Bio


My work combines my passion for surgery with my interest in infectious disease, public health, and humanitarian disaster response. Surgery and healthcare can be powerful diplomatic tools. Trauma is ubiquitous to the human experience. Regardless of nationality or socioeconomic status a critically injured trauma patient is a person left without options, often dependent upon a surgeon for life-saving procedures and care. The experience of being cared for in a time of great vulnerability by another person of a different nationality, or utilizing a trauma system created in conjunction with another nation, can create firm cross-cultural bonds. This bond can transcend racial, cultural, and economic boundaries and lead to feelings of goodwill that might not otherwise exist. Follow me on Twitter @explorersurgeon and on Instagram @joe_d_forrester

Clinical Focus


  • Trauma
  • Surgical Infectious Disease
  • Global Surgery
  • Disaster Response
  • Wilderness Medicine
  • Fellow

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


  • Research Council Member, Wilderness Medical Society (2016 - 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)

Personal Interests


Rock climbing; Kayaking

All Publications


  • 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

    Abstract

    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 DOI 10.1186/s13017-019-0228-3

    View details for Web of Science ID 000460085100001

    View details for PubMedID 30858872

    View details for PubMedCentralID PMC6394026

  • Tactics to Prevent Intra-Abdominal Infections in General Surgery. Surgical infections Weiser, T. G., Forrester, J. D., Forrester, J. A. 2019

    Abstract

    BACKGROUND: Abdominal infections following surgery have many severe consequences. Several effective, well-evaluated infection prevention and control processes exist to avoid these infections.METHODS: This manuscript reviews and provides supporting evidence for common management strategies useful to avoid postoperative abdominal infection.RESULTS: Prevention of abdominal infection begins with preparation of the environment using standard infection control practices. Peri-operative use of systemic antibiotics, an antibiotic bowel preparation in colorectal surgery, and effective antiseptic preparation of the surgical site all reduce infection rates. Peri-operative supplemental oxygenation, maintenance of core body temperature, and physiologic euglycemia will reduce both incisional and organ-space infections in the abdominal surgery patient. Strategic use of irrigation and drain placement may be useful in some circumstances.CONCLUSION: Specific methods of prevention are documented to reduce intra-abdominal infections. Prevention requires a multi-disciplinary team including the surgeon, anesthesiologist, and all operating room personnel.

    View details for DOI 10.1089/sur.2018.282

    View details for PubMedID 30628859

  • 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
  • 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

    Abstract

    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 DOI 10.1089/sur.2018.078

    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

    Abstract

    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 DOI 10.1016/j.wem.2017.10.004

    View details for PubMedID 29373216

  • 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

    Abstract

    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 DOI 10.1136/tsaco-2018-000250

    View details for PubMedID 30623028

  • 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. 2018

    Abstract

    Intussusception is the process by which one segment of intestine "telescopes" into another segment. Escherichia coli O157:H7 is a rare cause of intussusception that uncommonly requires a surgical procedure.Case report and literature review.We reviewed 25 cases of infection with E. coli O157:H7 that resulted in intussusception, all of which involved minors. Our case identifies the first reported adult with intussusception secondary to E. coli infection necessitating surgical intervention. In total, two (8%) required operation. Hemolytic uremic syndrome did not develop in any patient, and there were no deaths.E. coli O157:H7-associated intussusception is rare and does not commonly require operation. If conservative management fails, a surgical procedure may be necessary to resect the pathologic lead point.

    View details for DOI 10.1089/sur.2018.137

    View details for PubMedID 30359547

  • 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 DOI 10.1001/jamasurg.2018.1059

    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

    Abstract

    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 DOI 10.1089/sur.2017.273

    View details for PubMedID 29341840

  • 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

    Abstract

    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

    Abstract

    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 Web of Science ID 000401125000011

    View details for PubMedID 28457346

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

    View details for DOI 10.1001/jamasurg.2017.4027

    View details for PubMedID 29071330

  • 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

    Abstract

    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 DOI 10.1089/sur.2017.149

    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

    Abstract

    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 DOI 10.1111/tmi.12937

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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 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

    Abstract

    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 DOI 10.1089/sur.2017.154

    View details for PubMedID 29048997

  • 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

    Abstract

    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 DOI 10.1089/sur.2017.188

    View details for PubMedID 29058569

  • Peritoneal encapsulation syndrome: A case report and literature review International Journal of Surgery Case Reports Mbanje, C., Mazingi, D., Forrester, J. D., Mungazi, S. G. 2017; 41: 520-523

    Abstract

    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 DOI 10.1016/j.ijscr.2017.10.058

    View details for PubMedCentralID PMC5723259

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

    View details for DOI 10.1001/jamasurg.2017.4867

    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

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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

  • 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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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