Objective To determine the real world effectiveness of statins and impact of baseline factors on low-density lipoprotein cholesterol (LDL-C) reduction among children and adolescents. Study design We analyzed data prospectively collected from a quality improvement initiative in the Boston Children’s Hospital Preventive Cardiology Program. We included patients ≤ 21 years of age initiated on statins between September 2010 and March 2014. The primary outcome was first achieving goal LDL-C, defined as <130 mg/dL, or <100 mg/dL with high-level risk factors (e.g. diabetes, etc.). Cox proportional hazards models assessed the impact of baseline clinical and lifestyle factors. Results Among the 1521 pediatric patients evaluated in 3813 clinical encounters over 3.5 years, 97 patients (6.3%) were started on statin therapy and had follow-up data (median age 14 [IQR 7] years), 54% were female, 24% obese, 62% with at least one lifestyle risk factor. The median baseline LDL-C was 215 (IQR 78) mg/dL and median follow-up after starting statin was 1.0 (IQR 1.3) year. The cumulative probability of achieving LDL-C goal within 1 year was 60% (95% CI 47, 69). Male sex (HR 0.5 [95% CI 0.3, 0.8]) and higher baseline LDL-C (HR 0.92 [95% CI 0.87, 0.98] per 10 mg/dL) were associated with not achieving LDL-C goals, but not age, BMI percentile, lifestyle factors or family history. Conclusions The majority of pediatric patients started on statins reached LDL-C treatment goals within 1 year. Males and those with higher baseline LDL-C were less likely to be successful and may require increased support.
Annual incidence of non-fatal ballistic civilian has been increasing for the last decade. The aim of the present study was to clarify the optimal reconstructive management of civilian ballistic facial injuries. A systematic review of PubMed was performed. Articles were evaluated for defect type and site, reconstructive modality, complications, and outcomes. A total of 30 articles were included. Most common region of injury was mandibular with a 46.6% incidence rate. All-cause complication rate after reconstruction was 31.0%. About 13.3% of patients developed a postoperative infection. Gunshot wounds had overall lower complication rates as compared with shotgun wounds at 9.0% and 17.0%. By region, complications for gunshot wounds were 35% and 34% for mandible and maxilla, respectively. Immediate surgical intervention with conservative serial debridement is recommended. However, for patients with pre-existing psychiatric disorders, secondary revisions should be delayed until proper psychiatric stabilization. When there is extensive loss of soft tissue in the midface, aesthetic outcomes are achieved with a latissimus dorsi or anterolateral thigh free flap. Radial forearm flap is favored for thin lining defects. Open reduction is suggested for bony-tissue stabilization. The fibula flap is recommended for bony defects >5 cm in both midface and mandible. For bony defects, <5 cm bone grafting was preferred. Delaying bone grafting does not worsen patient outcomes. Surgical treatment of ballistic facial trauma requires thorough preparation and precise planning. An algorithm that summarizes the approach to the main decision points of surgical management and reconstruction after ballistic facial trauma has been presented in this study.
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