Joseph D. Forrester

Geographic Distribution and Expansion of Human Lyme Disease, United States.

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.

Evolution of Ebola Virus Disease from Exotic Infection to Global Health Priority, Liberia, Mid-2014

As the disease spread, the scale of the epidemic required a multi-faceted public health response.

WSES guidelines for management of Clostridium difficile infection in surgical patients

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.

Third-Degree Heart Block Associated With Lyme Carditis: Review of Published Cases

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.

Decreased Ebola Transmission after Rapid Response to Outbreaks in Remote Areas, Liberia, 2014.

Basic interventions and community acceptance can result in rapid control of outbreaks.

Leclercia adecarboxylata Bacteremia in a Trauma Patient: Case Report and Review of the Literature

BACKGROUND 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. METHODS A case is described and previous cases of L. adecarboxylata infection are reviewed. CASE REPORT 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. CONCLUSION 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.

Injury and Illness Encountered in Shenandoah National Park

Abstract Objective.—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. Methods.—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. Results.—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. Conclusions.—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.

Epidemiology of Lyme disease in low-incidence states

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.

Cardiac Tropism of Borrelia burgdorferi: An Autopsy Study of Sudden Cardiac Death Associated with Lyme Carditis

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.

Self-reported Determinants of Access to Surgical Care in 3 Developing Countries

IMPORTANCE Surgical care is recognized as a growing component of global public health. OBJECTIVE 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. DESIGN, SETTING, AND PARTICIPANTS 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. MAIN OUTCOMES AND MEASURES 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. RESULTS 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%). CONCLUSIONS AND RELEVANCE 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.