My research focuses on the care of the injured patient, surgical infectious disease, and global public health. I want to change how humans interact with the microbial world.

After receiving my BA in Biochemistry from The Colorado College I went to the University of Virginia for medical school. During these years, I fell in love with surgery, but maintained my fascination with microbes. To explore this interest in the microbial world I obtained a Masters of Science in Infectious Disease from the London School of Hygiene and Tropical Medicine. Then I came to Stanford for general surgery residency. During my two professional development years in surgery residency I applied for and was accepted into the Epidemic Intelligence Service (EIS), the premier training program for infectious disease field epidemiology. My domestic investigations concerned pathogens including Lyme disease and tick-borne relapsing fever, in addition to two Tier 1 bioterrorism agents plague and tularemia. Internationally, I was a field agent in Liberia during the 2014 Ebola outbreak and performed several high-visibility, high-risk investigations. These investigations included establishing how the first two Americans, Kent Brantley and Nancy Writebol became infected, and assessing the Ebola burden and Ebola preparedness in southeast Liberia, among others. Following my experience with EIS, I completed my general surgery residency training at Stanford, followed by completion of surgical critical care fellowship training at Stanford.

Ongoing projects currently include:

-Determining who benefits from surgical stabilization of rib fractures and how we can stabilize rib fractures most effectively
-Understanding the limitations of surgical infectious disease surveillance and improving capacity for surgical infection surveillance globally
-Using to technology to increase the speed by which we can identify and track surgical pathogens

Follow me on Twitter @explorersurgeon and on Instagram @joe_d_forrester

Clinical Focus

  • Trauma
  • Surgical Infectious Disease
  • Global Surgery
  • Disaster Response
  • Wilderness Medicine
  • General Surgery
  • Rib Fractures
  • Rib Fracture Non-Union
  • Surgical Critical Care

Academic Appointments

Administrative Appointments

  • Associate Trauma Medical Director, Stanford Healthcare (2020 - Present)

Honors & Awards

  • Best Session Presentation - "Gene Directed Surgery for Hereditary Diffuse Gastric Cancer", Pacific Coast Surgical Association (February 2018)
  • International Exchange Scholarship - Dublin, Ireland, Resident and Associate Society - American College of Surgeons (November, 2016)
  • Humanism and Excellence in Teaching Award, Gold Foundation (April, 2016)
  • Excellence in International Program Delivery - Ebola, Liberia, Centers for Disease Control and Prevention (March, 2016)
  • Honorable Discharge - Lieutenant, U.S. Public Health Service (June, 2015)
  • Director's Recognition Award - Lyme Carditis, Centers for Disease Control and Prevention (May, 2015)
  • Excellence in Emergency Response Award - Ebola, Liberia, Centers for Disease Control and Prevention (March, 2015)
  • Epidemiology and Surveillance Government Service Award - Plague and Tularemia, US and abroad, Centers for Disease Control and Prevention (June, 2015)
  • Paul C. Schnitker Award Finalist, Centers for Disease Control and Prevention (August, 2015)
  • Travel Scholarship, American Association for the Surgery of Trauma (August, 2015)
  • Honor Award, Centers for Disease Control and Prevention (April, 2015)
  • Mitch Singal Award Finalist, Centers for Disease Control and Prevention (April, 2015)
  • Excellence in Peer Review Award, Wilderness Medical Society (2013)
  • R. Scott Jones Award in Surgery, University of Virginia (2010)
  • Raven Society, University of Virginia (2010)
  • Alpha Omega Alpha, University of Virginia (2009)
  • Otis and Margaret T. Barnes Departmental Service Award, The Colorado College (2006)
  • Phi Beta Kappa, The Colorado College (2006)

Boards, Advisory Committees, Professional Organizations

  • Chair - Research Committee, Wilderness Medical Society (2020 - Present)
  • Education Committee, Chest Wall Injury Society (2019 - Present)
  • Committee Member, Therapeutics and Guidelines Committee - Surgical Infection Society (2019 - Present)
  • Reviewer, College of Surgeons of East, Central and South Africa (2019 - Present)
  • Member, Chest Wall Injury Society (2019 - Present)
  • Committee Member, Surgical Infection Society ad hoc Committee on Global Surgery (2018 - Present)
  • Associate Editor, Malawi Medical Journal (2017 - Present)
  • Reviewer, Surgical Infections (2015 - Present)
  • Reviewer, Wilderness and Environmental Medicine Journal (2017 - Present)

Professional Education

  • Board Certification: American Board of Surgery, Critical Care Medicine (2019)
  • Fellowship: Stanford University Surgical Critical Care Fellowship (2019) CA
  • Board Certification: American Board of Surgery, General Surgery (2018)
  • Residency: Stanford University General Surgery Residency (2018) CA
  • Medical Education: University of Virginia School of Medicine (2011) VA
  • General Surgery Residency, Stanford University (2018)
  • EISO, Centers for Disease Control and Prevention, Epidemic Intelligence Service Officer, Bacterial Diseases Branch, Division of Vector-borne Diseases, National Center for Emerging and Zoonotic Infectious Disease (2013)
  • MSc, London School of Hygiene and Tropical Medicine, Infectious Disease (2012)
  • MD, The University of Virginia, Medicine (2011)
  • BA, The Colorado College, Biochemistry (2006)

Research & Scholarship

Current Research and Scholarly Interests

I am broadly interested in research exploring the care of the injured patient both in high- and low-resource settings. I have specific on-going projects assessing surgical site infection surveillance in low-resource settings, and surgical management of acute and chronic non-union rib fractures.

Clinical Trials

  • Early Percutaneous Cryoablation for Pain Control After Rib Fractures Among Elderly Patients Not Recruiting

    The purpose of this study is to provide long-term pain control for elderly patients with rib fractures in order to minimize their risk of complications and return them to baseline functional capacity

    Stanford is currently not accepting patients for this trial. For more information, please contact Sharon Cardenas-Ledezma, BS, (650) 724-4023.

    View full details


All Publications

  • Appendicitis in Low-Resource Settings. Surgical infections Bessoff, K. E., Forrester, J. D. 2020


    Background: Acute appendicitis is one of the most common surgical emergencies globally. Its incidence is increasing in low- and middle-Human Development Index countries (LMHDICs). Although a proportion of patients can be treated successfully with non-operative management consisting of antibiotics, supportive therapy, and close observation, current diagnostic algorithms lack the granularity to identify these patients accurately. Methods: We reviewed published literature describing practice patterns and clinical outcomes for appendicitis in LMHDICs and compared them with studies from high-Human Development Index countries, as well as guidelines published by international surgical societies. Results: We identified shortcomings in current diagnostic and therapeutic strategies used in LMHDICs. Delays in obtaining surgical care inherent in many LMHDIC healthcare systems make prompt surgical care the mainstay for the treatment of acute appendicitis. Laparoscopic appendectomy leads to better outcomes than open appendectomy in resource-constrained settings and when available should be the surgical technique of choice. Conclusions: Acute appendicitis is common in LMHDICs, and if possible, laparoscopic appendectomy should be the procedure of choice.

    View details for DOI 10.1089/sur.2019.365

    View details for PubMedID 32023168

  • Survey of National Surgical Site Infection Surveillance Programs in Low- and Middle-Income Countries. Surgical infections Forrester, J. D., Berndtson, A. E., Santorelli, J., Raschke, E., Weiser, T. G., Coombs, A. V., Sawyer, R. G., Chou, J., Knight, H. P., Valenzuela, J. Y., Rickard, J. 2020


    Background: Surgical site infection (SSI) surveillance programs are strongly recommended as a core component of effective national infection prevention and control (IPC) programs. Participation in national SSI surveillance (nSSIS) programs has been shown to decrease reported SSIs among high-income countries (HICs), and it is expected that the same is possible among low- and middle-income countries (LMICs). We sought to determine what, if any nSSIS programs exist among LMICs. Methods: A cross-sectional survey was performed to evaluate existence of nSSIS of World Bank-defined LMICs. A digital survey assessment for presence of national IPC and nSSIS programs was delivered to persons capable of identifying the presence of such a program. Statistical analysis was performed using STATA. Institutional Review Board approval was obtained for this study. Results: Of the 137 countries identified, 55 (40%) were upper middle income (UMI), 47 (34%) were lower middle income (LMI), and 34 (25%) were low income. Representatives from 39 (28%) LMICs completed the survey. Of these respondent countries, 13 (33%) reported the presence of a national IPC program. There was no difference between countries with IPC programs and those without with respect to country income designation, population size, World Health Organization region, or conflict status. Only five (13% of all respondents) reported presence of a nSSIS program. Conclusions: National surgical site infection surveillance programs are an integral component of a country's ability to provide safe surgical procedures. Presence of nSSIS was reported infrequently in LMICs. International governing bodies should be encouraged to guide LMIC leadership in establishing a nSSIS infrastructure that will help enable safe surgical procedures.

    View details for DOI 10.1089/sur.2020.053

    View details for PubMedID 32397833

  • Impact of shelter-in-place order for COVID-19 on trauma activations: Santa Clara County, California, March 2020. Trauma surgery & acute care open Forrester, J. D., Liou, R., Knowlton, L. M., Jou, R. M., Spain, D. A. 2020; 5 (1): e000505


    The shelter-in-place order for Santa Clara County, California on 16 March was the first of its kind in the USA. It was unknown what impact this order would have on trauma activations.We performed a retrospective analysis of institutional trauma registries among the two American College of Surgeons Level 1 trauma centers serving Santa Clara County, California. Trauma activation volumes at the trauma centers from January to March 2020 were compared with month-matched historical cohorts from 2018 to 2019.Only 81 (3%) patients were trauma activations at the trauma centers in the 15 days after the shelter-in-place order went into effect on 16 March 2020, compared with 389 activations during the same time period in 2018 and 2019 (p<0.0001). There were no other statistically significant changes to the epidemiology of trauma activations. Only one trauma activation had a positive COVID-19 test.Overall trauma activations decreased 4.8-fold after the shelter-in-place order went into effect in Santa Clara County on 16 March 2020, with no other effect on the epidemiology of persons presenting after traumatic injury.Shelter-in-place orders may reduce strain on healthcare systems by diminishing hospital admissions from trauma, in addition to reducing virus transmission.

    View details for DOI 10.1136/tsaco-2020-000505

    View details for PubMedID 32426529

    View details for PubMedCentralID PMC7228662

  • Bundled Interventions to Reduce Surgical Site Infections Are Effective and Urgently Needed. JAMA network open Forrester, J. D. 2020; 3 (3): e201895

    View details for DOI 10.1001/jamanetworkopen.2020.1895

    View details for PubMedID 32219403

  • Placement of Surgical Feeding Tubes Among Patients With Severe Traumatic Brain Injury Requiring Exploratory Abdominal Surgery : Better Early Than Late. The American surgeon Cha, P. I., Jou, R. M., Spain, D. A., Forrester, J. D. 2020; 86 (6): 635–42


    The purpose of this study was to identify trauma patients who would benefit from surgical placement of an enteral feeding tube during their index abdominal trauma operation.We performed a retrospective analysis of all patients admitted to 2 level I trauma centers between January 2013 and February 2018 requiring urgent exploratory abdominal surgery.Six-hundred and one patients required exploratory abdominal surgery within 24 hours of admission after trauma activation. Nineteen (3% of total) patients underwent placement of a feeding tube after their initial exploratory surgery. On multivariate analysis, an intracranial Abbreviated Injury Scale ≥4 (odds ratio [OR] = 9.24, 95% CI 1.09-78.26, P = .04) and a Glasgow Coma Scale ≤8 (OR = 4.39, 95% CI 1.38-13.95, P = .01) were associated with increased odds of requiring a feeding tube. All patients who required a feeding tube had an Injury Severity Score ≥15. While not statistically significant, patients with an open surgical feeding tube compared with interventional radiology/percutaneous endoscopic gastrostomy placement had lower median intensive care unit length of stay, fewer ventilator days, and shorter median total hospital length of stay.Trauma patients with severe intracranial injury already requiring urgent exploratory abdominal surgery may benefit from early, concomitant placement of a feeding tube during the index abdominal operation, or at fascial closure.

    View details for DOI 10.1177/0003134820923302

    View details for PubMedID 32683978

  • Racial disparities in knowledge, attitudes and practices related to COVID-19 in the USA. Journal of public health (Oxford, England) Alobuia, W. M., Dalva-Baird, N. P., Forrester, J. D., Bendavid, E., Bhattacharya, J., Kebebew, E. 2020


    Recent reports indicate racial disparities in the rates of infection and mortality from the 2019 novel coronavirus (coronavirus disease 2019 [COVID-19]). The aim of this study was to determine whether disparities exist in the levels of knowledge, attitudes and practices (KAPs) related to COVID-19.We analyzed data from 1216 adults in the March 2020 Kaiser Family Foundation 'Coronavirus Poll', to determine levels of KAPs across different groups. Univariate and multivariate regression analysis was used to identify predictors of KAPs.In contrast to White respondents, Non-White respondents were more likely to have low knowledge (58% versus 30%; P < 0.001) and low attitude scores (52% versus 27%; P < 0.001), but high practice scores (81% versus 59%; P < 0.001). By multivariate regression, White race (odds ratio [OR] 3.06; 95% confidence interval [CI]: 1.70-5.50), higher level of education (OR 1.80; 95% CI: 1.46-2.23) and higher income (OR 2.06; 95% CI: 1.58-2.70) were associated with high knowledge of COVID-19. Race, sex, education, income, health insurance status and political views were all associated with KAPs.Racial and socioeconomic disparity exists in the levels of KAPs related to COVID-19. More work is needed to identify educational tools that tailor to specific racial and socioeconomic groups.

