Danijela Jelovac, M.D.

• Assistant Professor of Oncology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/5503711/danijela-jelovac

Instructor in Medicine [1989] Instructor in Plastic and Reconstructive Surgery Andrea Freyer Dugas cholesterol test kit australia discount 10 mg crestor overnight delivery, M cholesterol juice buy crestor canada. Instructor in Art as Applied to Medicine [2002] Instructor in Psychiatry [1999] Elana Judith Fertig healthy delicious cholesterol lowering foods discount crestor 10 mg amex, Ph high density cholesterol foods order crestor 10mg line. Instructor in Pediatrics [2010] Instructor in Orthopaedic Surgery [2005] Marjorie Ann Fessler, Ed. Instructor in Pediatrics [1995] Instructor in Psychiatry [1989] Gregory Charles Fey, M. Instructor in Radiology [2011] (from 09/09/2011) Instructor in Medicine [2011] Cynthia Dianne Fields, M. Instructor in Psychiatry [2010] Instructor in Medicine [2011; 2009] (from Beverly A. Instructor in Pediatrics [2003] Instructor in Anesthesiology and Critical Care Jerold H. Instructor in Ophthalmology [1997] Instructor in Otolaryngology-Head and Neck Donald E. Instructor in Medicine [1991] Instructor in Medicine [2011] Catherine Anne Foss, Ph. Instructor in Psychiatry [1974], Joint Appointment Instructor in Neurology [2004] in Medicine [2002] Kenneth L. Instructor in Medicine [2006] Instructor in Art as Applied to Medicine [2002; 1993] Stephen B. Instructor in Medicine [1996] Instructor in Medicine [1999] Jason Neil Goldstein, M. Instructor in Neurology [1998] Instructor in Radiology [2010; 2008] Juan Fernando Gomez, M. Instructor in Radiology [2011] Instructor in Pediatrics [2008] Anna Marie Gonzaga, M. Pathobiology [2011; 1998] (from 10/01/2011), Instructor in Medicine [2010] Research Associate in Molecular and Comparative Pathobiology [1998] (to 09/30/2011) John L. Instructor in Radiology [2010; 2006] Instructor in Psychiatry [2010] Neeraj Gandotra, M. Instructor in Orthopaedic Surgery [2002] Instructor in Psychiatry [2004] Travis Francis Ganunis, M. Instructor in Medicine [1995] Instructor in Pediatrics [1992; 1985] Venkat Pradeep Gundareddy, M. Instructor in Medicine [2010] Instructor in Medicine [1991; 1992] Hilary Eileen Gwynn, M. Instructor in Neurology [2007] Instructor in Psychiatry [1997] Florence Hackerman, M. Instructor in Psychiatry [2004; 2002] Instructor in Medicine [2010] Tammy Denise Hadley, M. Instructor in Psychiatry [1996] Instructor in Radiation Oncology and Molecular Radiation Sciences [2010] Stephen A. Instructor in Psychiatry [1994] Instructor in Medicine [2010] Sheila Mohajer Hofert, M. Instructor in Physical Medicine and Rehabilitation Instructor in Medicine [2004] [2008] Lenard H. Instructor in Medicine [2009] Instructor in Gynecology and Obstetrics [2006] Raymond J. Instructor in Plastic and Reconstructive Surgery Instructor in Physical Medicine and Rehabilitation [2004] [2004] Hilary R. Instructor in Physical Medicine and Rehabilitation Instructor in Anesthesiology and Critical Care [2010] Medicine [2001] Robert Y. Instructor in Medicine [2005] Instructor in Pediatrics [2011; 2006] Steven Li-Wen Hsu, M. Jones, Instructor in Radiology [2011] Instructor in Art as Applied to Medicine [2001] Amy Laura Huberman, M. Instructor in Psychiatry [2010] Instructor in Psychiatry [1981] Paula Jill Hurley, Ph. Instructor in Urology [2008] Instructor in Medicine [2011] Eric Kenneth Hutchinson, D. Instructor in Molecular and Comparative Instructor in Neurology [2010; 2008] Pathobiology [2011] Christine Kajubi, M. Instructor in Medicine [2007] Instructor in Medicine [2010] Zachary Aaron Kaminsky, Ph. Assistant Professor of Psychiatry [2011; 2010] Instructor in Medicine [2006] (from 08/01/2011), Instructor in Psychiatry [2010] (to 07/31/2011) Elias S. Instructor in Plastic and Reconstructive Surgery Instructor in Medicine [2006] [1989] Koko Ishizuka, M. Instructor in Psychiatry [2011; 2009] Instructor in Medicine [2001] Hanna Jaaro-Peled, Ph. Instructor in Psychiatry [2010] Instructor in Medicine [2008] Allesa Paige Jackson, M. Instructor in Psychiatry [2002] Instructor in Medicine [2003] Cheryl Anne Jackson, M. Instructor in Medicine [1996] Instructor in Gynecology and Obstetrics [2007] Lisa Anne Jacobson, Ph. Instructor in Psychiatry [2010] Instructor in Medicine [2006] Julie Mendelson Jacobstein, M. Instructor in Gynecology and Obstetrics [2006] Instructor in Psychiatry [1986] Gabrielle Andrea Jacquet, M. Instructor in Emergency Medicine [2011] Instructor in Plastic and Reconstructive Surgery Alpa Laheri Jani, M. Instructor in Medicine [1986; 1981] Instructor in Physical Medicine and Rehabilitation Kevin P. Instructor in Medicine [2006] Instructor in Anesthesiology and Critical Care Na Young Ji, M. Instructor in Medicine [2010] Instructor in Radiology [2011] Adnan Nawaz Kiani, M. Instructor in Medicine [2008; 2006] Instructor in Anesthesiology and Critical Care Barbara Ann Kim, M. Instructor in Gynecology and Obstetrics [2011] Instructor in Emergency Medicine [2009] Jenny J. Instructor in Oncology [2010] Instructor in Otolaryngology-Head and Neck Myoung Sook Kim, Ph. Instructor in Gynecology and Obstetrics [1994] Instructor in Orthopaedic Surgery [2001] Thomas J. Instructor in Medicine [2005] Instructor in Physical Medicine and Rehabilitation