Help for Josh's Neck Instability, Lyme, & POTS
Donation protected
Joshua has been diagnosed with POTS (Postural Orthostatic Tachycardia Syndrome), EDS (Ehlers Danlos Syndrome), ME/CFS (Myalgic Encephalomyelitis/Chronic Fatigue Syndrome), CCI (Craniocervical Instability), AAI (Atlanto-axial Instability), and Lyme Disease. *This is the beginning of Josh's story and updates of the worsening progression and quick decline in health are in periodically attached posts below.* All throughout his story are linked videos that we hope help explain some of these confusing and overwhelming diagnoses.
Hi, my name is Josh. In late April 2019, I suddenly became so ill that I have now become essentially disabled and almost completely bed bound. My decline of health mostly started after I contracted some sort of pathogen and getting my neck injured from forceful chiropractic manipulations. Instead of getting sick and then recovering in a couple weeks, I became sick and stayed sick. The symptoms hit out of no-where. I experienced extreme fatigue, chills, organ pain, and the lymph nodes on the side of my neck became swollen. Once the initial flu like symptoms died down, I started to develop other symptoms. I had constant debilitating fatigue, exercise intolerance, brain fog, temperature dysregulation, gut issues, low blood pressure, lightheadedness, trouble breathing, tachycardia, palpitations and much more. If I got up too quickly from a seated position my vision would begin to black out and I would feel like I was about to pass out. I had no idea what was wrong with me and was always visiting the nurse at school because I felt so bad. It became extremely difficult to get any work done on time and I almost didn't graduate my senior year of high school because of it. We started visiting multiple doctors to find out what was going on. They couldn't figure out what was wrong as all my blood tests came back relatively normal. I started researching my symptoms and found out about a disorder called P.O.T.S. which stands for Postural Orthostatic Tachycardia Syndrome. Basically whenever I stand up all my blood from my upper body rushes down and pools in my legs and feet due to gravity. The heart tries to compensate for this lack of blood by increasing heart rate to maintain consciousness. Many people pass out due to a lack of blood flow to the brain. It also affects basically every organ and system of your body as P.O.T.S is a form of autonomic nervous system dysfunction. The autonomic nervous system controls everything you don't consciously think about including heart rate, blood pressure, breathing, digestion, etc. This explains the huge range of symptoms people experience along with the lightheadedness and tachycardia if this system gets disrupted. The condition usually develops after someone contracts a viral or bacterial infection, physical trauma such as a head injury, surgery, or other stressors on the body. After learning about this I went and got a tilt table test done which showed my heart rate went from 85 to 146 when being tilted to the vertical position, and my blood pressure dropped to 103/78. I felt very nauseous and unwell so the nurses ended the test and put me in the horizontal position again to prevent me from passing out or getting worse.
There is no "official" cure for P.O.T.S as it's a complex illness with many underlying causes. The only way to get well or find remission from P.O.T.S. is to discover and treat the underlying condition which is ultimately causing it. Most doctors just treat the symptoms and the standard treatments for P.O.T.S doesn't help everyone. Most doctors don't even know about P.O.T.S so many people with this condition have to find specialists for it. After trying standard treatments and not getting better I started looking at other options. I was rapidly deteriorating and kept developing new symptoms as time progressed to my dismay. I unintentionally lost over 30 pounds despite eating a lot which has made me become very underweight. I became bedridden and my family has to do most things for me such as make and bring me food. Just getting to walk over to the bathroom has become extremely difficult. The simplest tasks most people don't even think about became some of the greatest challenges for me. Most of my days consist of lying in bed immobilized just trying to deal with an onslaught of severe symptoms. Just simply sitting up in bed cause tachycardia, palpitations, lightheadedness, breathlessness, vertigo, and fatigue. The only time I'm able to leave the house is for medical tests and appointments and even that small amount of effort causes a significant worsening of symptoms. Since traditional doctors didn't help at all, my family and I went to a P.O.T.S Center in Texas for more answers on what exactly is going on. They did a bunch of tests which ruled out a lot of other conditions that could potentially cause this condition which was very helpful. I found out I have an inherited connective tissue disorder called Ehlers-Danlos Syndrome (EDS) which is common in P.O.T.S patients. EDS is a connective tissue disorder where you have hypermobile joints and ligaments due to faulty collagen production. Having EDS predisposed myself to develop this condition. I also found out that my vagus nerve is either damaged or dysfunctional. The vagus nerve is considered to be one of the most important nerves in the body. It is actually a pair of two nerves that come out of your brain stem and run down the sides of your neck and enter into your body. It helps control almost every single organ to work properly. If it gets damaged you can start having issues with your heart, lungs, stomach, liver, gallbladder, intestines, and more. The vagus nerve is essential for proper functioning of your autonomic nervous system so if it gets injured or damaged that's when you can run into serious problems. It also makes your para-sympathetic nervous system work properly which is the "rest and digest" system of the body. Because of this issue I found out that my sympathetic nervous system is in overdrive and also that my body isn't clearing inflammation properly. They prescribed a bunch of medications but my stomach couldn't handle it. I got a lot of answers and it ruled out a bunch of other conditions but there was still something missing.
