Race, nutritional status, and survival from breast cancer.

The effects of nutritional status on differences in the survival of black and white women with breast cancer were studied in a cohort of 1,960 Georgia women diagnosed during 1975-1979. After data were adjusted for stage of disease, socioeconomic status, and other prognostic factors, poorer survival rates were shown in black women. Within each stage classification, lower levels of serum albumin and hemoglobin and higher relative body weight were more common among blacks and were independently associated with poorer survival. Among women with stage 3 disease, adjustment for these variables substantially reduced the excess mortality rate among blacks, suggesting that racial differences in survival may be partly explained by differences in nutritional status or extent of disease within stage.

Diabetic ketoacidosis in obese African-Americans.

Our preliminary data indicate that 15% of African-American patients presenting with diabetic ketoacidosis (DKA) are obese. To determine underlying mechanisms, we analyzed the clinical characteristics and indexes of insulin secretion and insulin sensitivity in 35 obese patients with DKA, 22 obese patients with hyperglycemia, 10 lean patients with DKA, and 10 obese nondiabetic subjects. Studies were performed 1 day after resolution of DKA and after 12 weeks of follow-up. At presentation, both obese DKA and obese hyperglycemic patients had no detectable insulin response to intravenous glucose, but they did respond to glucagon administration. The acute insulin response (AIR) to glucagon in obese DKA patients (0.9 +/- 0.1 ng/ml, P < 0.01), but significantly greater than in lean patients with DKA (0.1 +/- 0.1 ng/ml, P < 0.01). After 12 weeks of follow-up, the AIR to glucose improved in both groups of obese diabetic patients but remained significantly lower than in nondiabetic control subjects (both P < 0.01). In contrast, the AIR to glucagon was not significantly different from that in obese control subjects. Insulin sensitivity was decreased in both groups of obese diabetic patients at presentation and improved after follow-up to levels similar to those in obese nondiabetic control subjects. Reactivity with islet cell antibodies was not detected in any of the patients. During follow-up, 25 of 35 obese DKA and 16 of 22 hyperglycemic patients were able to discontinue insulin therapy, with continued good metabolic control. Our results indicate that in African-Americans, obese patients with DKA represent a subset of type II diabetes.(ABSTRACT TRUNCATED AT 250 WORDS)

Olanzapine treatment of psychotic and behavioral symptoms in patients with Alzheimer disease in nursing care facilities: a double-blind, randomized, placebo-controlled trial. The HGEU Study Group.

BACKGROUND: Patients with Alzheimer disease (AD) commonly exhibit psychosis and behavioral disturbances that impair patient functioning, create caregiver distress, and lead to institutionalization. This study was conducted to assess the efficacy and safety of olanzapine in treating psychosis and/or agitation/aggression in patients with AD. METHODS: A multicenter, double-blind, placebo-controlled, 6-week study was conducted in 206 elderly US nursing home residents with AD who exhibited psychotic and/or behavioral symptoms. Patients were randomly assigned to placebo or a fixed dose of 5, 10, or 15 mg/d of olanzapine. The primary efficacy measure was the sum of the Agitation/Aggression, Hallucinations, and Delusions items (Core Total) of the Neuropsychiatric Inventory-Nursing Home version. RESULTS: Low-dose olanzapine (5 and 10 mg/d) produced significant improvement compared with placebo on the Core Total (-7.6 vs -3.7 [P<.001] and -6.1 vs -3. 7 [P =.006], respectively). Core Total improvement with olanzapine, 15 mg/d, was not significantly greater than placebo. The Occupational Disruptiveness score, reflecting the impact of patients' psychosis and behavioral disturbances on the caregiver, was significantly reduced in the 5-mg/d olanzapine group compared with placebo (-2.7 vs -1.5; P =.008). Somnolence was significantly more common among patients receiving olanzapine (25.0%-35.8%), and gait disturbance occurred in those receiving 5 or 15 mg/d (19.6% and 17.0%, respectively). No significant cognitive impairment, increase in extrapyramidal symptoms, or central anticholinergic effects were found at any olanzapine dose relative to placebo. CONCLUSION: Low-dose olanzapine (5 and 10 mg/d) was significantly superior to placebo and well tolerated in treating agitation/aggression and psychosis in this population of patients with AD.