Angela Kim-Lee, M. Instructor in Psychiatry [2011] Instructor in Psychiatry [2005] James Mark Leipzig, M. Instructor in Orthopaedic Surgery [1998] Instructor in Medicine [2011; 2009] Enzo J. Instructor in Psychiatry [1990] Instructor in Pediatrics [1984; 1980] Charles Mitchell Leve, M. Instructor in Anesthesiology and Critical Care Instructor in Medicine [2010] Medicine [2003] Buddy Gene Kozen, Jr. Instructor in Emergency Medicine [2007] Instructor in Oncology [1979], Instructor in Otolaryngology-Head and Neck Surgery [2010] Chris Kraft, Ph. Instructor in Medicine [2009] Instructor in Gynecology and Obstetrics [1988] Guanshu Liu, Ph. Instructor in Radiology [2010; 2008] Instructor in Plastic and Reconstructive Surgery [2005] Manchang Liu, M. Instructor in Radiology [2007] Instructor in Surgery [2011] (from 08/01/2011) Olga I.

In party; I feel positive emotions and to groups they like to talk cholesterol medication atorvastatin buy crestor without a prescription, assert comfortable around seek out stimulation and the themselves cholesterol lowering foods red yeast rice best order for crestor, and draw attention to people; I talk to a lot company of others themselves ideal cholesterol panel buy discount crestor on line. They are generally emotions; I make cooperative rather than considerate cholesterol medication bad breath order crestor with mastercard, friendly, generous, helpful, people feel at ease. Neuroticism I am not usually A tendency to experience Those who score high in neuroticism relaxed; I get upset negative emotions, such as are more likely to interpret ordinary easily; I am easily anger, anxiety, or situations as threatening and minor disturbed. They called emotional may have trouble thinking clearly, instability making decisions, and coping effectively with stress. For example, when people enter their first serious relationship, they become more agreeable and less neurotic. Also, when we start our first job, we become more conscientious and agreeable (Vazire, 2014). Personality stability remains strong in middle adulthood (Lucas & Donnellan, 2011), however, there are slight changes in personality as one ages. According to the research, conscientiousness and agreeableness show small increases with age, while neuroticism, extraversion, and openness show slight declines with age (Lachman & Bertrand, 2001; Lucas & Donnellan, 2011; Allemand, Zimprich, & Martin, 2008). When differences are found, women tend to score slightly higher than men on conscientiousness, agreeableness, and neuroticism, and some studies show women may be slightly higher on extraversion, but only on the aspects of extraversion that involve gregariousness, warmth, and Source positive emotions, while men score higher on the assertiveness and excitement seeking aspects of extraversion (Costa, Terracciano, & McCrae, 2001; Weisberg, DeYoung, & Hirsh, 2011). Rather than studying hundreds of traits, researchers can focus on only five underlying dimensions. For instance, the trait dimension of need for achievement relates to the Big Five variable of conscientiousness, and self-esteem relates to low neuroticism. On the other hand, the Big Five factors do not seem to capture all the important dimensions of personality. For instance, the Big Five does not capture moral behavior (Ashton & Lee, 2008), although this variable is important in many theories of personality. There is also evidence that the Big Five factors are not the same across all cultures (Cheung & Leung, 1998). Personality will only predict behavior when the behaviors are aggregated or averaged across different situations. We might not be able to use the personality trait of friendliness to determine how friendly Malik will be on Friday night, but we can use it to predict how friendly he will be the next year in a variety of situations. When many measurements of behavior are combined, there is much clearer evidence for the stability of traits and for the effects of traits on behavior (Roberts & DelVecchio, 2000; Srivastava, John, Gosling, & Potter, 2003). Describe evidence for the effects of genetics, the environment, and interactions of the two on personality. In 2003, 35 years after she was adopted, Elyse, acting on a whim, inquired about her biological family at the adoption agency. One question that is exceedingly important for the study of personality concerns the extent to which it is the result of nature or nurture. If nature is more important, then our personalities will form early in our lives and will be difficult to change later. If nurture is more important, however, then our experiences are likely to be particularly important, and we may be able to alter our personalities over time. In this section we will see that the personality traits of humans and animals are determined in large part by their genetic makeup. Thus, it is no surprise that identical twins Paula Bernstein and Elyse Schein turned out to be very similar, even though they had been raised separately, but we will also see that genetics does not determine everything. These abilities and characteristics are known as instincts, or complex inborn patterns of behaviors that help ensure survival and reproduction (Tinbergen, 1951). Birds naturally build nests, dogs are naturally loyal to their pack, and