Not long after getting ill, my neck started bothering me. It would crack very audibly and noticeably right at the base of the skull. Other areas of my neck would grind and crack as well. I get extreme headaches that come about randomly and sharp pain at the top of my neck. There is also a sensation that my neck is too weak to hold my head up. I started doing more research and found to my surprise that many people with P.O.T.S have issues with their necks. In fact it's actually the cause of their P.O.T.S as the neck instability presses on the brain stem which is the Autonomic Nervous System Epicenter. Many people not only develop P.O.T.S after acquiring an infection, but also by injuring their head and neck such as whiplash from a car accident, concussions, falls, etc. I personally talked to many people who had developed dysautonomia after getting whiplash injuries and having their necks manipulated. It was recommended to get a Digital Motion X-Ray (DMX) done which is a special type of X-Ray that shows how your neck moves in motion. I went and got a DMX done and it showed that I have instability at my C1 vertebrae where it is slipping left and right whenever I tilt or bend my neck. Here is a few snapshots from my report below:
There should be no extra or abnormal movement at all as even a couple millimeters of extra movement can cause damage to the neural structures in the area. The DMX also showed instability at C3, C4, C5 & C6. It turns out my ligaments holding my vertebrae in place are damaged. It just so happens that a month before I got sick, I went to a chiropractor to help an old injury to my collar bone. While I was there he manipulated and cracked my neck multiple times which wasn't necessary in my view as my neck was not bothering me at the time. I had multiple visits with him all through the month of April in hopes of correcting my collarbone. I noticed throughout the month that's when I started to have issues with the lightheadedness, tunnel vision, exercise intolerance, and tachycardia when standing. I felt the worst after the last adjustment but never made any connections on what caused it at the time. It was then only a week later in early May when I became extremely sick with a pathogen. This is what caused the downward cascade of health and is when the majority of the autonomic symptoms became prominent. These high velocity manipulations most likely damaged and misaligned my neck especially considering that I have a connective tissue disorder. It also explains how my vagus nerve became damaged and dysfunctional as it runs right in front of C1 & C2 where I have the extra movement due to injured ligaments. The vagus nerve is also involved in the proper functioning of the immune system and controlling the inflammatory response in the body. So if the nerve becomes compromised somehow, any pathogen you get can cause more damage to your body and nervous system which most likely happened in my case. Below, I attached images of my neck in the neutral position from a CT scan rendered in 3D. My C1 is shifted over and my C2 is rotated forward while looking straight. A few doctors think my alar ligaments are probably torn from the manipulations as they are the ligaments that hold these two important vertebrae in the correct alignment. There should be no overhang or rotation in the neutral position. This is very abnormal and it is causing compression of the vagus nerve and irritating my brainstem which is likely resulting in the autonomic dysfunction. 
This is neurosurgeon Dr. Gilete who is one of the experts in this condition explaining and diagnosing someone's neck instability below. I had a consultation with him and he diagnosed me with Craniocervical Instability (CCI), Atlantoaxial Instability (AAI), Subaxial Instability, and neutral C1 - C2 misalignment (as seen above). With CCI, my skull is essentially sliding backwards too much whenever I look upward due to damaged and hypermobile ligaments. With AAI, my head is turning too far when looking left and right and the atlantoaxial joints are subluxing when this happens. Subaxial Instability is all the vertebrae below C1 and C2 that have become unstable. I also have evidence of Intracranial Hypertension which is when your spinal fluid accumulates and becomes too high on the brain. This causes severe headaches along with nausea and vomiting. If it gets too bad it can even lead to blindness. There are many things that can cause it but in my case it's most likely due to inadequate drainage of spinal fluid because of the neutral misalignment of my neck.
