TAG: "Health policy"

UCSF sugar science initiative launched


Researchers highlight strong links between sugar and chronic disease.

By Kristen Bole, UC San Francisco

Researchers at UC San Francisco have launched SugarScience, a groundbreaking research and education initiative designed to highlight the most authoritative scientific findings on added sugar and its impact on health.

The national initiative is launching in partnership with outreach programs in health departments across the country, including the National Association of City and County Health Organizations and cities nationwide.

Developed by a team of UCSF health scientists in collaboration with scientists at UC Davis and Emory University School of Medicine, the initiative reflects an exhaustive review of more than 8,000 scientific papers that have been published to date on the health effects of added sugar.

The research shows strong evidence of links between the overconsumption of added sugar and chronic diseases, including Type 2 diabetes, heart disease and liver disease. It also reveals evidence linking sugar to Alzheimer’s disease and cancer, although the team assessed that more research is needed before those links can be considered conclusive.

Laura Schmidt, UC San Francisco

“The average American consumes nearly three times the recommended amount of added sugar every day, which is taking a tremendous toll on our nation’s health,” said Laura Schmidt, Ph.D., a UCSF professor in the Philip R. Lee Institute for Health Policy and the lead investigator on the project. “This is the definitive science that establishes the causative link between sugar and chronic disease across the population.”

The initiative aims to bring scientific research out of medical journals and into the public domain by showcasing key findings that can help individuals and communities make informed decisions about their health. For example, SugarScience.org cites research showing that drinking just one can of soda per day can increase a person’s risk of dying from heart disease by nearly one-third, and can raise the risk of getting Type 2 diabetes by one-quarter.

More than 27 million Americans have been diagnosed with heart disease, which is the nation’s leading cause of death. Another 25.8 million Americans have Type 2 diabetes, caused by the body’s resistance to the hormone insulin coupled with the inability to produce enough insulin to regulate blood sugar levels. Of greatest concern is the rising number of children suffering from these chronic diseases.

Kristen Bibbins-Domingo, UC San Francisco

“Twenty years ago, Type 2 diabetes was unheard of among children, but now, more than 13,000 children are diagnosed with it each year,” said Kirsten Bibbins-Domingo, M.D., Ph.D., a UCSF professor of medicine, epidemiology and biostatistics, and director of the UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center. “Diabetes is a devastating disease and we know that it is directly related to the added sugar we consume in food and beverages.”

Another rising concern is the impact of added sugar on Non-Alcoholic Fatty Liver Disease (NAFLD), which affects 31 percent of adults and 13 percent of children, and can lead to cirrhosis and liver failure.

“As pediatricians, we had evidence of the connection between sugar and diabetes, heart disease, and liver disease for years, but we haven’t had this level of definitive scientific evidence to back up our concerns,” said Robert Lustig, M.D., M.S.L., a pediatric endocrinologist at UCSF Benioff Children’s Hospital San Francisco and a member of the SugarScience team. “Our goal is to make that science digestible to the American public, and take the first step toward a national conversation based on the real scientific evidence.”

Robert Lustig, UC San Francisco

While there are no federal recommended daily values for added sugar, the American Heart Association recommends consuming less than 6 tsp. (25 g) for women and 9 tsp. (38 g) for men. Guidelines for children depend on caloric intake, but range between 3-6 tsp (12-25 g) per day. Americans currently consume 19.5 tsp. of added sugar, on average, every day.

Added sugar is defined as any caloric sweetener that is added in food preparation, at the table, in the kitchen or in a processing plant. It can be difficult for people to know how much sugar they are consuming, since roughly 74 percent of processed foods contain added sugar, which is listed under at least 60 different names on food labels.

The 12-member SugarScience team will continue to monitor scientific research about added sugar and will track findings at SugarScience.org. The initiative harnesses the power of UCSF’s extensive health sciences enterprise, which ranges from basic laboratory research to clinical, population and policy sciences, with an emphasis on translating science into public benefit. All four of UCSF’s graduate schools – dentistry, medicine, nursing and pharmacy – lead their fields in research funding from the National Institutes of Health, reflecting the caliber of their research.