Sulfonylurea treatment prevents recurrence of hyperglycemia in obese African-American patients with a history of hyperglycemic crises.

OBJECTIVE: Many newly diagnosed obese African-American patients with history of severe hyperglycemia or diabetic ketoacidosis (DKA) are able to discontinue pharmacological treatment with continued good metabolic control. However, many of these individuals relapse into hyperglycemia within 1 year. In such patients, we compared the effect of low-dose sulfonylurea and dietary therapy in the prevention of recurrence of hyperglycemia. RESEARCH DESIGN AND METHODS: We conducted an intention-to-treat study in 35 obese newly diagnosed diabetic patients (17 with DKA and 18 with severe hyperglycemia). After discontinuation of insulin, seven of 17 patients with DKA and seven of 18 patients with hyperglycemia were managed with diet and glyburide (1.25-2.5 mg/day), whereas other patients were followed with diet alone. In all patients, pancreatic insulin reserve was documented 1 day after resolution of hyperglycemic crises and within 1 week of discontinuation of insulin. Recurrence of hyperglycemia was defined as fasting blood glucose > 7.8 mmol/l (140 mg/dl) or random blood glucose > 10 mmol/l (180 mg/dl) on two or more consecutive determinations, or HbA1c > 7.5%. RESULTS: Both treatment groups were comparable in age, sex, duration of diabetes, months of insulin therapy, BMI, glucose, and HbA1c. At presentation, the acute C-peptide response to glucagon in obese DKA patients was lower than in patients with hyperglycemia (P < 0.01), but responses were comparable after discontinuation of insulin. Sulfonylurea treatment significantly reduced recurrence of hyperglycemia in both obese DKA and obese hyperglycemic patients (P = 0.03). With a median follow-up of 16 months, hyperglycemia recurred in six of 10 DKA patients and in five of 11 hyperglycemia patients treated with diet alone, compared with one of seven DKA and one of seven hyperglycemia patients treated with glyburide. Readmission with metabolic decompensation occurred in four patients treated with diet but in none of the patients treated with diet and glyburide. CONCLUSIONS: Low-dose sulfonylurea therapy prevents recurrence of hyperglycemia in newly diagnosed obese African-American patients with a history of hyperglycemic crises.

Immunogenetic analysis suggests different pathogenesis for obese and lean African-Americans with diabetic ketoacidosis.

OBJECTIVE: When presenting with diabetic ketoacidosis (DKA), lean and obese patients differ in their subsequent clinical course. Although lean patients tend to remain insulin dependent, most obese patients recover endogenous insulin secretion and discontinue insulin therapy. The aim of this study was to determine whether obese African-American patients with DKA could be determined to have type 1 or type 2 diabetes based on insulin secretion or the presence of immunological and genetic markers. RESEARCH DESIGN AND METHODS: This was a prospective study that analyzed the clinical characteristics, insulin secretion indices, immunological markers (islet cell, GAD, ICA512, and insulin autoantibodies), and HLA susceptibility genes (DR/DQ) in 131 patients with DKA (77 obese and 54 lean), 51 obese patients with hyperglycemia but no DKA, and 25 nondiabetic subjects. All subjects were African-American. Beta-cell function was evaluated by the C-peptide response to glucagon (1 mg i.v.) within 48 h of resolution of DKA or hyperglycemia. RESULTS: The acute C-peptide response was lower in obese DKA patients (1.0+/-0.1 ng/ml) than in obese patients with hyperglycemia (1.7+/-0.2 ng/ml, P < 0.01), but was higher than that in lean DKA patients (0.2+/-0.1 ng/ml, both P < 0.01). The overall prevalence of autoantibodies in obese subjects with DKA (17%) and obese subjects with hyperglycemia (16%) was lower than that in lean subjects with DKA (65%, P < 0.01). Obese patients with hyperglycemia and positive autoantibodies had lower rates of insulin secretion than those without antibodies. Regardless of body weight, all DKA patients with GAD autoantibodies carried the DQB1*0201 allele. However, there were no significant differences in HLA distribution between the three patient groups. CONCLUSIONS: Our results indicate that most obese African-American patients with DKA have type 2 diabetes characterized by higher insulin secretion, the absence of autoimmune markers, and a lack of HLA genetic association. In contrast, most lean African-American patients with DKA have metabolic and immunological features of type 1 diabetes. At presentation, assessment of beta-cell function and determination of autoimmune markers allow for correct classification of diabetes in African-Americans with hyperglycemic crises.

