CHICAGO—Women with chronic, nonspecific neck pain may find some relief from strength or endurance training, according to a study in the May 21 issue of The Journal of the American Medical Association (JAMA).

According to background information in the article, "neck pain has been the most common chief complaint among working-aged women visiting their physicians. In a Canadian study, 54 percent of the general population had experienced neck pain during the past 6 months, and approximately 5 percent were highly disabled by neck pain."

Jari Ylinen, M.D., from the Jyvaskyla Central Hospital, Jyvaskyla, Finland, and colleagues investigated the effect of intensive isometric neck strength training and lighter endurance training of neck muscles in rehabilitation of women with chronic, nonspecific neck pain.

A total of 180 female office workers were recruited from various workplaces through their respective occupational health care systems to participate in the study. They ranged in age from 25 to 53 years, had full-time jobs, were motivated for rehabilitation, and had constant or frequently occurring neck pain for more than six months.

The participants were randomly assigned to either two training groups or to a control group, with 60 patients in each group. The endurance training group performed dynamic neck exercises, including lifting the head up from lying down (on their back; supine) or face-down (prone) positions. The strength training group performed high-intensity isometric (muscular contractions against resistance) neck strengthening and stabilization exercises with an elastic band. Both training groups performed dynamic exercises for the shoulders, upper body and arms with dumbbells. All groups were advised to do aerobic and stretching exercises regularly three times a week at home.

"Our study showed that participation in one-year endurance and strength training programs led to a considerable reduction in average neck pain and disability compared with the control group," the authors report. "Neck function, including neck strength and range of motion (ROM), was improved significantly in both training groups compared with the control group." Maximal isometric neck strength had improved flexion by 110 percent, rotation by 76 percent and extension by 69 percent in the strength training group. The respective improvements in the endurance training group were 28 percent, 29 percent, and 16 percent and in the control group were 10 percent, 10 percent, and 7 percent.

CHICAGO—Black and white elderly Medicare patients hospitalized for heart failure received comparable quality of care, according to an article in the May 21 issue of The Journal of the American Medical Association (JAMA).

According to information in the article, heart failure affects nearly 5 million persons in the United States, with an additional 550,000 diagnosed each year. Black Americans are disproportionately affected and have a higher incidence and prevalence of heart failure than other racial groups. Despite this greater burden, it is unclear whether black patients receive the same quality of care for heart failure as white patients do.

Saif S. Rathore, M.P.H., of the Yale University School of Medicine, New Haven, Conn., and colleagues evaluated differences in quality of care and patient outcomes between black and white Medicare beneficiaries hospitalized with heart failure.

The researchers reviewed the medical records of 29,732 fee-for-service Medicare beneficiaries hospitalized with heart failure in 1998 and 1999. The patients were part of the National Heart Failure (NHF) Project, an initiative to improve quality of care for Medicare beneficiaries hospitalized with heart failure.

The researchers found that black and white patients had similar rates of left ventricular ejection fraction (LVEF, a measurement of heart function) (67.8 percent black vs. 66.6 percent white). Among patients described as ideal for ACE inhibitor (a medication used to lower blood pressure) use, black patients had higher rates of use than white patients (81.0 percent vs. 73.8 percent white) but had similar rates of ACE inhibitor or angiotensin receptor blocker (ARB, another medication used to lower blood pressure) use (85.7 percent black vs. 82.5 percent white). After adjustment for confounding factors like age and sex, black patients had comparable rates of LVEF assessment, and remained more likely to be prescribed ACE inhibitors than were white patients, but there were no significant racial differences in the combined end point of prescription of ACE inhibitors or ARBs.

The researchers also found that black patients had a slightly higher readmission rate within one year of discharge as did white patients (68.2 percent vs. 63 percent), but were at a lower risk for dying within 30 days (6.3 percent vs. 10.7 percent) and 1 year (31.5 percent vs. 40.1 percent) after discharge.

CHICAGO—Combination therapy with hormone replacement and alendronate (a bisphosphonate drug prescribed for increasing bone mass) yielded greater improvements in bone mineral density at the spine and hip than either therapy alone, according to a study in the May 21 issue of The Journal of the American Medical Association (JAMA).

"The impact of osteoporosis is most pronounced in elderly women who have the greatest risk of fracture," the authors provide as background information. "Available antiresorptive agents increase bone mineral density (BMD) and reduce fractures in women with postmenopausal osteoporosis." The authors write that previous clinical trials show an increase in BMD correlates well with a reduction in bone fractures.

