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Reduced AMI incidence associated with smoking bans

Clinical question Is there a clinical benefit from stricter smoking ordinances?

Bottom line This observational study found that a citywide smoking ban was associated with a reduction in the incidence of acute MI (AMI) by approximately 70 per 100,000 person-years (that is, approximately 1 fewer AMI for every 1,400 persons per year). Share this information with local politicians and other community leaders who are resisting curbs on smoking. Another study by the CDC found that a smoking ban in El Paso, Tex, had no negative economic consequences for bars and restaurants. (Level of evidence = 4)

Bartecchi C, Alsever RN, Nevin-Woods C, et al. Reduction in the incidence of acute myocardial infarction associated with a citywide smoking ordinance. Circulation. 2006;114(14):1490-1496.

Synopsis A small study in Helena, Mont, found a 40% decline in AMIs during a 6-month smoking ban. In this study, the authors studied the incidence of AMI in the geographically isolated town of Pueblo, Colo. The isolation makes it likely that most patients with AMI live in the immediate vicinity and reduces the likelihood of exposure to secondhand smoke elsewhere. The ban began on July 1, 2003, and included tobacco use in all public buildings, restaurants, bars, bowling alleys, and workplaces. The researchers compared the incidence of AMI in the 1.5 years before and after the ban for patients living within the city limits (where the ban applied) and for those living outside the city limits (where there was no ban). They also looked at what happened during the same time to a nearby, but also geographically isolated, community that had no such ban (Colorado Springs and surrounding El Paso County, Colo). Patients with AMI were identified on the basis of their final primary hospital diagnosis. Patients dying before arriving at the hospital were not included. The analysis was adjusted for seasonality, since the incidence of AMI peaks in the winter. The authors found a significant decrease in the incidence of AMI for residents within the city (257 vs 187/100,000 person-years; seasonally adjusted relative risk [RR] = 0.74; 95% confidence interval, 0.64-0.86) but not for those living outside the city limits (RR = 0.87; 0.64-1.17). The incidence of AMI did not change between the two observation periods in the control community of El Paso County (RR = 0.99; 0.90-1.08). Also, even after doing a worst-case analysis by assuming that all AMI deaths occurred outside the hospital, the rate of AMI was still significantly lower in areas with the smoking ban.

Acupuncture is effective for long-term back pain relief

Clinical question Is acupuncture effective for long-term relief of low back pain?

Bottom line Over the long term (1 to 2 years), treatment of nonspecific low back pain with a short course of acupuncture is as effective as a range of usual care provided by physicians. (Level of evidence = 1b)

Thomas KJ, MacPherson H, Thorpe L, et al. Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ. 2006;333:623.

Synopsis TAcupuncture has been shown to be effective for some patients for short-term relief of low back pain. The researchers of this study evaluated the long-term effect following a short course of acupuncture. They enrolled 241 patients with nonspecific low back pain of 4 to 52 weeks’ duration. Patients with identified causes of pain or red flag symptoms (spinal disease, prolapsed central disk, progressive motor weakness, etc.) were excluded. The patients were randomized, using concealed allocation, to receive 10 weekly treatments with acupuncture or to receive usual care, including physical therapy, manipulation, exercises, and drugs at the discretion of the patients’ primary physicians. Patients were aware of the treatment they received since no sham acupuncture was used. The primary outcome was the bodily pain dimension of the SF-36, a widely used scale for evaluating back pain that ranges from 0 to a best score of 100 (no pain). Twelve months after treatment, scores improved from a baseline average of 30 to an average of 64 in the acupuncture care group and an average of 58 in the usual-care group. At 2 years after treatment, acupuncture scores were statistically better than usual care: 68 vs. 60, though this difference might not be clinically noticeable. Patient satisfaction was higher with acupuncture. Patient expectation of benefit of acupuncture was weakly associated with greater improvement. Acupuncture treatment was more expensive than usual care but was cost-effective based on the health gain associated with the treatment (BMJ. 2006;333:626).

Clinical criteria can predict risk of serious head injury in kids

Clinical question Can clinical factors be used to identify children with low risk of serious intracranial pathology after head injury?

Bottom line Clinical factors can accurately predict which children don’t have serious intracranial pathology after head injury. The clinical prediction rule developed in this study requires validation. (Level of evidence = 3b)

Dunning J, Daly JP, Lomas JP, et al, for the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events Study Group. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006;91(11):885-891.

Synopsis This team of researchers identified more than 22,000 children younger than 16 years with any head injury. Specially trained physicians assessed each child with a standardized history and physical examination, including mechanism of injury and Glasgow Coma Scale. The authors then developed a set of clinical criteria to identify children with “clinically significant intracranial injury,” defined as death as a result of head injury, requirement for neurosurgical intervention, or marked abnormalities on the CT scan. A total of 744 of the children provided CT scans, but all children completed a clinical follow-up with the authors. The clinical prediction rule (summarized below) was highly sensitive (98%; 95% CI, 96-100) and also had decent specificity (87%; 86-87). The positive likelihood ratio of 7.5 (6.9-7.7) and negative likelihood ratio of 0.02 (0-0.05) suggests this rule is best at ruling out serious intracranial injury. This prediction rule needs to be validated. The clinical decision rule is that a CT scan is required if any of the following criteria are present. History: witnessed loss of consciousness for longer than 5 minutes; history of amnesia (either antegrade or retrograde) for longer than 5 minutes; abnormal drowsiness; more than three discrete episodes of vomiting after head injury; suspicion of nonaccidental injury; or seizure after head injury in a patient who has no history of epilepsy. Examination: Glasgow coma score (GCS) higher than 14, or GCS lower than 15 if younger than 1 year; suspicion of penetrating or depressed skull injury or tense fontanelle; signs of a basal skull fracture (blood or CSF from ear or nose, panda eyes, Battle’s sign, hemotympanum, facial crepitus, or serious facial injury); focal neurologic deficit; or presence of bruise, swelling, or laceration longer than 5 cm if younger than 1 year. Mechanism: High-speed road traffic accident either as pedestrian, cyclist, or occupant (defined as accident with speed greater than 40 miles per hour); fall of more than 3 m in height; or injury from a high-speed projectile or an object. If none of the above variables are present, the patient is at low risk of intracranial pathology.