    View details for DOI 10.1093/pubmed/fdaa069

    View details for PubMedID 32490519

  • Necessity of routine chest radiograph in blunt trauma resuscitation: time to evaluate dogma with evidence. The journal of trauma and acute care surgery Choi, J., Forrester, J. D., Spain, D. A. 2020

    View details for DOI 10.1097/TA.0000000000002793

    View details for PubMedID 32467468

  • Precautions for Operating Room Team Members during the COVID-19 Pandemic. Journal of the American College of Surgeons Forrester, J. D., Nassar, A. K., Maggio, P. M., Hawn, M. T. 2020


    The novel corona virus SARS-CoV-2 (COVID-19) can infect healthcare workers. We developed an institutional algorithm to protect operating room team members during the COVID-19 pandemic and rationally conserve personal protective equipment (PPE).An interventional platform (operating room, interventional suites, and endoscopy) PPE taskforce was convened by the hospital and medical school leadership and tasked with developing a common algorithm for PPE use, to be used throughout the interventional platform. In conjunction with our infection disease experts, we developed our guidelines based upon potential patterns of spread, risk of exposure and conservation of PPE.A decision tree algorithm describing our institutional guidelines for precautions for operating room team members was created. This algorithm is based on urgency of operation, anticipated viral burden at the surgical site, opportunity for a procedure to aerosolize virus, and likelihood a patient could be infected based on symptoms and testing.Despite COVID-19 being a new threat, we have shown that by developing an easy-to-follow decision tree algorithm for the interventional platform teams, we can ensure optimal healthcare worker safety.

    View details for DOI 10.1016/j.jamcollsurg.2020.03.030

    View details for PubMedID 32247836

  • Mortality After General Surgery Among Hospitalized Patients With Hematologic Malignancy Journal of Surgical Research Forrester, J. D., Syed, M., Tennakoon, L., Spain, D. A., Knowlton, L. M. 2020; 256: P502-511
  • Hospital Readmission After Climbing-Related Injury in the United States. Wilderness & environmental medicine Forrester, J. D., Hunter, K. A., Tennakoon, L., Spain, D. A. 2020


    Rock climbing and mountaineering may result in injury requiring hospital admission. Readmission frequency after climbing-related injury is unknown. The aim of this study was to assess readmission frequency, morbidity, and mortality after admission for climbing-related injury.We performed a retrospective analysis of the 2012 to 2014 national readmission database, a nationally representative sample of all hospitalized patients. Rock climbing, mountain climbing, and wall climbing injuries were identified using International Classification of Diseases-Ninth Revision-Clinical Modification codes (E004.0). Outcomes evaluated included readmission frequency, morbidity, mortality, inpatient admission, and costs. Adjusted analyses accounting for survey methodology were performed. Data are presented as mean±SD.A weighted-estimate 1324 inpatient admissions were associated with a climbing-related injury. Most patients were aged 18 to 44 y (64%), and 68% (n=896) were male. Isolated extremity injures were more common than other injuries (49%, n=645). Sixty-five percent (n=856) underwent a major operative procedure. Less than 1% of all climbing-related visits resulted in death. Within 6 mo of the index hospitalization, 2% (n=23) of the patients had at least 1 readmission, with a time to readmission of 9.9±6.6 (95% CI 4.5-15.4) d. Only female sex was associated with increased odds of readmission (odds ratio=5.5; 95% CI 1.5-20.1; P=0.01).There is a very low frequency of readmissions after being admitted to the hospital for climbing-related injury. A considerable opportunity to describe the long-term burden of climbing-related injury exists, and further research should be done to assess injury burden treated in the outpatient setting.

    View details for DOI 10.1016/j.wem.2020.05.005

    View details for PubMedID 32800446

  • Surgical Infection Society Guidelines for Antibiotic Use in Patients with Traumatic Facial Fractures. Surgical infections Forrester, J. D., Wolff, C. J., Choi, J., Colling, K. P., Huston, J. M. 2020


    Background: Facial fractures are common in traumatic injury. Antibiotic administration practices for traumatic facial fractures differ widely. Methods: The Surgical Infection Society's (SIS's) Therapeutics and Guidelines Committee convened to develop guidelines for antibiotic administration in the management of traumatic facial fractures. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Pre-operative antibiotics were defined as those administered more than 1 hour before surgery. Peri-operative antibiotics were those administered within 1 hour of the start of surgery depending on the type of antibiotic and as late as ≤24 hours after surgery. Post-operative antibiotics were defined as those administered >24 hours after surgery. Prophylactic antibiotics were those administered for >24 hours without a documented infection. Evaluation of the published evidence was performed with the GRADE system. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: We recommend that in adult patients with non-operative upper face, midface, or mandibular fractures, prophylactic antibiotics not be prescribed and that in adult patients with operative, non-mandibular fractures, pre-operative antibiotics likewise not be prescribed. We recommend that in adult patients with operative, mandibular fractures, pre-operative antibiotics not be prescribed; and in adult patients with operative, non-mandibular facial fractures, post-operative (>24 hours) antibiotics again not be prescribed. We recommend that in adult patients with operative, mandibular facial fractures, post-operative antibiotics (> 24 hours) not be prescribed. Conclusions: This guideline summarizes the current SIS recommendations regarding antibiotic management of patients with traumatic facial fractures.

    View details for DOI 10.1089/sur.2020.107

    View details for PubMedID 32598227

  • Splenectomy for benign and malignant hematologic pathology: Modern morbidity, mortality, and long-term outcomes. Surgery open science Alobuia, W. M., Perrone, K., Iberri, D. J., Brar, R. S., Spain, D. A., Forrester, J. D. 2020; 2 (4): 19–24


    The role of splenectomy to diagnose and treat hematologic disease continues to evolve. In this single-center retrospective review, we describe modern morbidity, mortality, and long-term outcomes associated with splenectomy for benign and malignant hematologic disorders.We analyzed all nontrauma splenectomies performed for benign or malignant hematologic disorders from January 2009 to September 2018. Variables collected included demographics, preexisting comorbidities, laboratory results, intra- and postoperative features, and long-term follow-up. Outcomes of interest included postoperative complications, 30-day mortality, and overall mortality.We identified 161 patients who underwent splenectomy for hematologic disorders. Median age was 54 years (range 19-94), and 83 (52%) were female. Splenectomy was performed for 95 (59%) patients with benign hematologic disorders and for 66 (41%) with malignant conditions. Most splenectomies were laparoscopic (76%), followed by laparoscopic hand assisted (11%), open (8%), and laparoscopic converted to open (6%). Median follow-up was 761 days (interquartile range: 179-2025 days). Major complications occurred in 21 (13%) patients. Three (2%) patients died within 30 days; 16 (9%) died more than 30 days after operation, none from surgical complications, with median time to death of 438 days (interquartile range: 231-1497 days). Among malignant cases, only preoperative thrombocytopenia predicted death (odds ratio = 5.8, 95% confidence interval = 1.1-31.8, P = .04). For benign cases, increasing age was associated with inferior survival (odds ratio = 2.3, 95% confidence interval = 1.0-5.1, P = .05).Splenectomy remains an important diagnostic and therapeutic option for patients with benign and malignant hematologic disorders and can be performed with a low complication rate. Despite considerable burden of comorbid disease in these patients, early postoperative mortality was uncommon.

    View details for DOI 10.1016/j.sopen.2020.06.004

    View details for PubMedID 32939448

    View details for PubMedCentralID PMC7479208

  • Pulmonary contusions in patients with rib fractures: The need to better classify a common injury. American journal of surgery Choi, J., Tennakoon, L., You, J. G., Kaghazchi, A., Forrester, J. D., Spain, D. A. 2020


    Pulmonary contusions are common injuries. Computed tomography reveals vast contused lung volume spectrum, yet pulmonary contusions are defined dichotomously (unilateral vs bilateral). We assessed whether there is stepwise increased risk of pulmonary complications among patients without, with unilateral, and with bilateral pulmonary contusion.We identified adults admitted with rib fractures using the largest US inpatient database. After propensity-score-matching patients without vs with unilateral vs bilateral pulmonary contusions and adjusting for residual confounders, we compared risk for pneumonia, ventilator-associated pneumonia (VAP), respiratory failure, intubation, and mortality.Among 148,140 encounters of adults with multiple rib fractures, 19% had concomitant pulmonary contusions. Matched patients with pulmonary contusions had increased risk of pneumonia 19% [95%CI:16-33%], respiratory failure 40% [95%CI: 31-50%], and intubation 46% [95%CI: 33-61%]. Delineation showed bilateral contusions, not unilateral contusions, attributed to increased risk of complications.There is likely a correlation between contused lung volume and risk of pulmonary complications; dichotomously classifying pulmonary contusions is insufficient. Better understanding this correlation requires establishing the clinically significant contusion volume and a correspondingly refined classification system.

    View details for DOI 10.1016/j.amjsurg.2020.07.022

    View details for PubMedID 32854902

  • Lessons from Epidemics, Pandemics, and Surgery. Journal of the American College of Surgeons Hakes, N. A., Choi, J., Spain, D. A., Forrester, J. D. 2020

    View details for DOI 10.1016/j.jamcollsurg.2020.08.736

    View details for PubMedID 32828842

  • Concerns about Proposed Update to COVID-19 Screening Protocols before Surgery: In Reply to Yenigun and Colleagues. Journal of the American College of Surgeons Forrester, J. D., Hawn, M. T. 2020

    View details for DOI 10.1016/j.jamcollsurg.2020.08.757

    View details for PubMedID 32951984

  • Surgical Infections in Low- and Middle-Income Countries: A Global Assessment of the Burden and Management Needs. Surgical infections Rickard, J., Beilman, G., Forrester, J., Sawyer, R., Stephen, A., Weiser, T. G., Valenzuela, J. 2019


    Background: The burden of surgical infections in low- and middle-income countries (LMICs) remains poorly defined compared with high-income countries. Although there are common infections necessitating surgery prevalent across the world, such as appendicitis and peptic ulcer disease, other conditions are more localized geographically. To date, comprehensive assessment of the burden of surgically treatable infections or sequelae of surgical infections in LMICs is lacking. Methods: We reviewed the literature to define the burden of surgical infections in LMICs and characterize the needs and challenges of addressing this issue. Results: Surgical infections comprise a broad range of diseases including intra-abdominal, skin and soft tissue, and healthcare-associated infections and other infectious processes. Treatment of surgical infections requires a functional surgical ecosystem, microbiology services, and appropriate and effective antimicrobial therapy. Systems must be developed and maintained to evaluate screening, prevention, and treatment strategies. Solutions and interventions are proposed focusing on reducing the burden of disease, improving surveillance, strengthening antibiotic stewardship, and enhancing the management of surgical infections. Conclusions: Surgical infections constitute a large burden of disease globally. Challenges to management in LMICs include a shortage of trained personnel and material resources. The increasing rate of antimicrobial drug resistance, likely related to antibiotic misuse, adds to the challenges. Development of surveillance, infection prevention, and antimicrobial stewardship programs are initial steps forward. Education is critical and should begin early in training, be an active process, and be sustained through regular programs.

    View details for DOI 10.1089/sur.2019.142

    View details for PubMedID 31816263

  • Mortality after Emergency General Surgery among Patients with Hematologic Malignancy: A National Assessment Forrester, J. D., Tennakoon, L., Spain, D. A., Knowlton, L. M. ELSEVIER SCIENCE INC. 2019: S103–S104
  • Tuberculosis and the Acute Abdomen: An Evaluation of the National Inpatient Sample. Surgical infections Forrester, J. D., Cha, P., Tennakoon, L., Staudenmayer, K. 2019


    Background: Tuberculosis can cause acute abdominal pathology requiring operation. While most cases of tuberculosis resolve with appropriate anti-mycobacterial therapy, a surgical procedure still may be required. We sought to describe the modern epidemiology of acute abdominal pathology associated with tuberculosis in the United States. Methods: We retrospectively analyzed the 2010-2014 National Inpatient Sample for admissions associated with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for both tuberculosis and acute abdominal pain. Cases of acute abdominal tuberculosis were defined as inpatient admissions with a diagnosis of tuberculosis and a diagnosis of acute abdominal pain. Outcomes of interest included need for abdominal operation and death after operation. Adjusted analyses accounting for survey methodology were performed. Results: There were 66,034 inpatient admissions associated with tuberculosis of which 3638 (6%) included a diagnosis of acute abdominal pain. Among cases, 1578 (43%) were 45-64 years old and 2344 (64%) were male. Most patients were Hispanic (n=1090, 30%) or black (n=924, 25%) and were in the lowest quartile of income by zip code (n=1367, 38%). A total of 347 (0.5% of total) patients underwent an operation. Procedures included peritoneal biopsy (n=136, 39%), repair or resection of a hollow viscus (n=122, 35%), and abdominal exploration (n=111, 32%). In adjusted analysis, undergoing a surgical procedure was found to depend on the type of tuberculosis infection (odds ratio [OR]=1.17 for intestinal, peritoneal, or genitourinary tuberculosis versus other types, 95% confidence interval [CI]=[1.12-1.22]) and whether the patient was white or Asian race versus black and Hispanic (OR=1.11, 95% CI [1.02-1.21]). Thirty-nine (11%) of the 347 patients who underwent a surgical procedure died during hospitalization. Conclusions: An operation still may be required for patients with tuberculosis presenting with acute abdominal pain. Black and Hispanic patients are less likely to receive surgical intervention than whites or Asians. The inhospital deaths from acute abdominal pain necessitating operation among patients with tuberculosis are high.

