Dr. Forrester is a fellowship-trained surgeon and an assistant professor of surgery in the Stanford Medicine Division of Acute Care Surgery.

He is the associate trauma medical director for Stanford Medicine and the medical director of the Stanford Chest Wall Injury Center.

Prior to joining Stanford Medicine, Dr. Forrester was an epidemic intelligence service officer for the Centers for Disease Control and Prevention (CDC). He worked in the bacterial pathogen branch in the Division of Vector-Borne Diseases of the National Center for Emerging and Zoonotic Infectious Diseases. The CDC honored him for excellence in international, occupational, and environmental health.

He has helped advance the field of acute care surgery by participating in numerous quality improvement initiatives. He co-developed COVID-19 tracheostomy guidelines and led the team performing these procedures for Stanford Medicine. He also helped develop the best practice guidelines for surgical stabilization of rib fracture at Stanford Medicine.

Dr. Forrester has co-authored more than 120 articles and chapters published in Surgery, the Journal of Patient Safety, Journal of Trauma and Acute Care Surgery, Journal of the American College of Surgeons, JAMA Surgery, CDC’s Morbidity and Mortality Weekly Report, Clinical Infectious Diseases, Emerging Infections, and elsewhere. Topics have included pain management after chest wall surgery, approaches to surgical stabilization of rib fractures, and health care-associated infections.

Dr. Forrester frequently presents nationally at meetings of the American College of Surgeons, AAST, Chest Wall Injury Society, Surgical Infection Society, Epidemiological Intelligence Service-CDC, and other organizations.

He is a member of the Chest Wall Injury Society, Surgical Infection Society, and Wilderness Medicine Society where he holds leadership positions. He is the moderator for the monthly Chest Wall Injury Society Case review series. Dr. Forrester is an associate member of the American Association for the Surgery of Trauma.

In the field of acute care surgery, he has particular clinical interest in patients with chest wall injury and enterocutaneous and enteroatmospheric fistulae.

Clinical Focus

  • Trauma
  • Surgical Infectious Disease
  • General Surgery
  • Wilderness Medicine
  • Rib Fractures
  • Rib Fracture Non-Union
  • Surgical Critical Care
  • Climate change
  • Enterocutaneous and Enteroatmospheric fistulae
  • Abdominal wall and chest wall hernia

Academic Appointments

Administrative Appointments

  • Associate Chair - Clinical Affairs, Department of Surgery (2023 - Present)
  • Physician Improvement Leader, Department of Surgery (2023 - Present)
  • Associate Trauma Medical Director, Stanford Healthcare (2020 - Present)
  • Director - Chest Wall Injury Center, Stanford Healthcare (2020 - Present)

Honors & Awards

  • President's Award, Chest Wall Injury Society (April 2021)
  • 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

  • Board of Directors, Wilderness Medical Society (2022 - Present)
  • Research Committee Chair, Wilderness Medical Society (2020 - 2022)
  • Education Committee Chair, Chest Wall Injury Society (2022 - Present)
  • Education Committee, Chest Wall Injury Society (2019 - 2022)
  • Faculty Fellow, Center for Innovation in Global Health (CIGH) (2021 - Present)
  • Committee Member, Therapeutics and Guidelines Committee - Surgical Infection Society (2019 - Present)
  • Member, Chest Wall Injury Society (2019 - Present)
  • Committee Member, Surgical Infection Society ad hoc Committee on Global Surgery (2018 - Present)

Professional Education

  • Board Certification: American Board of Surgery, Surgical Critical Care (2019)
  • Residency: Stanford University Dept of General Surgery (2018) CA
  • Fellowship: Stanford University Surgical Critical Care Fellowship (2019) CA
  • Board Certification: American Board of Surgery, General Surgery (2018)
  • 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)

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

  • Treatment of Adult Traumatic Rib Fractures With Percutaneous Cryoneurolysis Recruiting

    The purpose of this research study is to examine the effectiveness of using the Iovera Smart Time 190, for ultrasound-guided cryoneurolysis, in trauma patients 18-64 years old with rib fractures that are not candidates for surgical stabilization. This will offer patients the benefits of cryoneurolysis of the intercostal nerves, thereby providing short and long term pain control while their ribs heal. The Iovera Smart Tip 190 is FDA approved for cryoneurolysis.

    View full details

  • A Feasibility Study to Evaluate Safety & Benefit of Eclipse XL1 System in Adult Patients With SBS Not Recruiting

    The Feasibility Study to Evaluate Safety and Probable Benefit of the Eclipse XL1 System in Adult Patients with Short Bowel Syndrome shall enroll up to 5 Subjects at up to 2 study sites in the United States.

    Stanford is currently not accepting patients for this trial.

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  • 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 Alexandra Myers, (650) 724 - 8445.

    View full details

Stanford Advisees

All Publications

  • The Surgical Infection Society Guidelines on the Management of Intra-Abdominal Infection: 2024 Update. Surgical infections Huston, J. M., Barie, P. S., Dellinger, E. P., Forrester, J. D., Duane, T. M., Tessier, J. M., Sawyer, R. G., Cainzos, M. A., Rasa, K., Chipman, J. G., Kao, L. S., Pieracci, F. M., Colling, K. P., Heffernan, D. S., Lester, J. 2024


    Background: The Surgical Infection Society (SIS) published evidence-based guidelines for the management of intra-abdominal infection (IAI) in 1992, 2002, 2010, and 2017. Here, we present the most recent guideline update based on a systematic review of current literature. Methods: The writing group, including current and former members of the SIS Therapeutics and Guidelines Committee and other individuals with content or guideline expertise within the SIS, working with a professional librarian, performed a systematic review using PubMed/Medline, the Cochrane Library, Embase, and Web of Science from 2016 until February 2024. Keyword descriptors combined "surgical site infections" or "intra-abdominal infections" in adults limited to randomized controlled trials, systematic reviews, and meta-analyses. Additional relevant publications not in the initial search but identified during literature review were included. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system was utilized to evaluate the evidence. The strength of each recommendation was rated strong (1) or weak (2). The quality of the evidence was rated high (A), moderate (B), or weak (C). The guideline contains new recommendations and updates to recommendations from previous IAI guideline versions. Final recommendations were developed by an iterative process. All writing group members voted to accept or reject each recommendation. Results: This updated evidence-based guideline contains recommendations from the SIS for the treatment of adult patients with IAI. Evidence-based recommendations were developed for antimicrobial agent selection, timing, route of administration, duration, and de-escalation; timing of source control; treatment of specific pathogens; treatment of specific intra-abdominal disease processes; and implementation of hospital-based antimicrobial agent stewardship programs. Summary: This document contains the most up-to-date recommendations from the SIS on the prevention and management of IAI in adult patients.

    View details for DOI 10.1089/sur.2024.137

    View details for PubMedID 38990709

  • Predicting Increased Incidence of Common Antibiotic-Resistant and Antibiotic-Associated Pathogens Using Ensemble Species Distribution Modeling. The Journal of infectious diseases Brough, S. C., Caddell, L., Liou, R. J., Patil, A., De Leo, G., Forrester, J. D. 2024


    The Centers for Disease Control estimates antibiotic-associated pathogens result in 2.8 million infections and 38,000 deaths annually in the United States. This study applies species distribution modeling to elucidate the impact of environmental determinants of human infectious disease in an era of rapid global change. We modeled methicillin-resistant Staphylococcus aureus and Clostridioides difficile using 31 publicly accessible bioclimatic, healthcare, and sociodemographic variables. Ensemble models were created from 8 unique statistical and machine learning algorithms. Using International Classification of Diseases, 10th Edition codes, we identified 305,528 diagnoses of methicillin-resistant S.aureus and 302,001 diagnoses of C.difficile presence. Three environmental factors - average maximum temperature, specific humidity, and agricultural land density - emerged as major predictors of increased methicillin-resistant S.aureus and C.difficile presence; variables representing healthcare availability were less important. Species distribution modeling may be a powerful tool for identifying areas at increased risk for disease presence and have important implications for disease surveillance systems.

    View details for DOI 10.1093/infdis/jiae145

    View details for PubMedID 38536055

  • Chest Wall Injury Society (CWIS) recommendation for surgical stabilization of non-united rib fractures (SSNURF) to decrease pain, reduce opiate use, and improve patient reported outcomes in patients with rib fracture non-union after trauma. The journal of trauma and acute care surgery Forrester, J. D., Bauman, Z. M., Cole, P. A., Edwards, J. G., Knight, A., LaRoque, M., Raffa, T., White, T. W., Kartiko, S. 2023


    Rib fractures are common injuries which can be associated with acute pain and chronic disability. While most rib fractures ultimately go on to achieve bony union, a subset of patients may go on to develop non-union. Management of these non-united rib fractures can be challenging and variability in management exists.The Chest Wall Injury Society's Publication Committee convened to develop recommendations for use of surgical stabilization of non-united rib fractures (SSNURF) to treat traumatic rib fracture non-unions. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject the recommendation.No identified studies compared SSNURF to alternative therapy and the overall quality of the body of evidence was rated as low. Risk of bias was identified in all studies. Despite these limitations, there is lower quality evidence suggesting SSNURF may be beneficial for decreasing pain, reducing opiate use, and improving patient reported outcomes among patients with symptomatic rib non-union. However, these benefits should be balanced against risk of symptomatic hardware failure and infection.This guideline document summarizes the current CWIS recommendations regarding use of SSNURF for management of rib non-union.Level IV, therapeutic/care management.

    View details for DOI 10.1097/TA.0000000000004083

    View details for PubMedID 37728432

  • Chest Wall Injury Society Recommendations for Management of Surgical Site or Implant-Related Infections After Surgical Stabilization of Traumatic Rib or Sternal Fractures. Surgical infections Forrester, J. D., Faliks, B., Cardarelli, C., Choudhry, M. S., Patel, B., Ricaurte, D., Sarani, B., Sfakianos, M., Kartiko, S., Huston, J. M. 2023


    Background: Surgical stabilization of rib fractures (SSRF) and surgical stabilization of sternal fractures (SSSF) involves open reduction and internal fixation of fractures with an implantable titanium plate to restore and maintain anatomic alignment. The presence of this foreign, non-absorbable material presents an opportunity for infection. Although surgical site infection (SSI) and implant infection rates after SSRF and SSSF are low, they present a challenging clinical entity. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee and Chest Wall Injury Society's Publication Committee convened to develop recommendations for management of SSIs or implant-related infections after SSRF or SSSF. PubMed, Embase, Web of Science and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: For patients undergoing SSRF or SSSF who develop an SSI or an implant-related infection, there is insufficient evidence to suggest a single optimal management strategy. For patients with an SSI, systemic antibiotic therapy, local wound debridement, and vacuum-assisted closure have been used in isolation or combination. For patients with an implant-related infection, initial implant removal with or without systemic antibiotic therapy, systemic antibiotic therapy with local wound drainage, and systemic antibiotic therapy with local antibiotic therapy have been documented. For patients who do not undergo initial implant removal, 68% ultimately require implant removal to achieve source control. Conclusions: Insufficient evidence precludes the ability to recommend guidelines for the treatment of SSI or implant-related infection following SSRF or SSSF. Further studies should be performed to identify the optimal management strategy in this population.

    View details for DOI 10.1089/sur.2023.086

    View details for PubMedID 37204325

  • Effect of climate on surgical site infections and anticipated increases in the United States. Scientific reports Liou, R. J., Earley, M. J., Forrester, J. D. 2022; 12 (1): 19698


    Surgical site infections (SSI) are one of the most common and costly hospital-acquired infections in the United States. Meteorological variables such as temperature, humidity, and precipitation may represent a neglected group of risk factors for SSI. Using a national private insurance database, we collected admission and follow-up records for National Healthcare Safety Network-monitored surgical procedures and associated climate conditions from 2007 to 2014. We found that every 10 cm increase of maximum daily precipitation resulted in a 1.09 odds increase in SSI after discharge, while every g/kg unit increase in specific humidity resulted in a 1.03 odds increase in SSI risk after discharge. We identified the Southeast region of the United States at highest risk of climate change-related SSI, with an estimated 3% increase in SSI by 2060 under high emission assumptions. Our results describe the effect of climate on SSI and the potential burden of climate-change related SSI in the United States.

    View details for DOI 10.1038/s41598-022-24255-w

    View details for PubMedID 36385136

  • Surgical Infection Society: Chest Wall Injury Society Recommendations for Antibiotic Use during Surgical Stabilization of Traumatic Rib or Sternal Fractures to Reduce Risk of Implant Infection. Surgical infections Forrester, J. D., Bukur, M., Dvorak, J. E., Faliks, B., Hindin, D., Kartiko, S., Kheirbek, T., Lin, L., Manasa, M., Martin, T. J., Miskimins, R., Patel, B., Pieracci, F. M., Ritter, K. A., Schubl, S. D., Tung, J., Huston, J. M. 2022; 23 (4): 321-331


    Background: Surgical stabilization of rib fractures is recommended in patients with flail chest or multiple displaced rib fractures with physiologic compromise. Surgical stabilization of rib fractures (SSRF) and surgical stabilization of sternal fractures (SSSF) involve open reduction and internal fixation of fractures with a plate construct to restore anatomic alignment. Most plate constructs are composed of titanium and presence of this foreign, non-absorbable material presents opportunity for implant infection. Although implant infection rates after SSRF and SSSF are low, they present a challenging clinical entity often requiring prolonged antibiotic therapy, debridement, and potentially implant removal. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee and Chest Wall Injury Society's Publication Committee convened to develop recommendations for antibiotic use during and after surgical stabilization of traumatic rib and sternal fractures. Clinical scenarios included patients with concomitant infectious processes (sepsis, pneumonia, empyema, cellulitis) or sources of contamination (open chest, gross contamination) incurred as a result of their trauma and present at the time of their surgical stabilization. PubMed, Embase, and Cochrane databases were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: For patients undergoing SSRF or SSSF in the absence of pre-existing infectious process, there is insufficient evidence to suggest existing peri-operative guidelines or recommendations are inadequate. For patients undergoing SSRF or SSSF in the presence of sepsis, pneumonia, or an empyema, there is insufficient evidence to provide recommendations on duration and choice of antibiotic. This decision may be informed by existing guidelines for the concomitant infection. For patients undergoing SSRF or SSSF with an open or contaminated chest there is insufficient evidence to provide specific antibiotic recommendations. Conclusions: This guideline document summarizes the current Surgical Infection Society and Chest Wall Injury Society recommendations regarding antibiotic use during and after surgical stabilization of traumatic rib or sternal fractures. Limited evidence exists in the chest wall surgical stabilization literature and further studies should be performed to delineate risk of implant infection among patients undergoing SSSRF or SSSF with concomitant infectious processes.

