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D Lieberman

Publications and source records attributed to D Lieberman.

At least 19 recordsLinked to original sources

Simulated limnological effects of the Shasta Lake temperature control device.

We estimated the effects of a temperature control device (TCD) on a suite of thermodynamic and limnological attributes for a large storage reservoir, Shasta Lake, in northern California. Shasta Dam was constructed in 1945 with a fixed-elevation penstock. The TCD was installed in 1997 to improve downstream temperatures for endangered salmonids by releasing epilimnetic waters in the winter/spring and hypolimnetic waters in the summer/fall. We calibrated a two-dimensional hydrodynamic reservoir water quality model, CE-QUAL-W2, and applied a structured design-of-experiment simulation procedure to predict the principal limnological effects of the TCD under a variety of environmental scenarios. Calibration goodness-of-fit ranged from good to poor depending on the constituent simulated, with an R2 of 0.9 for water temperature but 0.3 for phytoplankton. Although the chemical and thermal characteristics of the discharge changed markedly, the reservoir's characteristics remained relatively unchanged. Simulations showed the TCD causing an earlier onset and shorter duration of summer stratification, but no dramatic affect on Shasta's nutrient composition. Peak inreservoir phytoplankton production may begin earlier and be stronger in the fall with the TCD, while outfall phytoplankton concentrations may be much greater in the spring. Many model predictions differed from our a priori expectations that had been shaped by an intensive, but limited-duration, data collection effort. Hydrologic and meteorological variables, most notably reservoir carryover storage at the beginning of the calendar year, influenced model predictions much more strongly than the TCD. Model results indicate that greater control over reservoir limnology and release quality may be gained by carefully managing reservoir volume through the year than with the TCD alone.

Climate↗

Infectious etiologies in acute exacerbation of COPD.

Acute exacerbation (AE) is a frequent episode during the prolonged chronic course of chronic obstructive pulmonary disease (COPD), which entails significant morbidity and mortality. The purpose of this study was to determine the frequency distribution of infectious etiologies in these episodes. Two hundred forty hospitalizations for AECOPD were included in a prospective, purely serologically based study. Paired sera were obtained for each of the hospitalizations and were tested using immunofluorescence or EIA methods to identify 13 different pathogens. Only significant changes in antibody titers were considered diagnostic. The mean age ( +/- SD) of the patients was 66.8 +/- 9.0 years and 179 (84%) were males. In 175 (72.9%) hospitalizations at least one infectious etiology was identified. In 117 (48.8%) hospitalizations at least one of 7 viral etiologies was identified. In 72 (30.0%) hospitalizations at least one of the following atypical bacteria was identified: Legionella spp. in 40 (16.7%), Mycoplasma pneumoniae in 34 (14.2%), and Coxiella burnetii in a single hospitalization. In 58 (24.2%) hospitalizations at least one classic bacterial etiology was found: Streptococcus pneumoniae in 48 (20.0%), Hemophilus influenzae in 10 (4.2%) and Moraxella catarrhalis in 9 (3.8%). More than one etiology was found in 72 (30.0%) hospitalizations. There were no significant differences in the etiologic distribution when the patients were classified by severity of airway obstruction or the clinical type of the exacerbation. We conclude that in most cases of hospitalization due to AECOPD the infectious etiology is viral or atypical bacteria and is classic bacteria in only a minority of cases. More than one etiologic cause can be identified in a third of the cases. The frequency distribution of the etiologies is not associated with the severity of airway obstruction or the clinical type of the exacerbation. The results of our study suggest that atypical bacteria should be covered in antibiotic regimens recommended for AECOPD. This issue should be addressed in future studies.

Adult↗

Outcomes of Helicobacter pylori treatment in community practice and impact of therapeutic effectiveness information on physician behaviour.

BACKGROUND: The effect of knowledge of Helicobacter pylori eradication rates on physician choice of treatment regimen is unknown. As practice variation results in differences in outcome, it is important to determine whether physician behaviour can be altered by such knowledge. AIMS: (i) To determine whether dissemination of practice variation and effectiveness data regarding H. pylori changes subsequent prescribing behaviour and (ii) whether this change results in an improvement in the effectiveness of therapy. METHODS: Community gastroenterologists in the Portland metropolitan area enrolled patients being treated for H. pylori. The regimen used, diagnostic method, indication and success in eradication was measured. Patient-centred factors were also measured, including symptoms, interest in post-treatment diagnostic testing and willingness to pay. RESULTS: Significantly more physicians participating in both studies used proton pump inhibitor-triple therapy based regimens in this trial (46% vs. 85%, P=0.01), although the overall difference between the two trials was not significant (62% vs. 83%, P=0.11). There was no change in overall eradication rates by per protocol analysis between trials (84% vs. 85%, P=0.78), but a significant decrease in effectiveness by intention-to-treat analysis observed in this study (80% vs. 71%, P=0.03). Significantly more patients were treated for reasons other than peptic ulcer disease in this study (P=0.0003). CONCLUSIONS: The overall effectiveness of H. pylori therapy in practice remains good. There has been a shift in the choice of treatment regimen and indication for therapy between the time periods of the two studies. Dissemination of treatment data appears to effect prescribing behaviour, but whether it has a beneficial effect on treatment outcome remains unproven.