SugarScience is made possible by an independent grant from the Laura and John Arnold Foundation. It is supported by the Clinical and Translational Science Institute and the Philip R. Lee Institute for Health Policy Studies at UCSF.

View original article

Related links:

CATEGORY: NewsComments (1)

Expanding palliative care in California could save billions of dollars


Berkeley Forum report highlights three programs that give patients greater choice of care.

Click image to view report

A report released today (Nov. 19) by the Berkeley Forum finds that California hospital spending could be reduced by billions of dollars over the next eight years if patients’ wishes about palliative care were honored.

The Berkeley Forum — a collaborative effort involving executive leadership of major health insurers, health care delivery systems and the state of California with health policy experts from the School of Public Health at UC Berkeley — previously issued a vision of increased choice and better value for patients nearing end of life.

The new report builds on that vision, highlighting three major programs that give patients in California greater choice of care outside the hospital. The programs’ interdisciplinary teams incorporate patient goals and wishes when planning treatment, resulting in patient-centered care that tends to move people out of intensive hospital settings and into care in the community.

“Our review shows that offering more choices to patients can not only increase satisfaction with care and improve outcomes, but also divert spending from expensive and unwanted services,” said Eric Kessell, policy director for the Berkeley Forum and lead author on the report.

The study also found that by expanding access to community-based palliative care to over 100,000 Californians a year through 2022, more than $5.5 billion could be moved from high-cost, unwanted hospital services while honoring patient wishes for care at home and in other community settings.

“The wishes of patients, their families and loved ones should be honored at the end of life,” said Richard Scheffler, co-chair of the Berkeley Forum. “Many of them do not want to die in a hospital. This report gives them other choices.”

In order to achieve this vision, conversations about palliative care will need to be incorporated throughout the health care delivery system, with increased use of nurse practitioners and other health care professionals, and a tripling of physicians certified in hospice and palliative medicine.

Stephen Shortell, chair of the Berkeley Forum, said, “The increased interest in palliative care is part of a larger movement toward greater patient and family engagement in all aspects of their care over the life course.”

“Expanding palliative care in California is the right thing to do on every level. It is what patients want, it improves outcomes, it lowers costs and most importantly provides compassionate relief to those suffering.”

— David Feinberg, president of the UCLA Health System, CEO of the UCLA Hospital System and UC Health’s representative on the Berkeley Forum

View original article

Related link:
Download the report (pdf)

CATEGORY: NewsComments (1)

Online tool provides health information by ZIP code, city, legislative district


UCLA site advances Center for Health Policy Research mission of democratizing data.

For the first time, anyone can easily access comprehensive California health statistics by ZIP code, city and legislative district thanks to a new web tool created by the UCLA Center for Health Policy Research. The easy-to-use AskCHIS Neighborhood Edition, or AskCHIS NE, enables users to customize searches, compare and “pool” small geographic areas, and map and chart their results.

AskCHIS NE covers a wide range of health topics, including rates of health insurance, chronic conditions like asthma and diabetes, and behaviors like smoking and physical activity; quality of children’s health; and access to health care and mental health care; and much more.

AskCHIS Neighborhood Edition is a service of the center’s renowned California Health Interview Survey, the nation’s largest state health survey. An existing companion web tool, AskCHIS, allows users to find health data at the county, region and state levels.

AskCHIS NE drills down even deeper than AskCHIS, allowing users to quickly find health disparities within specific cities or legislative districts. Using the system’s pooling feature, hospitals can build health profiles of their service areas, combining ZIP codes or cities. Community groups can decide which programs to offer at parks based on a neighborhood’s specific health needs. Journalists can compare obesity rates in neighborhoods they cover.

“This is the first time that Californians will be able to access neighborhood health information in just a few, simple steps,” said Ninez Ponce, the California Health Interview Survey’s principal investigator. “This information will help Californians make health decisions that are specifically targeted to the unique needs of their communities.”

Using AskCHIS NE is simple:

  • Log onto http://askchisne.ucla.edu. People who have previously used AskCHIS can use an existing logon ID and password; new users can create a free account before logging in for the first time.
  • Select a topic from the panel on the left.
  • Search for geographic areas of interest and click the “Create a table” button.
  • The search results are quickly displayed in a table, bar chart and interactive map.