    View details for DOI 10.1089/sur.2022.025

    View details for PubMedID 35522129

  • Chest wall injury centers-how we did it. Journal of thoracic disease Forrester, J. D., Bauman, Z. M., Doben, A. R., Eriksson, E. A. 2021; 13 (10): 6104-6107

    View details for DOI 10.21037/jtd-21-1198

    View details for PubMedID 34795958

    View details for PubMedCentralID PMC8575857

  • Nationwide Cost-Effectiveness Analysis of Surgical Stabilization of Rib Fractures by Flail Chest Status and Age Groups Journal of Trauma and Acute Care Surgery Choi, J., Mulaney, B., Laohavinij, W., Trimble, R., Tennakoon, L., Spain, D. A., Salomon, J. A., Goldhaber-Fiebert, J. D., Forrester, J. D. 2021
  • Rib Fracture Frailty Index: A Risk-Stratification Tool for Geriatric Patients with Multiple Rib Fractures. The journal of trauma and acute care surgery Choi, J., Marafino, B. J., Vendrow, E. B., Tennakoon, L., Baiocchi, M., Spain, D. A., Forrester, J. D. 2021


    Rib fractures are consequential injuries for geriatric patients (age ≥ 65 years). Although age and injury patterns drive many rib fracture management decisions, the impact of frailty-which baseline conditions affect rib fracture-specific outcomes-remains unclear for geriatric patients. We aimed to develop and validate the Rib Fracture Frailty (RFF) Index, a practical risk-stratification tool specific for geriatric patients with rib fractures. We hypothesized that a compact list of frailty markers can accurately risk stratify clinical outcomes after rib fractures.We queried nationwide US admission encounters of geriatric patients admitted with multiple rib fractures from 2016-2017. Partitioning-around-medoids clustering identified a development subcohort with previously-validated frailty characteristics. Ridge regression with penalty for multicollinearity aggregated baseline conditions most prevalent in this frail subcohort into RFF scores. Regression models with adjustment for injury severity, sex, and age assessed associations between frailty risk categories (low, medium, and high) and inpatient outcomes among validation cohorts (OR [95%CI]). We report results according to Transparent Reporting of Multivariable Prediction Model for Individual Prognosis guidelines.Development cohort (N = 55,540) cluster analysis delineated thirteen baseline conditions constituting the RFF Index. Among external validation cohort (N = 77,710), increasing frailty risk (low [reference group], moderate, high) was associated with stepwise worsening adjusted odds of mortality (1.5[1.2-1.7], 3.5 [3.0-4.0]), intubation (2.4[1.5-3.9], 4.7[3.1-7.5]), hospitalization ≥5 days (1.4[1.3-1.5], 1.8[1.7-2.0]), and disposition to home (0.6[0.5-0.6], 0.4[0.3-0.4]). Locally weighted scatterplot smoothing showed correlations between increasing RFF scores and worse outcomes.RFF Index is a practical frailty risk-stratification tool for geriatric patients with multiple rib fractures. The mobile app we developed may facilitate rapid implementation and further validation of RFF Index at the bedside.level III, prognostic study.

    View details for DOI 10.1097/TA.0000000000003390

    View details for PubMedID 34446653

  • Cost of Health Care-Associated Infections in the United States. Journal of patient safety Forrester, J. D., Maggio, P. M., Tennakoon, L. n. 2021


    Health care-associated infections (HAIs) are costly, and existing national cost estimates are out-of-date.We retrospectively analyzed the Agency for Healthcare Cost and Utilization Project's 2016 National Inpatient Sample, the largest all-payer U.S. inpatient database. We included all inpatient encounters with primary or secondary International Classification of Disease, 10th Revision Clinical Modification diagnosis codes corresponding to infection with catheter-associated urinary tract infections (T85.511), catheter- and line-associated blood stream infections (T80.211), surgical site infections (SSIs; T81.49), ventilator-associated pneumonias (J95.851), and Infection with Clostridioides difficile (CDI; A04.7). We combined HAI incidence data from the National Inpatient Sample with additional hospital inpatient HAI cost estimates to create national cost estimates for HAI individually and collectively.In 2016, 7.2 to 14.9 billion U.S. dollars were spent on HAIs in the United States. For admissions with any diagnosis of HAI, the frequencies of HAI in descending order were as follows: CDI (n = 356,754 [56%]), SSI (n = 196,215 [31%]), catheter- and line-associated blood stream infection (n = 42,811 [7%]), catheter-associated urinary tract infection (n = 23,546 [4%]), and ventilator-associated pneumonia (n = 16,767 [3%]). Collectively, CDI and SSI accounted for 79% of the cost of HAI in the United States.Health care-associated infections remain a significant economic burden for health care systems in the United States.

    View details for DOI 10.1097/PTS.0000000000000845

    View details for PubMedID 33881808

  • Nationwide Cost-Effectiveness Analysis of Surgical Stabilization of Rib Fractures by Flail Chest Status and Age Groups. The journal of trauma and acute care surgery Choi, J., Mulaney, B., Laohavinij, W., Trimble, R., Tennakoon, L., Spain, D. A., Salomon, J. A., Goldhaber-Fiebert, J. D., Forrester, J. D. 2020


    SSRF is increasingly utilized to manage patients with rib fractures. Benefits of performing SSRF appear variable and the procedure is costly, necessitating cost-effectiveness analysis for distinct subgroups. We aimed to assess the cost-effectiveness of surgical stabilization of rib fractures (SSRF) vs non-operative management among patients with rib fractures aged <65 vs ≥65 years, with vs without flail chest. We hypothesized that compared to non-operative management, SSRF is cost-effective only for patients with flail chest.This economic evaluation used a decision-analytic Markov model with a lifetime time horizon incorporating US population-representative inputs to simulate benefits and risks of SSRF compared to non-operative management. We report quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). Deterministic and probabilistic sensitivity analyses accounted for most plausible clinical scenarios.Compared to non-operative management, SSRF was cost-effective for patients with flail chest at willingness-to-pay threshold of $150,000/QALY gained. SSRF cost $25,338 and $123,377/QALY gained for those with flail chest aged <65 and ≥65 years, respectively. SSRF was not cost-effective for patients without flail chest; costing $172,704 and $243,758/QALY gained for those aged <65 and ≥65 years, respectively. One-way sensitivity analyses showed that under most plausible scenarios, SSRF remained cost-effective for subgroups with flail chest and non-operative management remained cost-effective for patients aged >65 without flail chest. Probability that SSRF is cost-effective ranged from 98% among patients aged <65 with flail chest to 35% among patients aged ≥65 without flail chest.SSRF is cost effective for patients with flail chest. SSRF may be cost-effective in some patients without flail chest, but delineating these patients requires further study.level II.

    View details for DOI 10.1097/TA.0000000000003021

    View details for PubMedID 33559982

  • Surgical Stabilization of Rib Fracture to Mitigate Pulmonary Complication and Mortality: A Systematic Review and Bayesian Meta-Analysis. Journal of the American College of Surgeons Choi, J. n., Gomez, G. I., Kaghazchi, A. n., Borghi, J. A., Spain, D. A., Forrester, J. D. 2020

    View details for DOI 10.1016/j.jamcollsurg.2020.10.022

    View details for PubMedID 33212228

  • 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

  • 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
  • Practical guide to building machine learning-based clinical prediction models using imbalanced datasets. Trauma surgery & acute care open Luu, J., Borisenko, E., Przekop, V., Patil, A., Forrester, J. D., Choi, J. 2024; 9 (1): e001222


    Clinical prediction models often aim to predict rare, high-risk events, but building such models requires robust understanding of imbalance datasets and their unique study design considerations. This practical guide highlights foundational prediction model principles for surgeon-data scientists and readers who encounter clinical prediction models, from feature engineering and algorithm selection strategies to model evaluation and design techniques specific to imbalanced datasets. We walk through a clinical example using readable code to highlight important considerations and common pitfalls in developing machine learning-based prediction models. We hope this practical guide facilitates developing and critically appraising robust clinical prediction models for the surgical community.

    View details for DOI 10.1136/tsaco-2023-001222

    View details for PubMedID 38881829

    View details for PubMedCentralID PMC11177772

  • <i>Tsukamurella</i> Bacteremia in a Surgical Patient: Case Report and Review of the Literature SURGICAL INFECTIONS Wong, S., Forrester, J. 2024


    Background: Tsukamurella species were first isolated in 1941. Since then, 48 cases of Tsukamurella bacteremia have been reported, a majority of which were immunosuppressed patients with central venous catheters.A case is described and previous cases of Tsukamurella bacteremia are reviewed. Patients and Methods: A 70-year-old total parenteral nutrition (TPN)-dependent female with recurrent enterocutaneous fistula (ECF), developed leukocytosis one week after a challenging ECF takedown. After starting broad-spectrum antibiotic agents, undergoing percutaneous drainage of intra-abdominal abscess, and subsequent repositioning of the drain, her leukocytosis resolved. Blood and peripherally inserted central catheter (PICC) cultures grew Tsukamurella spp. The patient was discharged to home with 14 days of daily 2 g ceftriaxone, with resolution of bacteremia. Conclusions: Tsukamurella spp. are a rare opportunistic pathogen predominantly affecting immunocompromised patients, with central venous catheters present in most cases. However, there have been few reported cases in immunocompetent individuals with predisposing conditions such as end-stage renal disease and uncontrolled diabetes mellitus.

    View details for DOI 10.1089/sur.2024.070

    View details for Web of Science ID 001214360000002

    View details for PubMedID 38709799

  • Eyes on the prize: harnessing computer vision for automated detection of traumatic rib and clavicle fractures in chest radiographs. Trauma surgery & acute care open Villarreal, J. A., Forrester, J. D. 2024; 9 (1): e001455

    View details for DOI 10.1136/tsaco-2024-001455

    View details for PubMedID 38646616

    View details for PubMedCentralID PMC11029340

  • Time to surgical stabilization of rib fractures: does it impact outcomes? Trauma surgery & acute care open Forrester, J. D., Sarani, B., Forssten, M. P., Cao, Y., Hildebrand, F., Mohammad Ismail, A., Ribeiro, M. A., Mohseni, S. 2024; 9 (1): e001233


    Objectives: Rib fractures are common, morbid, and potentially lethal. Intuitively, if interventions to mitigate downstream effects of rib fractures can be implemented early, likelihood of developing these complications should be reduced. Surgical stabilization of rib fractures (SSRF) is one therapeutic intervention shown to be useful for mitigating complications of these common fractures. Our aim was to investigate for association between time to SSRF and complications among patients with isolated rib fractures undergoing SSRF.Methods: The 2016-2019 American College of Surgeons Trauma Quality Improvement Program (TQIP) database was queried to identify patient >18 years with isolated thoracic injury undergoing SSRF. Patients were divided into three groups: SSRF ≤2days, SSRF >2days but <3days, and SSRF >3days. Poisson regression, and adjusting for demographic and clinical covariates, was used to evaluate the association between time to SSRF and the primary endpoint, in-hospital complications. Quantile regression was used to evaluate the effects of time to SSRF on the secondary endpoints, hospital and intensive care unit (ICU) length of stay (LOS).Results: Out of 2185 patients, 918 (42%) underwent SSRF <2days, 432 (20%) underwent SSRF >2days but <3days, and 835 (38%) underwent SSRF >3days. Hemothorax was more common among patients undergoing SSRF >3days, otherwise all demographic and clinical variables were similar between groups. After adjusting for potential confounding, SSRF >3days was associated with a threefold risk of composite in-hospital complications (adjusted incidence rate ratio: 3.15, 95% CI 1.76 to 5.62; p<0.001), a 4-day increase in total hospital LOS (change in median LOS: 4.09; 95% CI 3.69 to 4.49, p<0.001), and a nearly 2-day increase in median ICU LOS (change in median LOS: 1.70; 95% CI 1.32 to 2.08, p<0.001), compared with SSRF ≤2days.Conclusion: Among patients undergoing SSRF in TQIP, earlier SSRF is associated with less in-hospital complications and shorter hospital stays. Standardization of time to SSRF as a trauma quality metric should be considered.Level of evidence: Level II, retrospective.

    View details for DOI 10.1136/tsaco-2023-001233

    View details for PubMedID 39005708

  • An initiative to assess and improve the resources and patient care processes used among Chest Wall Injury Society collaborative centers (CWIS-CC2). The journal of trauma and acute care surgery Eriksson, E. A., Waite, A., Whitbeck, S. S., Bach, J. A., Bauman, Z. M., Cavlovic, L., Dale, K., DeVoe, W. B., Doben, A. R., Edwards, J. G., Forrester, J. D., Kaye, A. J., Green, J., Hsu, J., Hufford, A., Janowak, C., Kartiko, S., Moore, E. E., Patel, B., Pieracci, F., Sarani, B., Schubl, S. D., Semon, G., Thomas, B. W., Tung, J., Van Lieshout, E. M., White, T. W., Wijffels, M. M., Wullschleger, M. E. 2023


    Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers who epitomize their mission as CWIS Collaborative Centers (CWIS-CC). The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers.A survey was performed including all CWIS-CC evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each Chest Wall Injury Center (CWIC) care process, availability of resources, institutional support, research support, and educational offerings were recorded.Data was collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US based trauma centers. Eighty percent (16/20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5/20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80%(8/10) with APPs and 70%(7/10) with care coordinators. Forty percent(8/20) of centers have dedicated rib fracture research support and 35%(7/20) have SSRF-related grants. Forty percent (8/20) of centers have marketing support and 30%(8/20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4(1-9) surgeons perform surgical stabilization of rib fractures (SSRF). In the majority of trauma centers the trauma surgeons perform SSRF.Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal CWIC. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach.IV Economic & Value-Based Evaluations.

