestational diabetes mellitus: are mothers being followed-up? A retrospective study

2018 ◽  
Vol 68 (suppl 1) ◽  
pp. bjgp18X697469
Author(s):  
Rebecca Ward ◽  
Fahmy W Hanna ◽  
Ann Shelley-Hitchen ◽  
Ellen Hodgson ◽  
Adrian Heald ◽  
...  
Keyword(s):  
Gestational Diabetes ◽  
Median Time ◽  
Post Partum ◽  
Tolerance Test ◽  
Oral Glucose ◽  
Tertiary Referral Centre ◽  
Alternative Approach ◽  
Nice Guidance ◽  
History Of

BackgroundWomen with gestational diabetes (GDM) have an elevated risk of developing type 2 diabetes (T2DM). NICE Guidance recommends women who develop GDM are screened 6 weeks post-partum and annually thereafter.AimTo evaluate conformity to guidance of screening in women with GDM by 6-week post-partum fasting plasma glucose (FPG) and annual FPG and determine time between delivery and development of T2DM.MethodRecords at a tertiary referral centre were used to identify women (n = 54) diagnosed with GDM by antenatal oral glucose tolerance test between July 1999 and January 2007. Data from laboratory records were used to collect investigations of glycaemic status during the follow-up period (median follow-up 12.4 years, range 9.5–17.1 years).ResultsOf 252 women, 102 (40.2%) did not have a FPG at 6 weeks (+/−2 weeks). Of these, median time to first test was 1.2 years (range 0.04–10.8 years), with only 43.1% followed-up within 1 year. In those who had a 6-week FPG, 17 (11.3%) women had no further tests. A total of 84 (33% of those with gestational diabetes in the index pregnancy) women were diagnosed with T2DM; median time from delivery to diagnosis was 5.2 years (range 0.35–15.95). We found the only significant factor for a follow-up test at 1-year post-partum was the use of insulin.ConclusionOur data suggest an alternative approach is needed for monitoring women with a history of GDM. This needs to be appropriate for a generally healthy group in which traditional screening mechanisms may not be adequate or sufficient.

scholarly journals Long-term remission of acromegaly after somatostatin analogues withdrawal: a single-centre experience

2021 ◽  
Author(s):  
E. Sala ◽  
G. Carosi ◽  
G. Del Sindaco ◽  
R. Mungari ◽  
A. Cremaschi ◽  
...  
Keyword(s):  
Median Time ◽  
Pituitary Surgery ◽  
Somatostatin Analogues ◽  
Exclusion Criterion ◽  
Single Centre ◽  
Disease Evolution ◽  
Single Centre Experience ◽  
Pituitary Irradiation

Abstract Purpose A long-lasting remission of acromegaly after somatostatin analogues (SAs) withdrawal has been described in some series. Our aim was to update the disease evolution after SAs withdrawal in a cohort of acromegalic patients. Methods We retrospectively evaluated 21 acromegalic patients previously included in a multicentre study (Ronchi et al. 2008), updating data at the last follow-up. We added further 8 patients selected for SAs withdrawal between 2008–2018. Pituitary irradiation represented an exclusion criterion. The withdrawal was suggested after at least 9 months of clinical and hormonal disease control. Clinical and biochemical data prior and after SAs withdrawal were analysed. Results In the whole cohort (29 patients) mean age was 50 ± 14.9 years and 72.4% were females. In 69% pituitary surgery was previously performed. Overall, the median time of treatment before SAs withdrawal was 53 months (IQR = 24–84). At the last follow up in 2019, 23/29 patients (79.3%) had a disease relapse after a median time of 6 months (interquartile range or IQR = 3–12) from the drug suspension, while 6/29 (20.7%) were still on remission after 120 months (IQR = 66–150). IGF-1 levels were significantly lower before withdrawal in patients with persistent remission compared to relapsing ones (IGF-1 SDS: -1.5 ± 0.6 vs -0.11 ± 1, p = 0.01). We did not observe any other difference between patients with and without relapse, including SAs formulation, dosage and treatment duration. Conclusion A successful withdrawal of SAs is possible in a subset of well-controlled acromegalic patients and it challenges the concept that medical therapy is a lifelong requirement.