The interactive map makes it easy to for users to see health disparities across the landscape. Data for one ZIP code can be loaded and displayed, but the user also can zoom out to view adjacent ZIP codes or the entire state for comparison.

As in AskCHIS, results can be easily exported into Excel spreadsheets. But AskCHIS NE also makes it easy for users to download the charts and maps for use in reports and presentations. The site also makes HTML coding available for use in online media.

“AskCHIS NE truly moves forward the center’s mission of democratizing data,” said Bogdan Rau, the project manager for AskCHIS NE. “It’s provided as a public service so that everyone who needs access to quality, authoritative health information can benefit.”

AskCHIS Neighborhood Edition is sponsored by grants from Kaiser Permanente and the California Wellness Foundation.

Heavy website traffic is expected when AskCHIS NE launches. If the site is busy, please try again later.

Visit the UCLA Center for Health Policy Research — and see a demo of AskCHIS NE — at Booth 1043 at the American Public Health Association annual meeting in New Orleans, Nov. 16 – 19. View the schedule for the meeting.

View original article

CATEGORY: NewsComments Off

Laws protecting doctors vs. malpractice suits may not change how they practice


Study suggests that what has been called ‘defensive medicine,’ might just be medicine.

Changing laws to protect physicians from medical malpractice lawsuits may not yield cost savings through a reduction in “defensive medicine,” according to a new study by UCLA and RAND Corp.

Studying the behavior of emergency physicians in three states that raised the standard for malpractice in the emergency room to “gross negligence,” researchers found that strong new legal protections did not change the care that physicians ordered or reduce costs.

The results are published in the Oct. 16 edition of the New England Journal of Medicine.

“Our findings suggest that malpractice reform may have less effect on costs than people assume,” said Dr. Daniel Waxman, the study’s lead author and an emergency physician at the David Geffen School of Medicine at UCLA. “Physicians say they order unnecessary tests strictly out of fear of being sued, but our results suggest the story is more complicated.”

Read more

For more health news, visit UC Health, subscribe by email or follow us on Flipboard.

CATEGORY: NewsComments Off

Study: Hospital mergers, acquisitions leading to increased patient costs


Counterintuitive findings published in Journal of the American Medical Association.

The trend of hospitals consolidating medical groups and physician practices in an effort to improve the coordination of patient care is backfiring and increasing the cost of patient care, according to a new study led by a UC Berkeley health policy expert.

The counterintuitive findings, published today (Oct. 21) in the Journal of the American Medical Association, come as a growing number of local hospitals and large, multi-hospital systems in this country are acquiring physician groups and medical practices.

“This consolidation is meant to better coordinate care and to have a stronger bargaining position with insurance plans,” said study lead author James Robinson, professor and head of health policy and management at UC Berkeley’s School of Public Health. “The movement also aligns with the goals of the Affordable Care Act, since physicians and hospitals working together in ‘accountable care organizations’ can provide care better than the traditional fee-for-service and solo practice models. The intent of consolidation is to reduce costs and improve quality, but the problem with all this is that hospitals are very expensive and complex organizations, and they are not known for their efficiency and low prices.”

Robinson teamed up with study co-author Kelly Miller, program analyst at Integrated Healthcare Association, a nonprofit organization that promotes health care quality improvement, accountability and affordability in California.

The researchers analyzed four years of data, from 2009 to 2012, on 158 major medical groups and 4.5 million patients in California. Groups were put into three categories: owned by physicians, owned by a local hospital or hospital system, or owned by a large hospital system that spans multiple geographic markets in the state.

The measure of costs included physician visits, inpatient hospital admissions, outpatient surgery and diagnostic procedures, drugs, and all other forms of medical care except for mental health services. (The researchers did not have data on mental health services since they are paid for separately.)

After controlling for such factors as the mix of severely ill patients and geographic differences in cost, the researchers found that per patient expenditures were 19.8 percent higher for physician groups in multi-hospital systems compared with physician-owned organizations. Groups owned by local hospitals were better, but per patient costs still ran 10.3 percent higher compared with physician-owned groups.