Anti-Bacterial Agents↗

Effective and safe endoscopic reversal of nondysplastic Barrett's esophagus with thermal electrocoagulation combined with high-dose acid inhibition: a multicenter study.

BACKGROUND: Barrett's esophagus is a metaplastic change in the esophageal lining with an increased risk for adenocarcinoma. Multiple endoscopic techniques have been applied in an effort to reverse Barrett's. This is a multicenter trial defining the efficacy and safety of multipolar electrocoagulation combined with high-dose acid inhibition. METHODS: Patients with a 2- to 6-cm segment of Barrett's esophagus without dysplasia were enrolled at 3 centers. They were treated with omeprazole 40 mg twice daily and then with up to 6 sessions with electrocoagulation aimed at eliminating all the endoscopically apparent Barrett's. Four quadrant large-capacity biopsies every 2 cm were centrally assessed for residual intestinal metaplasia. RESULTS: Fifty-eight patients reached the endpoint of failure of visual reversal of Barrett's after 6 treatment sessions or a 6-month follow-up after the last session. Eighty-five percent had visual reversal and 78% both visual and histologic reversal. Four patients had histologic evidence of residual intestinal metaplasia. Transient esophageal symptoms were common. One patient developed a stricture requiring dilation and one required overnight hospitalization for chest pain. CONCLUSIONS: The majority of patients with 2 to 6 cm of nondysplastic Barrett's esophagus can be safely reversed with this combination therapy. Long-term follow-up will be necessary to document the durability of the new squamous epithelium.

Adult↗

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Journal Article↗

The economic impact of the diagnosis of dysplasia in Barrett's esophagus.

OBJECTIVE: Cost-effective strategies for identifying patients with Barrett's esophagus who are most likely to develop cancer have not been developed. Surveillance endoscopy is currently used, and we hypothesized that more frequent surveillance intervals would identify patients with "transient positive" diagnoses of dysplasia--dysplasia found on one examination but not on subsequent ones. Our aim was to explore the potential economic impact of transient positive diagnoses of dysplasia on alternative surveillance strategies over a 10-yr period. METHODS: Data were derived from a 2-yr randomized, prospective study comparing omeprazole to ranitidine in 95 patients with Barrett's esophagus. A transient positive diagnosis of dysplasia was defined as a patient who was diagnosed with dysplasia during the study period but whose 24-month biopsies revealed no dysplasia. We calculated the number of transient positive diagnoses of dysplasia and modeled the potential economic impact of a diagnosis of dysplasia over a 10-yr period. RESULTS: Thirty patients (31%) had at least one reading of dysplasia during the study period. Nineteen patients (20%) had a transient positive diagnosis of dysplasia. During the study period, no cancers were found. A surveillance strategy of every other year and every 6 months for dysplasia would result in 1072 endoscopies over a 10-yr period at a discounted cost of $1,587,184. A total of 61% of endoscopies would be because of transient positive diagnoses of dysplasia. A strategy of yearly surveillance and every 6 months for dysplasia would result in 1404 endoscopies at a discounted cost of $2,096,733, of which 28% would result from transient positive diagnoses of dysplasia. The discounted incremental costs of more frequent surveillance in this cohort of patients over 10 yr is $509,549. CONCLUSIONS: Based on current practice strategies, transient positive diagnoses of dysplasia account for 28-61% of endoscopies in Barrett's surveillance programs. This analysis suggests that the endoscopy workload and costs associated with surveillance could be substantially reduced if patients with transient positive diagnoses of dysplasia reverted to usual surveillance after two negative examinations.

Anti-Ulcer Agents↗

Community-acquired pneumonia in the elderly: a practical guide to treatment.

