BACKGROUND: Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings. OBJECTIVE: To evaluate the effectiveness of a multimodal intervention strategy to improve processes of end-of-life care in inpatient settings. DESIGN: Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design. PARTICIPANTS: Six Veterans Affairs Medical Centers (VAMCs). INTERVENTION: Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools. MAIN MEASURES: Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n= 6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, donot-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends. KEY RESULTS: Significant intervention effects were observed for orders for opioid pain medication (OR:

This paper describes black/white differences in risk factors for atherosclerosis in the large multicenter Atherosclerosis Risk in Communities (ARIC) Project sponsored by the National Heart, Lung, and Blood Institute. It is based on data collected at baseline in ARIC's four geographically distinct clinical centers. Participants were randomly selected (4264 black and 11,479 white men and women, ages forty-five to sixty-four years at entry). There were striking differences in obesity between black and white women, higher fasting glucose and greater prevalence of diabetes in blacks, and lower high-density lipoprotein values in white men. Not unexpectedly, blood pressure in black participants exceeded that in whites. Clustering of multiple risk factors was more common in the black population. Conversely, prevalence of no risk factors was greatest among whites. In conclusion, while African-Americans and Caucasians share much the same group of risk factors for atherosclerosis, there are clinically important racial differences in emphasis.

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Dear editor, Blood pressure is an important and modifiable vascular risk factor that should be taken into consideration when planning secondary stroke prevention measures. It has been recommended that in those older than age 50, systolic blood pressure (SBP) of [140 mmHg is a more important cardiovascular disease risk factor than diastolic blood pressure [1]. Impressive evidence has accumulated to warrant greater attention to the importance of SBP as a major risk factor for stroke. However, few studies examine the level of blood pressure control at the time of hospital discharge following stroke. We examined whether control of blood pressure was adequate at hospital discharge following a stroke by retrospectively reviewing the medical records of 137 consecutive patients admitted with a stroke during a six-month period admitted to our hospital. We recorded the blood pressure of patients at admission and at discharge. Type of anti-hypertensive medication was documented. Existing risk factors for stroke including diabetes mellitus, atrial fibrillation, previous stroke, ischemic heart disease were recorded.Of 137 patients admitted with stroke, 124 (90.5%) suffered an ischemic insult while 13 (9.5%) had an intracerebral hemorrhage. Mean age at the time of stroke onset was 71 years. Seventy-seven (56%) of all patients were female. One hundred and five patients survived during the hospital stay. Of all surviving patients at the time of discharge, the overall mean discharge BP was 129/71 mmHg. However, 30(29%) had a SBP [140 mmHg and 73(70%) had a SBP of [120 mmHg.Sixty-three percent had a previous history of hypertension, 55% had a current or past history of smoking, 41% had a previous CVA or TIA and 36% had atrial fibrillation (32.3% diagnosed at admission).Sixty-one percent were on anti-hypertensive medication prior to admission and 31.4% were started on new antihypertensive medications or had their medications changed during the course of admission. The average BP at the time of intervention was 165/91 mmHg. The most commonly used medications were ACE inhibitors (58%) followed by beta-blockers (28%).Hypertension is associated with the increased risk of recurrent stroke in patients who have already had an ischemic or hemorrhagic event [2]. Patients with hypertension have a 1.4 times increase in the risk of recurrent stroke after adjustment of other vascular risk factors [3].In our study, the overall blood pressure control at time of discharge was satisfactory (mean BP at the time of discharge was 129/71 mmHg).However, the SBP was not adequately controlled in 29% of our patients at the time of discharge. Clinical trials have shown that control of isolated systolic hypertension reduces total mortality, cardiovascular mortality and stroke [4]. Poor SBP control is largely responsible for the unacceptably low rates of overall BP control [5].Although 63% had a previous history of hypertension and 61% were on treatment, only 31% had their antihypertensive regimen changed during the course of their admission, indicating a les...