    View details for DOI 10.1097/TA.0000000000004158

    View details for PubMedID 37889926

  • Incidence of surgical rib fixation at chest wall injury society collaborative centers and a guide for expected number of cases (CWIS-CC1). European journal of trauma and emergency surgery : official publication of the European Trauma Society Eriksson, E. A., Wijffels, M. M., Kaye, A., Forrester, J. D., Moutinho, M., Majerick, S., Bauman, Z. M., Janowak, C. F., Patel, B., Wullschleger, M., Clevenger, L., Van Lieshout, E. M., Tung, J., Woodfall, M., Hill, T. R., White, T. W., Doben, A. R. 2023


    Surgical stabilization of rib fractures (SSRF) improves outcomes in certain patient populations. The Chest Wall Injury Society (CWIS) began a new initiative to recognize centers who epitomize their mission as CWIS Collaborative Centers (CWIS-CC). We sought to describe incidence and epidemiology of SSRF at our institutions.A retrospective registry evaluation of all patients (age > 15 years) treated at international trauma centers from 1/1/20 to 7/30/2021 was performed. Variables included: age, gender, mechanism of injury, injury severity score, abbreviated injury severity score (AIS), emergency department disposition, length of stay, presence of rib/sternal fractures, and surgical stabilization of rib/sternal fractures. Classification and regression tree analysis (CART) was used for analysis.Data were collected from 9 centers, 26,084 patient encounters. Rib fractures were present in 24% (n = 6294). Overall, 2% of all patients underwent SSRF and 8% of patients with rib fractures underwent SSRF. CART analysis of SSRF by AIS-Chest demonstrated a difference in management by age group. AIS-Chest 3 had an SSRF rate of 3.7, 7.3, and 12.9% based on the age ranges (16-19; 80-110), (20-49; 70-79), and (50-69), respectively (p = 0.003). AIS-Chest > 3 demonstrated an SSRF rate of 9.6, 23.3, and 39.3% for age ranges (16-39; 90-99), (40-49; 80-89), and (50-79), respectively (p = 0.001).Anticipated rate of SSRF can be calculated based on number of rib fractures, AIS-Chest, and age. The disproportionate rate of SSRF in patients age 50-69 with AIS-Chest 3 and age 50-79 with AIS-Chest > 3 should be further investigated, as lower frequency of SSRF in the other age ranges may lead to care inequalities.

    View details for DOI 10.1007/s00068-023-02343-4

    View details for PubMedID 37624405

    View details for PubMedCentralID 5548197

  • Impact of Medicaid Expansion and Firearm Legislation on Cost of Firearm Injuries. American journal of preventive medicine Brough, S. C., Tennakoon, L., Spitzer, S. A., Thomas, A., Forrester, J. D., Spain, D. A., Weiser, T. G. 2023


    Firearm injury-related hospitalizations in the United States cost $900 million annually. Prior to the Affordable Care Act (ACA), government insurance programs covered 41% of costs. This study describes the effect of ACA Medicaid expansion and state level firearm legislation on coverage and costs for firearm injuries.This cross-sectional study included 35,854,586 hospitalizations from 27 states in 2013 and 2016. Data analyses were performed in 2022. Firearm injuries were classified by mechanism: assault, unintentional, self-harm, or undetermined. Impact of ACA expansion was determined using difference-in-differences analysis. Differences in per capita costs between states with stronger and weak firearm legislation were compared using univariable and multivariable analyses.The authors identified 31,451 initial firearm injury-related hospitalizations. In states with weak firearm legislation, hospitalization costs per 100,000 residents were higher from unintentional ($25,834; p=0.04) and self-inflicted injuries ($11,550; p=0.02); there were no state-level differences in assault or total per capita firearm-related hospitalization costs. ACA expansion increased government coverage of costs by 15 percentage points (95% CI 3-29) and decreased costs to uninsured/self-pay by 14 percentage points (95% CI 6-21). In 2016, states with weak firearm legislation and no ACA expansion had the highest proportion of hospitalization costs attributed to uninsured/self-pay patients (24%, 95% CI 15-34).ACA expansion increased government coverage of hospitalizations for firearm injuries. Unintentional and self-harm costs were significantly higher for states with weak firearm legislation. States with weak firearm legislation that did not expand Medicaid had highest proportion of uninsured/self-pay patients.Economic & Value Based Evaluations, Level III.

    View details for DOI 10.1016/j.amepre.2023.08.011

    View details for PubMedID 37582417

  • Surgical fixation of a traumatic fracture through a congenitally anomalous sternum: a case report. Trauma surgery & acute care open Faliks, B., Thomas, E., Forrester, J. D. 2023; 8 (1): e001155

    View details for DOI 10.1136/tsaco-2023-001155

    View details for PubMedID 37484835

    View details for PubMedCentralID PMC10360415

  • Challenges in trauma and acute care surgery. Trauma surgery & acute care open Agolia, J. P., Forrester, J. D. 2023; 8 (1): e001162

    View details for DOI 10.1136/tsaco-2023-001162

    View details for PubMedID 37213866

    View details for PubMedCentralID PMC10193078

  • Xanthogranulomatous inflammation requiring small bowel anastomosis revision: A case report. World journal of gastrointestinal surgery Wang, W., Korah, M., Bessoff, K. E., Shen, J., Forrester, J. D. 2023; 15 (3): 488-494


    Xanthogranulomatous inflammation (XGI) is an uncommon process involving an accumulation of inflammatory cells, commonly lipid-laden macrophages. XGI has been described to occur throughout the body but only rarely in the lower gastrointestinal tract. We describe a case of XGI contributing to chronic obstructive symptoms in the terminal ileum, in which the patient had an initial diagnostic laparoscopy, continued to have symptoms, then proceeded to have the definitive treatment. To our knowledge, this is the first report of XGI associated with a prior small bowel anastomosis.We report the case of a 42-year-old female who presented with intermittent epigastric pain and subjective fevers. She had undergone a laparoscopic small bowel resection for Meckel's diverticulum five years prior. Her workup was notable for computed tomography scan demonstrating mild inflammation and surrounding stranding at the level of the prior anastomosis. She underwent a laparotomy, resection of the prior anastomosis and re-anastomosis, with final histopathological examination findings consistent with mural XGI.XGI can occur at the site of a prior bowel anastomosis and cause chronic obstructive symptoms.

    View details for DOI 10.4240/wjgs.v15.i3.488

    View details for PubMedID 37032803

    View details for PubMedCentralID PMC10080595

  • Additional Outcomes and Limitations in the Treatment of Acute Unstable Chest Wall Injuries. JAMA surgery Forrester, J. D., Eriksson, E. A., Pieracci, F. M. 2023

    View details for DOI 10.1001/jamasurg.2022.8166

    View details for PubMedID 36884228

  • FasterRib: A Deep Learning Algorithm to Automate Identification and Characterization of Rib Fractures on Chest Computed Tomography Scans. The journal of trauma and acute care surgery Edamadaka, S., Brown, D. J., Swaroop, R., Kolodner, M., Spain, D. A., Forrester, J. D., Choi, J. 2023


    Characterizing and enumerating rib fractures is critical to informing clinical decisions, yet in-depth characterization is rarely performed due to the manual burden of annotating these injuries on computed tomography (CT) scans. We hypothesized that our deep learning model, FasterRib, could predict the location and percentage displacement of rib fractures using chest CT scans.The development and internal validation cohort comprised over 4,700 annotated rib fractures from 500 chest CT scans within the public RibFrac. We trained a convolutional neural network to predict bounding boxes around each fracture per CT slice. Adapting an existing rib segmentation model, FasterRib outputs the three-dimensional locations of each fracture (rib number and laterality). A deterministic formula analyzed cortical contact between bone segments to compute percentage displacements. We externally validated our model on our institution's dataset.FasterRib predicted precise rib fracture locations with 0.95 sensitivity, 0.90 precision, 0.92 f1-score, with an average of 1.3 false positive fractures per scan. On external validation, FasterRib achieved 0.97 sensitivity, 0.96 precision, and 0.97 f1-score, and 2.24 false positive fractures per scan. Our publicly-available algorithm automatically outputs the location and percent displacement of each predicted rib fracture for multiple input CT scans.We built a deep learning algorithm that automates rib fracture detection and characterization using chest CT scans. FasterRib achieved the highest recall and the second highest precision among known algorithms in literature. Our open source code could facilitate FasterRib's adaptation for similar computer vision tasks and further improvements via large-scale external validation.Level III. Diagnostic tests/criteria.

    View details for DOI 10.1097/TA.0000000000003913

    View details for PubMedID 36872505

  • Components of Existing National Surgical Site Infection Surveillance Programs Based on a Case Series of Low- and Middle-Income Countries: Building Blocks for Success and Opportunities for Improvement. Surgical infections Forrester, J. D., Bekele, A., Stefan, A., Tshokey, T., Berndtson, A. E., Beyene, R. T., Chou, J., Sawyer, R. G., Valenzuela, J. Y., Rickard, J. 2023


    Background: Surgical site infection (SSI) surveillance programs are recommended to be included in national infection prevention and control (IPC) programs, yet few exist in low- or middle-income countries (LMICs). Our goal was to identify components of surveillance in existing programs that could be replicated elsewhere and note opportunities for improvement to build awareness for other countries in the process of developing their own national surgical site infection surveillance (nSSIS) programs. Methods: We administered a survey built upon the U.S. Centers for Disease Control and Prevention's framework for surveillance system evaluation to systematically deconstruct logistical infrastructure of existing nSSIS programs in LMICs. Qualitative analyses of survey responses by thematic elements were used to identify successful surveillance system components and recognize opportunities for improvement. Results: Three respondents representing countries in Europe and Central Asia, sub-Saharan Africa, and South Asia designated as upper middle-income, lower middle-income, and low-income responded. Notable strengths described by respondents included use of local paper documentation, staggered data entry, and limited data entry fields. Opportunities for improvement included outpatient data capture, broader coverage of healthcare centers within a nation, improved audit processes, defining the denominator of number of surgical procedures, and presence of an easily accessible, free SSI surveillance training program for healthcare workers. Conclusions: Outpatient post-surgery surveillance, national coverage of healthcare facilities, and training on how to take local SSI surveillance data and integrate it within a broader nSSIS program at the national level remain areas of opportunities for countries looking to implement a nSSIS program.

    View details for DOI 10.1089/sur.2022.331

    View details for PubMedID 36629853

  • Novel Use of a Real-Time Prediction Model to Enhance Early Detection of Need for Massive Transfusion-Artificial Intelligence Behind the Drapes. JAMA network open Villarreal, J. A., Forrester, J. D. 2022; 5 (12): e2246648

    View details for DOI 10.1001/jamanetworkopen.2022.46648

    View details for PubMedID 36515953

  • Pectoralis Major Tendon Rupture While Bouldering. Wilderness & environmental medicine Forrester, J. D., Chona, D. V., McAdams, T. R. 2022


    Pectoralis major tendon ruptures are rare injuries. We present a case of a pectoralis major tendon rupture incurred while bouldering that required surgical repair. The diagnosis of pectoralis major tendon rupture relies predominantly on clinical examination. Among athletes, outcomes after surgical repair are superior to those after nonoperative therapy in most cases of complete tendon rupture. Although infrequent, pectoralis major tendon ruptures can occur while climbing, and early recognition and expedited surgical treatment are paramount to maximize functional recovery.

    View details for DOI 10.1016/j.wem.2022.09.004

    View details for PubMedID 36400648

  • Rib fracture fixation in a patient on veno-venous extracorporeal membrane oxygenation following a motor vehicle collision. Trauma surgery & acute care open Fawzy, Y., Hindin, D., Faliks, B., Tung, J., Forrester, J. D. 2022; 7 (1): e001004

    View details for DOI 10.1136/tsaco-2022-001004

    View details for PubMedID 36389118

    View details for PubMedCentralID PMC9664310

  • Surgical Infection Society Guidelines: 2022 Updated Guidelines for Antibiotic Use in Open Extremity Fractures. Surgical infections Buckman, S. A., Forrester, J. D., Bessoff, K. E., Parli, S. E., Evans, H. L., Huston, J. M. 2022; 23 (9): 817-828


    Background: Open fractures, defined as fractures communicating with the environment through a skin wound, cause substantial morbidity after traumatic injury. Current evidence supports administration of prophylactic systemic antibiotic agents to patients with open extremity fractures to decrease infectious complications. Methods: The Therapeutic and Guidelines Committee of The Surgical Infection Society convened to revise guidelines for antibiotic use in open fractures. PubMed was queried for pertinent studies. Evaluation of the published evidence was performed using the GRADE framework. All committee members voted to accept or reject each recommendation. Results: In type I or II open extremity fractures, we recommend against administration of extended-spectrum antibiotic coverage compared with gram-positive coverage alone to decrease infections complications, hospital length of stay or mortality. In type III open extremity fractures, we recommend antibiotic therapy for no more than 24 hrs after injury, in the absence of clinical signs of active infection, to decrease infectious complications, hospital length of stay or mortality, and we recommend against extended antimicrobial coverage beyond gram-positive organisms to decrease infectious complications, hospital length of stay or mortality. In type III open extremity fractures with associated bone loss, we recommend antibiotic therapy in addition to systemic therapy to decrease infectious complications. Conclusions: Although antibiotic agents remain a standard of care for infection prevention after open extremity fractures, our findings and surveys of clinical practice patterns clearly show that additional robust clinical trials are needed to provide stronger corroborating evidence.