humans instinctively learn to walk, Source speak, and understand language. Some genes tend to increase a given characteristic and others work to decrease that same characteristic. The complex relationship among the various genes, as well as a variety of random factors, produces our personality. Having a given pattern of genes does not necessarily mean that a particular trait will develop, because some traits might occur only in some environments. For example, a person may have a genetic variant that is known to increase his or her risk for developing alcoholism, but if that person 260 never drinks because they live in a country where alcohol is not available, then the person will not become alcoholic. In addition to the effects of inheritance (nature) and environment (nurture), interactions between these two also influence personality. A high stress environment affects a genetically anxious person differently than a low stress environment. Perhaps the most direct way to study the role of genetics in personality is to selectively breed animals for the trait of interest. In this approach the scientist chooses the animals that most strongly express the personality characteristics of interest and breeds these animals with each other. In this manner, scientists have studied the role of genetics in how worms respond to stimuli, how fish develop courtship rituals, how rats differ in play, and how pigs differ in their responses to stress. Behavioral Genetics Although selective breeding studies can be informative, they are clearly not useful for studying humans. For this, psychologists rely on behavioral genetics, which is a variety of research techniques that scientists use to learn about the genetic and environmental influences on human behavior by comparing the traits of biologically and nonbiologically related family members (Baker, 2004). Behavioral genetics is based on the results of family studies, twin studies, and adoptive studies. The presence of the trait in first-degree relatives (parents, siblings, and children) is compared to the prevalence of the trait in second degree relatives (aunts, uncles, grandchildren, grandparents, nephews, and nieces) and in more distant family members. The scientists then analyze the patterns of the trait in the family members to see the extent to which it is shared by closer and more distant relatives. Source Although family studies can reveal whether a trait runs in a family, it cannot explain why. In a twin study, the data from many pairs of twins are collected and the rates of similarity for identical and fraternal pairs are compared. A correlation coefficient is calculated that assesses the extent to which the trait for one twin is associated with the trait in the other twin. Studies on twins rely on the fact that identical (or monozygotic) twins have essentially the same set of genes, while fraternal (or dizygotic) twins have, on average, a half-identical set. In other words, if environmental factors are the same, then the only factor that can make identical twins more similar than fraternal twins is their greater genetic similarity. Monozygotic or identical twins occur when a fertilized egg splits apart in the first two weeks of development. Sometimes, however, two eggs or ova are released and fertilized by two separate sperm. These two individuals share the same amount of genetic material as would any two children from the same mother and father. Older mothers are more likely to have dizygotic twins than are younger mothers, and couples who use fertility drugs are also more likely to give birth to dizygotic twins. Consequently, there has been an increase in the number of fraternal twins recently (Bortolus et al. Source: Monozygotic Twins Source Dizygotic Twins An adoption study compares biologically related people, including twins, who have been reared either separately or apart. Evidence for genetic influence on a trait is found when children who have been adopted show traits that are more similar to those of their biological parents than to those of their adoptive parents. Although twin and adoption studies differ in their methodologies, both studies conclude that genetics is important in determining personality, as well as other cognitive (intelligence levels) and behavioral (psychopathologies) characterisitcs (Kim & Kim, 2011; Plominm, Defries, Knopik, & Neiderhiser, 2013). Results indicate that identical twins are much more similar than fraternal twins, and therefore these results strongly suggest genetic influences. Similarly, adoption studies demonstrate stronger family resemblances, even when family members are separated due to adoption. However, adoption studies do not demonstrate the level of heritability that the twin studies do (Kim & Kim, 2011). Molecular genetics is the study of which genes are associated with which personality traits (Goldsmith et al. Molecular genetics researchers have also developed new techniques that allow them to find the locations of genes within chromosomes and to identify the effects those genes have when activated or deactivated.