    View details for DOI 10.1089/sur.2019.174

    View details for PubMedID 31464571

  • BASE Jumping Injuries Presenting to Emergency Departments in the United States: an Assessment of Morbidity, Emergency Department, and Inpatient Costs WILDERNESS & ENVIRONMENTAL MEDICINE Forrester, J. D., Yelorda, K., Tennakoon, L., Spain, D. A., Staudenmayer, K. 2019; 30 (2): 150–54
  • 2019 update of the WSES guidelines for management of Clostridioides (Clostridium) difficile infection in surgical patients WORLD JOURNAL OF EMERGENCY SURGERY Sartelli, M., Di Bella, S., McFarland, L. V., Khanna, S., Furuya-Kanamori, L., Abuzeid, N., Abu-Zidan, F. M., Ansaloni, L., Augustin, G., Bala, M., Ben-Ishay, O., Biffl, W. L., Brecher, S. M., Camacho-Ortiz, A., Cainzos, M. A., Chan, S., Cherry-Bukowiec, J. R., Clanton, J., Coccolini, F., Cocuz, M. E., Coimbra, R., Cortese, F., Cui, Y., Czepiel, J., Demetrashvili, Z., Di Carlo, I., Di Saverio, S., Dumitru, I. M., Eckmann, C., Eiland, E. H., Forrester, J. D., Fraga, G. P., Frossard, J. L., Fry, D. E., Galeiras, R., Ghnnam, W., Gomes, C. A., Griffiths, E. A., Guirao, X., Ahmed, M. H., Herzog, T., Kim, J., Iqbal, T., Isik, A., Itani, K. F., Labricciosa, F. M., Lee, Y. Y., Juang, P., Karamarkovic, A., Kim, P. K., Kluger, Y., Leppaniemi, A., Lohsiriwat, V., Machain, G. M., Marwah, S., Mazuski, J. E., Metan, G., Moore, E. E., Moore, F. A., Ordonez, C. A., Pagani, L., Petrosillo, N., Portela, F., Rasa, K., Rems, M., Sakakushev, B. E., Segovia-Lohse, H., Sganga, G., Shelat, V. G., Spigaglia, P., Tattevin, P., Trana, C., Urbanek, L., Ulrych, J., Viale, P., Baiocchi, G. L., Catena, F. 2019; 14: 8


    In the last three decades, Clostridium difficile infection (CDI) has increased in incidence and severity in many countries worldwide. The increase in CDI incidence has been particularly apparent among surgical patients. Therefore, prevention of CDI and optimization of management in the surgical patient are paramount. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of CDI in surgical patients according to the most recent available literature. The update includes recent changes introduced in the management of this infection.

    View details for PubMedID 30858872

  • Tactics to Prevent Intra-Abdominal Infections in General Surgery SURGICAL INFECTIONS Weiser, T. G., Forrester, J. D., Forrester, J. A. 2019; 20 (2): 139–45
  • A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare. JAMA surgery Wren, S. M., Wild, H. B., Gurney, J., Amirtharajah, M., Brown, Z. W., Bulger, E. M., Burkle, F. M., Elster, E. A., Forrester, J. D., Garber, K., Gosselin, R. A., Groen, R. S., Hsin, G., Joshipura, M., Kushner, A. L., Norton, I., Osmers, I., Pagano, H., Razek, T., Sáenz-Terrazas, J. M., Schussler, L., Stewart, B. T., Traboulsi, A. A., Trelles, M., Troke, J., VanFosson, C. A., Wise, P. H. 2019


    Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols.To describe a consensus framework for surgical care designed to respond to this emerging need.An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision.The working group's method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018.Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements.Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.

    View details for DOI 10.1001/jamasurg.2019.4547

    View details for PubMedID 31722004

  • Rhinovirus-associated severe acute respiratory distress syndrome (ARDS) managed with airway pressure release ventilation (APRV). Trauma surgery & acute care open Ayala, C., Baiu, I., Owyang, C., Forrester, J. D., Spain, D. 2019; 4 (1): e000322

    View details for DOI 10.1136/tsaco-2019-000322

    View details for PubMedID 31392279

    View details for PubMedCentralID PMC6660799

  • The Golden Hour After Injury Among Civilians Caught in Conflict Zones. Disaster medicine and public health preparedness Forrester, J. D., August, A., Cai, L. Z., Kushner, A. L., Wren, S. M. 2019: 1–9


    ABSTRACTIntroduction:The term "golden hour" describes the first 60 minutes after patients sustain injury. In resource-available settings, rapid transport to trauma centers within this time period is standard-of-care. We compared transport times of injured civilians in modern conflict zones to assess the degree to which injured civilians are transported within the golden hour in these environments.We evaluated PubMed, Ovid, and Web of Science databases for manuscripts describing transport time after trauma among civilian victims of trauma from January 1990 to November 2017.The initial database search identified 2704 abstracts. Twenty-nine studies met inclusion and exclusion criteria. Conflicts in Yugoslavia/Bosnia/Herzegovina, Syria, Afghanistan, Iraq, Israel, Cambodia, Somalia, Georgia, Lebanon, Nigeria, Democratic Republic of Congo, and Turkey were represented, describing 47 273 patients. Only 7 (24%) manuscripts described transport times under 1 hour. Transport typically required several hours to days.Anticipated transport times have important implications for field triage of injured persons in civilian conflict settings because existing overburdened civilian health care systems may become further overwhelmed if in-hospital health capacity is unable to keep pace with inflow of the severely wounded.

    View details for DOI 10.1017/dmp.2019.42

    View details for PubMedID 31203832

  • Cougar (Puma concolor) Injury in the United States. Wilderness & environmental medicine Wang, Y. Y., Weiser, T. G., Forrester, J. D. 2019


    Human encounters with the cougar (Puma concolor) are rare in the United States but may be fatal.We performed a retrospective analysis of cougar attacks in the United States. We asked Fish and Wildlife Department officials from the 16 states in which cougars are known to live to identify all verified cougar attacks recorded in state history. Variables describing the human victim, cougar, and conditions surrounding the attack were recorded. The Fisher exact test was used for comparison.Ten states reported 74 cougar attacks from 1924 to 2018. Persons less than 18 y of age were heavily represented among victims; 48% were <18 y old, and 35% were less than 10 y old. Attacks were more common in the summer and fall months. Most attacks occurred during daylight hours. The head, neck, and chest were the most common anatomic sites of injury. Sixteen (46%) victims were hospitalized after being attacked, among the 35 victims with these data available. Eleven (15%) attacks were fatal among 71 reports with this information. None of the hospitalized victims died (P=0.02). No victim variables were predictive of death.Cougar attacks are uncommon but can be fatal. Attacks commonly affect children and young adults, although all age groups are at risk of attack and death. Most attacks occur during the daytime in the summer and fall. As development and recreational activities put humans in closer contact with cougars, establishing validated public health messaging is critical to minimize injurious encounters.

    View details for DOI 10.1016/j.wem.2019.04.002

    View details for PubMedID 31248816

  • LAPRA-TY for laparoscopic repair of traumatic diaphragmatic hernia without intracorporeal knot tying. Trauma surgery & acute care open Choi, J., Pan, J., Forrester, J. D., Spain, D., Browder, T. D. 2019; 4 (1): e000334


    A 38-year-old man was brought in by ambulance as a trauma activation after sustaining a self-inflicted stab wound in the left upper quadrant with a kitchen knife. His primary survey was unremarkable and his vital signs were normal. Secondary survey revealed a 2 cm transverse stab wound inferior and medial to the left nipple. Extended focused assessment with sonography for trauma (FAST) did not show intra-abdominal or pericardial fluid and chest X-ray did not show a definite pneumothorax or hemothorax.Wound exploration at bedside.Admit for observation and serial examinations.Exploratory laparotomy and open repair of traumatic diaphragmatic injury (TDI).Thoracotomy and open repair of TDI.Diagnostic laparoscopy and laparoscopic repair of TDI.

    View details for DOI 10.1136/tsaco-2019-000334

    View details for PubMedID 31321313

    View details for PubMedCentralID PMC6606065

  • The "T's" of snakebite injury in the USA: fact or fiction? Trauma surgery & acute care open Jaramillo, J. D., Hakes, N. A., Tennakoon, L., Spain, D., Forrester, J. D. 2019; 4 (1): e000374


    Background: Venomous snakebites can result in serious morbidity and mortality. In the USA, the "T's of snakebites" (testosterone, teasing, touching, trucks, tattoos & toothless (poverTy), Texas, tequila, teenagers, and tanks) originate from anecdotes used to colloquially highlight venomous snakebite risk factors. We performed an epidemiologic assessment of venomous snakebites in the USA with the objective of evaluating the validity of the "T's of snakebites" at a national level.Methods: We performed a retrospective analysis of the National Emergency Department Sample. Data from January 1, 2016 to December 31, 2016 were obtained. All emergency department (ED) encounters corresponding to a venomous snakebite injury were identified using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. Primary outcomes were mortality and inpatient admission. Demographic, injury, and hospital characteristics were assessed. Data were analyzed according to survey methodology. Weighted values are reported.Results: In 2016, 11 138 patients presented to an ED with a venomous snakebite. There were 4173 (37%) persons aged 18 to 44, and 7213 (65%) were male. Most snakebites were reported from the South (n=9079; 82%), although snakebites were reported from every region in the USA. Only 3792 (34%) snakebites occurred in rural counties. Persons in the lowest income quartile by zip code were the most heavily represented (n=4337; 39%). The most common site of injury was the distal upper extremity (n=4884; 44%). Multivariate analysis revealed that species of snake (OR=0.81; 95% CI 0.73 to 0.88) and older age (OR=1.42; 95% CI 1.08 to 1.87) were associated with hospital admission. There were <10 inpatient deaths identified, and no variables were predictive of death.Discussion: Some of the "T's of snakebites" may be valid colloquial predictors of the risk for venomous snakebites. Based on national data, common demographics of venomous snakebite victims include lower income, Caucasian, and adult men in the South who are bit on the upper extremity. Understanding common demographics of venomous snakebite victims can effectuate targeted public health prevention messaging.Level of evidence: IV.

    View details for DOI 10.1136/tsaco-2019-000374

    View details for PubMedID 31803846

  • Climbing-Related Injury Among Adults in the United States: 5-Year Analysis of the National Emergency Department Sample WILDERNESS & ENVIRONMENTAL MEDICINE Forrester, J. D., Tran, K., Tennakoon, L., Staudenmayer, K. 2018; 29 (4): 425–30
  • First Reported Case of Intussusception Caused by Escherichia coli O157:H7 in an Adult: Literature Review and Case Report SURGICAL INFECTIONS Cha, P. I., Gurland, B., Forrester, J. D. 2019; 20 (1): 95–99
  • Unachievable zeros JOURNAL OF THORACIC DISEASE Forrester, J. D. 2018; 10: S3218–S3219
  • Surgical Instrument Reprocessing in Resource-Constrained Countries: A Scoping Review of Existing Methods, Policies, and Barriers. Surgical infections Forrester, J. A., Powell, B. L., Forrester, J. D., Fast, C., Weiser, T. G. 2018; 19 (6): 593–602


    BACKGROUND: Surgical infections are a major cause of morbidity and mortality in low- and middle-income countries (LMICs). Inadequately reprocessed surgical instruments can be a vector for pathogens. Little has been published on the current state of surgical instrument reprocessing in LMICs.METHODS: We performed a scoping review of English-language articles in PubMed, Web of Science, and Google Scholar databases describing current methods, policies, and barriers to surgical instrument reprocessing in LMICs. We conducted qualitative analysis of all studies to categorize existing practices and barriers to successful surgical instrument reprocessing. Barriers were non-exclusively categorized by theme: training/education, resource availability, environment, and policies/procedures. Studies associating surgical infections with existing practices were separately evaluated to assess this relationship.RESULTS: Nine hundred seventy-two abstracts were identified. Forty studies met criteria for qualitative analysis and three studies associated patient outcomes with surgical instrument reprocessing. Most studies (n=28, 70%) discussed institution-specific policies/procedures; half discussed shortcomings in staff training. Sterilization (n=38, 95%), verification of sterilization (n=19, 48%), and instrument cleaning and decontamination (n=16, 40%) were the most common instrument reprocessing practices examined. Poor resource availability and the lack of effective education/training and appropriate policies/procedures were cited as the common barriers. Of the case series investigating surgical instrument reprocessing with patient outcomes, improperly cleaned and sterilized neurosurgical instruments and contaminated rinse water were linked to Pseudomonas aeruginosa ventriculitis and Mycobacterium port site infections, respectively.CONCLUSIONS: Large gaps exist between instrument reprocessing practices in LMICs and recommended policies/procedures. Identified areas for improvement include instrument cleaning and decontamination, sterilization aspects of instrument reprocessing, and verification of sterilization. Education and training of staff responsible for reprocessing instruments and realistic, defined policies and procedures are critical, and lend themselves to improvement interventions.