    View details for DOI 10.1089/sur.2022.206

    View details for PubMedID 36350736

  • Cryoneurolysis: Interest and Caution. Anesthesiology Rathmell, J. P., Forrester, J. D., Schreiber, K. 2022; 137 (5): 521-523

    View details for DOI 10.1097/ALN.0000000000004365

    View details for PubMedID 36264090

  • Evidence-based surgery for laparoscopic cholecystectomy. Surgery open science Fisher, A. T., Bessoff, K. E., Khan, R. I., Touponse, G. C., Yu, M. M., Patil, A. A., Choi, J., Stave, C. D., Forrester, J. D. 2022; 10: 116-134


    Laparoscopic cholecystectomy is frequently performed for acute cholecystitis and symptomatic cholelithiasis. Considerable variation in the execution of key steps of the operation remains. We conducted a systematic review of evidence regarding best practices for critical intraoperative steps for laparoscopic cholecystectomy.We identified 5 main intraoperative decision points in laparoscopic cholecystectomy: (1) number and position of laparoscopic ports; (2) identification of cystic artery and duct; (3) division of cystic artery and duct; (4) indications for subtotal cholecystectomy; and (5) retrieval of the gallbladder. PubMed, EMBASE, and Web of Science were queried for relevant studies. Randomized controlled trials and systematic reviews were included for analysis, and evidence quality was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation framework.Fifty-two articles were included. Although all port configurations were comparable from a safety standpoint, fewer ports sometimes resulted in improved cosmesis or decreased pain but longer operative times. The critical view of safety should be obtained for identification of the cystic duct and artery but may be obtained through fundus-first dissection and augmented with cholangiography or ultrasound. Insufficient evidence exists to compare harmonic-shear, clipless ligation against clip ligation of the cystic duct and artery. Stump closure during subtotal cholecystectomy may reduce rates of bile leak and reoperation. Use of retrieval bag for gallbladder extraction results in minimal benefit. Most studies were underpowered to detect differences in incidence of rare complications.Key operative steps of laparoscopic cholecystectomy should be informed by both compiled data and surgeon preference/patient considerations.

    View details for DOI 10.1016/j.sopen.2022.08.003

    View details for PubMedID 36132940

    View details for PubMedCentralID PMC9483801

  • DeepBackRib: Deep Learning to Understand Factors Associated with Readmissions after Rib Fractures. The journal of trauma and acute care surgery Choi, J., Alawa, J., Tennakoon, L., Forrester, J. D. 2022


    Deep neural networks yield high predictive performance, yet obscure interpretability limits clinical applicability. We aimed to build an explainable deep neural network that elucidates factors associated with readmissions after rib fractures among non-elderly adults, termed DeepBackRib. We hypothesized DeepBackRib could accurately predict readmissions and a game theoretic approach to elucidate how predictions are made would facilitate model explainability.We queried the 2017 National Readmissions Database for index hospitalization encounters of adults aged 18-64 years hospitalized with multiple rib fractures. The primary outcome was 3-month readmission(s). Study cohort was split 60-20-20 into training-validation-test sets. Model input features included demographic/injury/index hospitalization characteristics and index hospitalization International Classification of Diseases, 10th revision diagnosis codes. The seven-layer DeepBackRib comprised multi-pronged strategies to mitigate overfitting and was trained to optimize recall. Shapley Additive Explanation (SHAP) analysis identified the marginal contribution of each input feature for predicting readmissions.20,260 patients met inclusion criteria, among whom 11% (N = 2,185) experienced 3-month readmissions. Feature selection narrowed 3,164 candidate input features to 61, and DeepBackRib yielded 91%, 85%, and 82% recall on the training, validation, and test sets, respectively. SHAP analysis quantified the marginal contribution of each input feature in determining DeepBackRib's predictions: underlying chronic obstructive pulmonary disease and long index hospitalization length-of-stay had positive associations with three-month readmissions, while private primary payer and diagnosis of pneumothorax during index admission had negative associations.We developed and internally validated a high-performing deep learning algorithm that elucidates factors associated with readmissions after rib fractures. Despite promising predictive performance, standalone deep learning algorithms are insufficient for clinical prediction tasks: a concerted effort is needed to ensure clinical prediction algorithms remain explainable.Level III, Prognostic and epidemiological.

    View details for DOI 10.1097/TA.0000000000003791

    View details for PubMedID 36121263

  • Female sex is independently associated with reduced inpatient mortality after endovascular repair of blunt thoracic aortic injury. Journal of vascular surgery Ho, V. T., Sorondo, S., Forrester, J. D., George, E. L., Tran, K., Lee, J. T., Garcia-Toca, M., Stern, J. R. 2022


    Female sex has been associated with decreased mortality following blunt trauma, but whether sex influences outcomes of thoracic endovascular aortic repair (TEVAR) for traumatic blunt thoracic aortic injury (BTAI) is unknown.In this retrospective study of a prospectively maintained database, the Vascular Quality Initiative (VQI) registry was queried from 2013-2020 for patients undergoing TEVAR for BTAI. Univariate Student's t-tests and chi-squared tests were performed, followed by multivariate logistic regression for variables associated with inpatient mortality.211 (26.2%) of 806 patients were female. Female patients were older (47.9 vs. 41.8 years, p<0.0001) and less likely to smoke (38.3% vs. 48.2%, p=0.044). Most patients presented with grade III BTAI (54.5% female, 53.6% male,), followed by grade IV (19.0% female, 19.5% male). Mean Injury Severity Scores (30.9 + 20.3 female, 30.5 + 18.8 male) and regional Abbreviated Injury Score did not vary by sex. Postoperatively, female patients were less likely to die as inpatients (3.8% vs 7.9% , p=0.042) and to be discharged home (41.4% vs. 52.2%, p=0.008). On multivariate logistic regression, female sex (OR 0.05, p=0.002) was associated with reduced inpatient mortality. Advanced age (OR 1.06, p< 0.001), postoperative transfusion (OR 1.05, p=0.043), increased Injury Severity Score (OR 1.03, p=0.039), postoperative stroke (OR 9.09, p= 0.016), postoperative myocardial infarction (OR 9.9, p=0.017), and left subclavian coverage (OR 2.7, p= 0.029) were associated with inpatient death.Female sex is associated with lower odds of inpatient mortality following TEVAR for BTAI, independent of age, injury severity, BTAI grade, and postoperative complications. Further study of the influence of sex on post-discharge outcomes is needed.

    View details for DOI 10.1016/j.jvs.2022.07.178

    View details for PubMedID 35944732

  • Explainable Machine Learning to Bring Database to the Bedside: Development and Validation of the TROUT (Trauma fRailty OUTcomes) Index, a Point-of-Care Tool to Prognosticate Outcomes after Traumatic Injury based on Frailty. Annals of surgery Choi, J., Anderson, T., Tennakoon, L., Spain, D. A., Forrester, J. D. 2022


    Exemplify an explainable machine learning framework to bring database to the bedside; develop and validate a point-of-care frailty assessment tool to prognosticate outcomes after injury.A geriatric trauma frailty index that captures only baseline conditions, is readily-implementable, and validated nationwide remains underexplored. We hypothesized Trauma fRailty OUTcomes (TROUT) Index could prognosticate major adverse outcomes with minimal implementation barriers.We developed TROUT index according to Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis guidelines. Using nationwide US admission encounters of patients aged ≥65 years (2016-2017; 10% development, 90% validation cohorts), unsupervised and supervised machine learning algorithms identified baseline conditions that contribute most to adverse outcomes. These conditions were aggregated into TROUT Index scores (0-100) that delineate three frailty risk strata. After associative (between frailty risk strata and outcomes, adjusted for age, sex, and injury severity [as effect modifier]) and calibration analysis, we designed a mobile application to facilitate point-of-care implementation.Our study population comprised 1.6 million survey-weighted admission encounters. Fourteen baseline conditions and one mechanism of injury constituted the TROUT Index. Among the validation cohort, increasing frailty risk (low=reference group, moderate, high) was associated with stepwise increased adjusted odds of mortality (OR[95%CI]: 2.6[2.4-2.8], 4.3[4.0-4.7]), prolonged hospitalization (OR[95%CI]: 1.4[1.4-1.5], 1.8 [1.8-1.9]), disposition to a facility (OR[95%CI]: 1.4[1.4-1.5], 1.8[1.7-1.8]), and mechanical ventilation (OR[95%CI]: 2.3[1.9-2.7], 3.6[3.0-4.5]). Calibration analysis found positive correlations between higher TROUT Index scores and all adverse outcomes. We built a mobile application ("TROUT Index") and shared code publicly.The TROUT Index is an interpretable, point-of-care tool to quantify and integrate frailty within clinical decision-making among injured patients. The TROUT Index is not a stand-alone tool to predict outcomes after injury; our tool should be considered in conjunction with injury pattern, clinical management, and within institution-specific workflows. A practical mobile application and publicly-available code can facilitate future implementation and external validation studies.

    View details for DOI 10.1097/SLA.0000000000005649

    View details for PubMedID 35920568

  • Effect of Seasonality on Variation Among Patients Presenting With Rib Fractures in the United States. The American surgeon Sheira, D., Tennakoon, L., Forrester, J. D. 2022: 31348221102609


    BACKGROUND: A prior single-site study from the Midwest exploring seasonality of traumatic rib fractures found injuries are more common during summer months and lower in winter months. There have been no modern studies evaluating seasonality of these common injuries nationally. Our aim was to describe temporal and spatial distribution of rib fractures in the United States. We hypothesized presentations for traumatic rib fractures follow a seasonal pattern, with greater frequency of rib fractures in the summer and lower levels in the winter.METHODS: We obtained hospital emergency department (ED) encounter data from Nationwide Emergency Department Sample (NEDS) from January 1, 2018 to December 31, 2018. We used ICD-10 codes to identify all patients with diagnostic codes specific to rib fractures. To examine seasonal patterns, we constructed negative binomial regression models using seasons as covariates to predict incidence of rib fracture encounters across regions.RESULTS: Of 15,439,004 trauma-related ED encounters in 2018, 384431 (2%) encounters included a diagnosis of rib fracture(s). The percentage of ED trauma encounters with rib fractures was similar across the 4 regions. Rib fractures were more common in the summer in the Midwest, South, and West as compared to winter [22% (95% CI = 10-34%, P = .007), 12% (95% CI = 5-20%, P = 0.02), and 11% (95% CI = 5-17%, P = .008), respectively].DISCUSSION: Our hypothesis was generally supported by our evaluation of NEDS. However, while seasonal variation in rib fractures does appear to exist in the Midwest, South, and West, this variation is not ubiquitous across the United States.

    View details for DOI 10.1177/00031348221102609

    View details for PubMedID 35574592

  • Improving tracheostomy delivery for trauma and surgical critical care patients: timely trach initiative. BMJ open quality McShane, E. K., Sun, B. J., Maggio, P. M., Spain, D. A., Forrester, J. D. 2022; 11 (2)


    BACKGROUND: Tracheostomy is recommended within 7days of intubation for patients with severe traumatic brain injury (TBI) or requiring prolonged mechanical ventilation. A quality improvement project aimed to decrease time to tracheostomy to ≤7days after intubation for eligible patients requiring tracheostomy in the surgical intensive care unit (SICU).LOCAL PROBLEM: From January 2017 to June 2018, approximately 85% of tracheostomies were performed >7days after intubation. The tracheostomy was placed a median of 10 days after intubation (range: 1-57).METHODS: Quality improvement principles were applied at an American College of Surgeons-verified level I trauma centre to introduce and analyse interventions to improve tracheostomy timing. Using the electronic health record, we analysed changes in tracheostomy timing, hospital length of stay (LOS), ventilator-associated pneumonia and peristomal bleeding rates for three subgroups: patients with TBI, trauma patients and all SICU patients.INTERVENTIONS: In July 2018, an educational roll-out for SICU residents and staff was launched to inform them of potential benefits of early tracheostomy and potential complications, which they should discuss when counselling patient decision-makers. In July 2019, an early tracheostomy workflow targeting patients with head injury was published in an institutional Trauma Guide app.RESULTS: Median time from intubation to tracheostomy decreased for all patients from 14 days (range: 4-57) to 8days (range: 1-32, p≤0.001), and median hospital LOS decreased from 38 days to 24 days (p<0.001, r=0.35). Median time to tracheostomy decreased significantly for trauma patients after publication of the algorithm (10 days (range: 3-21days) to 6days (range: 1-15days), p=0.03). Among patients with TBI, family meetings were held earlier for patients who underwent early versus late tracheostomy (p=0.008).CONCLUSIONS: We recommend regular educational meetings, enhanced by digitally published guidelines and strategic communication as effective ways to improve tracheostomy timing. These interventions standardised practice and may benefit other institutions.