Treatment trial of oxiracetam in Alzheimer's disease.

Twenty-four carefully assessed patients with probable Alzheimer's disease were enrolled in a double-blind, placebo-controlled treatment study of oxiracetam, a nootropic agent reported to improve memory performance in patients with dementia. A broad battery of neuropsychological tests failed to reveal any improvement in the treated group or in any treated patient when individual test scores were analyzed. These findings indicate that oxiracetam is ineffective in reducing cognitive impairment due to Alzheimer's disease.

The dynamics of CD4+ T-lymphocyte decline in HIV-infected individuals: a Markov modeling approach.

We modeled the decline of CD4+ T-lymphocytes (T4 cells) in HIV-infected individuals with a continuous-time Markov process. The model partitions the HIV infection period into six progressive T4-cell count intervals (states), followed by a seventh state: a definitive HIV-infection end point, i.e., AIDS diagnosis or Walter Reed stage 6 (opportunistic infections). The Markov model was used to estimate the state-specific progression rates from data as functions of important progression cofactors. We applied the model to data on 1,796 HIV-positive individuals in the U.S. Army. The estimated mean waiting time from seroconversion to when the T4-cell count persistently drops below 500/mm3, but is greater than 349/mm3, is 4.1 years, and the waiting time to a T4-cell count of less than 200/mm3 is estimated at 8.0 years. The estimated rate of T4-cell decline was higher for HIV-infected individuals with initially high numbers of T4 cells, but the estimated rate of decline remains relatively uniform when the T4-cell count dropped persistently below 500/mm3. The opportunistic infection incubation period, i.e., the time from seroconversion to opportunistic infection diagnosis, is estimated at 9.6 years. Age is found to be an important cofactor. The estimated mean opportunistic infection incubation periods are 11.1, 10.0, and 8.9 years for the youngest (less than or equal to 25 years old), the middle (26-30 years old), and the oldest (greater than 30 years old) age groups, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective evaluation of the gastrointestinal tract in patients with iron deficiency and no systemic or gastrointestinal symptoms or signs.

BACKGROUND: Although endoscopic evaluation of the gastrointestinal tract is commonly performed to evaluate iron deficiency, little data is available regarding the underlying causes, yield of evaluation, and long-term outcome for those in whom gastrointestinal and systemic symptoms and signs are absent. METHODS: In- or out-patients seen by the gastroenterology consultative service at a large inner-city hospital over a 56-month period were considered eligible for the study when iron deficiency (serum ferritin <50 ng/mL) was documented. Exclusion criteria included: any gastrointestinal or systemic symptoms/signs, radiographic or endoscopic examinations of the gastrointestinal tract within 3 and 5 years, respectively, or obvious source of blood loss. Patients underwent colonoscopy and if no lesions other than carcinoma were found, upper endoscopy was then performed with a pediatric colonoscope. RESULTS: Fifty-two patients were evaluated (mean age, 66 +/- 13 years; range, 20 to 89 years; 32 men/20 women). At the time of evaluation, the mean (+/-SD) hematocrit was 25% +/- 7% (range, 14% to 42%). Overall, 23 patients (44%; 95% CI 30% to 59%) had an identifiable gastrointestinal lesion considered the cause of iron deficiency, including: colonic carcinoma, 11 (21%); colonic and/or esophagogastric/duodenal vascular ectasias, 9 (17%); and gastric carcinoma, colonic polyposis, and colonic ulcers in 1 patient each. Long-term follow-up (median 24 months, range 2 to 63 months) identified only 1 patient with a cause found (colonic carcinoma), and in this patient, complete colonoscopy was not technically possible at the time of initial evaluation. There were no clinical or laboratory features that distinguished patients with an etiology for iron deficiency to the idiopathic group. CONCLUSIONS: Approximately half of patients with iron deficiency in whom gastrointestinal or systemic signs or symptoms are absent have an underlying gastrointestinal lesion. Nevertheless, despite a thorough endoscopic evaluation, some patients will have no etiology found; the prognosis for these patients is excellent.

Cigarette smoking and severe uncontrolled hypertension in inner-city African Americans.