Staged Management of Severely Displaced Calcaneal Fractures With Transarticular Pinning: A Damage Control Strategy

2021 ◽  
pp. 107110072110130
Author(s):  
Kyeong-Hyeon Park ◽  
Chang-Wug Oh ◽  
Joon-Woo Kim ◽  
Hee-June Kim ◽  
Dong-Hyun Kim ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Internal Fixation ◽  
Kirschner Wire ◽  
Wound Complications ◽  
Calcaneal Fractures ◽  
Simple Method ◽  
Wire Fixation ◽  
The Mean ◽  
Radiographic Union

Background: Severely displaced calcaneal fractures can result in considerable morphology derangement and may be accompanied by soft tissue compromise. Delayed operative restoration of the calcaneal morphology may result in acute retensioning of the damaged soft tissue with associated wound-related complications. In this study, we describe a staged treatment of displaced intra-articular calcaneal fractures that uses temporary transarticular Kirschner wire (K-wire) fixation and staged conversion to definite fixation. Methods: We identified all of the patients who were treated at our institution for calcaneal fractures between 2015 and 2019. A total of 17 patients with 20 calcaneal fractures were selectively treated with 2-stage management. Temporary transarticular K-wire fixation was performed 24 hours after the injury to restore calcaneal morphology and the surrounding soft tissue. After the soft tissue was considered safe, delayed open reduction and internal fixation was performed. The time to definite surgery, radiographic alignment, wound complications, time to radiographic union, and hindfoot American Orthopaedic Foot & Ankle Society (AOFAS) scores were recorded. Results: The average follow-up period was 17 months (range, 12-43). The average Böhler angle increased from a mean of −22 degrees (range, −109 to 25) to 25 degrees (range, 0 to 47) after temporary transarticular K-wire fixation. The mean time from temporary pinning to conversion to definite internal fixation was 20 (range, 10-32) days. There were no immediate postoperative complications. The average time to radiographic union was 13.7 (range, 10-16) weeks. The mean AOFAS score was 87 (range, 55-100). No infections or wound complications were reported during the follow-up period. Conclusion: Temporary transarticular pinning for staged calcaneal fracture treatment is safe and effective in restoring the calcaneal morphology. This novel and relatively simple method may facilitate delayed operation and decrease wound-related complications. Level of Evidence: Level IV, retrospective case series.

scholarly journals Health-related quality of life 1–3 years post-myocardial infarction: its impact on prognosis

Open Heart ◽  
2021 ◽  
Vol 8 (1) ◽  
pp. e001499
Author(s):  
Stuart Pocock ◽  
David B Brieger ◽  
Ruth Owen ◽  
Jiyan Chen ◽  
Mauricio G Cohen ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Resource Use ◽  
Rate Ratio ◽  
Index Score ◽  
Health Related Quality ◽  
Lower Index ◽  
Related Quality ◽  
Health Related

ObjectiveTo assess associations of health-related quality of life (HRQoL) with patient profile, resource use, cardiovascular (CV) events and mortality in stable patients post-myocardial infarction (MI).MethodsThe global, prospective, observational TIGRIS Study enrolled 9126 patients 1–3 years post-MI. HRQoL was assessed at enrolment and 6-month intervals using the patient-reported EuroQol-5 dimension (EQ-5D) questionnaire, with scores anchored at 0 (worst possible) and 1 (perfect health). Resource use, CV events and mortality were recorded during 2-years’ follow-up. Regression models estimated the associations of index score at enrolment with patient characteristics, resource use, CV events and mortality over 2-years’ follow-up.ResultsAmong 8978 patients who completed the EQ-5D questionnaire, 52% reported ‘some’ or ‘severe’ problems on one or more health dimensions. Factors associated with a lower index score were: female sex, older age, obesity, smoking, higher heart rate, less formal education, presence of comorbidity (eg, angina, stroke), emergency room visit in the previous 6 months and non-ST-elevation MI as the index event. Compared with an index score of 1 at enrolment, a lower index score was associated with higher risk of all-cause death, with an adjusted rate ratio of 3.09 (95% CI 2.20 to 4.31), and of a CV event, with a rate ratio of 2.31 (95% CI 1.76 to 3.03). Patients with lower index score at enrolment had almost two times as many hospitalisations over 2-years’ follow-up.ConclusionsClinicians managing patients post-acute coronary syndrome should recognise that a poorer HRQoL is clearly linked to risk of hospitalisations, major CV events and death.Trial registration numberClinicalTrials.gov Registry (NCT01866904) (https://clinicaltrials.gov).