The incidence of community-acquired pneumonia (CAP), an infectious disease, sharply increases among the elderly and the main risk factor for CAP in this age group is chronic comorbidity. The use of the term CAP in the elderly population should be reserved for pneumonia acquired outside of the nursing home setting, since nursing home-acquired pneumonia differs from CAP in terms of its aetiology and clinical manifestations. The main aetiology for CAP is Streptococcus pneumoniae, but atypical pathogens also play an important role as causative agents. The clinical presentations of CAP in the elderly can be different from those in younger patients, and therefore it is important to be aware of and familiar with these differences to avoid unnecessary delays in reaching the correct diagnosis. Imaging is essential to diagnose CAP and to assess its severity. Clinical and laboratory indices can be used to identify elderly patients with CAP who are at low risk for mortality and who can be treated as outpatients. The decision not to hospitalise elderly patients with CAP is contingent on a good clinical condition and the existence of home support systems. The aetiology of CAP cannot be determined on the basis of clinical manifestations, imaging or routine laboratory test results, and the initial antibiotic therapy for elderly patients with CAP should be empirical, based on accepted guidelines. In the light of developments in recent years, elderly patients with CAP, except those who are severely ill, can be treated empirically with once-daily antibiotic monotherapy in the initial phase, using a third-generation fluoroquinolone preparation, such as sparfloxacin, levofloxacin or moxifloxacin, or a new macrolide such as clarithromycin, azithromycin or dirithromycin. In addition to antibiotic therapy, it is critically important to identify and treat the physiological disturbances that accompany CAP as well as decompensation of chronic comorbid conditions. As soon as the patient's condition permits, oral antibiotic therapy should replace intravenous therapy and early discharge from the hospital should be considered. Since influenza and pneumococcus immunisation can reduce morbidity and mortality from CAP, it is important to implement regular immunisation programmes in the primary care setting.

Aged↗

Geriatric Depression Screening Scale (GDS) in patients hospitalized for physical rehabilitation.

OBJECTIVE: To determine the prevalence of symptoms of depression and the factors affecting their presence in an elderly population at the start of rehabilitation. To assess changes in the severity of these symptoms during rehabilitation and the correlation between these changes and corresponding changes in the patient's functional state. DESIGN: A population-based prospective study. SETTING: A geriatric ward in a general university hospital in southern Israel. PARTICIPANTS: Two hundred and seventy-six elderly patients hospitalized for physical rehabilitation, 150 following hip fracture (HF) and 126 after stroke. MEASUREMENTS: Symptoms of depression were measured by the Geriatric Depression Screening Scale (GDS). The functional state was assessed using the FIM scale. A broad spectrum of clinical, functional, social and demographic variables was measured using conventional tests. The association between the GDS and these variables was tested by stepwise multiple regression. RESULTS: One hundred and thirteen patients (41%) showed signs of depressions (GDS>10), with 12 (4%) patients having severe symptoms (GDS>20). No significant difference was found between HF and stroke patients in symptoms of depression. Only four of the 41 variables tested were found to be significantly and independently associated with the GDS: pre-event functional state (beta=-0.311, p<0.001), the self-care component of the FIM scale on admission to the hospital (beta=-0.267, p<0.001), living alone (beta=0.149, p=0.015) and impaired visual acuity (beta=0.137, p=0.026). The total variance in GDS accounted for by these four variables (adjusted R-square) was 0. 24. The severity of depression symptoms decreased significantly during rehabilitation and the GDS at discharge was significantly lower than on admission (p=0.008). This change correlated significantly with the corresponding change in functional state (R=-0.15, p=0.03). CONCLUSIONS: Symptoms of depression are common in elderly patients beginning rehabilitation. These symptoms are affected independently, and almost exclusively, by the functional state of the patient, both prior to the event and after its occurrence. The depressed condition improves towards the end of hospitalization and the degree of improvement is correlated with the corresponding change in the patient's functional state.

Aged↗

Prospective determination of distal colon findings in average-risk patients with proximal colon cancer.

BACKGROUND: Recent guidelines indicate that colonoscopy and sigmoidoscopy are both acceptable options for screening average-risk patients for colorectal cancer. Retrospective studies have found that a majority of patients with cancer proximal to the splenic flexure have a normal screening flexible sigmoidoscopy. METHODS: This was a multicenter, prospective description of colonoscopic findings and family history in consecutive patients with proximal colon cancer. RESULTS: Among 116 prospectively identified average-risk patients with cancer proximal to the splenic flexure, 40 (34.5%) had neoplasia distal to the splenic flexure. The prevalence of patients with adenomas greater than or equal to 1 cm, with only one tubular adenoma less than 1 cm, and with only hyperplastic polyps were 16.4%, 8.6%, and 6.9%, respectively. CONCLUSIONS: Most average-risk patients with cancer proximal to the splenic flexure will have a normal screening flexible sigmoidoscopy. These patients have an unexpectedly high prevalence of large distal adenomas, but the prevalence of both single small tubular adenomas and hyperplastic polyps alone is similar to that expected during screening of the general population. Clinicians and payers should continue to seek methods to improve the cost-effectiveness and availability of screening colonoscopy in average-risk persons.

