Ebola virus outbreak

Sclosages · 25-10-2014 12:36am

gozunda wrote: »

Golly Gosh right back at ya - it's the prior use of nasty little comments that make your replies puerile imo. What is a diat btw?

The point IS humans are the same the world over. In the instance in Africa one individual left a health facility in Liberia knowing he was likley infected after being advised not to by medical staff and travelled by plane to Nigeria where he infected others.

In the instance in New York the doctor working with Ebola patients (with a very high risk for potential infection) left Africa to return by plane to the US, did not follow basic self quarantine procedures and has potentially now put others at risk from the disease by a lack of professional behaviour. It is very obvious that it's not even in the same ballpark as your less than complete scenario that a "NY Doc with vague low grade symptoms heading out for a game of bowling".

According to WHO the incubation period, that is, the time interval from infection with the virus to onset of symptoms is 2 to 21 days. The doctor in question had arrived in NY some 10 days previous and was reported as having experienced some indications of infection prior to Going bowling. He also went for a jog, may have gone to a restaurant and traveled the city's vast subway system. As a professional medic the guy was either in denial or was unbelievably lax. At least the African gentleman had some excusability in that was not a trained medical professional.

I agree with the above. Incredibly naive, arrogant, ignorant or simply inconsiderate of that doctor. He, of all people should know what he's dealing with.

Sclosages · 25-10-2014 12:46am

I know of a doctor a couple of years ago who was in a hospital infected with winter vomiting bug. I asked her, whether she was taking extra precautions. Oh yes, I won't get it said she! I wear gloves when touching a patient, I even wear gloves opening the curtains into a patient's bed! Guess who was in isolation with a serious dose of the winter vomiting bug 2 days later? The glove wielding hand-washing doctor.

If any you have time on your hands, do a little experiment for me.

Put some red lipstick on the tips of each of your fingers. Now walk about, doing your business.
If you can't afford a complete house repainting, even wash your hands as per usual.
Now walk around the house, doing your usual business.
You will have red lipstick on walls, light-switches, door handles, doors, sheets, pillow cases, sinks, taps, toilet handles, everywhere.
THAT is why THIS **** SPREADS!

Smidge · 25-10-2014 12:54am

I have had experience of this.
I had a very sick child in a single isolation room (nothing contagious)
Unfortunately there was the NV on the same floor/ nearby wards.

I then also had a very sick child who contracted NV through the staff contact ( I didn't get it and never left the iso room)

People really underestimate how lax a lot of medical staff are with hygiene and disease control.

Sclosages · 25-10-2014 12:57am

Smidge wrote: »

I have had experience of this.
I had a very sick child in a single isolation room (nothing contagious)
Unfortunately there was the NV on the same floor/ nearby wards.

I then also had a very sick child who contracted NV through the staff contact ( I didn't get it and never left the iso room)

People really underestimate how lax a lot of medical staff are with hygiene and disease control.

Blissfully arrogant I think!

Smidge · 25-10-2014 1:02am

Sclosages wrote: »

Blissfully arrogant I think!

Me?

Sclosages · 25-10-2014 1:04am

Smidge wrote: »

Me?

Hardly!

Doctors. Think they know everything there is to know about disease transmission. Arrogance.

ceadaoin. · 25-10-2014 1:10am

But sure norovirus isn't airborne. Everyone knows that you have to roll around in vomit to get it :rolleyes:

Scary to think that ebola is spread in a similar way. I read a post the other day about a hospital experience after childbirth. Understaffed, bloody sheets left on the bed for days and blood clots left on the floors of the bathroom. Absolutely disgusting. If this is indicative of the state of irish hospitals then I would be very worried if, or more likely, when a case arrives.

Sclosages · 25-10-2014 1:18am

ceadaoin. wrote: »

But sure norovirus isn't airborne. Everyone knows that you have to roll around in vomit to get it :rolleyes:

Scary to think that ebola is spread in a similar way. I read a post the other day about a hospital experience after childbirth. Understaffed, bloody sheets left on the bed for days and blood clots left on the floors of the bathroom. Absolutely disgusting. If this is indicative of the state of irish hospitals then I would be very worried if, or more likely, when a case arrives.

As far as I'm concerned, snot is an airborne lethal missile.
Even this blowing into tissues. It's still on your hands (seeping through the tissues).
People should not go to work when snothering.