Both these alternatives interpret variation in commitment to moral norms as a maladaptive byproduct of a weakness or inconsistency in human psyche cholesterol cell membrane definition purchase crestor 20 mg. Either the difficulty of self-sacrifice or the difficulty of foregoing short-term benefits for long-term ones is proposed as the psychological constraint that limits compliance with moral rules cholesterol level by age purchase crestor 20mg amex. An evolutionary perspective raises doubts about the explanatory power of both these solutions cholesterol levels liver disease order 5 mg crestor with amex. If moral behavior were simply a hindrance to the competitive 67 ascendancy of the individual cholesterol test dischem buy generic crestor line, one would expect it to dwindle, and if it were simply adaptive, then absolute compliance would evolve and presumably sweep to with fixation. Given this situation, Peters (2003) recently drew attention to the fact that evolutionary studies of morality have still failed to produce an effective explanation of the fact that humans appear to be disposed both toward and against prosocial or group-serving behavior. An attempt to explain the adaptive significance of perfectly moral behavior, although a common goal, is misguided since such behavior is never observed. We contend that a successful theory must address the adaptive significance of the facultative adherence to moral absolutes. From this perspective, the traits that appear to be adaptations are the capacity for moral behavior and the tendency toward moral deliberation, as distinct from the execution of any particular behaviors all the time. If this is correct, the key to understanding morality from an evolutionary perspective lies in discovering the extrinsic factors that govern moral deliberation and moral commitment. The merit of an evolutionary explanation for moral behavior can be judged on its ability to predict what conditions will produce compliance versus defection. Can variability in human environments explain our plasticity in following the rules Morality and intergroup competition Richard Alexander has shown that two related facts are key elements in an evolutionary understanding of morality. First, humans "evolved to live in groups, within which they both cooperate and compete and outside of which they presumably failed consistently"; secondly, "some acts of costly beneficence enable the survival of the entire group, when that outcome is essential for our own survival" (Alexander, 2004; see also 1992; 1987). Social grouping evolved in humans in an unprecedented way, with low within-group relatedness (relative to eusocial animals) and multiple breeding males within groups. Alexander built on earlier writers such as Darwin (1871) and Keith (1949) in explaining the evolution of this phenomenon. The most important mechanisms for this cooperation appear to have been (a) extensive and differential nepotism, and, arising in this context, (b) social reciprocity of two different sorts. The direct sort is the process of "indefinitely continuing interactions between intelligent beings in which each can benefit from cooperating with the other, and defection will in the long run represent net losses to the defector. The indirect sort of reciprocity arises when multiple parties interact in the same way that two do in direct reciprocity. In a species with powers of observation, memory, and communication of individual reputations within a social group, rewards for cooperating (and punishments for defecting) can be administered by "society at large, or from other than the actual recipient of beneficence" (Alexander, 1979). If humans have tended throughout their history to fail outside social groups, and if threats from other groups have rendered the suppression of competition within a group necessary for individual reproductive success, it is not surprising that individuals should often subjugate their own interests to those of their groups. Insofar as morality requires attention to group causes such as the welfare of others, morality functions as social cement and thus tends to contribute to long-term individual interests, i. Moreover, as indirect reciprocity became important for insuring service to the group, individuals perceived as morally upstanding would gain additional benefits through the approbation of others. These two interactive processes are broadly similar to the two kinds of games (public goods and image scoring) that recent experimental studies have employed to illustrate the dynamics of human cooperation. Indirect reciprocity may be able to account for part of the facultative or inconstant nature of human commitment to moral norms. The net effect is dependent on (a) the direct costs and benefits of the action, (b) the likelihood of being observed or of reports being believed, (c) the reputational shift that will result, and (d) the expected return on that shift in future interactions. Sensitivity to cues of these parameters and their net effect on fitness would account for a degree of nonrandom variation in adherence to moral norms. Such, perhaps, is the adaptive value of the refined moral systems characteristic of extant human groups, where the proceeds from indirect reciprocity arguably have grown to be more relevant to decision-making than the proceeds from continued group persistence. For an average member of a modern group, the likelihood of suffering a significant fitness cost from the damage to reputation