I also have ME/CFS (Myalgic Encephalomyelitis/Chronic Fatigue Syndrome) along with all my other diagnoses. People's quality of life with ME/CFS is extremely poor and severe patient's quality of life is compared to those who are in the end stages of AIDS or who are in the end stages of renal failure. Like P.O.T.S, ME/CFS is a syndrome with numerous symptoms including profound exhaustion, cognitive impairment, and sensory overload to name a few. Almost all people with ME/CFS have some form of autonomic dysfunction. However the most defining symptom of ME/CFS is Post Exertional Malaise (PEM) which is an extreme worsening of symptoms after any sort of exercise or energy exertion. This makes any type of exercise or prolonged activity near impossible and can make many patients bedridden for days afterwards. The condition could even become permanently worse if you continue to force exercise and over exert oneself. Many researchers are finding inflammation of the brainstem and spinal cord with this illness which is most likely the driver of symptoms. They are also finding significant disruptions to the immune system, energy metabolism, and mitochondrial dysfunction in this illness. Many severe patients cannot walk, talk, shower, or even eat anymore due to their gastrointestinal system shutting down requiring them to get a feeding tube to live. The name Chronic Fatigue Syndrome doesn't do this illness justice as it's much more than just being fatigued. The campaign for ME/CFS patients is #MillionsMissing because so much of the world has no clue about this disease and so many can't advocate for themselves, become completely bed bound, and rely on others for daily care. I had no idea about any of these devastating illnesses until I developed them myself. We have linked many videos to better explain ME/CFS and what their quality of life is like and how it isn't just an invisible illness. It also develops after getting a viral/bacterial infection, or physical trauma such as a car accident, concussion, surgery etc. It's one of the many co-morbid conditions that can develop as these are a spectrum of illnesses that commonly occur with each other, especially if you have EDS. There have been many reports of people either finding full remission or having a substantial improvement in their ME/CFS symptoms once fixing their underlying neck instability. However there is no guarantee, and currently there is still no cure for this disease.
Now I am faced with another challenge. There's only two real ways to potentially fix my neck injury and potentially help the conditions caused by it. One is a neck fusion and the other is an experimental treatment called Prolotherapy. I don't want to get my neck fused unless absolutely necessary and all other options are up. Prolotherapy is a treatment where they inject your ligaments in the neck with a solution to help tighten and scar up the ligaments that have been damaged. This then keeps the vertebrae from slipping all over the place and damaging the brain stem and spinal cord. However prolotherapy is also pretty expensive with each treatment costing in the thousands of dollars. My parents have already spent well over $18,000.00 dollars trying to find out what is wrong with me and to get me some help. From E.R. visits, doctor's tests and appointments, medical bills, P.O.T.S. treatment center, and alternative therapies, it's been adding up. We are all very exhausted and it's been very difficult financially trying to deal with this. This has been the most difficult thing to go through in my entire life, as well as my Mom and Dad's lives. Every day is a fight and is very challenging. It has been a lot of information for my family and I to take in and understand during a short period of time. It is extremely important to me that more people and the medical community are educated about these diseases so that more funding can go towards helping the millions of others with these life debilitating conditions. So many are suffering out there with this and they have been underdiagnosed, disbelieved, and even abused by the medical system. There has been a lack of understanding and recognition of these complex illnesses in the medical community so more awareness needs to be made about these conditions. This is most definitely not the end and we are still learning more each day. We are going to need a lot more M.R.I.'s, special testing, and consults with specialist doctors and neurosurgeons going forward. If it wasn't for God and every single person praying for me, I truly don't think I'd still be here. I desperately want to be out in the world having a productive life and helping others instead of being so unwell. I also want to provide hope to other people no matter what they are struggling with and to never give up. I deeply appreciate everyone who has prayed for me and my family, and who have helped us out. If anyone would be willing to donate a little bit, my family and I would be extremely grateful. If you read this far, I am again deeply appreciative and thankful that you are willing to hear my story. Thank you.