Smidge · 25-10-2014 1:21am

Sclosages wrote: »

Hardly!

Doctors. Think they know everything there is to know about disease transmission. Arrogance.

Wasn't sure just wanted to check!
I wouldn't say it was solely arrogance in my case. Just total and utter lack of cleanliness and following of protocol.
Sloppy and lazy are the words that come to mind.
And for those who have never had NV or seen a good dose of it....let me tell you it's horrible.

MadYaker · 25-10-2014 1:59am

Anyone know any good ebola jokes?

WakeUp · 25-10-2014 6:22am

Grayson wrote: »

here's a nice snippet on it.

http://www.usatoday.com/story/news/nation/2014/10/06/how-ebola-spreads/16802063/

While it's theoretically possible for someone to become infected through coughing, the WHO's new statement explains why this is highly unlikely.

"Theoretically, wet and bigger droplets from a heavily infected individual, who has respiratory symptoms caused by other conditions or who vomits violently, could transmit the virus – over a short distance – to another nearby person. This could happen when virus-laden heavy droplets are directly propelled by coughing or sneezing (which does not mean airborne transmission) onto the mucus membranes or skin with cuts or abrasions of another person."

Its interesting in that article the use of the word "theoretical" by themselves and the WHO. there were some studies done in 95 in the medical research institute, Maryland by some scientists P Jarhling among them his name has cropped up a bit. not sure if this has been posted yet previously in the thread. maybe its already established that it is possible albeit through high enough volumes of virus loads and it isnt just a theory.
____________________________________________________________

Lethal experimental infections of rhesus monkeys by aerosolized Ebola virus:

The potential of aerogenic infection by Ebola virus was established by using a head-only exposure aerosol system. Virus-containing droplets of 0.8-1.2 microns were generated and administered into the respiratory tract of rhesus monkeys via inhalation. Inhalation of viral doses as low as 400 plaque-forming units of virus caused a rapidly fatal disease in 4-5 days. The illness was clinically identical to that reported for parenteral virus inoculation, except for the occurrence of subcutaneous and venipuncture site bleeding and serosanguineous nasal discharge. Immunocytochemistry revealed cell-associated Ebola virus antigens present in airway epithelium, alveolar pneumocytes, and macrophages in the lung and pulmonary lymph nodes; extracellular antigen was present on mucosal surfaces of the nose, oropharynx and airways. Aggregates of characteristic filamentous virus were present within type I pneumocytes, macrophages, and air spaces of the lung by electron microscopy. Demonstration of fatal aerosol transmission of this virus in monkeys reinforces the importance of taking appropriate precautions to prevent its potential aerosol transmission to humans.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1997182/

Grayson · 25-10-2014 7:49am

Sclosages wrote: »

I know of a doctor a couple of years ago who was in a hospital infected with winter vomiting bug. I asked her, whether she was taking extra precautions. Oh yes, I won't get it said she! I wear gloves when touching a patient, I even wear gloves opening the curtains into a patient's bed! Guess who was in isolation with a serious dose of the winter vomiting bug 2 days later? The glove wielding hand-washing doctor.

If any you have time on your hands, do a little experiment for me.

Put some red lipstick on the tips of each of your fingers. Now walk about, doing your business.
If you can't afford a complete house repainting, even wash your hands as per usual.
Now walk around the house, doing your usual business.
You will have red lipstick on walls, light-switches, door handles, doors, sheets, pillow cases, sinks, taps, toilet handles, everywhere.
THAT is why THIS **** SPREADS!

So what you're saying is that we should isolate all doctors and place them in permanent quarantine?

I'd also recommend that you educate yourself about ebola. It's not the flu virus. It's extremely hard to pick it up from a surface. You generally need to have direct contact with the patient.

here's an article i posted here yesterday.

http://well.blogs.nytimes.com/2014/10/23/can-you-get-ebola-from-a-bowling-ball/?_php=true&_type=blogs&partner=rss&emc=rss&_r=0

THAT'S NOT HOW THIS ****SPREADS
(I generally don't do caps lock, but I felt if i descended to your level you might understand it)

gozunda · 25-10-2014 8:05am

Grayson wrote: »

So what you're saying is that we should isolate all doctors and place them in permanent quarantine?