that an immoral choice can produce, is much higher than the likelihood of suffering a significant fitness cost from the loss of group unity that might arise from that choice. This is so even if Darwin and Alexander are correct in arguing that the need for solidarity against threats from other groups is precisely what drove the evolution of human cooperation, including those actions maintained by indirect reciprocity, in the first place. To elaborate more fully the relationship between indirect reciprocity and human social structure, one can demonstrate that indirect reciprocity today depends on a concept of group service, but the existence of group service does not depend on indirect reciprocity. Humans expend significant effort debating the validity of claims of selflessness and bestowing praise for actions deemed selfless. Shrewdness does persist, because it can sometimes be an effective way to exploit the system, but it is discouraged by moral norms and thus suppressed by indirect reciprocity. The centrality of the concept of service or selflessness in moral norms (Roes & Raymond, 2002; Ridley, 1996) 70 suggests that within-group cooperation in the face of intergroup competition still underlies indirect reciprocity today. Otherwise, entertaining the idea that the actions of others can have group-serving motivations would be maladaptive. Moreover, in order for the earliest form of indirect reciprocity to produce fitness benefits, a belief in group service must already have existed, implying an independent evolutionary origin. The human social situation of within-group cooperation as a form of between-group competition explains why the concept of selflessness, rather than shrewdness, is the value encouraged by indirect reciprocity. Following this reasoning, we propose that there was a period in the evolution of morality when group service was adaptive due to rising intergroup competition, but before indirect reciprocity became dominant. Furthermore, the dynamics that drove cooperation at this intermediate stage in the evolution of morality may still be important today. Since moral norms are still pervaded by a strong group-service element, something about human social group dynamics are probably still today providing the values for indirect reciprocity, i. Group stability Competition between groups implies that groups, like individuals, vary in how well they are doing. In the absence of a governing structure, such that groups are autonomous or nearly so, competition between groups for limited resources will function like competition between individuals, with variation in groups likelihood of persistence analogous to the concept of fitness that evolutionary biologists use to compare individuals. Principle of stability-dependent cooperation If humans are facultative in adherence to moral norms (section 2), and moral norms arose and are probably still maintained in the context of intergroup competition 71 (section 3), then variation in individual commitment to moral norms over time and space may reflect variation in the degree to which groups require service. Thus, the first of two principles we introduce to describe the dynamical function of morality in human history is stability-dependent cooperation. We propose that people vary in the relative importance they place on the individual versus the group in their working value systems or decision rules, because individual sacrifice in service to the group at a given time and place is adaptive in inverse proportion to the stability of the group relative to its competitors. Even proponents of a relatively strict developmental structure to morality have allowed for, and found indirect evidence of, apparently adaptive differences among cultures in the way morality is used to guide individual decisions (Nisan & Kohlberg, 1982; Edwards, 1975). Also, evolutionary psychologists and anthropologists have shown that rules of social exchange can vary in ways that are predictable from environmental conditions (review in Cohen & Vandello, 2001; Cosmides & Tooby, 1992). The principle of stability-dependent cooperation offered here predicts adaptive variation specifically in commitment to moral rules, as distinct from in the rules themselves or the development of their recognition. The foundation for this principle is the dynamic of natural selection in situations where individuals with divergent interests exist in collectives on which their persistence depends. A parallel dynamic best explains the overarching cooperation of genetic elements temporarily united in a genome. The genome works together, and subsets only rarely seek their own interests at the expense of other elements (Buss, 1987), because the persistence of a gene or chromosome depends on the survival and reproduction of the individual housing it. Cooperation to increase individual fitness is therefore usually the best strategy for a genomic element. When genetic elements behave competitively within a genome, as in T-haplotype mice (Lyon, 2003) this tends to produce negative fitness consequences for the individual, and thus for all other elements within it. Service to group causes fosters unity, and can decrease the effects of resource limitation. Conversely, within-group competition arising from individual