Why would consolidation lead to increased costs? It could be that once a medical group has been acquired, physicians in those groups are expected to admit their patients to the high-priced hospital, Robinson said.

“Hospital-owned medical groups usually are expected to conduct ambulatory surgery and diagnostic procedures in the outpatient departments of their parent hospital, but hospital outpatient departments are much more costly and charge much higher prices than freestanding, non-hospital ambulatory centers,” he said.

Robinson said that public policy should not encourage mergers and acquisitions as a means of promoting collaboration. Instead, he said, policymakers should consider supporting the use of bundled payments for hospitals and physicians to improve coordination of care.

“Hospitals are an essential part of the health care system, but they should not be the center of the delivery system,” said Robinson. “Rather, physician-led organizations based in ambulatory and community settings are likely to be more efficient and provide cheaper care.”

The study authors noted that their findings are limited to California, and that further studies should be done using data from other states.

“Nevertheless, these findings are important since California is the nation’s leader in terms of having physicians participate in large medical groups that already perform the functions ascribed to ‘accountable care organizations’ by the Obama administration,” said Robinson.

The Robert Wood Johnson Foundation provided support for this research.

View original article

CATEGORY: NewsComments Off

Increased hospital use after Medicaid expansion is mostly temporary


UCLA study finds pent-up demand for health care will decline after first year of enrollment.

The expansion of Medicaid to millions of uninsured people should not have the catastrophic impact some predicted for state budgets because the increases in hospital and emergency room usage are only temporary, according to a new study by the UCLA Center for Health Policy Research.

“We found that the surge doesn’t last long once people get coverage,” said Nigel Lo, a research analyst at the UCLA Center for Health Policy Research and the study’s lead author. “Our findings suggest that early and significant investments in infrastructure and in improving the process of care delivery can effectively address the pent-up demand for health care services of previously uninsured people. Fears that these new enrollees will overuse health care services are just not true.”

Using two years of claims data from 182,000 low-income, uninsured people enrolled in California’s state-run health insurance programs, the UCLA researchers found that people who previously had had the least medical care used hospital emergency rooms at a high rate of 600 visits per 1,000 people. But usage declined sharply in the first quarter to 424 visits (a 29 percent drop), followed by another 25 percent decline the following quarter. Between 2011 and 2013, the overall decline was 69.5 percent (183 ER visits). The report also shows that their hospital admissions declined sharply, from 194 to 42, a decline of 78.5 percent.

“California’s success should set an example for states that are on the fence about expanding Medicaid,” said co-author Gerald Kominski, professor of health policy and management and director of the Center for Health Policy Research. “It’s an investment: Build more infrastructure and care delivery early on, and you can manage chronic care, address unmet health care needs, and keep cost increases to a manageable level.”

The Affordable Care Act has extended Medicaid eligibility in 27 states, but many other states have refused coverage in part because of predictions that state budgets would be overwhelmed by the demands of the previously uninsured, particularly once federal subsidies stop covering the full expansion cost in 2017. Three states — Indiana, Missouri and Utah — are considering expansion, and other state legislatures will soon debate the issue.

The Obama administration is pushing states to expand Medicaid, arguing that they are not only leaving millions of their residents uninsured, but are also forcing their hospitals to absorb billions of dollars in uncompensated costs for treating people without insurance.

The UCLA study looked at data from two programs in California — the Health Care Coverage Initiative, which ran from 2007 to 2010, and the Low Income Health Program, which ran from 2011 to 2013. On Jan. 1, 2014, these enrollees became part of the 1.5 million Californians who were able to transition under the Affordable Care Act into Medi-Cal, California’s Medicaid program that provides health insurance to low-income people.

The authors said that because California’s Low Income Health Program had provided preventative medical care and regular treatment for chronic diseases, the newly insured were no longer dependent on emergency room treatment and hospitalization. Improving care delivery through the use of an assigned source of primary care, care coordination and health risk assessments, as well as greater availability of specialty services and culturally competent self-care also potentially helped manage pent-up demand, they said.

The UCLA results provide new insights into previously published findings that costly emergency room visits in Oregon increased by 40 percent during the year after the state expanded Medicaid eligibility. By examining data over a longer period of time, the UCLA study was able to determine that such spikes in usage were only temporary.