Echocardiography for the 10-year prediction of cardiomyopathy in long-term survivors of childhood cancer

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
J.M Leerink ◽  
H.J.H Van Der Pal ◽  
E.A.M Feijen ◽  
P.G Meregalli ◽  
M.S Pourier ◽  
...  
Keyword(s):  
Childhood Cancer ◽  
Median Time ◽  
Cancer Diagnosis ◽  
Predictive Value ◽  
Validation Cohort ◽  
Funding Source ◽  
Derivation Cohort ◽  
After Cancer ◽  
Radiotherapy Dose

Abstract Background Childhood cancer survivors (CCS) treated with anthracyclines and/or chest-directed radiotherapy receive life-long echocardiographic surveillance to detect cardiomyopathy early. Current risk stratification and surveillance frequency recommendations are based on anthracycline- and chest-directed radiotherapy dose. We assessed the added prognostic value of an initial left ventricular ejection fraction (EF) measurement at >5 years after cancer diagnosis. Patients and methods Echocardiographic follow-up was performed in asymptomatic CCS from the Emma Children's Hospital (derivation; n=299; median time after diagnosis, 16.7 years [inter quartile range (IQR) 11.8–23.15]) and from the Radboud University Medical Center (validation; n=218, median time after diagnosis, 17.0 years [IQR 13.0–21.7]) in the Netherlands. CCS with cardiomyopathy at baseline were excluded (n=16). The endpoint was cardiomyopathy, defined as a clinically significant decreased EF (EF<40%). The predictive value of the initial EF at >5 years after cancer diagnosis was analyzed with multivariable Cox regression models in the derivation cohort and the model was validated in the validation cohort. Results The median follow-up after the initial EF was 10.9 years and 8.9 years in the derivation and validation cohort, respectively, with cardiomyopathy developing in 11/299 (3.7%) and 7/218 (3.2%), respectively. Addition of the initial EF on top of anthracycline and chest radiotherapy dose increased the C-index from 0.75 to 0.85 in the derivation cohort and from 0.71 to 0.92 in the validation cohort (p<0.01). The model was well calibrated at 10-year predicted probabilities up to 5%. An initial EF between 40–49% was associated with a hazard ratio of 6.8 (95% CI 1.8–25) for development of cardiomyopathy during follow-up. For those with a predicted 10-year cardiomyopathy probability <3% (76.9% of the derivation cohort and 74.3% of validation cohort) the negative predictive value was >99% in both cohorts. Conclusion The addition of the initial EF >5 years after cancer diagnosis to anthracycline- and chest-directed radiotherapy dose improves the 10-year cardiomyopathy prediction in CCS. Our validated prediction model identifies low-risk survivors in whom the surveillance frequency may be reduced to every 10 years. Calibration in both cohorts Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Dutch Heart Foundation

scholarly journals Implantable cardiac monitor after cryptogenic stroke: atrial fibrillation detection and predictors

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
E Ebrille ◽  
C Amellone ◽  
M.T Lucciola ◽  
F Orlando ◽  
M Suppo ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Multivariate Analysis ◽  
Risk Stratification ◽  
Median Time ◽  
Remote Monitoring ◽  
Cryptogenic Stroke ◽  
Screening Process ◽  
Cardiac Monitor ◽  
Implantable Cardiac Monitor