*I am Joshua's older sister Janessa and either myself or my parents will be helping update Joshua's page for him. I would like to link my dad's Venmo account if you feel led to donate there because gofundme does take a small percentage from donations. His Venmo is @Scott-Scherrman. Our family can not begin to express the gratitude for the kindness so many people have shown Joshua from all different walks of our lives. Thank you so so much.*
Hi, my name is Josh. In late April 2019, I suddenly became so ill that I have now become essentially disabled and almost completely bed bound. My decline of health mostly started after I contracted some sort of pathogen and getting my neck injured from forceful chiropractic manipulations. Instead of getting sick and then recovering in a couple weeks, I became sick and stayed sick. The symptoms hit out of no-where. I experienced extreme fatigue, chills, organ pain, and the lymph nodes on the side of my neck became swollen. Once the initial flu like symptoms died down, I started to develop other symptoms. I had constant debilitating fatigue, exercise intolerance, brain fog, temperature dysregulation, gut issues, low blood pressure, lightheadedness, trouble breathing, tachycardia, palpitations and much more. If I got up too quickly from a seated position my vision would begin to black out and I would feel like I was about to pass out. I had no idea what was wrong with me and was always visiting the nurse at school because I felt so bad. It became extremely difficult to get any work done on time and I almost didn't graduate my senior year of high school because of it. We started visiting multiple doctors to find out what was going on. They couldn't figure out what was wrong as all my blood tests came back relatively normal. I started researching my symptoms and found out about a disorder called P.O.T.S. which stands for Postural Orthostatic Tachycardia Syndrome. Basically whenever I stand up all my blood from my upper body rushes down and pools in my legs and feet due to gravity. The heart tries to compensate for this lack of blood by increasing heart rate to maintain consciousness. Many people pass out due to a lack of blood flow to the brain. It also affects basically every organ and system of your body as P.O.T.S is a form of autonomic nervous system dysfunction. The autonomic nervous system controls everything you don't consciously think about including heart rate, blood pressure, breathing, digestion, etc. This explains the huge range of symptoms people experience along with the lightheadedness and tachycardia if this system gets disrupted. The condition usually develops after someone contracts a viral or bacterial infection, physical trauma such as a head injury, surgery, or other stressors on the body. After learning about this I went and got a tilt table test done which showed my heart rate went from 85 to 146 when being tilted to the vertical position, and my blood pressure dropped to 103/78. I felt very nauseous and unwell so the nurses ended the test and put me in the horizontal position again to prevent me from passing out or getting worse.
There is no "official" cure for P.O.T.S as it's a complex illness with many underlying causes. The only way to get well or find remission from P.O.T.S. is to discover and treat the underlying condition which is ultimately causing it. Most doctors just treat the symptoms and the standard treatments for P.O.T.S doesn't help everyone. Most doctors don't even know about P.O.T.S so many people with this condition have to find specialists for it. After trying standard treatments and not getting better I started looking at other options. I was rapidly deteriorating and kept developing new symptoms as time progressed to my dismay. I unintentionally lost over 30 pounds despite eating a lot which has made me become very underweight. I became bedridden and my family has to do most things for me such as make and bring me food. Just getting to walk over to the bathroom has become extremely difficult. The simplest tasks most people don't even think about became some of the greatest challenges for me. Most of my days consist of lying in bed immobilized just trying to deal with an onslaught of severe symptoms. Just simply sitting up in bed cause tachycardia, palpitations, lightheadedness, breathlessness, vertigo, and fatigue. The only time I'm able to leave the house is for medical tests and appointments and even that small amount of effort causes a significant worsening of symptoms. Since traditional doctors didn't help at all, my family and I went to a P.O.T.S Center in Texas for more answers on what exactly is going on. They did a bunch of tests which ruled out a lot of other conditions that could potentially cause this condition which was very helpful. I found out I have an inherited connective tissue disorder called Ehlers-Danlos Syndrome (EDS) which is common in P.O.T.S patients. EDS is a connective tissue disorder where you have hypermobile joints and ligaments due to faulty collagen production. Having EDS predisposed myself to develop this condition. I also found out that my vagus nerve is either damaged or dysfunctional. The vagus nerve is considered to be one of the most important nerves in the body. It is actually a pair of two nerves that come out of your brain stem and run down the sides of your neck and enter into your body. It helps control almost every single organ to work properly. If it gets damaged you can start having issues with your heart, lungs, stomach, liver, gallbladder, intestines, and more. The vagus nerve is essential for proper functioning of your autonomic nervous system so if it gets injured or damaged that's when you can run into serious problems. It also makes your para-sympathetic nervous system work properly which is the "rest and digest" system of the body. Because of this issue I found out that my sympathetic nervous system is in overdrive and also that my body isn't clearing inflammation properly. They prescribed a bunch of medications but my stomach couldn't handle it. I got a lot of answers and it ruled out a bunch of other conditions but there was still something missing.