The study was funded by the California Department of Health Care Services and the Blue Shield of California Foundation.

View original article

CATEGORY: NewsComments Off

Sesame Street helps teach physicians a lesson


Incarceration plays major role in health disparities in U.S., says UC Riverside professor.

UC Riverside’s Scott Allen (left) is seen here with Sesame Street’s Alex, a blue-haired, green-nosed Muppet who has a father in jail, and Brown University’s Josiah Rich (right). (Photo courtesy of Pam Hacker, Sesame Street)

More than two million people are incarcerated in the United States, the highest incarceration rate in the world. So perhaps it comes as no surprise that last year the popular children’s television series Sesame Street introduced a character that has an incarcerated father.

With incarceration having found a home even on Sesame Street, public health practitioners, policymakers and health care providers ought to pay closer attention to incarceration’s impact on health inequality in the country, argue a team of two physicians and a medical researcher in an article published today (Oct. 6) in Annals of Internal Medicine.

Scott A. Allen, M.D., a professor of medicine in the School of Medicine at the University of California, Riverside, and his colleagues report that while many people need to be in prison for the safety of society, a majority are incarcerated due to behaviors linked to treatable diseases such as mental illness and addiction.

“In such cases, incarceration will improve neither the imprisoned person nor the social problem without medical intervention,” Allen writes, along with co-authors Dora M. Dumont, Ph.D., M.P.H., at the Rhode Island Department of Health and Josiah D. Rich, M.D., M.P.H., at Brown University.

Read more

For more health news, visit UC Health, subscribe by email or follow us on Flipboard.

CATEGORY: NewsComments Off

Higher nurse-to-patient standard enhances staff safety


Study finds drop in occupational injuries to nurses after mandated staffing ratios in California.

J. Paul Leigh, UC Davis

A 2004 California law mandating specific nurse-to-patient staffing standards in acute care hospitals significantly lowered job-related injuries and illnesses for both registered nurses and licensed practical nurses, according to a UC Davis study published online in the International Archives of Occupational and Environmental Health. The study is believed to be the first to evaluate the effect of the law on occupational health.

“We were surprised to discover such a large reduction in injuries as a result of the California law,” said study lead author J. Paul Leigh, a professor of public health sciences and investigator with the Center for Healthcare Policy and Research at UC Davis. “These findings should contribute to the national debate about enacting similar laws in other states.”

California is the only state in the country with mandated minimum nurse-to-patient staffing ratios. They are established based on type of service (such as pediatrics, surgery, or labor and delivery) and allow for flexibility in cases of health care emergencies. (The ratios are available on the California Department of Public Health website.)

According to Leigh, some hospitals have argued against extending the law to other states because of the increased costs of additional nursing staff. There is also no consensus that the law has improved patient outcomes, which was its primary intent. Some studies show improvement, while others do not.

“Our study links the ratios to something just as important — the lower workers’ compensation costs, improved job satisfaction and increased safety that comes with linking essential nursing staff levels to patient volumes,” Leigh said.

Read more

For more health news, visit UC Health, subscribe by email or follow us on Flipboard.

CATEGORY: NewsComments Off

Taking preventive health care into community spaces


Bringing health care to non-traditional locations increases use of preventive services.

Janet Frank, UCLA

A church. A city park. An office. These are not the typical settings for a medical checkup. But a new nationwide study by the UCLA Center for Health Policy Research shows that providing health services in unorthodox settings helps underserved adults get preventive care.

With support from the Centers for Disease Control and Prevention, the study’s authors reviewed 142 outreach programs nationwide and identified 20 that successfully used non-traditional settings, such as churches and parks, to promote or deliver preventive services (such as bone density and cancer screenings) to older underserved populations.

“The research shows that health providers might need to think outside the box on how and where to deliver health services,” said Janet Frank, lead author of the study and an adjunct associate professor at the UCLA Fielding School of Public Health. “The programs that fared the best did not wait for patients to come to them — they went to where the patients were.”

Read more

For more health news, visit UC Health, subscribe by email or follow us on Flipboard.

CATEGORY: NewsComments Off

Providing futile treatment prevents others from getting critical care they need


UCLA findings have implications for fairness of American health care system.