PURPOSE: Although over the past 2 decades great strides have been made in increasing the awareness, detection, and treatment of hypertension (HTN), actual control of blood pressure is far from optimal. We hypothesized that current cigarette smoking, by acting as a marker for poor health related behavioral patterns, would be significantly associated with uncontrolled blood pressure (BP). PATIENTS AND METHODS: Over a 3-month period in 1994, all patients who presented to a public hospital medical walk-in clinic were screened, and had their BP measured if they had been prescribed BP medication within 1 year and were aware of their diagnosis of HTN. Patients were defined as controlled hypertensives if both systolic BP and diastolic BP were < or = 140/90 mm Hg. Severe uncontrolled hypertensives were those with either systolic BP > or = 180 mm Hg or diastolic BP was > or = 110 mm Hg. RESULTS: Of the 221 patients meeting all inclusion criteria (1 refusal), 86 had uncontrolled HTN (mean BP = 192/106 mm Hg), 130 were controlled (mean BP = 130/80 mm Hg), and 5 were not African American. Severe uncontrolled hypertensives, when compared with controlled hypertensives, were significantly more likely to be current (versus former) smokers (odds ratio [OR] = 4.17; 95% confidence interval [CI]: 1.8 to 9.5), and be less compliant with medications (OR = 2.33; 95% CI: 1.3 to 4.1). Age, gender, alcohol use, marital status, education, and comorbidity were not associated with HTN control. In an adjusted logistic regression model, both current and never-smokers when compared with former smokers were significantly more likely to have uncontrolled HTN in compliant patients (OR = 14.4; 95% CI: 3.3 to 63.3 and OR = 5.7; 95% CI: 1.5 to 21.7, respectively). In noncompliant patients, smoking status was not associated with uncontrolled HTN. CONCLUSION: In disadvantaged African-American patients who report good medication compliance, former smoking status is strongly associated with HTN control. Physicians may need to be especially vigilant of BP control in patients who smoke.

Etiology of esophageal disease in human immunodeficiency virus-infected patients who fail antifungal therapy.

PURPOSE: To determine the etiologies of esophageal symptoms in human immunodeficiency virus (HIV)-infected patients failing antifungal treatment. METHODS: Between August 1, 1990 and December 31, 1994, all HIV-infected patients seen at a large inner-city hospital who had esophageal complaints despite being on antifungal therapy were prospectively evaluated for the cause of symptoms. Thus, the population studied included patients given empiric antifungal therapy for esophageal symptoms and patients who developed symptoms while on long-term antifungal therapy. Endoscopy was performed in all patients. The cause of symptoms was determined by the clinical, endoscopic, and pathologic findings, and follow-up after treatment. RESULTS: Over the 53-month study period, 74 patients failing empiric antifungal therapy were identified. The majority (77%) of these patients had esophageal ulcers; 25 patients had idiopathic ulcers and 24 had cytomegalovirus. In 2 patients, Candida was present with other causes of ulcerative esophagitis. Candida esophagitis alone was diagnosed in only 3 patients. No endoscopic abnormalities were observed in 14 patients (19%). An additional 24 patients developed esophageal symptoms while receiving antifungal therapy; endoscopic findings in these patients included ulceration in 16 (67%), Candida esophagitis alone in 2, and normal in 6. Empirically treated patients in whom odynophagia was not the only symptom, those with dysphagia alone, and those with a CD4 count > 100/mm3 were less likely to have an endoscopic diagnosis. CONCLUSIONS: Esophageal ulceration is the most common cause of esophageal symptoms in HIV-infected patients failing empiric antifungal therapy and those developing symptoms while receiving antifungal agents. Given these findings, endoscopy should be the test of choice for these nonresponders, rather than escalating the dose of antifungal agent, adding other empiric treatments, or performing barium esophagography.

The effects of olanzapine in reducing the emergence of psychosis among nursing home patients with Alzheimer's disease.