    View details for PubMedID 30156997

  • An Update on Fatalities Due to Venomous and Nonvenomous Animals in the United States (2008-2015). Wilderness & environmental medicine Forrester, J. A., Weiser, T. G., Forrester, J. D. 2018


    To review recent (2008-2015) United States mortality data from deaths caused by nonvenomous and venomous animals and compare with historical data.The Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database was queried to return all animal-related fatalities between 2008 and 2015. Mortality frequencies for animal-related fatalities were calculated using the estimated 2011 United States population. Inclusion criteria included all mortalities that were a consequence of bite, contact, attack, or envenomation (International Classification of Diseases 10th revision codes W53-W59 and X20-X29).There were 1610 animal-related fatalities, with the majority from nonvenomous animals (2.8 deaths per 10 million persons). The largest proportion of animal-related fatalities was due to "other mammals," largely composed of horses and cattle. Deaths attributable to Hymenoptera (hornets, wasps, and bees) account for 29.7% of the overall animal-related fatalities and have been steady over the last 20 years. Dog-related fatality frequencies are stable, although the fatality frequency of 4.6 deaths per 10 million persons among children 4 years of age or younger was nearly 4-fold greater than in the other age groups.Appropriate education and prevention measures aimed at decreasing injury from animals should be directed at the high-risk groups of agricultural workers and young children with dogs. Public policy and treatment pricing should align to ensure adequate available medication for those at risk of anaphylaxis from stings from Hymenoptera.

    View details for PubMedID 29373216

  • Undertreated Medical Conditions vs Trauma as Primary Indications for Amputation at a Referral Hospital in Cameroon. JAMA surgery Forrester, J. D., Teslovich, N. C., Nigo, L., Brown, J. A., Wren, S. M. 2018

    View details for PubMedID 29874368

  • Surgical Site Infections after Open Reduction Internal Fixation for Trauma in Low and Middle Human Development Index Countries: A Systematic Review. Surgical infections McQuillan, T. J., Cai, L. Z., Corcoran-Schwartz, I., Weiser, T. G., Forrester, J. D. 2018


    Musculoskeletal trauma represents a large source of morbidity in low and middle human development index countries (LMHDICs). Open reduction and internal fixation (ORIF) of traumatic long bone fractures definitively manages these injuries and restores function when conducted safely and effectively. Surgical site infections (SSIs) are a common complication of operative fracture fixation, although the risks of infection are ill-defined in LMHDIC.This study reviewed systematically all studies describing SSI after ORIF in LMDHICs. Studies were reviewed based on their qualitative characteristics, after which a quantitative synthesis of weighted pooled infection rates based on available patient-level data was performed to estimate published incidence of SSI.Forty-two studies met criteria for qualitative review and 32 studies comprising 3,084 operations were included in the quantitative analysis. Among 3,084 operations, the weighted pooled SSI rate was 6.4 infections per 100 procedures (95% confidence interval [CI] 4.6-8.2 infections per 100 procedures). Higher rates of infection were noted among the sub-group of open fractures (95% CI 13.9-23.0 infections per 100 procedures). Lower extremity injuries and procedures utilizing intra-medullary nails also had slightly higher rates of infection versus upper extremity procedures and other fixation devices.Reported rates of SSI after ORIF are higher in LMHDICs, and may be driven by high rates of infection in the sub-group of open fractures. This study provides a baseline SSI rate obtained from literature produced from LMHDICs. Infection rates are highly dependent on fracture sub-types.

    View details for PubMedID 29341840

  • Mortality, hospital admission, and healthcare cost due to injury from venomous and non-venomous animal encounters in the USA: 5-year analysis of the National Emergency Department Sample. Trauma surgery & acute care open Forrester, J. D., Forrester, J. A., Tennakoon, L., Staudenmayer, K. 2018; 3 (1): e000250


    Background: Injuries due to encounters with animals can be serious, but are often discussed anecdotally or only for isolated types of encounters. We sought to characterize animal-related injuries presenting to US emergency departments (ED) to determine the impact of these types of injuries.Methods: All ED encounters with diagnosis codes corresponding to animal-related injury were identified using ICD-9-CM codes from the 2010 2014 National Emergency Department Sample (NEDS). Outcomes assessed included inpatient admission, mortality, and healthcare cost. Survey methodology was applied to univariate and multivariate analyses. Weighted numbers are presented.Results: There were 6 457 534 ED visits resulting from animal-related injuries identified. Bites from non-venomous arthropods (n=2 648 880; 41%), dog bites (n=1 658 295; 26%) and envenomation from hornets, wasps or bees (n=812357; 13%) constitute the majority of encounters. There were 210516 patients (3%) admitted as inpatients. Inpatient admission was most common for those suffering from venomous snakes or lizard bites (24%, n=10332). Death was infrequent occurring in 1162 patients (0.02% of all ED presentations). The greatest number of deaths was due to bites from non-venomous arthropods (24% of deaths, n=278) whereas rat bites proved the most lethal (6.5 deaths per 10000 bites). Among persons aged 85 years or greater, odds of hospital admission for any animal-related injury was 6.42 (95% CI 5.57 to 7.40) and the OR for death was 27.71 (95% CI 10.38 to 73.99). Female sex was associated with improved survival (OR 0.55, 95% CI 0.41 to 0.73) and lower rates of hospital admission (OR 0.77, 95%CI 0.75 to 0.79). The total healthcare cost for these animal encounters during the observed time period was $5.96 billion (95%CI $5.43 to $6.50 billion).Conclusion: The morbidity, mortality, and healthcare cost due to animal encounters in the USA is considerable. Often overlooked, this particular mechanism of injury warrants further public health prevention efforts.Level of Evidence: Level IV.

    View details for PubMedID 30623028

  • Clinical phenotypes of US level I trauma centers: use of clustering methodology Forrester, J. D., Weiser, T. G., Maggio, P., Browder, T., Tennakoon, L., Spain, D. A., Staudenmayer, K. ACADEMIC PRESS INC ELSEVIER SCIENCE. 2017: 146–52


    American College of Surgeons Level I Trauma Centers (ACSL1TCs) meet the same personnel and structural requirements but serve different populations. We hypothesized that these nuanced differences may amenable to description through mathematical clustering methodology.The National Trauma Data Bank 2014 was used to derive information on ACSL1TCs. Explorative cluster hypothesis generation was performed using Ward's linkage to determine expected number of clusters based on patient and injury characteristics. Subsequent k-means clustering was applied for analysis. Comparison between clusters was performed using the Kruskal-Wallis or chi-square test.In 2014, 113 ACSL1TCs admitted 267,808 patients (median = 2220 patients, range: 928-6643 patients). Three clusters emerged. Cluster I centers (n = 53, 47%) were more likely to admit older, Caucasian patients who suffered from falls (P < 0.05) and had higher proportions of private (31%) and Medicare payers (29%) (P = 0.001). Cluster II centers (n = 18, 16%) were more likely to admit younger, minority males who suffered from penetrating trauma (P < 0.05) and had higher proportions of Medicaid (24%) or self-pay patients (19%) (P = 0.001). Cluster III centers (n = 42, 37%) were similar to cluster I with respect to racial demographic and payer status but resembled cluster II centers with respect to injury patterns (P < 0.05).Our analysis identified three unique, mathematically definable clusters of ACSL1TCs serving three broadly different patient populations. Understanding these mathematically definable clusters should have utility when assessing an institution's financial risk profile, directing prevention and outreach programs, and performing needs and resource assessments. Ultimately, clustering allows for more meaningful direct comparisons between phenotypically similar trauma centers.

    View details for PubMedID 28688640

  • Sex disparities among persons receiving operative care during armed conflicts. Surgery Forrester, J. D., Forrester, J. A., Basimouneye, J., Tahir, M., Trelles, M., Kushner, A. L., Wren, S. M. 2017


    Armed conflict increasingly involves civilian populations, and health care needs may be immense. We hypothesized that sex disparities may exist among persons receiving operative care in conflict zones and sought to describe predictors of disparity.We performed a retrospective analysis of operative interventions performed between 2008 and 2014 at Médecins Sans Frontières Operation Center Brussels conflict projects. A Médecins Sans Frontières Operation Center Brussels conflict project was defined as a program established in response to human conflict, war, or social unrest. Intervention- and country-level variables were evaluated. For multivariate analysis, multilevel mixed-effects logistic regression was used with random-effect modeling to account for clustering and population differences in conflict zones.Between 2008 and 2014, 49,715 interventions were performed in conflict zones by Médecins Sans Frontières Operation Center Brussels. Median patient age was 24 years (range: 1-105 years), and 34,436 (69%) were men. Patient-level variables associated with decreased interventions on women included: American Society of Anesthesiologists score (P = .003), degree of urgency (P = .02), mechanism (P < .0001), and a country's predominant religion (P = .006). Men were 1.7 times more likely to have an operative intervention in a predominantly Muslim country (P = .006).Conflict is an unfortunate consequence of humanity in a world with limited resources. For most operative interventions performed in conflict zones, men were more commonly represented. Predominant religion was the greatest predictor of increased disparity between sexes, irrespective of the number of patients presenting as a result of traumatic injury. It is critical to understand what factors may underlie this disparity to ensure equitable and appropriate care for all patients in an already tragic situation.

    View details for DOI 10.1016/j.surg.2017.03.001

    View details for PubMedID 28400124

  • A multi-institution analysis of general surgery resident peer-reviewed publication trends JOURNAL OF SURGICAL RESEARCH Forrester, J. D., Ansari, P., Are, C., Auyang, E., Galante, J. M., Jarman, B. T., Smith, B. R., Watkins, A. C., Melcher, M. L. 2017; 210: 92-98


    The process of taking a research project from conception to publication is one way to encourage surgeons to communicate hypothesis, critically assess literature and data, and defend research conclusions to a broad audience. The goal of this study was to define surgery resident publishing epidemiology and identify characteristics of residents and residency programs that might predict increased publication productivity.A survey was administered to eight general surgery residency programs to collect residency and resident variables from 1993-2013. The primary endpoint was the number of first-author publications produced per resident. Secondary endpoints included clinical setting at which the former resident was practicing, fellowship pursued, and manuscript quality.Between 1993 and 2013, 676 residents graduated, median age was 33 years (range: 29-43 years) and 182 (27%) were female. Three hundred and sixty-six (54%) residents produced 1229 first-author publications. Of these, 112 (31%) residents produced one manuscript, 125 (34%) produced two-three manuscripts, 107 (29%) produced four-nine manuscripts, and 22 (6%) produced 10 or more manuscripts. Publishing ≥1 manuscript in residency was associated with a 1.5 (P = 0.01) increased odds of having attended a top-tier research institution for medical school and a 2.3 (P < 0.001) increased odds of having dedicated research years incorporated into residency. Surgeons practicing at academic centers had 1.7 (P = 0.003) greater odds of having attended top-tier medical schools, and 1.5 (P = 0.02) greater odds of publishing during residency.Additional research directed at identifying interventions promoting resident publishing and scholastic achievement should benefit all surgery training programs looking to cultivate the next generation of critically thinking surgeons.

    View details for DOI 10.1016/j.jss.2016.11.015

    View details for PubMedID 28457346

  • Surgical Site Infections after Inguinal Hernia Repairs Performed in Low and Middle Human Development Index Countries: A Systematic Review. Surgical infections Cai, L. Z., Foster, D., Kethman, W. C., Weiser, T. G., Forrester, J. D. 2017


    Inguinal hernias are a common disorder in low- and middle-human development index countries (LMHDICs). Poor access to surgical care and lack of patient awareness often lead to delayed presentations of incarcerated or strangulated hernias and their associated morbidities. There is a scarcity of data on the baseline incidence of surgical site infections (SSIs) after hernia repair procedures in LMHDICs.We performed a systematic review of the literature describing the incidence and management of SSIs after inguinal hernia repair in LMHDICs. We conducted qualitative and quantitative analyses of manuscripts describing patients undergoing hernia repair to establish a baseline SSI rate for this procedure in these settings.Three hundred twenty-three abstracts were identified after applying search criteria, and 31 were suitable for the quantitative analysis. The overall pooled SSI rate was 4.1 infections/100 open hernia repairs (95% confidence interval [CI] 3.0-5.3 infections/100 open repairs), which is consistent with infection rates from high-human development index countries. A separate subgroup analysis of laparoscopic hernia repairs found a weighted pooled SSI rate of 0.4 infections/100 laparoscopic repairs (95% CI 0-2.4 infections/100 laparoscopic repairs).As surgical access continues to expand in LMHDIC settings, it is imperative to monitor surgical outcomes and ensure that care is provided safely. Establishing a baseline SSI rate for inguinal hernia repairs offers a useful benchmark for future studies and surgical programs in these countries.