self-interest can be self defeating: resource utilization becomes less efficient, and group unity erodes, increasing susceptibility to intergroup competition. Some writers, often extrapolating from economic models, have hypothesized a general tendency of cooperation either to decay, or to fluctuate in regular boom and bust cycles (Nowak & Sigmund, 1998). Some have gone on to suggest that, given these proposed tendencies, in order for cooperation to be maintained and group persistence to be assured over time, a certain specialized trait must have evolved and persist at some threshold level in the population, such as strong reciprocity involving costly punishment of the selfish (Gintis, 2000) or phenotypic defection involving unintentional lack of service (Lotem et al. Although punishment of various sorts of non-cooperators are certainly features of human culture (Axelrod, 1984), our hypothesis of stability-dependent cooperation is an alternative explanation for the persistence of groups. We propose that the reason why cooperation does not automatically collapse or cycle in the way suggested by economic models is because such models have not yet taken into consideration the general human tendency towards facultative adherence to moral norms, and the resulting negative feedback on booms and busts of cooperation.

Of note raise good cholesterol foods purchase crestor cheap online, there is nearly a 5 fold increase in the risk to patients in outbreaks where a patient is the index case compared with exposure of patients 287 during outbreaks where a staff member is the index case cholesterol hdl ratio definition best crestor 5mg. The average incubation period for gastroenteritis caused by noroviruses is 12-48 273 hours and the clinical course lasts 12-60 hours cholesterol food free buy generic crestor 5mg on-line. Illness is characterized by acute onset of nausea cholesterol lowering drugs 10 mg crestor free shipping, vomiting, abdominal cramps, and/or diarrhea. The disease is largely self-limited; rarely, death caused by severe dehydration can occur, particularly among the elderly with debilitating health conditions. The epidemiology of norovirus outbreaks shows that even though primary cases may result from exposure to a fecally-contaminated food or water, secondary and tertiary cases often result from person-to-person transmission that is facilitated 273, 288 by contamination of fomites and dissemination of infectious particles, 132, 142, 143, 147, 148, 273, 279, 280 especially during the process of vomiting. Widespread, persistent and inapparent contamination of the environment and fomites can 147, 275, 284 make outbreaks extremely difficult to control. It is hypothesized that infectious particles may be aerosolized from vomitus, inhaled, and swallowed. In addition, individuals who are responsible for cleaning the environment may be at increased risk of infection. Development of disease and transmission may be facilitated by the low infectious dose. An alternate phenolic agent that was shown to be effective against feline calicivirus was used 275, 293 for environmental cleaning in one outbreak. There are insufficient data to determine the efficacy of alcohol-based hand rubs against noroviruses when the 294 hands are not visibly soiled. Absence of disease in certain individuals during an outbreak may be explained by protection from infection conferred by the B 295 histo-blood group antigen. These viruses are transmitted to humans via contact with infected animals or via arthropod vectors. While none of these viruses is endemic in the United States, outbreaks in affected countries provide potential opportunities for importation by infected humans and animals. Furthermore, there are concerns that some of these agents 212 could be used as bioweapons. Person-to-person transmission is documented for Ebola, Marburg, Lassa and Crimean-Congo hemorrhagic fever viruses. In resource-limited healthcare settings, transmission of these agents to healthcare personnel, patients and visitors has been described and in some outbreaks has 298-300 accounted for a large proportion of cases. Transmissions within households also have occurred among individuals who had direct contact with ill 301 persons or their body fluids, but not to those who did not have such contact. Person-to-person transmission is associated primarily with direct blood and body fluid contact. Percutaneous exposure to contaminated blood carries a particularly 303, 304 high risk for transmission and increased mortality. The finding of large numbers of Ebola viral particles in the skin and the lumina of sweat glands has raised concern that transmission could occur from direct contact with intact skin 305 though epidemiologic evidence to support this is lacking. Postmortem 301, 306, 307 handling of infected bodies is an important risk for transmission. In rare situations, cases in which the mode of transmission was unexplained among individuals with no known direct contact, have led to speculation that airborne 298 transmission could have occurred. In one study of airplane passengers exposed to an in-flight index case of Lassa fever, there was no 308 transmission to any passengers. In the laboratory setting, animals have been infected experimentally with Marburg 309, or Ebola