    View details for DOI 10.1136/bmjoq-2021-001589

    View details for PubMedID 35551095

  • A decade of hospital costs for firearm injuries in the United States by region, 2005-2015: government healthcare costs and firearm policies. Trauma surgery & acute care open Spitzer, S. A., Forrester, J. D., Tennakoon, L., Spain, D. A., Weiser, T. G. 2022; 7 (1): e000854


    Firearm injuries are a costly, national public health emergency, and government-sponsored programs frequently pay these hospital costs. Understanding regional differences in firearm injury burden may be useful for crafting appropriate policies, especially with widely varying state gun laws.To estimate the volume of, and hospital costs for, fatal and non-fatal firearm injuries from 2005 to 2015 for each region of the United States and analyze the proportionate cost by payer status.We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify patients admitted for firearm-related injuries from 2005 to 2015. We converted hospitalization charges to costs, which were inflation-adjusted to 2015 dollars. We used survey weights to create regional estimates. We used the Brady Gun Law to determine significance between firearm restrictiveness and firearm hospitalizations by region.There were a total of 317 479 firearm related admissions over the study period: 52 829 (16.66%), 66 671 (21.0%), 134 008 (42.2%), and 63 972 (20.2%) for the Northeast, Midwest, South, and West respectively, demonstrating high regional variability. In the Northeast, hospital costs were $1.98 billion (13.9% of total), of which 56.0% was covered by government payers; for the Midwest, costs were $153 billion (19.7% of total), 40.4% of which was covered by government payers; in the South costs were highest at $3.2 billion (41.4% of total), but government payers only covered 34.3%; and costs for the West were $1.94 billion (25.0% of total), with government programs covering 41.6% of the cost burden.Hospital admissions and costs for firearm injuries demonstrated wide variation by region, suggesting opportunities for financial savings. As government insurance programs cover 41.5% of costs, tax dollars heavily subsidize the financial burden of firearm injuries and cost recovery options for treating residents injured by firearms should be considered. Injury control strategies have not been well applied to this national public health crisis.Level II, Economic and Value Based Evaluation.

    View details for DOI 10.1136/tsaco-2021-000854

    View details for PubMedID 35497324

    View details for PubMedCentralID PMC8995943

  • Surgical Infection Society Guidelines for Antibiotic Use in Patients Undergoing Cholecystectomy for Gallbladder Disease. Surgical infections Colling, K. P., Besshoff, K. E., Forrester, J. D., Kendrick, D., Mercier, P., Huston, J. M. 2022


    Background: Manifestations of gallbladder disease range from intermittent abdominal pain (symptomatic cholelithiasis) to potentially life-threatening illness (gangrenous cholecystitis). Although surgical intervention to treat acute cholecystitis is well defined, the role of antibiotic administration before or after cholecystectomy to decrease morbidity or mortality is less clear. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for antibiotic use in patients undergoing cholecystectomy for gallbladder disease to prevent surgical site infection, other infection, hospital length of stay, or mortality. PubMed, Embase, and the Cochrane Database were searched for relevant studies. Evaluation of the published evidence was performed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Using a process of iterative consensus, all authors voted to accept or reject each recommendation. Results: We recommend against routine use of peri-operative antibiotic agents in low-risk patients undergoing elective laparoscopic cholecystectomy. We recommend use of peri-operative antibiotic agents for patients undergoing laparoscopic cholecystectomy for acute cholecystitis. We recommend against use of post-operative antibiotic agents after elective laparoscopic cholecystectomy for symptomatic cholelithiasis. We recommend against use of post-operative antibiotic agents in patients undergoing laparoscopic cholecystectomy for mild or moderate acute cholecystitis. We recommend a maximum of four days of antibiotic agents, and perhaps a shorter duration in patients undergoing cholecystectomy for severe (Tokyo Guidelines grade III) cholecystitis. Conclusions: This guideline summarizes the current Surgical Infection Society recommendations for antibiotic use in patients undergoing cholecystectomy for gallbladder disease.

    View details for DOI 10.1089/sur.2021.207

    View details for PubMedID 35363086

  • Infection with Two Multi-Drug-Resistant Organisms in Solid Organ Transplant Patients Is Associated with Increased Mortality and Prolonged Hospitalization. Surgical infections Cao, S., Tennakoon, L., Brubaker, A. L., Forrester, J. D. 2022


    Background: Solid organ transplant recipients have several risk factors for peri-operative multi-drug-resistant infection: their immune system is dampened as a result of critical illness and surgical stress that may be further impaired by induction immunotherapy and broad-spectrum antibiotic prophylaxis promotes selection for resistant pathogens. Infection with multi-drug-resistant organisms (MDRO) results in morbidity and mortality for solid organ transplant recipients. Patients and Methods: To assess in-hospital mortality and hospitalization duration associated with these infections, we analyzed cross-sectional, retrospective data from the 2016 Agency for Healthcare and Quality, Healthcare Cost and Utilization Project's National Inpatient Sample. Our analysis included 31,105 index admissions records for liver, kidney, heart, lung, and pancreas transplant recipients in the United States. Outcomes were assessed by multivariable regression analysis adjusting for covariables. Results: One percent (355/29,451) of patients with diagnosis of no MDRO infections died, 3% (40/1491) with diagnosis of one MDRO infection died, and 15% (25/166) with diagnosis of two MDRO infections died. Diagnosis of one MDRO infection was associated with a 20-day increase in hospitalization duration (95% confidence interval [CI], 17-22) but not increased odds of death (odds ratio [OR], 1.2; 95% CI, 0.5-2.5). Diagnosis of two MDRO infections was associated with an increased odds of death (OR, 9.6' 95% CI, 3.3-27.9) and a 41-day increase in hospitalization duration (95% CI, 34-49). Conclusions: Strategies to decrease peri-operative MDRO infection may improve survival and decrease duration of hospitalization for solid organ transplant patients.

    View details for DOI 10.1089/sur.2021.300

    View details for PubMedID 35357980

  • Beyond 5 years: a matched cohort of sleeve gastrectomy versus gastric bypass. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery Blevins, K. S., Garcia, L., Forrester, J. D., Morton, J. M., Azagury, D. E. 2022


    Laparoscopic sleeve gastrectomy (LSG) has demonstrated excellent short-term outcomes. However, existing studies suffer from loss to follow-up, and most long-term data focus on laparoscopic Roux-en-Y gastric bypass (LRYGB). This study compares weight loss in patients ≥5 years from LSG with that in matched patients who underwent LRYGB.The purpose of this study was to compare long-term weight loss in patients undergoing LRYGB and LSG.University hospital, United States.We retrospectively evaluated patients who underwent LSG before August 2012 with follow-up data ≥5 years. LSG patients were matched 1:1 with LRYGB patients by sex, age at surgery, and preoperative body mass index. Univariate and multivariate analyses were performed with weight loss at the longest duration the primary outcome.One-hundred and sixty-five patients underwent LSG during the study period. Long-term follow-up data (≥5 years) were available for 85 patients (52%). There were no preoperative differences between those with and without follow-up data. Six LSG patients (7%) were excluded because they underwent reoperation that altered intestinal anatomy. Of the 79 patients remaining, 75 were matched with post-LRYGB patients. The average follow-up period was 6.4 years for LSG patients and 6.5 years for LRYGB patients (P = .08, not significant). Change in body mass index was 6.81 kg/m2 for LSG patients and 13.11 kg/m2 for LRYGB patients. Percentage of total body weight loss was 15.25% for LSG patients and 28.73% for LRYGB patients. Percentage of excess body weight loss was 37% for LSG patients and 67% for LRYGB patients (P < .0001). Weight loss for LSG patient follow-up in clinic versus outside the clinic was 46% versus 34% (P = .18, not significant).LSG is now the most common bariatric surgery in the United States. Long-term data are needed to confirm that observed short-term favorable outcomes are maintained. Recent studies have produced divergent results. We observed significantly less weight loss at ≥5 years in LSG patients compared with matched LRYGB patients.

    View details for DOI 10.1016/j.soard.2022.03.008

    View details for PubMedID 35484048

  • Building a Trainee-led Research Community to Propel Academic Productivity in Health Services Research. Journal of surgical education Choi, J., Tennakoon, L., Khan, S., Jaramillo, J. D., Rajasingh, C. M., Hakes, N. A., Forrester, J. D., Knowlton, L. M., Nassar, A. K., Weiser, T. G., Spain, D. A. 2022


    Academic productivity is an increasingly important asset for trainees pursuing academic careers. Medical schools and graduate medical education programs offer structured research programs, but providing longitudinal and individualized health services research education remains challenging. Whereas in basic science research, members at multiple training levels support each other within a dedicated community (the laboratory), health services research projects frequently occur within individual faculty-trainee relationships. An optimal match of expertise, availability, and interest may be elusive for an individual mentor-mentee pair. We aimed to share our experience building Surgeons Writing about Trauma (SWAT), a trainee-led research community that propels academic productivity by facilitating peer collaboration and opportunities to transition into independent researchers. We highlight challenges of health services research for trainees, present how structured mentorship and a peer community can address this challenge, and detail SWAT's operational structure to guide replication at peer institutions.

    View details for DOI 10.1016/j.jsurg.2022.02.008

    View details for PubMedID 35272969

  • Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury. European journal of trauma and emergency surgery : official publication of the European Trauma Society Prins, J. T., Van Lieshout, E. M., Ali-Osman, F., Bauman, Z. M., Caragounis, E. C., Choi, J., Christie, D. B., Cole, P. A., DeVoe, W. B., Doben, A. R., Eriksson, E. A., Forrester, J. D., Fraser, D. R., Gontarz, B., Hardman, C., Hyatt, D. G., Kaye, A. J., Ko, H. J., Leasia, K. N., Leon, S., Marasco, S. F., McNickle, A. G., Nowack, T., Ogunleye, T. D., Priya, P., Richman, A. P., Schlanser, V., Semon, G. R., Su, Y. H., Verhofstad, M. H., Whitis, J., Pieracci, F. M., Wijffels, M. M. 2022


    Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients.A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern.In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11-0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, - 2.96 days; 95% CI - 5.70 to - 0.23; p = 0.034).In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.

    View details for DOI 10.1007/s00068-022-01906-1

    View details for PubMedID 35192003

  • Surgery for Hereditary Diffuse Gastric Cancer: Long-Term Outcomes. Cancers Forrester, J. D., Foster, D., Ford, J. M., Longacre, T. A., Ladabaum, U., Fry, S., Norton, J. A. 2022; 14 (3)


    Gastric cancer is inherited as an autosomal dominant condition in hereditary diffuse gastric cancer (HDGC). The gene associated with HDGC is an E-cadherin gene CDH1. At the time of initiation of this study, it was estimated that 70% of patients who inherited the CDH1 gene mutation would develop gastric cancer. We hypothesized that the rate of signet ring cell cancer in asymptomatic patients with CDH1 mutations may be higher than anticipated and that the surgery could be conducted with acceptable short-term and long-term complications suggesting that the quality of life with the surgery is acceptable.We prospectively studied the role of total gastrectomy in symptomatic and asymptomatic patients with CDH1 mutations. A total of 43 patients with mutations of the CDH1 gene were studied prospectively, including 8 with symptoms and 35 without symptoms. Total gastrectomy was recommended to each. Quality of life was assessed in patients who underwent prophylactic gastrectomy. Proportions are compared with Fisher's exact test.In total, 13 (30%) asymptomatic patients declined surgery. Total gastrectomy was performed in 8 symptomatic patients and 22 asymptomatic patients of whom only 3 asymptomatic patients (14%) had endoscopically proven signet ring cell cancer preoperatively, while 21 of 22 (95%) had it on final pathology (p = 0.05). Each asymptomatic patient was T1, N0, while seven out of eight symptomatic patients had T3-T4 tumors and six had positive lymph nodes. None had operative complications or operative death. The median follow-up was 7 years. Five (63%) symptomatic patients died, while only one (95%) prophylactic patient died of a non-gastric cancer- or surgery-related issue (p = 0.05). A total of 15 prophylactic patients had long-term follow-up. Each had significant weight loss (mean 23%) but all had a normal body mass index. In total, 40% had bile reflux gastritis controlled with sucralfate. Each returned to work and, if given the choice, said that they would undergo the surgery again.Total gastrectomy is indicated for patients who have an inherented CDH1 mutation. Endoscopic screening is not reliable for diagnosing signet ring cell stomach cancer. If patients wait for symptoms, they will have a more advanced disease and significantly reduced survival. Operative complications of prophylactic gastrectomy are minimal, and long-term quality of life is acceptable.

    View details for DOI 10.3390/cancers14030728

    View details for PubMedID 35158993

  • Scalable Deep Learning Algorithm to Compute Percent Pulmonary Contusion among Patients with Rib Fractures. The journal of trauma and acute care surgery Choi, J., Mavrommati, K., Li, N. Y., Patil, A., Chan, K., Hindin, D. I., Forrester, J. D. 2022


    Pulmonary contusion exists along a spectrum of severity, yet is commonly binarily classified as present or absent. We aimed to develop a deep learning algorithm to automate percent pulmonary contusion computation and exemplify how transfer learning could facilitate large-scale validation. We hypothesized our deep learning algorithm could automate percent pulmonary contusion computation and that greater percent contusion would be associated with higher odds of adverse inpatient outcomes among patients with rib fractures.We evaluated admission-day chest computed tomography (CT) scans of adults aged ≥18 years admitted to our institution with multiple rib fractures and pulmonary contusions (2010-2020). We adapted a pre-trained convolutional neural network that segments 3-dimensional lung volumes and segmented contused lung parenchyma, pulmonary blood vessels, and computed percent pulmonary contusion. Exploratory analysis evaluated associations between percent pulmonary contusion (quartiles) and odds of mechanical ventilation, mortality, and prolonged hospital length-of-stay using multivariable logistic regression. Sensitivity analysis included pulmonary blood vessel volumes during percent contusion computation.A total of 332 patients met inclusion criteria (median 5 rib fractures), among whom 28% underwent mechanical ventilation and 6% died. The study population's median (IQR) percent pulmonary contusion was 4(2-8)%. Compared to the lowest quartile of percent pulmonary contusion, each increasing quartile was associated with higher adjusted odds of undergoing mechanical ventilation (OR[95%CI]: 1.5[1.1-2.1]) and prolonged hospitalization (OR[95%CI]: 1.6[1.1-2.2]), but not with mortality (OR[95%CI]: 1.1 [0.6-2.0]. Findings were similar on sensitivity analysis.We developed a scalable deep learning algorithm to automate percent pulmonary contusion calculating using chest CTs of adults admitted with rib fractures. Open code sharing and collaborative research is needed to validate our algorithm and exploratory analysis at large scale. Transfer learning can help harness the full potential of big data and high-performing algorithms to bring precision medicine to the bedside.IV.