For anyone who has been in direct contact with patients who have contracted the disease and who are at high risk from infection as a result - yes a period of isolation equal to the incubation of the disease would be a good idea.

Grayson wrote: »

I'd also recommend that you educate yourself about ebola. It's not the flu virus. It's extremely hard to pick it up from a surface. You generally need to have direct contact with the patient.
it

The issue here is doctors do have direct contact with one or more infected patients and for that reason this is why they are wearing this type of PPE but guess what some doctors / medical staff are still becoming infected

ceadaoin. · 25-10-2014 8:15am

Grayson wrote: »

So what you're saying is that we should isolate all doctors and place them in permanent quarantine?

I'd also recommend that you educate yourself about ebola. It's not the flu virus. It's extremely hard to pick it up from a surface. You generally need to have direct contact with the patient.

here's an article i posted here yesterday.

http://well.blogs.nytimes.com/2014/10/23/can-you-get-ebola-from-a-bowling-ball/?_php=true&_type=blogs&partner=rss&emc=rss&_r=0

THAT'S NOT HOW THIS ****SPREADS
(I generally don't do caps lock, but I felt if i descended to your level you might understand it)

Well if anyone educates themselves they will discover that they don't really know for sure all the ways it is transmitted. There is certainly some evidence for transmission through aerosols and fomites. Two of the cases that were brought back to the US for treatment had no direct contact with ebola patients but they still managed to become infected.

wildefalcon · 25-10-2014 10:31am

Sclosages wrote: »

Hardly!

Doctors. Think they know everything there is to know about disease transmission. Arrogance.

True that.

There was a case where a registrar was telling everyone no contact with hands, and he used his pen to demonstrate this.

They tested his pen to find it had dozens of different disease traces on it.

Only way :- BIG mean fully authorised security guard on each doorway (bouncer type), wash hands or no entry - and written warning on record if abused. Top management on bonus if 100% compliance. Top mgt fired in less than 99%. Free laundry for all medical staff, no uniforms worn outside hospital. Change uniforms before break. Every hospital, nationwide.

Also - severe restrictions on antibiotic use in agriculture, inc veterinary medicine. Even if it means domestic pets, like my poor dog (attacked by wild boar), don't get! Human use of AB must be approved by hospital.

Drastic measures - but so is MRSA and NV infestation. Some countries don't have MRSA, Why? Steal their procedures and culture.

Red Pepper · 25-10-2014 12:18pm

MadYaker wrote: »

Anyone know any good ebola jokes?

http://time.com/3535902/craig-spencer-ebowla-jokes-lack-empathy/

Grayson · 25-10-2014 12:19pm

gozunda wrote: »

For anyone who has been in direct contact with patients who have contracted the disease and who are at high risk from infection as a result - yes a period of isolation equal to the incubation of the disease would be a good idea.

The issue here is doctors do have direct contact with one or more infected patients and for that reason this is why they are wearing this type of PPE but guess what some doctors / medical staff are still becoming infected

But all doctors come in contact with infectious and possibly life threatening diseases. Should we isolate them all? make them all live in sequestered residences and only let them out for holidays (after an additional month of quarantine.

Additionally tens of thousands, if not hundreds of thousands of people have been somewhere near the disease. Should we round up all these Africans and maybe put them in big camps where they can be quarantined?

I know if sounds facetious, but I'm being semi serious. That's the road that this brings us down. Ebola is a disease, that's all. Following the correct procedures makes the risks minimal. I agree with tracking doctors who have been there but that's all that needs to be done. This doctor got infected but he also got himself to a world class facility before he was infectious.

In Texas the breakdown was because they didn't bother running particular protocols. The patient actually got himself to hospital relatively fast but they sent him away. The nurses in the hospital claimed that there was no protocols to follow. Literally no-one knew what they was doing and that's how two got infected. In spain they put a night nurse in charge of his treatment one night. the nurse was just back from holidays, had no training and didn't even know how to use the protective clothing. That's why it was passed to medical staff there.

if the proper protocols are followed, there's minimum risk of transmission. It's not the victims of ebola who are a danger to us, it's our own medical establishments incompetence. Simply refreshing everyone training and practising the protocols would be far more effective.

If there's one person person with it who can minimise the transmission of it, it's a trained medical professional who's worked with the disease and that's what this doctor was.