    View details for PubMedID 29048997

  • Peritoneal encapsulation syndrome: A case report and literature review. International journal of surgery case reports Mbanje, C., Mazingi, D., Forrester, J., Mungazi, S. G. 2017; 41: 520–23


    Peritoneal encapsulation is an infrequently described congenital anomaly that results in formation of an accessory peritoneal membrane. The case presented below is unique in that it illustrates one of the rare complications of this condition. It is important for clinicians to be aware of this condition and its complications in order to limit potential morbidity and mortality.We report on an eleven-year-old boy without prior abdominal symptoms who presented with an acute abdomen after an episode of intense physical exertion. At laparotomy, gangrenous small bowel loops were identified extruding from an opening in a peritoneal sac consistent with peritoneal encapsulation syndrome. All gangrenous bowel (mostly ileum) was resected. The sac was excised and a primary jejunum to ascending colon anastomosis was created. The patient did well post operatively and was subsequently discharged.Peritoneal encapsulation is an aberration of peritoneal development that is frequently confused with other visceral encapsulation syndromes of inflammatory origin. Due to its mostly asymptomatic course, its true incidence remains unknown. An appreciation of the condition and its potential complications allows surgeons to take appropriate action in the event of incidental discovery at laparoscopy or laparotomy.Peritoneal encapsulation is a rare, mostly asymptomatic, surgical finding which may predispose patients to an acute abdominal crisis.

    View details for PubMedID 29546031

    View details for PubMedCentralID PMC5723259

  • Surgical Site Infection after Sternotomy in Low- and Middle-Human Development Index Countries: A Systematic Review. Surgical infections Forrester, J. D., Cai, L. Z., Zeigler, S., Weiser, T. G. 2017; 18 (7): 774–79


    The burden of cardiovascular disease is increasing in low- and middle-human development index (LMHDI) countries, and cardiac operations are an important component of a comprehensive cardiovascular care package. Little is known about the baseline incidence of surgical site infections (SSIs) among patients undergoing sternotomy in LMHDI countries.A prospectively registered, systematic literature review of articles in the PubMed, Ovid, and Web of Science databases describing the epidemiology and management of SSIs among persons undergoing sternotomy in LMHDI countries was performed. We performed a quantitative synthesis of patients undergoing sternotomy for CABG to estimate published sternotomy SSI rates.Of the 423 abstracts identified after applying search criteria, 14 studies were reviewed in detail. The pooled SSI rate after sternotomy among reviewed studies was 4.3 infections per 100 sternotomies (95% confidence interval [CI] 1.3-6.0 infections per 100 sternotomies), which is comparable to infection rates in high-human development index countries.As the burden of cardiovascular disease in LMHDI settings increases, the ability to provide safe cardiac surgical care is paramount. Describing the baseline SSI rate after sternotomy in LMHDI countries is an important first step in creating baseline expectations for SSI rates in cardiac surgical programs in these settings.

    View details for PubMedID 28949848

  • Clostridium difficile infection in Low- and Middle-Human Development Index Countries: A systematic review. Tropical medicine & international health : TM & IH Forrester, J. D., Cai, L. Z., Mbanje, C., Rinderknecht, T. N., Wren, S. M. 2017


    To describe the impact and epidemiology of Clostridium difficile (C.difficile) infection (CDI) in low- and middle-human development index (LMHDI) countries.Prospectively registered, systematic literature review of existing literature in the PubMed, Ovid, and Web of Science databases describing the epidemiology and management of C.difficile in LMHDI countries. Risk factors were compared between studies when available.Of the 218 abstracts identified after applying search criteria, 25 studies were reviewed in detail. The weighted pooled infection rate among symptomatic non-immunosuppressed inpatients was 15.8% (95% CI 12.1%-19.5%) and was 10.1% (95% CI 3.0%-17.2%) among symptomatic outpatients. Subgroup analysis of immunosuppressed patient populations revealed pooled infection rates similar to non-immunosuppressed patient populations. Risk factor analysis was infrequently performed.While the percentages of patients with CDI in LMHDI countries among the reviewed studies are lower than expected, there remains a paucity of epidemiologic data evaluating burden of C. difficile infection in these settings. This article is protected by copyright. All rights reserved.

    View details for PubMedID 28796388

  • Patterns of Human Plague in Uganda, 2008-2016. Emerging infectious diseases Forrester, J. D., Apangu, T., Griffith, K., Acayo, S., Yockey, B., Kaggwa, J., Kugeler, K. J., Schriefer, M., Sexton, C., Ben Beard, C., Candini, G., Abaru, J., Candia, B., Okoth, J. F., Apio, H., Nolex, L., Ezama, G., Okello, R., Atiku, L., Mpanga, J., Mead, P. S. 2017; 23 (9): 1517–21


    Plague is a highly virulent fleaborne zoonosis that occurs throughout many parts of the world; most suspected human cases are reported from resource-poor settings in sub-Saharan Africa. During 2008-2016, a combination of active surveillance and laboratory testing in the plague-endemic West Nile region of Uganda yielded 255 suspected human plague cases; approximately one third were laboratory confirmed by bacterial culture or serology. Although the mortality rate was 7% among suspected cases, it was 26% among persons with laboratory-confirmed plague. Reports of an unusual number of dead rats in a patient's village around the time of illness onset was significantly associated with laboratory confirmation of plague. This descriptive summary of human plague in Uganda highlights the episodic nature of the disease, as well as the potential that, even in endemic areas, illnesses of other etiologies might be being mistaken for plague.

    View details for DOI 10.3201/eid2309.170789

    View details for PubMedID 28820134

  • Knowledge and practices related to plague in an endemic area of Uganda. International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases Kugeler, K. J., Apangu, T., Forrester, J. D., Griffith, K. S., Candini, G., Abaru, J., Okoth, J. F., Apio, H., Ezama, G., Okello, R., Brett, M., Mead, P. 2017


    Plague is a virulent zoonosis reported most commonly from sub-Saharan Africa. Early treatment with antibiotics is important to prevent mortality. Understanding knowledge gaps and common behaviors informs development of educational efforts to reduce plague mortality.We conducted a multi-stage cluster-sampled survey of 420 households in the plague-endemic West Nile region of Uganda to assess knowledge of symptoms and causes of plague and healthcare-seeking practices.Most (84%) respondents were able to correctly describe plague symptoms; approximately 75% linked plague with fleas and dead rats. Most respondents indicated they would seek health care at a clinic for possible plague, however plague-like symptoms were reportedly common and in practice, persons sought care for those symptoms at a health clinic infrequently.Persons in the plague-endemic region of Uganda have a high level of understanding of plague, yet topics for targeted educational messages are apparent.

    View details for DOI 10.1016/j.ijid.2017.09.007

    View details for PubMedID 28935246

  • Surgical Site Infections after Tissue Flaps Performed in Low and Middle Human Development Index Countries: A Systematic Review. Surgical infections Cai, L. Z., Chang, J., Weiser, T. G., Forrester, J. D. 2017


    Surgical site infections (SSIs) affect the safety of surgical care and are particularly problematic and prevalent in low and middle Human Development Index Countries (LMHDICs).We performed a systematic review of the existing literature on SSIs after tissue flap procedures in LMHDICs through the PubMed, Ovid, and Web of Science databases. Of the 405 abstracts identified, 79 were selected for full text review, and 30 studies met inclusion criteria for analysis.In the pooled analysis, the SSI rate was 5.8 infections per 100 flap procedures (95% confidence interval [CI] 2%-10%, range: 0-40%). The most common indication for tissue flap was pilonidal sinus repair, which had a pooled SSI rate of 5.6 infections per 100 flap procedures (95% CI 2%-10%, range: 0-15%). No fatalities from an infection were noted. The reporting of infection epidemiology, prevention, and treatment was poor, with few studies reporting antibiotic agent use (37%), responsible pathogens (13%), infection comorbidities (13%), or time to infection (7%); none reported cost.Our review highlights the need for more work to develop standardized hospital-based reporting for surgical outcomes and complications, as well as future studies by large, multi-national groups to establish baseline incidence rates for SSIs and best practice guidelines to monitor SSI rates.

    View details for PubMedID 28915094

  • Surgical Site Infections after Appendectomy Performed in Low and Middle Human Development-Index Countries: A Systematic Review. Surgical infections Foster, D., Kethman, W., Cai, L. Z., Weiser, T. G., Forrester, J. D. 2017


    Acute appendicitis is a common surgical emergency worldwide. Early intervention is associated with better outcomes. In low and middle Human Development-Index Countries (LMHDICs), late presentation and poor access to healthcare facilities can contribute to greater illness severity and higher complication rates, such as post-operative surgical site infections (SSIs). The current rate of SSIs post-appendectomy in low- and middle-index settings has yet to be described.We performed a systemic review of the literature describing the incidence and management of SSIs after appendectomy in LMHDICs. We conducted qualitative and quantitative analysis of the data in manuscripts describing patients undergoing appendectomy to establish a baseline SSI rate for this procedure in these settings.Four hundred twenty-three abstracts were initially identified. Of these, 35 studies met the criteria for qualitative and quantitative analysis. The overall weighted, pooled SSI rated were 17.9 infections/100 open appendectomies (95% confidence interval [CI] 10.4-25.3 infections/100 open appendectomies) and 8.8 infections/100 laparoscopic appendectomies (95% CI 4.5-13.2 infections/100 laparoscopic appendectomies). The SSI rates were higher in complicated appendicitis and when pre-operative antibiotic use was not specified.Observed SSI rates after appendectomy in LMHDICs are dramatically higher than rates in high Human Development-Index Countries. This is particularly true in cases of open appendectomy, which remains the most common surgical approach in LMHDICs. These findings highlight the need for SSI prevention in LMHDICs, including prompt access to medical and surgical care, routine pre-operative antibiotic use, and implementation of bundled care packages and checklists.

    View details for PubMedID 29058569

  • Trends in Country-Specific Surgical Randomized Clinical Trial Publications. JAMA surgery Forrester, J. A., Forrester, J. D., Wren, S. M. 2017

    View details for PubMedID 29282466

  • Unlikely Surgeons A Surgeon In The Village: An American Doctor Teaches Brain Surgery In Africa By Tony Bartelme Boston (MA) : Beacon Press , 2017 288 pp., $27.95. Health affairs (Project Hope) Forrester, J. D. 2017; 36 (11): 2026–27

    View details for DOI 10.1377/hlthaff.2017.0910

    View details for PubMedID 29137518

  • Using Epidemiology to Determine Surgical Needs in Low-Resource Settings. JAMA surgery Forrester, J. D., Wren, S. M. 2017: e174027

    View details for PubMedID 29071330

  • Coccidioidomycosis: Surgical Issues and Implications. Surgical infections Forrester, J. D., Guo, H. H., Weiser, T. G. 2016: -?


    Coccidioidomycosis, commonly called "valley fever," "San Joaquin fever," "desert fever," or "desert rheumatism," is a multi-system illness caused by infection with Coccidioides fungi (C. immitis or C. posadasii). This organism is endemic to the desert Southwest regions of the United States and Mexico and to parts of South America. The manifestations of infection occur along a spectrum from asymptomatic to mild self-limited fever to severe disseminated disease.Review of the English-language literature.There are five broad indications for surgical intervention in patients with coccidioidomycosis: Tissue diagnosis in patients at risk for co-existing pathology, perforation, bleeding, impingement on critical organs, and failure to resolve with medical management. As part of a multidisciplinary team, surgeons may be responsible for the care of infected patients, particularly those with severe disease.This review discusses the history, microbiology, epidemiology, pathology, diagnosis, and treatment of coccidioidomycosis, focusing on situations that may be encountered by surgeons.

    View details for PubMedID 27740893

  • Hernia Mesh Repair and Global Surgery-Reply. JAMA surgery Forrester, J. D., Forrester, J. A., Yang, G. P. 2016

    View details for DOI 10.1001/jamasurg.2016.3497

    View details for PubMedID 27732714

  • Trends in open vascular surgery for trauma: implications for the future of acute care surgery. journal of surgical research Forrester, J. D., Weiser, T. G., Maggio, P., Browder, T., Tennakoon, L., Spain, D., Staudenmayer, K. 2016; 205 (1): 208-212


    Trauma patients with vascular injuries have historically been within a general surgeon's operative ability. Changes in training and decline in operative trauma have decreased trainees' exposure to these injuries. We sought to determine how frequently vascular procedures are performed at US trauma centers to quantify the need for general surgeons trained to manage vascular injuries.We conducted a retrospective analysis of the National Trauma Data Base (NTDB) from 2012 compared with 2002. Patients with general surgical and vascular procedures were identified using International Classification of Diseases, Ninth Revision, procedure codes 38.0-39.99, excluding 38.9-38.99.General surgery or vascular operations were performed on 12,099 (24%) of 50,248 severely injured adult patients in 2002 and 21,854 (16%) of 138,009 injured patients in 2012. Nineteen percent to 26% of all patients underwent vascular procedures. Patients with combined general surgery and vascular procedures were less likely to be discharged home and more likely to die. In 2002, 6% of severely injured adult trauma patients underwent open vascular procedures at level III/IV trauma centers; by 2012, only 1% of vascular surgery procedures were performed at level III/IV centers (P < 0.001).Need for emergent vascular surgery remains common for severely injured patients. Future trauma systems and surgical training programs will need to account for the need for open vascular skills. The findings suggest that there is already a trend away from open vascular procedures at level III/IV trauma centers, which may be a sign of system compensation for changes in the workforce.