    View details for DOI 10.1097/TA.0000000000003619

    View details for PubMedID 35319542

  • Effectiveness of emergency general surgery - some answers, more questions. Anaesthesia Forrester, J. D., Wren, S. M. 2022

    View details for DOI 10.1111/anae.15719

    View details for PubMedID 35307814

  • Prevention of Creutzfeldt-Jakob Disease in Patients Undergoing Surgery. JAMA network open Sun, B. J., Forrester, J. D. 2022; 5 (3): e221561

    View details for DOI 10.1001/jamanetworkopen.2022.1561

    View details for PubMedID 35262721

  • Influence of Socioeconomic and Environmental Determinants of Health on Human Infection and Colonization with Antibiotic-Resistant and Antibiotic-Associated Pathogens: A Scoping Review. Surgical infections Forrester, J. D., Cao, S., Schaps, D., Liou, R., Patil, A., Stave, C., Sokolow, S. H., Leo, G. D. 2022


    Background: Antibiotic-resistant and antibiotic-associated pathogens are commonly encountered by surgeons. Pathogens such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridioides difficile infection (CDI), and carbapenem-resistant Enterobacteriaceae (CRE) result in considerable human morbidity, mortality, and excess healthcare expenditure. Human colonization or infection can result from exposure to these pathogens across a range of domains both inside and outside of the built healthcare environment, exposure that may be influenced by socioeconomic and environmental determinants of health, the importance of which has not been investigated fully. Methods: We performed a scoping review of published literature describing potential socioeconomic and environmental variables that may increase the likelihood of human infection or colonization with common antibiotic-resistant or antibiotic-associated pathogens, using MRSA, CDI, and CRE as examples. Results: We identified 7,916 articles meeting initial search criteria. Of these, 101 provided supportive evidence of socioeconomic and environmental determinants of human infection or colonization and were included in the scoping review after abstract and full-text screening. Sixty-seven evaluated MRSA, nine evaluated CRE, and 29 evaluated CDI. Twenty-nine articles evaluated exposure to livestock or companion animals; 28, exposure to antibiotics; 20, impact of socioeconomic factors, education level, or race; 14, the influence of temperature, humidity, or season; 13, the effect of travel or human population migration; 11, exposure to built healthcare environments; and eight assessed impact of population density or urbanization. Conclusions: Although articles outlining socioeconomic and environmental drivers of antibiotic-resistant and antibiotic-associated infection are still disconcertedly few, evidence of such associations are overwhelming for MRSA and CDI and supportive for CRE. Additional research is needed to investigate the role and importance of different potential socioeconomic and environmental drivers of antibiotic-resistant and antibiotic-associated infections and colonization in humans.

    View details for DOI 10.1089/sur.2021.348

    View details for PubMedID 35100052

  • Clinical Prediction Tools in Trauma: Where Do We Go From Here? JAMA network open Choi, J., Forrester, J. D. 2022; 5 (1): e2145867

    View details for DOI 10.1001/jamanetworkopen.2021.45867

    View details for PubMedID 35099551

  • A Parallel Pandemic: Increased Firearm Injuries at Five Northern California Trauma Centers During the COVID-19 Pandemic, an Interrupted Time-Series Analysis. Annals of surgery Matthay, Z. A., Callcut, R. A., Kwok, A. M., Aarabi, S., Forrester, J. D., Kornblith, L. Z., Northern California Research Consortium for Trauma & Acute Care Surgery Study Group 1800


    OBJECTIVE: This study aimed to characterize changes in firearm injuries at five level 1 trauma centers in Northern California in the twelve months following the start of the COVID-19 pandemic compared to the preceding four years, accounting for regional variations and seasonal trends.SUMMARY AND BACKGROUND DATA: Increased firearm injuries have been reported during the early peaks of the COVID-19 pandemic despite shelter-in-place restrictions. However, these data are overwhelmingly from single center studies, during the initial phase of the pandemic prior to lifting of shelter-in-place restrictions, or do not account for seasonal trends.METHODS: An interrupted time-series analysis (ITSA) of all firearm injuries presenting to five adult level 1 trauma centers in Northern California was performed (January 2016-February 2021). ITSA modeled the association of the onset of the COVID-19 pandemic (March 2020) with monthly firearm injuries using the ordinary least squares method, included month indicators to adjust for seasonality, and specified lags of up to 12 months to account for autocorrelation.RESULTS: Prior to the start of COVID-19, firearm injuries averaged (±SD) of 86 (±16) and were decreasing by 0.5/month (p<0.01). The start of COVID-19 (March 2020) was associated with an alarming increase of 39 firearm injuries/month (p<0.01) followed by an ongoing rise of 3.5/month (p < 0.01). This resulted in an average of 130 (±26) firearm injuries/month during the COVID-19 period and included 8 of the 10 highest monthly firearm injury rates in the past five years.CONCLUSIONS: These data highlight an alarming escalation in firearm injuries in the 12 months following the onset of the COVID-19 pandemic in Northern California. Additional studies and resources are needed to better understand and address this parallel public health crisis.

    View details for DOI 10.1097/SLA.0000000000005334

    View details for PubMedID 34913894

  • Fatal Case of Perforated Cytomegalovirus Colitis: Case Report and Systematic Review. Surgical infections Fisher, A. T., Bessoff, K. E., Nicholas, V., Badger, J., Knowlton, L., Forrester, J. D. 2021


    Objective: We describe a patient with history of heart transplant on maintenance immunosuppression who presented with sigmoid colon perforation from cytomegalovirus (CMV) colitis and performed a systematic review of outcomes after perforated CMV colitis. Background: Cytomegalovirus enterocolitis is uncommon among solid organ transplant patients and can result in small or large bowel perforation. Methods: We systematically reviewed articles describing patients with CMV enterocolitis with small or large bowel perforations from PubMed, Embase, and Web of Science from database inception to February 2021. Results: Seventy-seven articles were identified containing 84 patients with perforated CMV enterocolitis. The most prevalent comorbid diagnosis was human immunodeficiency virus (HIV; 27 patients, 32%), and 37 patients (44%) were taking corticosteroids at time of presentation. The ileum was the most common location for a perforation (26 patients, 31%). Odds of survival were lower for patients with small bowel perforation (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.14-0.98) and HIV/acquired immunodeficiency syndrome (AIDS; OR, 0.32; 95% CI, 0.11-0.88). Odds of survival were higher for patients with large bowel perforation (OR, 2.64; 95% CI, 1.03-7.09), radiographically diagnosed perforation (OR, 3.45; 95% CI, 1.12-11.60) and those who received a CMV antiviral (OR, 9.19; 95% CI, 3.26-28.48). Conclusions: Perforated CMV enterocolitis is uncommon even in immunocompromised hosts. Clinicians should maintain a high level of suspicion for CMV-induced bowel perforation in this population because antiviral treatment is associated with increased odds of survival.

    View details for DOI 10.1089/sur.2021.173

    View details for PubMedID 34860604

  • Human-Factor Risk Mitigation in Outdoor Climbing Areas: Survey of Existing Policies in Regulated Climbing Areas WILDERNESS & ENVIRONMENTAL MEDICINE Meltzer, J. H., Forrester, J. D. 2021; 32 (4): 457-462
  • Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Management of Tick-Borne Illness in the United States WILDERNESS & ENVIRONMENTAL MEDICINE Ho, B. M., Davis, H. E., Forrester, J. D., Sheele, J. M., Haston, T., Sanders, L., Lee, M., Lareau, S., Caudell, M., Davis, C. B. 2021; 32 (4): 474-494
  • In Response. Anesthesia and analgesia Abola, R. E., Schwartz, J., Beg, T., Gan, T. J., Forrester, J. 2021; 133 (2): e30-e31

    View details for DOI 10.1213/ANE.0000000000005613

    View details for PubMedID 34257213

  • Scoping review of traumatic hemothorax: Evidence and knowledge gaps, from diagnosis to chest tube removal. Surgery Choi, J., Villarreal, J., Andersen, W., Min, J. G., Touponse, G., Wong, C., Spain, D. A., Forrester, J. D. 2021


    BACKGROUND: Traumatic hemothorax is a common injury that invites diagnostic and management strategy debates. Evidence-based management has been associated with improved care efficiency. However, the literature abounds with long-debated, re-emerging, and new questions. We aimed to consolidate up-to-date evidence on traumatic hemothoraces, focusing on clinical conundra debated in literature.METHODS: We conducted a scoping review of 21 clinical conundra in traumatic hemothorax diagnosis and management according to PRISMA-ScR guidelines. Experimental and observational studies evaluating patients (aged ≥18 years) with traumatic hemothoraces were identified through database searches (PubMed, EMBASE, Web of Science, Cochrane Library; database inception to Sep, 26 2020) and bibliography reviews of selected articles. Three reviewers screened and selected articles using standardized forms.RESULTS: We screened 1,440 articles for eligibility, of which 71 met criteria for synthesis. The review comprises 6 sections: (1) Presumptive antibiotics before tube thoracostomy; (2) Initial diagnostic and intervention decisions; (3) Chest tubes; (4) Retained hemothoraces; (5) Delayed hemothoraces; and (6) Chest tube removal). The 21 conundra across these sections follow the format of a question, our recommendation based on interpretation of available evidence, and succinct rationale. Rationale sections detail knowledge gaps and opportunities for future research.CONCLUSION: Even practices engrained into surgical dogma, such as obtaining chest x-rays after inserting or removing chest tubes and mandating operation for patients who develop chest tube output above a certain threshold, deserve re-evaluation. Some knowledge gaps require rigorous future investigation; sound clinical judgment can likely supplement others.

    View details for DOI 10.1016/j.surg.2021.03.030

    View details for PubMedID 33888318

  • Concomitant Sternal Fractures: Harbinger of Worse Pulmonary Complications and Mortality in Patients With Rib Fractures. The American surgeon Choi, J. n., Mulaney, B. n., Sun, B. n., Trimble, R. n., Tennakoon, L. n., Spain, D. A., Forrester, J. D. 2021: 3134821991978


    Sternal and rib fractures are common concomitant injuries. However, the impact of concurrent sternal fractures on clinical outcomes of patients with rib fractures is unclear. We aimed to unveil the pulmonary morbidity and mortality impact of concomitant sternal fractures among patients with rib fractures.We identified adult patients admitted with traumatic rib fractures with vs. without concomitant sternal fractures using the 2012-2014 National Inpatient Sample (NIS). After 2:1 propensity score matching and adjustment for residual imbalances, we compared risk of pulmonary morbidity and mortality between patients with vs. without concomitant sternal fractures. Subgroup analysis in patients with flail chest assessed whether sternal fractures modify the association between undergoing surgical stabilization of rib fractures (SSRF) and pulmonary morbidity or mortality.Of 475 710 encounters of adults admitted with rib fractures, 24 594 (5%) had concomitant sternal fractures. After 2:1 propensity score matching, patients with concomitant sternal fractures had 70% higher risk (95% CI: 50-90% higher, P < 0.001) of undergoing tracheostomy, 40% higher risk (30-50% higher, P <.001) of undergoing intubation, and 20% higher risk of respiratory failure (10-30% higher, P <.001) and mortality (10-40% higher, P =.007). Subgroup analysis of 8600 patients with flail chest showed concomitant sternal fractures did not impact the association between undergoing SSRF and any pulmonary morbidity or mortality.Concomitant sternal fractures are associated with increased risk for pulmonary morbidity and mortality among patients with rib fractures. However, our findings are limited by a binary definition of sternal fractures, which encompasses heterogeneous injury patterns with likely variable clinical relevance.

    View details for DOI 10.1177/0003134821991978

    View details for PubMedID 33522281

  • Chest Wall Analgesia-Where Do We Go From Here? JAMA network open Bessoff, K. E., Ko, A., Forrester, J. D. 2021; 4 (11): e2133839

    View details for DOI 10.1001/jamanetworkopen.2021.33839

    View details for PubMedID 34779854

  • Practical Computer Vision Application to Compute Total Body Surface Area Burn: Reappraising a Fundamental Burn Injury Formula in the Modern Era. JAMA surgery Choi, J., Patil, A., Vendrow, E., Touponse, G., Aboukhater, L., Forrester, J. D., Spain, D. A. 2021


    Critical burn management decisions rely on accurate percent total body surface area (%TBSA) burn estimation. Existing %TBSA burn estimation models (eg, Lund-Browder chart and rule of nines) were derived from a linear formula and a limited number of individuals a century ago and do not reflect the range of body habitus of the modern population.To develop a practical %TBSA burn estimation tool that accounts for exact burn injury pattern, sex, and body habitus.This population-based cohort study evaluated the efficacy of a computer vision algorithm application in processing an adult laser body scan data set. High-resolution surface anthropometry laser body scans of 3047 North American and European adults aged 18 to 65 years from the Civilian American and European Surface Anthropometry Resource data set (1998-2001) were included. Of these, 1517 participants (49.8%) were male. Race and ethnicity data were not available for analysis. Analyses were conducted in 2020.The contributory %TBSA for 18 body regions in each individual. Mobile application for real-time %TBSA burn computation based on sex, habitus, and exact burn injury pattern.Of the 3047 individuals aged 18 to 65 years for whom body scans were available, 1517 (49.8%) were male. Wide individual variability was found in the extent to which major body regions contributed to %TBSA, especially in the torso and legs. Anterior torso %TBSA increased with increasing body habitus (mean [SD], 15.1 [0.9] to 19.1 [2.0] for male individuals; 15.1 [0.8] to 18.0 [1.7] for female individuals). This increase was attributable to increase in abdomen %TBSA (mean [SD], 5.3 [0.7] to 8.7 [1.8]) among male individuals and increase in abdomen (mean [SD], 4.6 [0.6] to 6.8 [1.7]) and pelvis (mean [SD], 1.5 [0.2] to 2.9 [0.9]) %TBSAs among female individuals. For most body regions, Lund-Browder chart and rule of nines estimates fell outside the population's measured interquartile ranges. The mobile application tested in this study, Burn Area, facilitated accurate %TBSA burn computation based on exact burn injury pattern for 10 sex and body habitus-specific models.Computer vision algorithm application to a large laser body scan data set may provide a practical tool that facilitates accurate %TBSA burn computation in the modern era.