BACKGROUND: Elderly patients with Alzheimer's disease (AD) commonly exhibit psychotic symptoms, prompting clinicians to administer antipsychotics. This article compares the effects of olanzapine and placebo in the emergence of hallucinations or delusions in AD patients with symptoms of agitation/aggression but little or no psychotic symptomatology at baseline. METHOD: A multicenter, double-blind, placebo-controlled study was conducted in nursing home patients with AD according to DSM-IV criteria and symptoms of agitation/aggression and/or psychosis. Patients (N = 206) were randomly assigned to receive either placebo or fixed-dose olanzapine (5, 10, or 15 mg/day) for up to 6 weeks. This article analyzes data from a subgroup of patients (N = 165) with no or minimal delusions and/or hallucinations at baseline as measured by the Neuropsychiatric Inventory-Nursing Home Version (NPI/NH). Three subsets of patients were identified on the basis of their symptoms at baseline: those with no clinically significant hallucinations, those with no clinically significant delusions, and those with no clinically significant delusions or hallucinations. RESULTS: Of the patients without hallucinations or delusions at baseline (N = 75), the placebo-treated patients showed significantly greater development of these symptoms compared with olanzapine-treated patients overall (NPI/NH hallucinations + delusions mean change score, +2.73 vs. +0.27, p = .006). Similarly, of the patients without baseline hallucinations (N = 153), the placebo-treated patients showed greater hallucinations score increases than did olanzapine-treated patients overall (+1.25 vs. +0.33, p = .026), whereas patients without baseline delusions (N = 87) showed no significant treatment effects. Olanzapine had a favorable safety profile in each patient subset. CONCLUSION: These results suggest that, overall, olanzapine effectively attenuated emergence of psychosis in a short-term trial of patients with Alzheimer's disease.

Experience with routine voluntary perinatal human immunodeficiency virus testing in an inner city hospital.

Women enrolled in prenatal care at Grady Health System, Atlanta, GA, have routinely been offered HIV counseling and voluntary testing since 1987. Consistently >90% have accepted testing. With implementation of US Public Health Service guidelines for perinatal zidovudine prophylaxis in 1994, the mother-to-child HIV transmission rate rapidly decreased from 18% to 8% during the subsequent 2 years.

Patient appointment failures in pediatric resident continuity clinics.

OBJECTIVES: To determine appointment failure rates in pediatric resident continuity clinics nationally, and to identify characteristics of clinics with respect to factors that may affect appointment failure rates. DESIGN: A one-page questionnaire administered via facsimile machine to pediatric residencies' continuity clinic directors. RESULTS: Of 200 continuity clinic directors, 160 (80%) returned the survey. The mean no-show percentage was 30.9%, with a range of 3% to 80%. Among the factors studied, only mode of payment emerged as an independent predictor. CONCLUSIONS: Appointment failure is a substantial problem in pediatric resident continuity clinics, which needs attention if resident learning, patient care, and clinic efficiency are to be optimized.

Modifying risk for extracorporeal circulation: trial of four antiinflammatory strategies.

BACKGROUND: Despite recent rediscovery of beating heart cardiac surgical techniques, extracorporeal circulation remains appropriate for most heart operations. To minimize deleterious effects of cardiopulmonary bypass, antiinflammatory strategies have evolved. METHODS: Four state-of-the-art strategies were studied in a prospective, randomized, preoperatively risk stratified, 400-patient study comprising primary (n = 358), reoperative (n = 42), coronary (n = 307), valve (n = 27), ascending aortic (n = 9), and combined operations (n = 23). Groups were as follows: standard, roller pump, membrane oxygenator, methylprednisolone (n = 112); aprotinin, standard plus aprotinin (n = 109); leukocyte depletion, standard plus a leukocyte filtration strategy (n = 112); and heparin-bonded circuitry, centrifugal pumping with surface modification (n = 67). RESULTS: Analysis of variance, linear and logistic regression, and Pearson correlation were applied. Actual mortality (2.3%) was less than half the risk stratification predicted mortality (5.7%). The treatment strategies effectively attenuated markers of the inflammatory response to extracorporeal circulation. Compared with the other groups the heparin-bonded circuit had highly significantly decreased complement activation (p = 0.00001), leukocyte filtration blunted postpump leukocytosis (p = 0.043), and the aprotinin group had less fibrinolysis (p = 0.011). Primary end points, length of stay, and hospital charges, were positively correlated with operation type, age, pump time, body surface area, stroke, pulmonary sequelae, predicted risk for stroke, predicted risk for mortality, and risk strata/treatment group interaction (p = 0.0001). In low-risk patients, leukocyte filtration reduced length of stay by 1 day (p = 0.02) and mean charges by $2,000 to $6,000 (p = 0.05). For high-risk patients, aprotinin reduced mean length of stay up to 10 fewer days (p = 0.02) and mean charges by $6,000 to $48,000 (p = 0.0007). CONCLUSIONS: These pharmacologic and mechanical strategies significantly attenuated the inflammatory response to extracorporeal circulation. This translated variably into improved patient outcomes. The increased cost of treatment was offset for selected strategies through the added value of significantly reduced risk.