    View details for DOI 10.1016/j.jss.2016.06.032

    View details for PubMedID 27621021

  • Surgical Mesh Should Be Made Affordable to Low- and Middle-Income Countries JAMA SURGERY Forrester, J. D., Forrester, J. A., Yang, G. P. 2016; 151 (6): 499-500

    View details for DOI 10.1001/jamasurg.2015.5456

    View details for Web of Science ID 000377932700005

    View details for PubMedID 26934533

  • Cardiac Tropism of Borrelia burgdorferi: An Autopsy Study of Sudden Cardiac Death Associated with Lyme Carditis. American journal of pathology Muehlenbachs, A., Bollweg, B. C., Schulz, T. J., Forrester, J. D., DeLeon Carnes, M., Molins, C., Ray, G. S., Cummings, P. M., Ritter, J. M., Blau, D. M., Andrew, T. A., Prial, M., Ng, D. L., Prahlow, J. A., Sanders, J. H., Shieh, W. J., Paddock, C. D., Schriefer, M. E., Mead, P., Zaki, S. R. 2016; 186 (5): 1195-1205


    Fatal Lyme carditis caused by the spirochete Borrelia burgdorferi rarely is identified. Here, we describe the pathologic, immunohistochemical, and molecular findings of five case patients. These sudden cardiac deaths associated with Lyme carditis occurred from late summer to fall, ages ranged from young adult to late 40s, and four patients were men. Autopsy tissue samples were evaluated by light microscopy, Warthin-Starry stain, immunohistochemistry, and PCR for B. burgdorferi, and immunohistochemistry for complement components C4d and C9, CD3, CD79a, and decorin. Post-mortem blood was tested by serology. Interstitial lymphocytic pancarditis in a relatively characteristic road map distribution was present in all cases. Cardiomyocyte necrosis was minimal, T cells outnumbered B cells, plasma cells were prominent, and mild fibrosis was present. Spirochetes in the cardiac interstitium associated with collagen fibers and co-localized with decorin. Rare spirochetes were seen in the leptomeninges of two cases by immunohistochemistry. Spirochetes were not seen in other organs examined, and joint tissue was not available for evaluation. Although rare, sudden cardiac death caused by Lyme disease might be an under-recognized entity and is characterized by pancarditis and marked tropism of spirochetes for cardiac tissues.

    View details for DOI 10.1016/j.ajpath.2015.12.027

    View details for PubMedID 26968341

  • Self-reported Determinants of Access to Surgical Care in 3 Developing Countries JAMA SURGERY Forrester, J. D., Forrester, J. A., Kamara, T. B., Groen, R. S., Shrestha, S., Gupta, S., Kyamanywa, P., Petroze, R. T., Kushner, A. L., Wren, S. M. 2016; 151 (3): 257-263


    Surgical care is recognized as a growing component of global public health.To assess self-reported barriers to access of surgical care in Sierra Leone, Rwanda, and Nepal using the validated Surgeons OverSeas Assessment of Surgical Need tool.Data for this cross-sectional, cluster-based population survey were collected from households in Rwanda (October 2011), Sierra Leone (January 2012), and Nepal (May and June 2014) using the Surgeons OverSeas Assessment of Surgical Need tool.Basic demographic information, cost and mode of transportation to health care facilities, and barriers to access to surgical care of persons dying within the past year were analyzed.A total of 4822 households were surveyed in Nepal, Rwanda, and Sierra Leone. Primary health care facilities were commonly reached rapidly by foot (>70%), transportation to secondary facilities differed by country, and public transportation was ubiquitously required for access to a tertiary care facility (46%-82% of respondents). Reasons for not seeking surgical care when needed included no money for health care (Sierra Leone: n = 103; 55%), a person dying before health care could be arranged (all countries: 32%-43%), no health care facility available (Nepal: n = 11; 42%), and a lack of trust in health care (Rwanda: n = 6; 26%).Self-reported determinants of access to surgical care vary widely among Sierra Leone, Rwanda, and Nepal, although commonalities exist. Understanding the epidemiology of barriers to surgical care is essential to effectively provide surgical service as a public health commodity in developing countries.

    View details for DOI 10.1001/jamasurg.2015.3431

    View details for Web of Science ID 000372286200014

  • Nontraumatic Clostridium septicum Myonecrosis in Adults: Case Report and a 15-Year Systematic Literature Review Infectious Diseases In Clinical Practice Forrester, J. D., Shkolyar, E., Gregg, D., Spain, D. A., Weiser, T. G. 2016; 24 (6): 318-23
  • Lyme Disease: What the Wilderness Provider Needs to Know WILDERNESS & ENVIRONMENTAL MEDICINE Forrester, J. D., Vakkalanka, J. P., Holstege, C. P., Mead, P. S. 2015; 26 (4): 555-564


    Lyme disease is a multisystem tickborne illness caused by the spirochete Borrelia burgdorferi and is the most common vectorborne disease in the United States. Prognosis after initiation of appropriate antibiotic therapy is typically good if treated early. Wilderness providers caring for patients who live in or travel to high-incidence Lyme disease areas should be aware of the basic biology, epidemiology, clinical manifestations, and treatment of Lyme disease.

    View details for Web of Science ID 000366228200016

    View details for PubMedID 26141918

  • No Geographic Correlation between Lyme Disease and Death Due to 4 Neurodegenerative Disorders, United States, 2001-2010 EMERGING INFECTIOUS DISEASES Forrester, J. D., Kugeler, K. J., Perea, A. E., Pastula, D. M., Mead, P. S. 2015; 21 (11): 2036-2039


    Associations between Lyme disease and certain neurodegenerative diseases have been proposed, but supportive evidence for an association is lacking. Similar geographic distributions would be expected if 2 conditions were etiologically linked. Thus, we compared the distribution of Lyme disease cases in the United States with the distributions of deaths due to Alzheimer disease, amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), and Parkinson disease; no geographic correlations were identified. Lyme disease incidence per US state was not correlated with rates of death due to ALS, MS, or Parkinson disease; however, an inverse correlation was detected between Lyme disease and Alzheimer disease. The absence of a positive correlation between the geographic distribution of Lyme disease and the distribution of deaths due to Alzheimer disease, ALS, MS, and Parkinson disease provides further evidence that Lyme disease is not associated with the development of these neurodegenerative conditions.

    View details for DOI 10.3201/eid2111.150778

    View details for Web of Science ID 000363601500019

    View details for PubMedID 26488307

  • First case of mesh infection due to Coccidioides spp. and literature review of fungal mesh infections after hernia repair. Mycoses Forrester, J. D., Gomez, C. A., Forrester, J. A., Nguyen, M., Gregg, D., Deresinski, S., Banaei, N., Weiser, T. G. 2015; 58 (10): 582-587


    Fungal mesh infections are a rare complication of hernia repairs with mesh. The first case of Coccidioides spp. mesh infection is described, and a systematic literature review of all known fungal mesh infections was performed. Nine cases of fungal mesh infection are reviewed. Female and male patients are equally represented, median age is 49.5 years, and critical illness and preinfection antibiotic use were common. Fungal mesh infections are rare, but potentially fatal, complications of hernias repaired with mesh.

    View details for DOI 10.1111/myc.12364

    View details for PubMedID 26293423

  • Decreased Ebola Transmission after Rapid Response to Outbreaks in Remote Areas, Liberia, 2014 EMERGING INFECTIOUS DISEASES Lindblade, K. A., Kateh, F., Nagbe, T. K., Neatherlin, J. C., Pillai, S. K., Attfield, K. R., Dweh, E., Barradas, D. T., Williams, S. G., Blackley, D. J., Kirking, H. L., Patel, M. R., Dea, M., Massoudi, M. S., Wannemuehler, K., Barskey, A. E., Zarecki, S. L., Fomba, M., Grube, S., Belcher, L., Broyles, L. N., Maxwell, T. N., Hagan, J. E., Yeoman, K., Westercamp, M., Forrester, J., Mott, J., Mahoney, F., Slutsker, L., DeCock, K. M., Nyenswah, T. 2015; 21 (10): 1800-1807


    We measured the reproduction number before and after interventions were implemented to reduce Ebola transmission in 9 outbreaks in Liberia during 2014. We evaluated risk factors for secondary cases and the association between patient admission to an Ebola treatment unit (ETU) and survival. The reproduction number declined 94% from 1.7 (95% CI 1.1-2.6) to 0.1 (95% CI 0.02-0.6) after interventions began. The risk for secondary infections was 90% lower for patients admitted to an ETU (risk ratio 0.1, 95% CI 0.04-0.3) than for those who died in the community. The case-fatality rate was 68% (95% CI 60-74), and ETU admission was associated with a 50% reduction in death (hazard ratio 0.5, 95% CI 0.4-0.8). Isolation and treatment of Ebola patients had the dual benefit of interrupting community transmission and improving survival.

    View details for DOI 10.3201/eid2110.150912

    View details for Web of Science ID 000362158000014

    View details for PubMedID 26402477

  • WSES guidelines for management of Clostridium difficile infection in surgical patients WORLD JOURNAL OF EMERGENCY SURGERY Sartelli, M., Malangoni, M. A., Abu-Zidan, F. M., Griffiths, E. A., Di Bella, S., McFarland, L. V., Eltringham, I., Shelat, V. G., Velmahos, G. C., Kelly, C. P., Khanna, S., Abdelsattar, Z. M., Alrahmani, L., Ansaloni, L., Augustin, G., Bala, M., Barbut, F., Ben-Ishay, O., Bhangu, A., Biffl, W. L., Brecher, S. M., Camacho-Ortiz, A., Cainzos, M. A., Canterbury, L. A., Catena, F., Chan, S., Cherry-Bukowiec, J. R., Clanton, J., Coccolini, F., Cocuz, M. E., Coimbra, R., Cook, C. H., Cui, Y., Czepiel, J., Das, K., Demetrashvili, Z., Di Carlo, I., Di Saverio, S., Dumitru, I. M., Eckert, C., Eckmann, C., Eiland, E. H., Enani, M. A., Faro, M., Ferrada, P., Forrester, J. D., Fraga, G. P., Frossard, J. L., Galeiras, R., Ghnnam, W., Gomes, C. A., Gorrepati, V., Ahmed, M. H., Herzog, T., Humphrey, F., Kim, J. I., Isik, A., Ivatury, R., Lee, Y. Y., Juang, P., Furuya-Kanamori, L., Karamarkovic, A., Kim, P. K., Kluger, Y., Ko, W. C., LaBarbera, F. D., Lee, J. G., Leppaniemi, A., Lohsiriwat, V., Marwah, S., Mazuski, J. E., Metan, G., Moore, E. E., Moore, F. A., Nord, C. E., Ordonez, C. A., Pereira Junior, G. A., Petrosillo, N., Portela, F., Puri, B. K., Ray, A., Raza, M., Rems, M., Sakakushev, B. E., Sganga, G., Spigaglia, P., Stewart, D. B., Tattevin, P., Timsit, J. F., To, K. B., Trana, C., Uhl, W., Urbanek, L., van Goor, H., Vassallo, A., Zahar, J. R., Caproli, E., Viale, P. 2015; 10


    In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.

    View details for DOI 10.1186/s13017-015-0033-6

    View details for Web of Science ID 000359689200001

    View details for PubMedCentralID PMC4545872

  • Geographic Distribution and Expansion of Human Lyme Disease, United States EMERGING INFECTIOUS DISEASES Kugeler, K. J., Farley, G. M., Forrester, J. D., Mead, P. S. 2015; 21 (8): 1455-1457


    Lyme disease occurs in specific geographic regions of the United States. We present a method for defining high-risk counties based on observed versus expected number of reported human Lyme disease cases. Applying this method to successive periods shows substantial geographic expansion of counties at high risk for Lyme disease.

    View details for DOI 10.3201/eid2108.141878

    View details for Web of Science ID 000358458300029

    View details for PubMedID 26196670

  • Gastrointestinal Mucormycosis Requiring Surgery in Adults with Hematologic Malignant Tumors: Literature Review SURGICAL INFECTIONS Forrester, J. D., Chandra, V., Shelton, A. A., Weiser, T. G. 2015; 16 (2): 194-202


    Gastrointestinal mucormycosis is associated with high mortality rates. Appropriate and early antifungal therapy and prompt surgical intervention are essential.Case report and literature review.Nineteen case reports were reviewed describing adults with hematologic malignant tumors who developed intestinal mucormycosis and underwent surgery. The overall survival rate was 50%.Intestinal mucormycosis is an infection associated with a high mortality rate although adults with underlying hematologic malignant have improved outcomes compared with other groups.