    View details for DOI 10.1001/jamasurg.2021.5848

    View details for PubMedID 34817552

  • Intercostal Nerve Cryoablation during Surgical Stabilization of Rib Fractures. The journal of trauma and acute care surgery Choi, J., Min, J. G., Jopling, J. K., Meshkin, S., Bessoff, K. E., Forrester, J. D. 2021


    Intercostal nerve cryoablation (IC) offers potential for targeted and durable analgesia for patients with traumatic rib fractures. Our pilot study aimed to investigate thoracoscopic IC's safety, feasibility, and preliminary efficacy for patients undergoing surgical stabilization of rib fractures (SSRF). We hypothesized concurrent SSRF-IC is a safe and feasible procedure without immediate or long-term complications.We retrospectively evaluated patients aged ≥18 years who underwent SSRF (with or without IC) for acute rib fractures at our Level I trauma center between 1 September 2019 and 30 September 2020. We performed IC under thoracoscopic visualization (-70 °C for 2 minutes per intercostal nerve bundle). Among patients whose only operative procedure during hospitalization was SSRF, we evaluated post-SSRF length of stay, operative times, opioid requirements (oral morphine equivalents) and pain scores (Numerical Rating Scale). Generalized estimating equations compared SSRF and SSRF-IC group outcomes (population mean[robust standard error]). We assessed long-term outcomes of patients who underwent SSRF-IC.Thirty-four patients (144 ribs) underwent SSRF; of these, 20 patients (135 ribs) underwent SSRF-IC. Patients who did and did not undergo concurrent IC had no significant difference demographic, injury, or hospitalization characteristics. Among 20 patients who did not undergo other operations, 12 underwent SSRF-IC. We did not find significant difference between SSRF and SSRF-IC groups' median operative times or post-SSRF length of stay. Compared to SSRF group, SSRF-IC group did not have statistically significant change in pain score (0.2[1.5] lower) or opioid use (43.9[86.1] mg/day greater) between 12-hours before SSRF and last 24 admission hours. Among 17 SSRF-IC patients who followed-up post-discharge (median[range]: 160[9-357] days), one reported mild chest wall paresthesia; no other complications were reported.Pilot study performing 135 intercostal nerve cryoablations on 20 patients suggests IC is safe and feasible for patients undergoing SSRF. Evaluating IC's analgesic efficacy for rib fractures requires further study.Level IV, prognostic and epidemiological study.

    View details for DOI 10.1097/TA.0000000000003391

    View details for PubMedID 34446656

  • Evidence-based surgery for laparoscopic appendectomy: A stepwise systematic review. Surgery open science Bessoff, K. E., Choi, J., Wolff, C. J., Kashikar, A., Carlos, G. M., Caddell, L., Khan, R. I., Stave, C. D., Spain, D. A., Forrester, J. D. 2021; 6: 29-39


    Appendectomy is a common emergency surgery performed globally. Despite the frequency of laparoscopic appendectomy, consensus does not exist on the best way to perform each procedural step. We identified literature on key intraoperative steps to inform best technical practice during laparoscopic appendectomy.Research questions were framed using the population, indication, comparison, outcome (PICO) format for 6 key operative steps of laparoscopic appendectomy: abdominal entry, placement of laparoscopic ports, division of mesoappendix, division of appendix, removal of appendix, and fascial closure. These questions were used to build literature queries in PubMed, EMBASE, and the Cochrane Library databases. Evidence quality and certainty was assessed using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) definitions.Recommendations were rendered for 6 PICO questions based on 28 full length articles. Low quality evidence favors direct trocar insertion for abdominal entry and establishment of pneumoperitoneum. Single port appendectomy results in improved cosmesis with unclear clinical implications. There was insufficient data to determine the optimal method of appendiceal stump closure, but use of a specimen extraction bag reduces rates of superficial surgical site infection and intra-abdominal abscess. Port sites made with radially dilating trocars are less likely to necessitate closure and are less likely to result in port site hernia. When port sites are closed, a closure device should be used.Key operative steps of laparoscopic appendectomy have sufficient data to encourage standardized practice.

    View details for DOI 10.1016/j.sopen.2021.08.001

    View details for PubMedID 34604728

    View details for PubMedCentralID PMC8473533

  • Impact of COVID-19 on presentation, management, and outcomes of acute care surgery for gallbladder disease and acute appendicitis. World journal of gastrointestinal surgery Farber, O. N., Gomez, G. I., Titan, A. L., Fisher, A. T., Puntasecca, C. J., Arana, V. T., Kempinsky, A., Wise, C. E., Bessoff, K. E., Hawn, M. T., Korndorffer, J. R., Forrester, J. D., Esquivel, M. M. 2021; 13 (8): 859-870


    The ongoing coronavirus disease 2019 (COVID-19) pandemic has significantly disrupted both elective and acute medical care. Data from the early months suggest that acute care patient populations deferred presenting to the emergency department (ED), portending more severe disease at the time of presentation. Additionally, care for this patient population trended towards initial non-operative management.To examine the presentation, management, and outcomes of patients who developed gallbladder disease or appendicitis during the pandemic.A retrospective chart review of patients diagnosed with acute cholecystitis, symptomatic cholelithiasis, or appendicitis in two EDs affiliated with a single tertiary academic medical center in Northern California between March and June, 2020 and in the same months of 2019. Patients were selected through a research repository using international classification of diseases (ICD)-9 and ICD-10 codes. Across both years, 313 patients were identified with either type of gallbladder disease, while 361 patients were identified with acute appendicitis. The primary outcome was overall incidence of disease. Secondary outcomes included presentation, management, complications, and 30-d re-presentation rates. Relationships between different variables were explored using Pearson's r correlation coefficient. Variables were compared using the Welch's t-Test, Chi-squared tests, and Fisher's exact test as appropriate.Patients with gallbladder disease and appendicitis both had more severe presentations in 2020. With respect to gallbladder disease, more patients in the COVID-19 cohort presented with acute cholecystitis compared to the control cohort [50% (80) vs 35% (53); P = 0.01]. Patients also presented with more severe cholecystitis in 2020 as indicated by higher mean Tokyo Criteria Scores [mean (SD) 1.39 (0.56) vs 1.16 (0.44); P = 0.02]. With respect to appendicitis, more patients were diagnosed with a perforated appendix at presentation in 2020 [20% (36) vs 16% (29); P = 0.02] and a greater percentage were classified as emergent cases using the emergency severity index [63% (112) vs 13% (23); P < 0.001]. While a greater percentage of patients were admitted to the hospital for gallbladder disease in 2020 [65% (104) vs 50% (76); P = 0.02], no significant differences were observed in hospital admissions for patients with appendicitis. No significant differences were observed in length of hospital stay or operative rate for either group. However, for patients with appendicitis, 30-d re-presentation rates were significantly higher in 2020 [13% (23) vs 4% (8); P = 0.01].During the COVID-19 pandemic, patients presented with more severe gallbladder disease and appendicitis. These findings suggest that the pandemic has affected patients with acute surgical conditions.

    View details for DOI 10.4240/wjgs.v13.i8.859

    View details for PubMedID 34512909

    View details for PubMedCentralID PMC8394376

  • Surgical Infection Society Guidelines for Total Abdominal Colectomy versus Diverting Loop Ileostomy with Antegrade Intra-Colonic Lavage for the Surgical Management of Severe or Fulminant, Non-Perforated Clostridioides difficile Colitis. Surgical infections Forrester, J. D., Colling, K. P., Diaz, J. J., Faliks, B., Kim, P. K., Tessier, J. M., Tung, J., Huston, J. M. 2021


    Background: Clostridioides difficile infection (CDI) can result in life-threatening illness requiring surgery. Surgical options for managing severe or fulminant, non-perforated C. difficile colitis include total abdominal colectomy with end ileostomy or creation of a diverting loop ileostomy with antegrade vancomycin lavage. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for summarizing the current SIS recommendations for total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for severe or fulminant, non-perforated C. difficile colitis. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Severe infection was defined as laboratory diagnosis of C. difficile infection with leukocytosis (white blood cell count of ≥15,000 cells/mL) or elevated creatinine (serum creatinine level >1.5 mg/dL). Fulminant infection was defined as laboratory diagnosis of C. difficile infection with hypotension or shock, ileus, or megacolon. Perforation was defined as complete disruption of the colon wall. Total abdominal colectomy was defined as resection of the ascending, transverse, descending, and sigmoid colon with end ileostomy. For the purpose of the guideline, the terms subtotal colectomy, total abdominal colectomy, and rectal-sparing total colectomy were used interchangeably. Diverting loop ileostomy with antegrade enema was defined as creation of both a diverting loop ileostomy with intra-operative colonic lavage and post-operative antegrade vancomycin unless otherwise specified. Evaluation of the published evidence was performed using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: We recommend that total abdominal colectomy be the procedure of choice for definitive therapy of severe or fulminant, non-perforated C. difficile colitis. In select patients, colon preservation using diverting loop ileostomy with intra-colonic vancomycin may be associated with higher rates of ostomy reversal and restoration of gastrointestinal continuity but may lead to development of recurrent C. difficile colitis. Conclusions: This guideline summarizes the current Surgical Infection Society recommendations regarding use of total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for adults with severe or fulminant, non-perforated C. difficile infection.

    View details for DOI 10.1089/sur.2021.126

    View details for PubMedID 34619068

  • Time to transition: In support of alcohol-based surgical rub. Surgery Schaps, D., Forrester, J. D. 2021

    View details for DOI 10.1016/j.surg.2021.06.034

    View details for PubMedID 34311977

  • Systematic Review and Meta-Analysis of Hardware Failure in Surgical Stabilization of Rib Fractures: Who, What, When, Where, and Why? The Journal of surgical research Choi, J., Kaghazchi, A., Sun, B., Woodward, A., Forrester, J. D. 2021; 268: 190-198


    Surgical stabilization of rib fractures (SSRF) is increasingly used to reduce pulmonary complications and death among patients with rib fractures. However, the five Ws of hardware failure -who, what, when, where, and why- remains unclear. We aimed to synthesize available evidence on the five Ws and outline future research agenda for mitigating hardware failure.Experimental and observational studies published between 2009 and 2020 evaluating adults undergoing SSRF for traumatic rib fractures underwent evidence synthesis. We performed random effects meta-analysis of cohort/consecutive case studies. We calculated pooled prevalence of SSRF hardware failures using Freeman-Tukey double arcsine transformation and assessed study heterogeneity using DerSimonian-Laird estimation. We performed meta-regression with rib fracture acuity (acute or chronic) and hardware type (metal plate or not metal plate) as moderators.Twenty-nine studies underwent qualitative synthesis and 24 studies (2404 SSRF patients) underwent quantitative synthesis. Pooled prevalence of hardware failure was 4(3-7)%. Meta-regression showed fracture acuity was a significant moderator (P = 0.002) of hardware failure but hardware type was not (P = 0.23). Approximately 60% of patients underwent hardware removal after hardware failure. Mechanical failures were the most common type of hardware failure, followed by hardware infections, pain/discomfort, and non-union. Timing of hardware failure after surgery was highly variable, but 87% of failures occurred after initial hospitalization. Mechanical failures was attributed to technical shortcomings (i.e. short plate length) or excessive force on the thoracic cavity.SSRF hardware failure is an uncommon complication. Not all hardware failures are consequential, but insufficient individual patient data precluded characterizing where and why hardware failures occur. Minimizing SSRF hardware failure requires concerted research agenda to expand on the paucity of existing evidence.

    View details for DOI 10.1016/j.jss.2021.06.054

    View details for PubMedID 34333416

  • COVID-19 Impact on Surgical Resident Education and Coping. The Journal of surgical research Wise, C. E., Bereknyei Merrell, S. n., Sasnal, M. n., Forrester, J. D., Hawn, M. T., Lau, J. N., Lin, D. T., Schmiederer, I. S., Spain, D. A., Nassar, A. K., Knowlton, L. M. 2021; 264: 534–43


    Healthcare systems and surgical residency training programs have been significantly affected by the novel coronavirus disease 2019 (COVID-19) pandemic. A shelter-in-place and social distancing mandate went into effect in our county on March 16, 2020, considerably altering clinical and educational operations. Along with the suspension of elective procedures, resident academic curricula transitioned to an entirely virtual platform. We aimed to evaluate the impact of these modifications on surgical training and resident concerns about COVID-19.We surveyed residents and fellows from all eight surgical specialties at our institution regarding their COVID-19 experiences from March to May 2020. Residents completed the survey via a secure Qualtrics link. A total of 38 questions addressed demographic information and perspectives regarding the impact of the COVID-19 pandemic on surgical training, education, and general coping during the pandemic.Of 256 eligible participants across surgical specialties, 146 completed the survey (57.0%). Junior residents comprised 43.6% (n = 61), compared to seniors 37.1% (n = 52) and fellows 19.3% (n = 27). Most participants, 97.9% (n = 138), anticipated being able to complete their academic year on time, and 75.2% (n = 100) perceived virtual learning to be the same as or better than in-person didactic sessions. Participants were most concerned about their ability to have sufficient knowledge and skills to care for patients with COVID-19, and the possibility of exposure to COVID-19.Although COVID-19 impacted residents' overall teaching and clinical volume, residency programs may identify novel virtual opportunities to meet their educational and research milestones during these challenging times.