Not long after getting ill, my neck started bothering me. It would crack very audibly and noticeably right at the base of the skull. Other areas of my neck would grind and crack as well. I get extreme headaches that come about randomly and sharp pain at the top of my neck. There is also a sensation that my neck is too weak to hold my head up. I started doing more research and found to my surprise that many people with P.O.T.S have issues with their necks. In fact it's actually the cause of their P.O.T.S as the neck instability presses on the brain stem which is the Autonomic Nervous System Epicenter. Many people not only develop P.O.T.S after acquiring an infection, but also by injuring their head and neck such as whiplash from a car accident, concussions, falls, etc. I personally talked to many people who had developed dysautonomia after getting whiplash injuries and having their necks manipulated. It was recommended to get a Digital Motion X-Ray (DMX) done which is a special type of X-Ray that shows how your neck moves in motion. I went and got a DMX done and it showed that I have instability at my C1 vertebrae where it is slipping left and right whenever I tilt or bend my neck. Here is a few snapshots from my report below:
There should be no extra or abnormal movement at all as even a couple millimeters of extra movement can cause damage to the neural structures in the area. The DMX also showed instability at C3, C4, C5 & C6. It turns out my ligaments holding my vertebrae in place are damaged. It just so happens that a month before I got sick, I went to a chiropractor to help an old injury to my collar bone. While I was there he manipulated and cracked my neck multiple times which wasn't necessary in my view as my neck was not bothering me at the time. I had multiple visits with him all through the month of April in hopes of correcting my collarbone. I noticed throughout the month that's when I started to have issues with the lightheadedness, tunnel vision, exercise intolerance, and tachycardia when standing. I felt the worst after the last adjustment but never made any connections on what caused it at the time. It was then only a week later in early May when I became extremely sick with a pathogen. This is what caused the downward cascade of health and is when the majority of the autonomic symptoms became prominent. These high velocity manipulations most likely damaged and misaligned my neck especially considering that I have a connective tissue disorder. It also explains how my vagus nerve became damaged and dysfunctional as it runs right in front of C1 & C2 where I have the extra movement due to injured ligaments. The vagus nerve is also involved in the proper functioning of the immune system and controlling the inflammatory response in the body. So if the nerve becomes compromised somehow, any pathogen you get can cause more damage to your body and nervous system which most likely happened in my case. Below, I attached images of my neck in the neutral position from a CT scan rendered in 3D. My C1 is shifted over and my C2 is rotated forward while looking straight. A few doctors think my alar ligaments are probably torn from the manipulations as they are the ligaments that hold these two important vertebrae in the correct alignment. There should be no overhang or rotation in the neutral position. This is very abnormal and it is causing compression of the vagus nerve and irritating my brainstem which is likely resulting in the autonomic dysfunction. This is neurosurgeon Dr. Gilete who is one of the experts in this condition explaining and diagnosing someone's neck instability below. I had a consultation with him and he diagnosed me with Craniocervical Instability (CCI), Atlantoaxial Instability (AAI), Subaxial Instability, and neutral C1 - C2 misalignment (as seen above). With CCI, my skull is essentially sliding backwards too much whenever I look upward due to damaged and hypermobile ligaments. With AAI, my head is turning too far when looking left and right and the atlantoaxial joints are subluxing when this happens. Subaxial Instability is all the vertebrae below C1 and C2 that have become unstable. I also have evidence of Intracranial Hypertension which is when your spinal fluid accumulates and becomes too high on the brain. This causes severe headaches along with nausea and vomiting. If it gets too bad it can even lead to blindness. There are many things that can cause it but in my case it's most likely due to inadequate drainage of spinal fluid because of the neutral misalignment of my neck.I also have ME/CFS (Myalgic Encephalomyelitis/Chronic Fatigue Syndrome) along with all my other diagnoses. People's quality of life with ME/CFS is extremely poor and severe patient's quality of life is compared to those who are in the end stages of AIDS or who are in the end stages of renal failure. Like P.O.T.S, ME/CFS is a syndrome with numerous symptoms including profound exhaustion, cognitive impairment, and sensory overload to name a few. Almost all people with ME/CFS have some form of autonomic