    View details for DOI 10.1089/sur.2013.232

    View details for Web of Science ID 000352360400015

    View details for PubMedID 25405775

  • Evolution of Ebola Virus Disease from Exotic Infection to Global Health Priority, Liberia, Mid-2014 EMERGING INFECTIOUS DISEASES Arwady, M. A., Bawo, L., Hunter, J. C., Massaquoi, M., Matanock, A., Dahn, B., Ayscue, P., Nyenswah, T., Forrester, J. D., Hensley, L. E., Monroe, B., Schoepp, R. J., Chen, T., Schaecher, K. E., George, T., Rouse, E., Schafer, I. J., Pillai, S. K., De Cock, K. M. 2015; 21 (4): 578-584


    Over the span of a few weeks during July and August 2014, events in West Africa changed perceptions of Ebola virus disease (EVD) from an exotic tropical disease to a priority for global health security. We describe observations during that time of a field team from the Centers for Disease Control and Prevention and personnel of the Liberian Ministry of Health and Social Welfare. We outline the early epidemiology of EVD within Liberia, including the practical limitations on surveillance and the effect on the country's health care system, such as infections among health care workers. During this time, priorities included strengthening EVD surveillance; establishing safe settings for EVD patient care (and considering alternative isolation and care models when Ebola Treatment Units were overwhelmed); improving infection control practices; establishing an incident management system; and working with Liberian airport authorities to implement EVD screening of departing passengers.

    View details for DOI 10.3201/eid2104.141940

    View details for Web of Science ID 000351652100004

    View details for PubMedID 25811176

  • Rapid Response to Ebola Outbreaks in Remote Areas - Liberia, July-November 2014 MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT Kateh, F., Nagbe, T., Kieta, A., Barskey, A., Gasasira, A. N., Driscoll, A., Tucker, A., Christie, A., Karmo, B., Scott, C., Bowah, C., Barradas, D., Blackley, D., Dweh, E., Warren, F., Mahoney, F., Kassay, G., Calvert, G. M., Castro, G., Logan, G., Appiah, G., Kirking, H., Koon, H., Papowitz, H., Walke, H., Cole, I. B., Montgomery, J., Neatherlin, J., Tappero, J. W., Hagan, J. E., Forrester, J., Woodring, J., Mott, J., Attfield, K., DeCock, K., Lindblade, K. A., Powell, K., Yeoman, K., Adams, L., Broyles, L. N., Slutsker, L., Larway, L., Belcher, L., Cooper, L., Santos, M., Westercamp, M., Weinberg, M. P., Massoudi, M., Dea, M., Patel, M., Hennessey, M., Fomba, M., Lubogo, M., Maxwell, N., Moonan, P., Arzoaquoi, S., Gee, S., Zayzay, S., Pillai, S., Williams, S., Zarecki, S. M., Yett, S., James, S., Grube, S., Gupta, S., Nelson, T., Malibiche, T., Frank, W., Smith, W., Nyenswah, T. 2015; 64 (7): 188-192


    West Africa is experiencing its first epidemic of Ebola virus disease (Ebola). As of February 9, Liberia has reported 8,864 Ebola cases, of which 3,147 were laboratory-confirmed. Beginning in August 2014, the Liberia Ministry of Health and Social Welfare (MOHSW), supported by CDC, the World Health Organization (WHO), and others, began systematically investigating and responding to Ebola outbreaks in remote areas. Because many of these areas lacked mobile telephone service, easy road access, and basic infrastructure, flexible and targeted interventions often were required. Development of a national strategy for the Rapid Isolation and Treatment of Ebola (RITE) began in early October. The strategy focuses on enhancing capacity of county health teams (CHT) to investigate outbreaks in remote areas and lead tailored responses through effective and efficient coordination of technical and operational assistance from the MOHSW central level and international partners. To measure improvements in response indicators and outcomes over time, data from investigations of 12 of 15 outbreaks in remote areas with illness onset dates of index cases during July 16-November 20, 2014, were analyzed. The times to initial outbreak alerts and durations of the outbreaks declined over that period while the proportions of patients who were isolated and treated increased. At the same time, the case-fatality rate in each outbreak declined. Implementation of strategies, such as RITE, to rapidly respond to rural outbreaks of Ebola through coordinated and tailored responses can successfully reduce transmission and improve outcomes.

    View details for Web of Science ID 000350220300007

    View details for PubMedID 25719682

  • Tickborne Relapsing Fever - United States, 1990-2011 MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT Forrester, J. D., Kjemtrup, A. M., Fritz, C. L., Marsden-Haug, N., Nichols, J. B., Tengelsen, L. A., Sowadsky, R., Debess, E., Cieslak, P. R., Weiss, J., Evert, N., Ettestad, P., Smelser, C., Iralu, J., Nett, R. J., Mosher, E., Baker, J. S., Van Houten, C., Thorp, E., Geissler, A. L., Kugeler, K., Mead, P. 2015; 64 (3): 58-60


    Tickborne relapsing fever (TBRF) is a zoonosis caused by spirochetes of the genus Borrelia and transmitted to humans by ticks of the genus Ornithodoros. TBRF is endemic in the western United States, predominately in mountainous regions. Clinical illness is characterized by recurrent bouts of fever, headache, and malaise. Although TBRF is usually a mild illness, severe sequelae and death can occur. This report summarizes the epidemiology of 504 TBRF cases reported from 12 western states during 1990-2011. Cases occurred most commonly among males and among persons aged 10‒14 and 40‒44 years. Most reported infections occurred among nonresident visitors to areas where TBRF is endemic. Clinicians and public health practitioners need to be familiar with current epidemiology and features of TBRF to adequately diagnose and treat patients and recognize that any TBRF case might indicate an ongoing source of potential exposure that needs to be investigated and eliminated.

    View details for Web of Science ID 000348527400003

    View details for PubMedID 25632952

  • Epidemiology of Lyme disease in low-incidence states TICKS AND TICK-BORNE DISEASES Forrester, J. D., Brett, M., Matthias, J., Stanek, D., Springs, C. B., Marsden-Haug, N., Oltean, H., Baker, J. S., Kugeler, K. J., Mead, P. S., Hinckley, A. 2015; 6 (6): 721-723


    Lyme disease is the most common vector-borne disease in the U.S. Surveillance data from four states with a low-incidence of Lyme disease was evaluated. Most cases occurred after travel to high-incidence Lyme disease areas. Cases without travel-related exposure in low-incidence states differed epidemiologically; misdiagnosis may be common in these areas.

    View details for DOI 10.1016/j.ttbdis.2015.06.005

    View details for Web of Science ID 000362143800005

    View details for PubMedID 26103924

  • Ebola Virus Disease Cases Among Health Care Workers Not Working in Ebola Treatment Units - Liberia, June-August, 2014 MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT Matanock, A., Arwady, M. A., Ayscue, P., Forrester, J. D., Gaddis, B., Hunter, J. C., Monroe, B., Pillai, S. K., Reed, C., Schafer, I. J., Massaquoi, M., Dahn, B., De Cock, K. M. 2014; 63 (46): 1077-1081


    West Africa is experiencing the largest Ebola virus disease (Ebola) epidemic in recorded history. Health care workers (HCWs) are at increased risk for Ebola. In Liberia, as of August 14, 2014, a total of 810 cases of Ebola had been reported, including 10 clusters of Ebola cases among HCWs working in facilities that were not Ebola treatment units (non-ETUs). The Liberian Ministry of Health and Social Welfare and CDC investigated these clusters by reviewing surveillance data, interviewing county health officials, HCWs, and contact tracers, and visiting health care facilities. Ninety-seven cases of Ebola (12% of the estimated total) were identified among HCWs; 62 HCW cases (64%) were part of 10 distinct clusters in non-ETU health care facilities, primarily hospitals. Early recognition and diagnosis of Ebola in patients who were the likely source of introduction to the HCWs (i.e., source patients) was missed in four clusters. Inconsistent recognition and triage of cases of Ebola, overcrowding, limitations in layout of physical spaces, lack of training in the use of and adequate supply of personal protective equipment (PPE), and limited supervision to ensure consistent adherence to infection control practices all were observed. Improving infection control infrastructure in non-ETUs is essential for protecting HCWs. Since August, the Liberian Ministry of Health and Social Welfare with a consortium of partners have undertaken collaborative efforts to strengthen infection control infrastructure in non-ETU health facilities.

    View details for Web of Science ID 000345514900008

    View details for PubMedID 25412067

  • Notes from the field: update on Lyme carditis, groups at high risk, and frequency of associated sudden cardiac death--United States. MMWR. Morbidity and mortality weekly report Forrester, J. D., Meiman, J., Mullins, J., Nelson, R., Ertel, S., Cartter, M., Brown, C. M., Lijewski, V., Schiffman, E., Neitzel, D., Daly, E. R., Mathewson, A. A., Howe, W., Lowe, L. A., Kratz, N. R., Semple, S., Backenson, P. B., White, J. L., Kurpiel, P. M., Rockwell, R., Waller, K., Johnson, D. H., Steward, C., Batten, B., Blau, D., DeLeon-Carnes, M., Drew, C., Muehlenbachs, A., Ritter, J., Sanders, J., Zaki, S. R., Molins, C., Schriefer, M., Perea, A., Kugeler, K., Nelson, C., Hinckley, A., Mead, P. 2014; 63 (43): 982-983


    On December 13, 2013, MMWR published a report describing three cases of sudden cardiac death associated with Lyme carditis. State public health departments and CDC conducted a follow-up investigation to determine 1) whether carditis was disproportionately common among certain demographic groups of patients diagnosed with Lyme disease, 2) the frequency of death among patients diagnosed with Lyme disease and Lyme carditis, and 3) whether any additional deaths potentially attributable to Lyme carditis could be identified. Lyme disease cases are reported to CDC through the Nationally Notifiable Disease Surveillance System; reporting of clinical features, including Lyme carditis, is optional. For surveillance purposes, Lyme carditis is defined as acute second-degree or third-degree atrioventricular conduction block accompanying a diagnosis of Lyme disease. During 2001-2010, a total of 256,373 Lyme disease case reports were submitted to CDC, of which 174,385 (68%) included clinical information. Among these, 1,876 (1.1%) were identified as cases of Lyme carditis. Median age of patients with Lyme carditis was 43 years (range = 1-99 years); 1,209 (65%) of the patients were male, which is disproportionately larger than the male proportion among patients with other clinical manifestations (p<0.001). Of cases with this information available, 69% were diagnosed during the months of June-August, and 42% patients had an accompanying erythema migrans, a characteristic rash. Relative to patients aged 55-59 years, carditis was more common among men aged 20-39 years, women aged 25-29 years, and persons aged ≥75 years.

    View details for PubMedID 25356607

  • Developing an Incident Management System to Support Ebola Response - Liberia, July-August 2014 MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT Pillai, S. K., Nyenswah, T., Rouse, E., Arwady, M. A., Forrester, J. D., Hunter, J. C., Matanock, A., Ayscue, P., Monroe, B., Schafer, I. J., Poblano, L., Neatherlin, J., Montgomery, J. M., De Cock, K. M. 2014; 63 (41): 930-933


    The ongoing Ebola virus disease (Ebola) outbreak in West Africa is the largest and most sustained Ebola epidemic recorded, with 6,574 cases. Among the five affected countries of West Africa (Liberia, Sierra Leone, Guinea, Nigeria, and Senegal), Liberia has had the highest number cases (3,458). This epidemic has severely strained the public health and health care infrastructure of Liberia, has resulted in restrictions in civil liberties, and has disrupted international travel. As part of the initial response, the Liberian Ministry of Health and Social Welfare (MOHSW) developed a national task force and technical expert committee to oversee the management of the Ebola-related activities. During the third week of July 2014, CDC deployed a team of epidemiologists, data management specialists, emergency management specialists, and health communicators to assist MOHSW in its response to the growing Ebola epidemic. One aspect of CDC's response was to work with MOHSW in instituting incident management system (IMS) principles to enhance the organization of the response. This report describes MOHSW's Ebola response structure as of mid-July, the plans made during the initial assessment of the response structure, the implementation of interventions aimed at improving the system, and plans for further development of the response structure for the Ebola epidemic in Liberia.

    View details for Web of Science ID 000343197100004

    View details for PubMedID 25321071

  • Cluster of Ebola Cases Among Liberian and US Health Care Workers in an Ebola Treatment Unit and Adjacent Hospital - Liberia, 2014 MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT Forrester, J. D., Hunter, J. C., Pillai, S. K., Arwady, M. A., Ayscue, P., Matanock, A., Monroe, B., Schafer, I. J., Nyenswah, T. G., De Cock, K. M. 2014; 63 (41): 925-929


    The ongoing Ebola virus disease (Ebola) epidemic in West Africa, like previous Ebola outbreaks, has been characterized by amplification in health care settings and increased risk for health care workers (HCWs), who often do not have access to appropriate personal protective equipment. In many locations, Ebola treatment units (ETUs) have been established to optimize care of patients with Ebola while maintaining infection control procedures to prevent transmission of Ebola virus. These ETUs are considered essential to containment of the epidemic. In July 2014, CDC assisted the Ministry of Health and Social Welfare of Liberia in investigating a cluster of five Ebola cases among HCWs who became ill while working in an ETU, an adjacent general hospital, or both. No common source of exposure or chain of transmission was identified. However, multiple opportunities existed for transmission of Ebola virus to HCWs, including exposure to patients with undetected Ebola in the hospital, inadequate use of personal protective equipment during cleaning and disinfection of environmental surfaces in the hospital, and potential transmission from an ill HCW to another HCW. No evidence was found of a previously unrecognized mode of transmission. Prevention recommendations included reinforcement of existing infection control guidance for both ETUs and general medical care settings, including measures to prevent cross-transmission in co-located facilities.