Abstract Objective The main objective of our study was to analyze the incidence and predictors of atrial fibrillation (AF) in patients with cryptogenic stroke (CS) who received an implantable cardiac monitor (ICM) at our Institution. Methods From November 2013 to October 2017, a total of 133 patients who had suffered a CS were implanted with an ICM after a thorough screening process. The median time between the thromboembolic event and ICM implantation was 64 days [IQ range: 16–111]. All implanted patients were followed with remote monitoring until the first detected episode of AF or up to December 2018. Every remote monitoring transmission and related electrograms were analyzed by the dedicated Electrophysiology Nursing team and confirmed by experienced Electrophysiologists. AF was defined by any episode lasting greater than or equal to 2 minutes. Results During a median follow-up of 14.8 months [IQ range: 3.0–31.2], AF was detected in 65 out of 133 patients (48.9%). The median time from ICM implantation and AF detection was 3.5 months [IQ range: 0.9–6.7]. The prevalence of AF was 22.6%, 34.4%, 40.8% and 48.3% at 3, 6, 12 and 24 months respectively. At the multivariate analysis, high premature atrial contractions (PAC) burden and left atrium (LA) dilation were the only independent predictors of AF detection (HR 2.82, 95% CI 1.64–4.83, p<0.001 for PAC; HR 1.75, 95% CI 1.03–2.97, p=0.038 for LA dimension). Patients were dived into categories based on the probability of AF detection (low, intermediate and high risk) and a new risk stratification algorithm was implemented (Figure 1). Conclusion After a thorough screening process, AF detection in patients with CS and ILM was quite high. Having a high PAC burden and LA dilation predicted AF episodes at the multivariate analysis. A new risk stratification algorithm was developed. Figure 1 Funding Acknowledgement Type of funding source: None

scholarly journals Percutaneous Nephrostomy Tube-related Infections

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S349-S349 ◽  
Author(s):  
Hanine El Haddad ◽  
George Viola ◽  
Ying Jiang ◽  
Issam Raad ◽  
Kenneth V Rolston ◽  
...  
Keyword(s):  
Urinary Tract ◽  
Median Time ◽  
Antimicrobial Therapy ◽  
Urinary Tract Obstruction ◽  
Recurrent Infection ◽  
Percutaneous Nephrostomy ◽  
Infectious Complications ◽  
High Rate ◽  
History Of

Abstract Background Percutaneous nephrostomy tubes (PCN) are indicated for relief of urinary tract obstruction. These devices are prone to mechanical and infectious complications. The infection rate at 90 days is ±20%. Our objective was to determine whether discordant antimicrobial coverage provided prior to PCN exchange was associated with a higher rate of recurrent infection compared with those who received concordant therapy. Methods We retrospectively reviewed 780 patients that had undergone initial PCN placement at our institution between July 2014 and February 2017. We only included patients that had developed a definite PCN infection, subsequent PCN exchange, with a minimum 30 day post-PCN exchange follow up. We defined PCN infection as the presence of a positive urine culture (≥104 cfu/mL) plus symptoms consistent with a urinary tract infection. Recurrence was defined as a new PCN infection with the isolation of the same organism to the initial episode. Antibiotics were defined as concordant if they had activity against all organisms’ isolated based on antimicrobial susceptibilities. Results A total of 47 patients met our inclusion criteria. The median age of patients was 59, with 49% being male. The most common underlying tumors were urothelial (45%), cervical (17%) and prostate cancer (15%). Clinical characteristics included ureteral stents (17%), diabetes (19%), history of GU surgery (38%), and active chemotherapy at the time of PCN insertion (70%). The median time to onset of infection was 42 days. Infections were polymicrobial in 50% of the cases. The most common organisms encountered were Pseudomonas spp. (36%), Enterococcus spp. (23%) and Escherichia coli (18%). The median length of follow up of PCN tubes after exchange was 55 days. There were 12 (26%) recurrences occurring at a median time of 27 days. The provision of discordant antibiotics preceding PCN exchange was significantly associated with recurrence of infection (66.7% vs. 12.8%; P < 0.002). Conclusion Discordant antimicrobial therapy provided during PCN exchange, in the setting of a PCN infection is associated with a higher rate of relapse. Therefore, to decrease the high rate for PCN reinfection, we propose that prior to PCN exchange secondary to infection, patients should be receiving concordant antimicrobial therapy. Disclosures All authors: No reported disclosures.

Abstract TP127: Mortality and Recurrence in Atherosclerotic Ischemic Stroke: Long-term Follow-up

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Miguel A Barboza ◽  
Rodrigo Uribe ◽  
Fabiola Serrano ◽  
Luis C Becerra-Pedraza ◽  
D. K Mantilla-Barbosa ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Functional Outcome ◽  
Median Time ◽  
Smoking History ◽  
Stroke Recurrence ◽  
Active Smoking ◽  
Long Term Outcome ◽  
Long Term Follow Up