Grayson · 25-10-2014 12:20pm

ceadaoin. wrote: »

Well if anyone educates themselves they will discover that they don't really know for sure all the ways it is transmitted. There is certainly some evidence for transmission through aerosols and fomites. Two of the cases that were brought back to the US for treatment had no direct contact with ebola patients but they still managed to become infected.

I'm going to go with the combined weight of virologists,epidemiologists and the medical and scientific community rather than your opinion.

I believe in climate change too.

MadYaker · 25-10-2014 12:39pm

If God sent the AIDS virus because of his hatred of homosexuality, then it's pretty obvious with the Ebola virus he's not too keen on blacks either.

25-10-2014 12:57pm

Just read that the little baby girl in Mali died

http://www.nytimes.com/2014/10/25/world/africa/mali-reports-first-death-from-ebola.html?_r=1

Grayson · 25-10-2014 1:10pm

MadYaker wrote: »

If God sent the AIDS virus because of his hatred of homosexuality, then it's pretty obvious with the Ebola virus he's not too keen on blacks either.

And medical staff. God hates science.

Jake1 wrote: »

Just read that the little baby girl in Mali died

http://www.nytimes.com/2014/10/25/world/africa/mali-reports-first-death-from-ebola.html?_r=1

That's sad. I heard a lot of the victims are children because parents hope it's not Ebola so they wait until it too late to report it. It's because their terrified their children will be taken away by strangers in hazmat suits and they'll never see their children again.

ceadaoin. · 25-10-2014 4:51pm

Grayson wrote: »

I'm going to go with the combined weight of virologists,epidemiologists and the medical and scientific community rather than your opinion.

I believe in climate change too.

It's not my opinion. There is evidence for transmission via fomites and droplets. You can't say definitively that it is not spread that way.

If anything it's a minor route of transmission and it's highly unlikely that anyone will catch it from a bowling ball that the doctor used. If he was further along and more contagious then it is possible. There is so much that isn't known about ebola

WakeUp · 25-10-2014 4:56pm

Grayson wrote: »

But all doctors come in contact with infectious and possibly life threatening diseases. Should we isolate them all? make them all live in sequestered residences and only let them out for holidays (after an additional month of quarantine.

Additionally tens of thousands, if not hundreds of thousands of people have been somewhere near the disease. Should we round up all these Africans and maybe put them in big camps where they can be quarantined?

I know if sounds facetious, but I'm being semi serious. That's the road that this brings us down. Ebola is a disease, that's all. Following the correct procedures makes the risks minimal. I agree with tracking doctors who have been there but that's all that needs to be done. This doctor got infected but he also got himself to a world class facility before he was infectious.

In Texas the breakdown was because they didn't bother running particular protocols. The patient actually got himself to hospital relatively fast but they sent him away. The nurses in the hospital claimed that there was no protocols to follow. Literally no-one knew what they was doing and that's how two got infected. In spain they put a night nurse in charge of his treatment one night. the nurse was just back from holidays, had no training and didn't even know how to use the protective clothing. That's why it was passed to medical staff there.

if the proper protocols are followed, there's minimum risk of transmission. It's not the victims of ebola who are a danger to us, it's our own medical establishments incompetence. Simply refreshing everyone training and practising the protocols would be far more effective.

If there's one person person with it who can minimise the transmission of it, it's a trained medical professional who's worked with the disease and that's what this doctor was.

clearly people infected with ebola are a danger to us. that is why they are put into isolation. and a awful lot of money spent on their treatment with the medical team placing their lives on the line to help, their previous contacts traced down and monitored, so on so forth. how many doctors come in contact with a bio level 4 agent. how many trained medical professionals in the west and other places are trained and have experience in dealing with such an agent. very few. training and hands on experience are two completely different things you cant compare them. no more than you can compare ebola or any other bio level agent 4 to other infections medical people in our part of the world have dealt with. you cant compare them either. I can understand to an extent what you are saying about medical incompetence and I would agree with you in some of it but to say that its on the people treating these patients fault that this has spread I think that is unfair. because they are doing the best and from what we have seen some of them have been in no way prepared for what they are expected to deal with. the only way to fight this is to contain it. and that includes people in the affected countries treating people hands on they fall into that bracket too. no chances should be taken. say these projected case rates some of the scientists come out with pan out lets say 90000 cases in some places. I mean if that happens there is only one way to deal with that you cant treat and care for that many ebola patients its impossible. if that happens there will be only one course of action.

gozunda · 25-10-2014 6:08pm

Grayson wrote: »

But all doctors come in contact with infectious and possibly life threatening diseases. Should we isolate them all? make them all live in sequestered residences and only let them out for holidays (after an additional month of quarantine.