    View details for Web of Science ID 000343197100003

    View details for PubMedID 25321070

  • Assessment of Ebola Virus Disease, Health Care Infrastructure, and Preparedness - Four Counties, Southeastern Liberia, August 2014 MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT Forrester, J. D., Pillai, S. K., Beer, K. D., Bjork, A., Neatherlin, J., Massaquoi, M., Nyenswah, T. G., Montgomery, J. M., De Cock, K. 2014; 63 (40): 891-893
  • Environmental Sampling for Clostridium difficile on Alcohol-Based Hand Rub Dispensers in an Academic Medical Center SURGICAL INFECTIONS Forrester, J. D., Banaei, N., Buchner, P., Spain, D. A., Staudenmayer, K. L. 2014; 15 (5): 581-584


    Clostridum difficile is a gram-positive, spore-forming anaerobic bacillus that has substantial associated morbidity, mortality, and associated healthcare burdens. Clostridium difficile spores are not destroyed by alcohol. Alcohol gel dispensers are used commonly as the hand sanitization method of choice in hospitals. It is possible that gel dispensers are fomites for C. difficile.Thirty alcohol-based gel dispenser handles outside of rooms of patients with active C. difficile infection were sampled. The samples were assessed for C. difficile by both culture and polymerase chain reaction (PCR). The samples were also assessed for other organisms by culture.No C. difficile was cultured or detected by PCR on any of the gel dispensers. Coagulase-negative Staphyloccus spp., diptheroids, and Bacillus spp. were the organisms detected most commonly.At our institution, C. difficile is not present on alcohol-based gel dispensers, but other potentially pathogenis are.

    View details for DOI 10.1089/sur.2013.102

    View details for Web of Science ID 000343224800018

  • Third-Degree Heart Block Associated With Lyme Carditis: Review of Published Cases CLINICAL INFECTIOUS DISEASES Forrester, J. D., Mead, P. 2014; 59 (7): 996-1000


    Lyme carditis is an uncommon manifestation of Lyme disease that most commonly involves some degree of atrioventricular conduction blockade. Third-degree conduction block is the most severe form and can be fatal if untreated. Systematic review of the medical literature identified 45 published cases of third-degree conduction block associated with Lyme carditis in the United States. Median patient age was 32 years, 84% of patients were male, and 39% required temporary pacing. Recognizing patient groups more likely to develop third-degree heart block associated with Lyme carditis is essential to providing prompt and appropriate therapy.

    View details for DOI 10.1093/cid/ciu411

    View details for Web of Science ID 000343411900015

    View details for PubMedID 24879781

  • Clostridium ramosum Bacteremia: Case Report and Literature Review SURGICAL INFECTIONS Forrester, J. D., Spain, D. A. 2014; 15 (3): 343-346


    Clostridium ramosum is a common enteric anaerobe but infrequently also a cause of pathologic infection.Case report and literature review.We reviewed 12 case reports describing infection with C. ramosum. When pathogenic, C. ramosum is cultured most commonly from the inner ear, anaerobic blood samples, or abscesses. Patients with such infections fall into two demographic groups, consisting of young children with ear infections or immunocompromised adults with bacteremia. Resistance of C. ramosum to antibiotics is uncommon.Clostridium ramosum is a common but generally commensal bacterial species. Rarely, it becomes pathogenic in young children or immunosuppressed adults.

    View details for DOI 10.1089/sur.2012.240

    View details for Web of Science ID 000338009600029

    View details for PubMedID 24283763

  • Resident Awareness of Documentation Requirements and Reimbursement: A Multi-Institutional Survey ANNALS OF THORACIC SURGERY Yount, K. W., Reames, B. N., Kensinger, C. D., Boeck, M. A., Thompson, P. W., Forrester, J. D., Upchurch, G. R., Gauger, P. G., Kron, I. L., Lau, C. L. 2014; 97 (3): 858-864


    The current economic environment necessitates efforts to prevent avoidable losses in clinical revenue in academic cardiothoracic surgery programs. Inadequate documentation frequently results in delayed, denied, or reduced reimbursement. With the recent increase in integrated residency programs, documentation and compliance are becoming increasingly dependent on junior residents; however, their understanding of reimbursement and documentation guidelines is currently unknown.An electronically distributed, multi-institutional survey of 6 general and subspecialty surgery programs was conducted consisting of open-ended numeric estimation of Medicare reimbursement for various levels of patient encounters. Closed-ended questions were used to assess resident knowledge of documentation requirements, accompanied by self-estimated compliance with those requirements.Thirty-seven percent (n = 106) of residents completed the survey. Most residents (77%) believe they play the primary role in documentation; however, knowledge of and compliance with higher level documentation practices range from 19% to 78% and 41% to 76%, respectively. On average, residents overestimate Medicare reimbursement of lower level encounters by as much as 77% and underestimate higher level encounters by as much as 38%. In many cases, the standard deviation of residents' estimates approaches the actual reimbursement value.Residents have a limited knowledge of documentation requirements. Self-reported compliance, even when guidelines are known, is low. Estimation of financial reimbursement is extremely variable. Residents overestimate reimbursement of lower level encounters and underappreciate reimbursement at higher levels. Ensuring appropriate reimbursement for services rendered will require formal cardiothoracic resident education and ongoing quality control.

    View details for DOI 10.1016/j.athoracsur.2013.09.100

    View details for Web of Science ID 000332408500029

    View details for PubMedID 24315406

    View details for PubMedCentralID PMC3943630

  • Three Sudden Cardiac Deaths Associated with Lyme Carditis - United States, November 2012-July 2013 MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT Ray, G., Schulz, T., Daniels, W., Daly, E. R., Andrew, T. A., Brown, C. M., Cummings, P., Nelson, R., Cartter, M. L., Backenson, P. B., White, J. L., Kurpiel, P. M., Rockwell, R., Rotans, A. S., Hertzog, C., Squires, L. S., Linden, J. V., Prial, M., House, J., Pontones, P., Batten, B., Blau, D., DeLeon-Carnes, M., Muehlenbachs, A., Ritter, J., Sanders, J., Zaki, S. R., Mead, P., Hinckley, A., Nelson, C., Perea, A., Schriefer, M., Molins, C., Forrester, J. D. 2013; 62 (49): 993-996
  • Fatalities From Venomous and Nonvenomous Animals in the United States (1999-2007) WILDERNESS & ENVIRONMENTAL MEDICINE Forrester, J. A., Holstege, C. P., Forrester, J. D. 2012; 23 (2): 146-152


    To review recent (1999-2007) US mortality data from deaths caused by nonvenomous and venomous animals and compare recent data with historic data.The CDC WONDER Database was queried to return all animal-related fatalities between 1999 and 2007. Rates for animal-related fatalities were calculated using the estimated 2003 US population. Inclusion criteria included all mortalities that were a consequence of bite, contact, attack, or envenomation (ICD-10 codes W53-W59 and X20-X29).There were 1802 animal-related fatalities with the majority coming from nonvenomous animals (60.4%). The largest percentage (36.4%) of animal-related fatalities was attributable to "other mammals," which is largely composed of farm animals. Deaths attributable to Hymenoptera (hornets, wasps, and bees) have increased during the past 60 years in the United States and now account for more than 79 fatalities per year and 28.2% of the total animal-related fatalities from 1999 to 2007. Dog-related fatalities have increased in the United States, accounting for approximately 28 fatalities per year and 13.9% of the total animal-related fatalities.Prevention measures aimed at minimizing injury from animals should be directed at certain high-risk groups such as farmworkers, agricultural workers, and parents of children with dogs.

    View details for Web of Science ID 000305098100010

    View details for PubMedID 22656661

  • Leclercia adecarboxylata Bacteremia in a Trauma Patient: Case Report and Review of the Literature SURGICAL INFECTIONS Forrester, J. D., Adams, J., Sawyer, R. G. 2012; 13 (1): 63-66


    Leclercia adecarboxylata is a rarely described gram-negative pathogen. Since the advent of rapid molecular typing techniques, L. adecarboxylata has been described in 23 case reports, often associated with polymicrobial infections or in immunosuppressed hosts.A case is described and previous cases of L. adecarboxylata infection are reviewed.A 55-year old male victim of trauma developed septic shock several days after presentation to the emergency department. Blood and central vein catheter cultures grew L. adecarboxylata; Haemophilus influenzae and Streptococcus pneumoniae were present in bronchoalveolar lavage samples. With aggressive hemodynamic and ventilator support in addition to antibiotic therapy, the patient cleared the catheter-related blood stream infection. After a challenging intensive care unit stay, the patient eventually was discharged to an inpatient rehabilitation unit.An L. adecarboxylata catheter-related blood stream infection developed in the setting of both underlying immunosuppression and polymicrobial infection. As molecular typing techniques continue to improve, L. adecarboxylata is likely to be an increasingly recognized gram-negative pathogen. Interactions between L. adecarboxylata infection, immunosuppression, and polymicrobial infections remain to be elucidated.

    View details for DOI 10.1089/sur.2010.093

    View details for Web of Science ID 000301760800010

    View details for PubMedID 22217232

  • Respiratory Infection With Nocardia cyriacigeorgica in an Immunosuppressed Host Infectious Disease in Clinical Practice Forrester, J. D., Forrester, J. M. 2011; 19 (6)
  • A case of cyanide poisoning and the use of arterial blood gas analysis to direct therapy. Hospital practice Holstege, C. P., Forrester, J. D., Borek, H. A., Lawrence, D. T. 2010; 38 (4): 69-74


    Cyanide poisoning is a difficult diagnosis for health care professionals. Existing reports clearly demonstrate that the initial diagnosis is often missed in surreptitious cases. The signs and symptoms can mimic numerous other disease processes. We report a case in which a suicidal patient ingested cyanide and was found unresponsive by 2 laboratory coworkers. The coworkers employed cardiopulmonary resuscitation with mouth-to-mouth resuscitation. The suicidal patient died shortly after arrival to the hospital, while the 2 coworkers who performed mouth-to-mouth resuscitation presented with signs and symptoms that mimicked early cyanide toxicity but were instead due to acute stress response. An arterial blood gas analysis may help aid in the diagnosis of cyanide toxicity. Electrocardiographic findings in a patient with cyanide poisoning range significantly, depending on the stage of the poisoning.

    View details for DOI 10.3810/hp.2010.11.342

    View details for PubMedID 21068529

  • A Mystery Infection WILDERNESS & ENVIRONMENTAL MEDICINE Forrester, J. D., Holstege, C. P. 2010; 21 (3): 262-264

    View details for Web of Science ID 000282163300012

    View details for PubMedID 20832706

  • Intoxication With a Ramp (Allium tricocca) Mimicker WILDERNESS & ENVIRONMENTAL MEDICINE Forrester, J. D., Price, J. H., Holstege, C. P. 2010; 21 (1): 61-63

    View details for Web of Science ID 000280437300011

    View details for PubMedID 20591356

  • Injury and Illness Encountered in Shenandoah National Park WILDERNESS & ENVIRONMENTAL MEDICINE Forrester, J. D., Holstege, C. P. 2009; 20 (4): 318-326


    There have been no studies to date exploring the nature of injuries and illness experienced by individuals in a National Park in the southeastern United States. The purpose of this study was to determine the incidence of such illnesses and injuries to visitors in Shenandoah National Park.This study was a retrospective review of the case incident reports from Shenandoah National Park from 2003 to 2007. Data obtained included age, sex, time and date report was received, medical symptoms, trauma type, location of injury, mechanism of injury, level of care, time to patient, time to disposition, disposition type, location, and activity at time of event.There were 159 total cases, corresponding to a reported incident rate of 2.7 persons reported injured or ill per 100 000 visitors to Shenandoah National Park. A total of 23.3% of all reported injuries occurred in persons less than 18 years of age. The most common reported adult injury was soft tissue injury, with the most common anatomical location being the distal lower extremity. The most common activity in which adults were involved at the time of the injury was hiking. Of the pediatric trauma cases, the most common mechanism of injury was a fall. Of the adult medical illnesses, the most common complaint was chest pain.The pattern of adult and pediatric trauma is consistent among several geographically different National Parks in the United States and represents an injury pattern that all wilderness/outdoor care providers need to be competent to treat. Among adult visitors, the most common medical complaint was chest pain, a complaint more prevalent at Shenandoah National Park compared to other parks. Knowing that trauma injury patterns are relatively similar to those of other parks but that medical illness is more locale specific can help health care providers tailor their resource allotment and health management protocols.

    View details for Web of Science ID 000273503700003

    View details for PubMedID 20030438

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