    View details for DOI 10.1016/j.jss.2021.01.017

    View details for PubMedID 33862581

  • Efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain after surgery or trauma: a systematic review Trauma Surgery & Acute Care Open Cha, P. I., Min, J. G., Patil, A., Choi, J., Kothary, N. N., Forrester, J. D. 2021: e000690
  • Outcomes after Surgery among Patients Diagnosed with One or More Multi-Drug-Resistant Organisms. Surgical infections Gupta, A. n., Tennakoon, L. n., Spain, D. A., Forrester, J. D. 2021


    Background: Infections with multi-drug-resistant organisms (MDROs) may be difficult to treat and prolong patient hospitalization and recovery. Multiple MDRO coinfections may increase the complexity of clinical management. However, association between multiple MDROs and outcomes of patients who undergo surgery is unknown. Patients and Methods: We performed a retrospective, cross-sectional analysis of the 2016 National Inpatient Sample for identified by International Classification of Disease, 10th Revision Clinical Modification (ICD-10-CM) diagnosis codes associated with multi-drug-resistant organisms: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), multi-drug-resistant gram-negative bacilli, and Clostridioides difficile infection (CDI). Admitted patients with diagnosis codes for MDROs were cross-matched with codes for common general surgery procedures. Outcomes of interest included length of stay and mortality. Weighted univariable and multivariable analyses accounting for the survey methodology were performed. Results: Of 1,550,224 patients undergoing surgery in 2016, 39,065 (3%) admissions were diagnosed with an MDRO and 1,176 (0.1%) were associated with dual MDROs diagnoses. Patients diagnosed with one MDRO were hospitalized three times longer (17.3 days; 95% confidence interval [CI], 16.8-17.7) and patients diagnosed with two MDROs five times longer (31.6 days; 95% CI, 27.0-36.2; p < 0.0001) than undiagnosed patients (6.1 days; 95% CI, 6.1-6.1; all p < 0.0001). On multivariable analysis, the strongest predictor of mortality was a diagnosis of two MDRO infections (odds ratio [OR], 4.8; 95% CI, 3.16-7.21; p < 0.0001). The second strongest predictor was diagnosis of single MDRO infection (OR, 2.9; 95% CI, 2.64-3.20; p < 0.0001). Conclusion: Presence of an MDRO was associated with increased odds of mortality and length of stay in admitted surgical patients. Interventions to reduce MDRO infection among surgical patients may reduce hospital length of stay and mortality.

    View details for DOI 10.1089/sur.2020.400

    View details for PubMedID 33471591

  • Heterogeneity in managing rib fractures across non-trauma and level I, II, and III trauma centers. American journal of surgery Choi, J. n., Kaghazchi, A. n., Dickerson, K. L., Tennakoon, L. n., Spain, D. A., Forrester, J. D. 2021


    We aimed to elucidate management patterns and outcomes of high-risk patients with rib fractures (elderly or flail chest) across non-trauma and trauma centers. We hypothesized highest-capacity (level I) centers would have best outcomes for high-risk patients.We queried the 2016 National Emergency Department Sample to identify adults presenting with rib fractures. Multivariable regression assessed ED and inpatient events across non-trauma and level III/II/I trauma centers.Among 504,085 rib fracture encounters, 46% presented to non-trauma centers. Elderly patients with multiple rib fractures had stepwise increase in inpatient admission odds and stepwise decrease in pneumonia odds at higher-capacity trauma centers compared to non-trauma centers. Among patients with flail chest, odds of undergoing surgical stabilization (SSRF) increased at trauma centers. Undergoing SSRF was associated with reduced mortality but remained underutilized.Half of patients with rib fractures present to non-trauma centers. Nationwide care-optimization for high-risk patients requires further effort.

    View details for DOI 10.1016/j.amjsurg.2021.02.013

    View details for PubMedID 33612257

  • Early National Landscape of Surgical Stabilization of Sternal Fractures. World journal of surgery Choi, J. n., Khan, S. n., Syed, M. n., Tennakoon, L. n., Forrester, J. D. 2021


    Operative management of chest wall injuries aims to restore respiratory mechanics and mitigate pulmonary complications. Extensive studies support surgical stabilization of rib fractures (SSRF) for select patients, but role for surgical stabilization of sternal fractures (SSSF) remains unclear. We aimed to understand national prevalence of SSSF and compare outcomes after surgical stabilization and non-operative management of sternal fractures.We retrospectively analyzed adult patients (age ≥ 18 years) admitted with sternal fractures after blunt trauma using the 2016 National Trauma Data Bank. We compared odds of inpatient mortality, pneumonia, and respiratory failure for propensity score matched patients (4:1) who underwent non-operative management vs SSSF. We characterized subgroup of patients with concurrent rib and sternal fractures who underwent concomitant SSRF-SSSF.We identified 14,760 encounters of adults admitted with sternal fractures; 270 (1.8%) underwent SSSF. Compared to matched patients who underwent non-operative management, patients who underwent SSSF had lower odds of mortality (OR [95%CI]: 0.19 [0.06-0.62], p = 0.006). Adjusted for trauma center level, Mantel-Haenszel mortality odds remained lower for patients who underwent SSSF. Odds of pneumonia and respiratory failure were similar between matched groups. Among 46% of patients who had concomitant rib fractures, 0.3% (n = 18) underwent concurrent SSRF-SSSF and these patients survived hospitalization without pneumonia or respiratory failure.A vast majority of patients who suffer sternal fractures undergo non-operative management. Potential mortality benefit of SSSF and concurrent SSRF-SSSF's role for commonly concomitant rib and sternal fractures deserve further study. Our preliminary findings call for delineating heterogeneity of sternal fractures and establishing consensus SSSF indications.

    View details for DOI 10.1007/s00268-021-06007-5

    View details for PubMedID 33604709

  • Modified percutaneous tracheostomy in patients with COVID-19. Trauma surgery & acute care open Sun, B. J., Wolff, C. J., Bechtold, H. M., Free, D., Lorenzo, J., Minot, P. R., Maggio, P. G., Spain, D. A., Weiser, T. G., Forrester, J. D. 2020; 5 (1): e000625


    Patients hospitalized with COVID-19 are at risk of developing hypoxic respiratory failure and often require prolonged mechanical ventilation. Indication and timing to perform tracheostomy is controversial in patients with COVID-19.This was a single-institution retrospective review of tracheostomies performed on patients admitted for COVID-19 between April 8, 2020 and August 1, 2020 using a modified percutaneous tracheostomy technique to minimize hypoxia and aerosolization.Twelve tracheostomies were performed for COVID-related respiratory failure. Median patient age was 54 years (range: 36-76) and 9 (75%) were male. Median time to tracheostomy was 17 days (range: 10-27), and 5 (42%) patients had failed attempts at extubation prior to tracheostomy. There were no intraprocedural complications, including hypoxia. Post-tracheostomy bleeding was noted in two patients. Eight (67%) patients have been discharged at the time of this study, and there were four patient deaths unrelated to tracheostomy placement. No healthcare worker transmissions resulted from participating in the tracheostomy procedure.A modified percutaneous tracheostomy is feasible and can be safely performed in patients infected with COVID-19.Level V, case series.

    View details for DOI 10.1136/tsaco-2020-000625

    View details for PubMedID 34192161

    View details for PubMedCentralID PMC7736959

  • 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; 231 (6): 789–90
  • Common, Severe, and Preventable: Agricultural Machinery Trauma in the US Hakes, N. A., Jaramillo, J. D., Choi, J., Spain, D. A., Tennakoon, L., Forrester, J. D. ELSEVIER SCIENCE INC. 2020: E231
  • 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; 31 (3): 298–302
  • 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

  • Outcome after surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures and moderate to severe traumatic brain injury (CWIS-TBI). The journal of trauma and acute care surgery Prins, J. T., Van Lieshout, E. M., Ali-Osman, F. n., Bauman, Z. M., Caragounis, E. C., Choi, J. n., Benjamin Christie, D. n., Cole, P. A., DeVoe, W. B., Doben, A. R., Eriksson, E. A., Forrester, J. D., Fraser, D. R., Gontarz, B. n., Hardman, C. n., Hyatt, D. G., Kaye, A. J., Ko, H. J., Leasia, K. N., Leon, S. n., Marasco, S. F., McNickle, A. G., Nowack, T. n., Ogunleye, T. D., Priya, P. n., Richman, A. P., Schlanser, V. n., Semon, G. R., Su, Y. H., Verhofstad, M. H., Whitis, J. n., Pieracci, F. M., Wijffels, M. M. 2020


    Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared to nonoperative management, is associated with favorable outcomes in patients with TBI.A multicenter, retrospective cohort study was performed in patients with rib fractures and TBI between January 2012 and July 2019. Patients who underwent SSRF were compared to those managed nonoperatively. The primary outcome was mechanical ventilation-free days. Secondary outcomes were Intensive Care Unit (ICU-LOS) and hospital length of stay (HLOS), tracheostomy, occurrence of complications, neurologic outcome, and mortality. Patients were further stratified into moderate (GCS 9-12) and severe (GCS ≤8) TBI.The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. SSRF was performed at a median of 3 days and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (OR 0.59 (95% CI 0.38-0.98), p=0.043) and 30-day mortality (OR 0.32 (95% CI 0.11-0.91), p=0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (0.19 (95% CI 0.04-0.88), p=0.034).In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI.Therapeutic, level IV.

    View details for DOI 10.1097/TA.0000000000002994

    View details for PubMedID 33093293

  • National readmission rates after surgical stabilization of traumatic rib fractures The Journal of Cardiothoracic Trauma Cha, P. I., Hakes, N. A., Choi, J., Tennakoon, L., Spain, D. A., Forrester, J. D. 2020; 5 (1): 16-21

    View details for DOI 10.4103/jctt.jctt_6_20

  • A Practical Guide for Anesthesia Providers on the Management of COVID-19 Patients in the Acute Care Hospital. Anesthesia and analgesia Abola, R. E., Schwartz, J. n., Forrester, J. D., Gan, T. J. 2020


    The Coronavirus Disease 2019 (COVID-19) pandemic has infected millions of individuals and posed unprecedented challenges to health care systems. Acute care hospitals have been forced to expand hospital and intensive care capacity and deal with shortages in personal protective equipment. This guide will review two areas where the anesthesiologists will be caring for COVID-19 patients: the operating room and on airway teams. General principles for COVID-19 preparation and hospital procedures will be reviewed to serve as a resource for anesthesia departments to manage COVID-19 or future pandemics.

    View details for DOI 10.1213/ANE.0000000000005295

    View details for PubMedID 33122542

  • 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. n., 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

  • 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
  • Surgical Infection Society Guidelines for Antibiotic Use in Patients with Traumatic Facial Fractures. Surgical infections Forrester, J. D., Wolff, C. J., Choi, J. n., 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. n., 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. n., Tennakoon, L. n., You, J. G., Kaghazchi, A. n., 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

  • 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

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

    View details for DOI 10.1016/j.jamcollsurg.2020.08.736

    View details for PubMedID 32828842

  • 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

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

  • 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. n., Bhattacharya, J. n., Kebebew, E. n. 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. n., Forrester, J. D., Spain, D. A. 2020

    View details for DOI 10.1097/TA.0000000000002793

    View details for PubMedID 32467468

  • 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
  • LAPRA-TY for laparoscopic repair of traumatic diaphragmatic hernia without intracorporeal knot tying. Trauma surgery & acute care open Choi, J. n., Pan, J. n., Forrester, J. D., Spain, D. n., 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

  • 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. n., Amirtharajah, M. n., Brown, Z. W., Bulger, E. M., Burkle, F. M., Elster, E. A., Forrester, J. D., Garber, K. n., Gosselin, R. A., Groen, R. S., Hsin, G. n., Joshipura, M. n., Kushner, A. L., Norton, I. n., Osmers, I. n., Pagano, H. n., Razek, T. n., Sáenz-Terrazas, J. M., Schussler, L. n., Stewart, B. T., Traboulsi, A. A., Trelles, M. n., Troke, J. n., 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. n., Baiu, I. n., Owyang, C. n., Forrester, J. D., Spain, D. n. 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. n., 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

  • 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
  • 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; 153 (9): 858–60
  • Surgical Instrument Reprocessing in Resource-Constrained Countries: A Scoping Review of Existing Methods, Policies, and Barriers SURGICAL INFECTIONS Forrester, J. A., Powell, B., Forrester, J. D., Fast, C., Weiser, T. G. 2018; 19 (6): 593–602
  • Trends in Country-Specific Surgical Randomized Clinical Trial Publications JAMA SURGERY Forrester, J. A., Forrester, J. D., Wren, S. M. 2018; 153 (4): 386–88
  • 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

  • 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

  • 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. n., 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. n., 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

  • Using Epidemiology to Determine Surgical Needs in Low-Resource Settings JAMA SURGERY Forrester, J. D., Wren, S. M. 2017; 152 (12)
  • 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: 520-523


    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 PubMedID 29546031

    View details for PubMedCentralID PMC5723259

  • Evaluating the Impact of Blinded vs Non-Blinded Interviews on the General Surgery Resident Selection Process Shipper, E. S., Forrester, J., Lau, J. N., Melcher, M. L. ELSEVIER SCIENCE INC. 2017: S174–S175
  • 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

  • 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): 1517-1521


    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

  • 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

  • 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

  • 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. n., 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. n., 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

  • 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. n., 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 Inguinal Hernia Repairs Performed in Low and Middle Human Development Index Countries: A Systematic Review. Surgical infections Cai, L. Z., Foster, D. n., 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

  • Surgical Site Infections after Appendectomy Performed in Low and Middle Human Development-Index Countries: A Systematic Review. Surgical infections Foster, D. n., Kethman, W. n., 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

  • 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
  • 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

  • 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

    View details for PubMedCentralID PMC4622257

  • 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

  • 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