The prevalence and significance of leukocytosis in upper gastrointestinal bleeding.

Although leukocytosis has long been recognized to occur in patients with hemorrhage, there are no data regarding leukocytosis in patients with upper gastrointestinal bleeding. We evaluated the prevalence and significance of the admission white blood cell count in consecutive patients admitted to Grady Memorial Hospital with upper gastrointestinal bleeding seen prospectively over a 50-month period. Any white count greater than 8.5 x 10(3)/mm3 was considered abnormal. Of the 731 patients eligible for the study, leukocytosis was seen in 463 (63%). When compared to patients with a normal white count, patients with leukocytosis on admission were more likely to be tachycardic (31.4% versus 24.3%, P = 0.04) and hypotensive (10.9% versus 5.7%, P = 0.018), required more units of blood (4.6+/-5.9 versus 3.5+/-6.0, P = 0.01), had a longer hospital stay (7.3+/-9.7 versus 5.9+/-6.2 days, P = 0.01), and required more frequent surgical intervention for bleeding (8.0% versus 4.2%, P = 0.04). No significant difference in mortality was seen between patients with leukocytosis and those with a normal white count (8.7% versus 6.4%, P = 0.27). Leukocytosis is common in patients with upper gastrointestinal bleeding, appears to reflect the severity of the bleeding episode, and is associated with a more complicated course.

Oil contamination of raptors migrating along the Red Sea.

There are few accounts of oil contamination of raptors, and it has not been considered a threat for them. However, we and our colleagues found oil-based asphalt on 55 individuals of 9 species out of 1052 raptors (5.2%) captured and examined in the spring of 1985 and 1986 during our raptor migration study at Elat, Israel. Some were extensively contaminated and probably succumbed to the effects of ingested asphalt. The birds most likely picked up the contamination while drinking water from pools with surface oil. Examples of the contamination will be described. Over 1.2 million raptors were counted passing Elat during the spring of 1985. If 5% of these were contaminated, that would be over 60,000 birds, and this does not consider the raptors that migrate along the Red Sea and do not pass near Elat, nor those that pass Elat unseen by the counters. Thus asphalt contamination could be a major problem for raptors migrating along the Red Sea.

Knowledge about smoking, reasons for smoking, and reasons for wishing to quit in inner-city African Americans.

OBJECTIVE: To determine knowledge about smoking, reasons for smoking, and reasons for wishing to quit and the association of these variables with abstinence at ten weeks and six months. DESIGN: Descriptive study and longitudinal intervention. SETTING: Inner-city public hospital clinics. PARTICIPANTS: 410 African-American cigarette smokers interested in quitting were surveyed at baseline and subsequently enrolled into a double-blind, placebo-controlled, randomized trial of the transdermal nicotine patch. MAIN OUTCOME MEASURES: Descriptive information about smoking knowledge, reasons for smoking, and reasons for wishing to quit, and association of these variables with abstinence at 10 weeks and 6 months. RESULTS: Among the 410 patients randomized, mean age was 48 years, 61% were female, 41% had less than a high school education, 51% had an annual household income less than $8,000, and the average number of cigarettes smoked a day was twenty. The average number of questions answered correctly was nine out of eleven (84%). The most cited reason for smoking was relaxation/tension reduction and the least cited were stimulation and handling of the cigarette. Ninety-nine percent of patients stated they wished to quit for health reasons. Knowledge, reasons for smoking, and reasons for wishing to quit were not significantly associated with 10-week or 6-month abstinence. CONCLUSIONS: In this group of inner-city African-American smokers, knowledge about cigarette smoking was high. Reasons for smoking were related to relaxation, craving, and pleasure, and reasons for wishing to quit were largely health-related. Knowledge, reasons for smoking, and reasons for wishing to quit were not associated with 10 week or 6 month abstinence. Since knowledge about smoking is already high, future efforts should be directed at promoting cessation through proven behavioral and pharmacological approaches, rather than didactic patient education.