Background and purpose: Atherosclerotic ischemic stroke is the second most frequent etiology of stroke in the adult population. Functional outcome, mortality and recurrence of stroke rates on the long-term follow-up are poorly studied. This study investigates long-term outcome among patients with ischemic stroke secondary to atherosclerotic causality, and identifies the main factors associated with poor outcome, recurrence, and death. Methods: We analyzed data from our consecutive acute ischemic stroke database, over a period of 25 years (1990-2015). The endpoints were: bad outcome (Modified Rankin Score ≥3), recurrence and mortality at discharge, and final follow-up. Multivariate Cox and Kaplan-Meier analysis were used to estimate the probability of death and recurrence. Results: A total of 946 consecutive atherosclerotic stroke patients were included (571 [60.4%] males, median age 65 years [interquartile range 57-73 years] for the entire population); dyslipidemia (64.2%), hypertension (63.3%), diabetes (35.0%), and active smoking history (31.8%) were the most prevalent risk factors.After a median follow-up of 38 months (IQR 12-75 months), 59.3% patients had a bad outcome at discharge. A result of 26.1% had stroke recurrence (median time until recurrence: 9 months [IQR 12-84 months], with 12.9% cases presenting ≥2 recurrences), and 24.1% were dead (median time to death: 18.5 months [IQR 11-74 months]) at the final follow-up period. After multivariate adjustment, hypertension (HR 4.2, CI 95% 2.8-6.1; p<0.001) was the strongest predictor of recurrence. Additionally, diabetes (HR 2.6, CI 95% 2.0-3.5; p<0.001), bad functional outcome after recurrence (HR 2.3, CI 95% 1.9-2.9; p<0.001), age ≥65 years (HR 2.2, CI 95% 1.7-2.9; p<0.001), and active smoking (HR 1.8, CI 95% 1.3-2.3; p<0.001) were the strongest predictors of mortality. Conclusions: Atherosclerotic ischemic stroke has a high rate of recurrence, associated mainly with hypertension. Mortality is predicted by diabetes, bad functional outcome at recurrence, and older age.

Abstract 51: Access to Primary Stroke Centers for Older Adults and Implications for Travel Times, and Mortality

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Kimon Bekelis ◽  
Kendrew Wong ◽  
Nancy Marth ◽  
Weiping Zhou ◽  
Jonathan Skinner
Keyword(s):  
Regional Variation ◽  
Fee For Service ◽  
Travel Times ◽  
Stroke Patients ◽  
Multivariable Regression ◽  
Potential Impact ◽  
One Year ◽  
Multivariable Regression Models ◽  
Regionalization Of Care

Background: Regionalization of care to primary stroke centers (PSC) may improve outcomes for stroke patients. We evaluated the current access of Medicare stroke patients to PSC, and its potential impact on mortality. Methods: We performed a retrospective cohort study of a 100% sample of Medicare fee-for-service claims data for patients admitted with stroke in 2008-2009, with one-year follow-up through 2010. Population weighted centroids were created, helicopter pad locations were identified, and driving distances were calculated based on real road network data. Driving and flying speeds, dispatch, scene, and pre-hospital times were estimated using validated models, adjusted for population density. The association of 30-day mortality with travel times, and treatment at a PSC was investigated using multivariable regression models. Results: During the study period, 510,822 patients (mean age 79.6 years, 59.7% females) had a stroke. There was significant regional variation in our cohort, (Figure) with 8.6% of stroke patients having ground access to a PSC within 30 minutes, 14.9% from 30 to 45 minutes, 11.1% from 45 to 60 minutes, 43.9% from 1 to 4.5 hours, and 21.5% over 4.5 hours. The latter group could be limited to 0.1% of stroke patients, if existing helicopter services were used optimally. 164,485 (32.2%) patients received treatment in a PSC, and had modestly decreased mortality (OR, 0.97; 95% CI, 0.95-0.99). For this group, actual travel time to the PSC was not associated with mortality for patients within one hour of the PSC. On the contrary, travel times from 1 to 4.5 hours (OR, 1.15; 95% CI, 1.08-1.22), and over 4.5 hours (OR, 1.41; 95% CI, 1.29-1.54) were associated with increased mortality. Conclusions: There is significant regional variation in access to PSC for elderly stroke patients, with a potential impact on outcomes. Optimal use of helicopter services may address these disparities. Funding: NIH (P01-AG19783, and U01-AG046830-01).

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