Adenocarcinoma↗

Seasonal variation in hospital admissions for community-acquired pneumonia: a 5-year study.

OBJECTIVES: We conducted a retrospective analysis of computerized hospitalization and regional meteorological and geophysical data in a university hospital in southern Israel. The aim of the study was to determine and depict the seasonal variation in hospitalization for community-acquired pneumonia (CAP-H) and the factors affecting it, for all age groups combined and by age group, over a 5-year period. METHODS: All cases of CAP-H over the period from January 1, 1990 to December 31, 1994 were studied by season of the year and age group. The rates of CAP-H for the four seasons were compared by t-tests. Mathematical models based on quasi-Fourier generalized linear models were developed and used to evaluate potential variables and their relative contributions to CAP-H. RESULTS: A total of 4101 CAP-H were analysed in the study. Throughout the study period the prevalence of CAP-H was significantly higher in the winter and spring than in the summer and fall for all age groups combined and within each age group (P<0.00001). When CAP-H was compared between the winter and the spring, we found that in the 0-16 age group CAP-H was higher in the winter (P<.0.00001), in the 17-64 age group it was higher in the spring (P<0.002), and in the 65+ age group as well as for all age groups combined there were no significant differences between these two seasons. The most important factor explaining the variance in CAP-H in the 0-16 age group were direct and indirect effects of minimum daily temperature (31%), in the 17-64 age group direct and indirect effects of the difference between minimum and maximum daily temperatures (19%), and in the 65+ age group it was geophysical factors (13%). CONCLUSIONS: There is a significant seasonal variation in CAP-H with higher rates for all age groups in the winter and spring. The extent to which the prevalence of CAP-H is dominant in the winter and spring seasons differs among the age groups, as does the principal variable explaining these differences. The most important factor is the direct and indirect effects of meteorological variables in the 0-16 and 17-64 age groups, and a geophysical one among the more elderly patients.

Adolescent↗

Atypical pathogens in community-acquired pneumonia.

The atypical pathogens are an important and significant cause of CAP. The clinical and radiologic manifestations of CAP caused by these pathogens are modulated by the immunologic and physiologic status of the host, and therefore are not pathogen-specific. The range of frequencies found in various studies for the atypical pathogens among the causes of CAP is broad. These frequencies are affected by very important factors that should be recognized. In a significant percentage of patients, an atypical pathogen can be identified together with an additional cause. The significance of multiple causes has not been clarified sufficiently. The principal diagnostic techniques in use today for the causative diagnosis of CAP are serologic tests. Different serologic methods have been used in various studies and diagnostic criteria are not standardized. In the future it is likely that diagnostic testing will be based on the PCR technique on serum samples. The effectiveness and importance of antimicrobial therapy in some patients with atypical pathogen CAP are unclear. The accepted therapy today for atypical pathogen CAP, which is based on erythromycin, will probably be changed in the near future in favor of the new generations of fluoroquinolone or the new macrolide preparations.

Adult↗

Characterization of elderly patients in rehabilitation: stroke versus hip fracture.

PURPOSE: To compare the characteristics of elderly patients hospitalized for rehabilitation following stroke with those following hip fracture (HF). METHODS: A prospective study in a geriatrics department of a general university hospital in southern Israel. Five hundred and sixteen hospitalized elderly patients were included in the study, 221 following stroke and 295 following HF. The characteristics were compared by univariate and logistic regression analyses. RESULTS: The mean age (+/-SD) of the stroke patients was 71.7+/-7.8 years compared to 77.4+/-7.9 for HF (p < 0.000001). Fifty-three per cent of the stroke patients were women compared to 76% of the HF patients (p < 0.000001). Stroke patients had significantly lower levels of folic acid (p = 0.00002). HF patients had more hearing and visual impairments (p = 0.008 and p = 0.017, respectively), but these were related to age differences between the groups. The Folstein Minimental test result was significantly higher in the HF group (p = 0.002). There were no differences in the symptoms of depression score as measured by geriatric depression screening scale. The Functional Independent Measure scale showed a higher pre-event functional capacity among the stroke patients (p < 0.000001), but there was no difference in this scale on admission to rehabilitation or upon discharge. CONCLUSIONS: There is a difference in the nature of the stroke and HF events. When either event involves an elderly patient with a broad range of limitations and diseases, a new medical condition develops. In this condition the symptoms of depression and the functional state at admission and upon discharge are not significantly different between these groups of patients.

Activities of Daily Living↗