Each disease must be treated on its own level of danger but yes there are times when medical professionals and others may need to enter into a quarantine. As pointed out Ebola as a epidemic is currently unparalleled in the level of infection of medical personal - this despite medical personnel utilising high levels of protection and containment protocols. The incubation period of Ebola is approximately 21 days - within this period medics coming from epidemic hotspots such as Liberia face potential infection. Quarantine is a well tested and accepted means to control and minimise infectious diseases. It is of note US are now considering making such quarantine compulsory.

Grayson wrote: »

Additionally tens of thousands, if not hundreds of thousands of people have been somewhere near the disease. Should we round up all these Africans and maybe put them in big camps where they can be quarantined?

being 'near' and caring for and handling highly infectious patients is not comparable.

Grayson wrote: »

I know if sounds facetious, but I'm being semi serious. That's the road that this brings us down. Ebola is a disease, that's all. Following the correct procedures makes the risks minimal. I agree with tracking doctors who have been there but that's all that needs to be done. This doctor got infected but he also got himself to a world class facility before he was infectious.

. Again self imposed quarantined for a period of 21 days imo should not a significant issue in the management and containment of a very dangerous infection.

Grayson wrote: »

In Texas the breakdown was because they didn't bother running particular protocols. The patient actually got himself to hospital relatively fast but they sent him away. The nurses in the hospital claimed that there was no protocols to follow. Literally no-one knew what they was doing and that's how two got infected. In spain they put a night nurse in charge of his treatment one night. the nurse was just back from holidays, had no training and didn't even know how to use the protective clothing. That's why it was passed to medical staff there.

The hospital have never identified what the actual protocols broken and the nursing staff at the hospital point to other potential issues in managing the patient. Again the person who clearly had contact with an infectious person before he flew to the states should have undergone quarantine. If anything the protocol broken was the failure of the patient to admit that he had been in contact with a person who had Ebola. If this had been known he could have been quarantined.

Grayson wrote: »

if the proper protocols are followed, there's minimum risk of transmission. It's not the victims of ebola who are a danger to us, it's our own medical establishments incompetence. Simply refreshing everyone training and practising the protocols would be far more effective.

There have been several incidences where the process of transmission remains unexplained and where Staff had minimal contact with infected patients. As with much medical knowledge - I believe not everything is known about the current strain of Ebola.

Grayson wrote: »

If there's one person person with it who can minimise the transmission of it, it's a trained medical professional who's worked with the disease and that's what this doctor was.

This doctor should have realised (or perhaps he did) that he was at a higher risk from developing the diseases. Did he return to the US so he could access medical care? Or was he naive enough considering other similar cases - to belief that he did not that have to undergo voluntary quarantine. Even if his concern were for his nearest and dearest - this would appear to be logical thing to do.

ProfessorPlum · 25-10-2014 8:18pm

The doctor, Craig Spencer is a well respected and much experienced doctor who has spent many many periods in Africa and other needy areas giving his time and expertise, and putting his own life and health at risk to help others. He is a fellow in emergency medicine and has a masters in public health medicine. He is a hero and is deserving of our thanks and support. If it wasn't for him and those like him - doctors, nurses, and ancillary staff - who head out to these places that most of us would be sh1ting ourselves even thinking about (we see it here on this thread), the situation would be far far worse yhan it is now. So maybe stop telling us all how 'unprofessional, and 'lax' and 'naieve' he is and show a bit of respect. The NY City health department has said he wasn't infectious in the community, the only 'symptoms' he had before the morning he called himself in was 'some fatigue' (after a month working long days in very onerous conditions followed by 2 long haul flights through several time zones). If he has infected anyone in the community I'll eat my hat. The new quarantine measures are political posturing and have been taken without any discussion with the medical experts so make of that what you will.
I wish the doctor a speedy and full recovery and hope that he will be welcomed back into his community with open arms and a great amount of thanks for the good work that he has done and I'm sure will continue to do.