dysfunction. However the most defining symptom of ME/CFS is Post Exertional Malaise (PEM) which is an extreme worsening of symptoms after any sort of exercise or energy exertion. This makes any type of exercise or prolonged activity near impossible and can make many patients bedridden for days afterwards. The condition could even become permanently worse if you continue to force exercise and over exert oneself. Many researchers are finding inflammation of the brainstem and spinal cord with this illness which is most likely the driver of symptoms. They are also finding significant disruptions to the immune system, energy metabolism, and mitochondrial dysfunction in this illness. Many severe patients cannot walk, talk, shower, or even eat anymore due to their gastrointestinal system shutting down requiring them to get a feeding tube to live. The name Chronic Fatigue Syndrome doesn't do this illness justice as it's much more than just being fatigued. The campaign for ME/CFS patients is #MillionsMissing because so much of the world has no clue about this disease and so many can't advocate for themselves, become completely bed bound, and rely on others for daily care. I had no idea about any of these devastating illnesses until I developed them myself. We have linked many videos to better explain ME/CFS and what their quality of life is like and how it isn't just an invisible illness. It also develops after getting a viral/bacterial infection, or physical trauma such as a car accident, concussion, surgery etc. It's one of the many co-morbid conditions that can develop as these are a spectrum of illnesses that commonly occur with each other, especially if you have EDS. There have been many reports of people either finding full remission or having a substantial improvement in their ME/CFS symptoms once fixing their underlying neck instability. However there is no guarantee, and currently there is still no cure for this disease.
Now I am faced with another challenge. There's only two real ways to potentially fix my neck injury and potentially help the conditions caused by it. One is a neck fusion and the other is an experimental treatment called Prolotherapy. I don't want to get my neck fused unless absolutely necessary and all other options are up. Prolotherapy is a treatment where they inject your ligaments in the neck with a solution to help tighten and scar up the ligaments that have been damaged. This then keeps the vertebrae from slipping all over the place and damaging the brain stem and spinal cord. However prolotherapy is also pretty expensive with each treatment costing in the thousands of dollars. My parents have already spent well over $18,000.00 dollars trying to find out what is wrong with me and to get me some help. From E.R. visits, doctor's tests and appointments, medical bills, P.O.T.S. treatment center, and alternative therapies, it's been adding up. We are all very exhausted and it's been very difficult financially trying to deal with this. This has been the most difficult thing to go through in my entire life, as well as my Mom and Dad's lives. Every day is a fight and is very challenging. It has been a lot of information for my family and I to take in and understand during a short period of time. It is extremely important to me that more people and the medical community are educated about these diseases so that more funding can go towards helping the millions of others with these life debilitating conditions. So many are suffering out there with this and they have been underdiagnosed, disbelieved, and even abused by the medical system. There has been a lack of understanding and recognition of these complex illnesses in the medical community so more awareness needs to be made about these conditions. This is most definitely not the end and we are still learning more each day. We are going to need a lot more M.R.I.'s, special testing, and consults with specialist doctors and neurosurgeons going forward. If it wasn't for God and every single person praying for me, I truly don't think I'd still be here. I desperately want to be out in the world having a productive life and helping others instead of being so unwell. I also want to provide hope to other people no matter what they are struggling with and to never give up. I deeply appreciate everyone who has prayed for me and my family, and who have helped us out. If anyone would be willing to donate a little bit, my family and I would be extremely grateful. If you read this far, I am again deeply appreciative and thankful that you are willing to hear my story. Thank you.
*I am Joshua's older sister Janessa and either myself or my parents will be helping update Joshua's page for him. I would like to link my dad's Venmo account if you feel led to donate there because gofundme does take a small percentage from donations. His Venmo is @Scott-Scherrman. Our family can not begin to express the gratitude for the kindness so many people have shown Joshua from all different walks of our lives. Thank you so so much.*
Organizer
Joshua Scherrman
Organizer
Bethlehem, PA