viruses via direct inoculation of the nose, mouth and/or conjunctiva 310 311, 312 and by using mechanically generated virus-containing aerosols. Transmission of Ebola virus among laboratory primates in an animal facility has 313 been described. Secondarily infected animals were in individual cages and separated by approximately 3 meters. Although the possibility of airborne transmission was suggested, the authors were not able to exclude droplet or indirect contact transmission in this incidental observation. Inconsistencies among the various recommendations have raised questions about the appropriate precautions to use in U. Single gloves are adequate for routine patient care; double-gloving is advised during invasive procedures. N95 or higher level respirators may provide added protection for individuals in a room during aerosol-generating procedures (Table 3, Appendix A). When a patient with a syndrome consistent with hemorrhagic fever also has a history of travel to an endemic area, precautions are initiated upon presentation and then modified as more information is obtained (Table 2). Transmission risks associated with specific types of healthcare settings Numerous factors influence differences in transmission risks among the various healthcare settings. These factors, as well as organizational priorities, goals, and resources, influence how different healthcare settings adapt transmission prevention guidelines to meet 315, 316 their specific needs. However, certain hospital settings and patient populations have unique conditions that predispose patients to infection and merit special mention. These are often sentinel sites for the emergence of new transmission risks that may be unique to that setting or present opportunities for transmission to other settings in the hospital. Furthermore, adverse patient outcomes in this setting 332 are more severe and are associated with a higher mortality. Burn Units Burn wounds can provide optimal conditions for colonization, infection, and transmission of pathogens; infection acquired by burn 320, 339, 340 patients is a frequent cause of morbidity and mortality. Shifts over time in the predominance of pathogens causing 343, infections among burn patients often lead to changes in burn care practices 355-358. Hydrotherapy equipment is an important environmental reservoir of gram negative organisms. Its use for burn care is discouraged based on demonstrated associations between use of contaminated hydrotherapy equipment and infections. Burn wound infections and colonization, as well as bloodstream 361 362 infections, caused by multidrug-resistant P. Advances in burn care, specifically early excision and grafting of the burn wound, use of topical antimicrobial agents, and institution of early enteral feeding, have led to decreased infectious complications. There also is controversy regarding the need for and type of barrier precautions for routine care of burn patients. One retrospective study demonstrated efficacy and cost effectiveness of a simplified barrier isolation protocol for wound colonization, emphasizing handwashing and use of gloves, caps, masks and plastic impermeable aprons (rather than isolation 365 gowns) for direct patient contact. However, there have been no studies that define the most effective combination of infection control precautions for use in burn settings. Additionally, there is a high prevalence of community-acquired infections among hospitalized infants and young children who have not yet become immune either by vaccination or by natural infection. The result is more patients and their sibling visitors with transmissible infections present in pediatric healthcare settings, 36, 40, 41 especially during seasonal epidemics. Close physical contact between healthcare personnel and infants and young children (eg. Practices and behaviors such as congregation of children in play areas where toys and bodily secretions are easily shared and family members rooming-in with pediatric patients can further increase the risk of transmission. Pathogenic bacteria have been recovered from 379 toys used by hospitalized patients; contaminated bath toys were implicated in 80 an outbreak of multidrug-resistant P. In addition, several patient factors increase the likelihood that infection will result from exposure to pathogens in healthcare settings. Children who attend child 383, 384 385 care centers and pediatric rehabilitation units may increase the overall burden of antimicrobial resistance (eg. In addition, healthcare may be provided in nonhealthcare settings such as workplaces with occupational health clinics, adult day care centers, assisted living facilities, homeless shelters, jails and prisons, school clinics and infirmaries. Each of these settings has unique circumstances and population risks to consider when designing and implementing an infection control program. Several of the most common settings and their particular challenges are discussed below. While this Guideline does not address each setting, the principles and strategies provided may be adapted and applied as appropriate. Nursing homes for the elderly predominate numerically and frequently represent long term care as a group of facilities.

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