Susan L. Greenspan, M.D., from the University of Pittsburgh Medical Center, Pittsburgh, and colleagues analyzed data from 373 women, ages 65 to 90 years, at a single academic U.S. medical center from January 1996 to May 2001. The study was designed to examine the effectiveness and safety of combination therapy with hormone therapy and alendronate, compared with each agent alone in a group of elderly women living in the community.

Participants in the study were randomly assigned to receive hormone therapy (conjugated equine estrogen, 0.625 mg/d, with or without medroxyprogesterone, 2.5 mg/d) and alendronate, 10 mg daily, both agents, or neither. All participants received calcium and vitamin D supplements.

"Bone mineral density at 3 years was significantly greater at all femoral (thigh) and vertebral sites in women treated with combination therapy than with monotherapy, with mean increases of 5.9 percent at the total hip, 10.4 percent at the postero-anterior lumbar spine, and 11.8 percent at the lateral lumbar spine," the authors report. "Mean increases in bone mass at the hip in women treated with alendronate alone were significantly greater than in those treated with hormone replacement therapy alone (4.2 percent vs. 3.0 percent), and alendronate resulted in more responders to therapy," the authors add.

"In summary, in community-dwelling elderly women, combination therapy with alendronate and hormone replacement is safe and efficacious," the authors write, although the study was too small to detect differences in rare but serious adverse events such as myocardial infarction or venous thrombosis. "Monotherapy with alendronate was shown to be superior to hormone replacement, and combination therapy with both was shown to be superior to either alone."

The authors continue, "Although findings from the Women's Health Initiative suggest an increased risk when hormone replacement is used for prevention of chronic disease, the study also demonstrated a statistically significant reduction in hip and vertebral fractures."

CHICAGO—Low-dose diuretics are more effective than beta blockers, ACE inhibitors, calcium channel blockers, and other initial antihypertensive therapies in preventing cardiovascular disease-related illnesses and death, according to an article in the May 21 issue of The Journal of the American Medical Association (JAMA).

Establishing relative benefit or harm from specific antihypertensive agents is limited by the complex array of studies that compare antihypertensive treatments, according to background information in the article. The authors used a new type of analysis called "network meta-analysis" to combine the complex array of studies. While meta-analysis allows studies that all compared the same treatments to be combined to better understand the totality of the evidence, network meta-analysis allows studies with only one treatment in common to be combined as well.

Bruce M. Psaty, M.D., Ph.D., of the Cardiovascular Health Research Unit, University of Washington, Seattle, and colleagues summarized the available clinical trial evidence concerning the safety and efficacy of various antihypertensive therapies that have been used as first-line agents. The therapies were evaluated in terms of major cardiovascular disease end points (such as heart attack, coronary heart disease death, congestive heart failure) and all-cause death.

The researchers used previous meta-analyses, MEDLINE searches, and journal reviews from January 1995 through December 2002. They identified long-term randomized controlled trials that assessed major cardiovascular disease end points as an outcome. Data were combined from 42 clinical trials that included 192,478 patients randomized to 7 major treatment strategies, including placebo.

"For all outcomes, the network meta-analysis confirmed that low-dose diuretics were superior to placebo. While several other treatment strategies were significantly better than placebo for some end points, none of the other first-line treatment strategies - beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers (CCBs), alpha-blockers, and angiotensin receptor blockers (ARBs) - was significantly better than low-dose diuretics for any major cardiovascular disease outcome. In 8 of the 30 between-drug comparisons, however, low-dose diuretics were significantly better than other treatments for the prevention of cardiovascular disease health outcomes. Among nonsignificant between-drug comparisons, 13 favored low-dose diuretics, 5 favored other therapies, and 4 were indifferent. This network meta-analysis provides compelling evidence that low-dose diuretics are the most effective first-line treatment for preventing the occurrence of cardiovascular disease morbidity and mortality," they write.

The researchers add that beta-blockers have long been identified as another preferred first-line treatment for hypertension. In this network meta-analysis, beta-blockers were inferior to the less expensive, low-dose diuretics for all outcomes, significantly so for cardiovascular disease events. "For uncomplicated hypertension, beta-blockers should be considered a second-line antihypertensive agent," the authors write.

HORMONE THERAPY COMBINED WITH ALENDRONATE THERAPY CAN INCREASE BONE MASS IN ELDERLY WOMEN