gozunda · 25-10-2014 8:26pm

ProfessorPlum wrote: »

The doctor, Craig Spencer is a well respected and much experienced doctor who has spent many many periods in Africa and other needy areas giving his time and expertise, and putting his own life and health at risk to help others. He is a hero and is deserving of our thanks and support. If it wasn't for him and those like him - doctors, nurses, and ancillary staff - who head out to these places that most of us would be sh1ting ourselves even thinking about (we see it here on this thread), the situation would be far far worse yhan it is now. So maybe stop telling us all how 'unprofessional, and 'lax' and 'naieve' he is and show a bit of respect. The NY City health department has said he wasn't infectious in the community, the only 'symptoms' he had before the morning he called himself in was 'some fatigue' (after a month working long days in very onerous conditions followed by 2 long haul flights through several time zones). If he has infected anyone in the community I'll eat my hat. The new quarantine measures are political posturing and have been taken without any discussion with the medical experts so make of that what you will.
I wish the doctor a speedy and full recovery and hope that he will be welcomed back into his community with open arms and a great amount of thanks for the good work that he has done and I'm sure will continue to do.

Yada yada .... If he is so well experienced and knowledgable then He SHOULD HAVE KNOWN BETTER. if he is going out to help fair play - but with such endeavours comes responsibility to those with whom he lives including his family and the rest of the population. Ok so he does good - it does not rule out him being responsible. End of.

Btw quarantine is a standard procedure in the face of serious epidemics. The guy obviously thinks he is invincible but it doesn't make him Mother fracking Teresa

Is it coincidence that he came home just as he had become infected or was he getting out as he knew the chances were he was infected and his best chance was treatment in the US? Who knows ...

ProfessorPlum · 25-10-2014 8:32pm

gozunda wrote: »

Yada yada .... If he is so well experienced and knowledgable then He SHOULD HAVE KNOWN BETTER. if he is going out to help fair play - but with such endeavours comes responsibility to those with whom he lives including his family and the rest of the population. Ok so he does good - it does not rule out him being responsible. End of.

Btw quarantine is a standard procedure in the face of serious epidemics. The guy obviously thinks he is invincible ....

Yada yada? Not once ounce of thanks or respect for these guys who head out there? Where do you think they're going to come from, those hundreds and thousand of volunteers we need to go out there to sort this mess out? A bit of support wouldn't go astray.
And HE DID KNOW BETTER - HES DONE NOTHING WRONG. I'll take his qualified judgement (and that of the city health dept who agree with him) over yours.

gozunda · 25-10-2014 8:33pm

ProfessorPlum wrote: »

Yada yada? Not once ounce of thanks or respect for these guys who head out there? Where do you think they're going to come from, those hundreds and thousand of volunteers we need to go out there to sort this mess out? A bit of support wouldn't go astray.
And HE DID KNOW BETTER - HES DONE NOTHING WRONG. I'll take his qualified judgement (and that of the city health dept who agree with him) over yours.

The yada yada was for you ok! Do read the rest of the post. I see your posts are back to form. Don't like informed opinion? Tough!

Is it coincidence that he came home just as he had become infected or was he getting out as he knew the chances were he was infected and his best chance was treatment in the US? Who knows ...

ProfessorPlum · 25-10-2014 8:38pm

gozunda wrote: »

The yada yada was for you ok! Do read the rest of the post. I see your posts are back to form. Don't like informed opinion? Tough!

I absolutely do. I read and listen to everyone's informed opinions. Some I don't agree with. You on the other hand seem to have difficulty listening to anyone who disagrees with you. Yada yada etc.
my posts are back to form? Didn't realise I'd gone off the boil. Apologies.

gozunda · 25-10-2014 8:44pm

ProfessorPlum wrote: »

I absolutely do. I read and listen to everyone's informed opinions. Some I don't agree with. You on the other hand seem to have difficulty listening to anyone who disagrees with you. Yada yada etc.
my posts are back to form? Didn't realise I'd gone off the boil. Apologies.

And then ignore what has been said and replace it with an alternative reality! Then make snide personal comments like the above and previous. You have repeatedly reverted to making similar remarks when you don't agree with any post. Life's to short - don't have time for that type of crud tbh ...

Ebola virus outbreak

Comments