Providing futile treatment in the intensive care unit sets off a chain reaction that causes other ill patients who need medical attention to wait for critical care beds, according to a study by UCLA and RAND Health.

The research is the first to show that when non-beneficial medical care is provided, others who might be able to benefit from treatment are harmed, said Dr. Thanh Huynh, the study’s lead author and an assistant professor of medicine in the division of pulmonary and critical care medicine at the David Geffen School of Medicine at UCLA.

The findings also have implications for the fairness of the American health care system, and they point toward policy improvements that would guide more efficient use of our limited health care resources, said senior author Dr. Neil Wenger, a UCLA professor of medicine and RAND Health scientist.

“Many people do not realize that there is a tension between what medicine is able to do and what medicine should do,” said Wenger, who also is director of the UCLA Health Ethics Center at the Geffen School of Medicine. “Even fewer realize that medicine is commonly used to achieve goals that most people, and perhaps most of society, would not value — such as prolonging the dying process in the intensive care unit when a patient cannot improve.

“But almost no one recognizes that these actions affect other patients, who might receive delayed care or, worse, not receive needed care at all because futile medical treatment was provided to someone else.”

The study appears in the August issue of the peer-reviewed journal Critical Care Medicine.

Read more

For more health news, visit UC Health, subscribe by email or follow us on Flipboard.

CATEGORY: NewsComments Off

Hospital charges for blood tests vary widely across California


UCSF study highlights difficulty of knowing health care prices.

Renee Hsia, UC San Francisco

New UC San Francisco research shows significant price differences for 10 common blood tests in California hospitals, with some patients charged as little as $10 for one test while others were charged $10,169 for the identical test.

The analysis of charges at more than 150 California hospitals looked at blood tests that are often required of patients, such as lipid panel, basic metabolic panel, and complete blood cell count with differential white cell count.

Hospital ownership and teaching status help explain a portion of the variation – prices generally were lower at government and teaching hospitals. Factors such as location, labor costs, patient capacity and percentage of uninsured population generally did not account for the price differences, the authors said, making it difficult for patients to know their costs in advance and to “act as rational consumers.”

The report was published in BMJ Open today (Aug. 15).

Charges for a basic metabolic test ranged from $35 to $7,303, depending on the hospital; the median charge was $214. The most extreme price difference was found in charges for a lipid panel: the median charge was $220, but overall charges ranged from $10 to as much as $10,169.

The results are of particular concern, said the authors, since there isn’t much room for variability in blood tests. Moreover, because the tests are identical across providers, consumers might be expected to think that hospital charges would be similar.

“You may hear people say that, ‘Charges don’t matter’ or that ‘No one pays full charges,’” said senior author Renee Y. Hsia, M.D., an associate professor of emergency medicine at UCSF and director of health policy studies in the Department of Emergency Medicine. She is also an attending physician in the emergency department at San Francisco General Hospital and Trauma Center.

“However, uninsured patients certainly face the full brunt of raw charges, especially if they don’t qualify for charity care discounts,” Hsia said. “And as employers are switching to more consumer-directed health plans with higher deductibles and co-pays, the out-of-pocket costs of even insured patients can be affected by these charges.”

Read more

For more health news, visit UC Health, subscribe by email or follow us on Flipboard.

CATEGORY: NewsComments Off

Medical schools urged to increase enrollment of undocumented immigrants


Accepting students eligible for federal DACA program could help address nation’s shortage of primary care physicians, UCLA center says.

Youhali Balderas-Medina Anaya, UCLA

A paper by researchers at the UCLA Center for the Study of Latino Health and Culture urges medical schools to do more to increase their enrollment of undocumented immigrants seeking access to the medical professions.

The authors of “Undocumented Students Pursuing Medical Education: The Implications of Deferred Action for Childhood Arrivals,” published in the current issue of the journal Academic Medicine, suggest that these students, who are often highly motivated and qualified, can help alleviate the nationwide shortage of primary care physicians, particularly in underserved, low-income areas.

“This country is in great need of primary care physicians to fill the ongoing shortage, yet qualified undocumented pre-medical students are still being denied access to medical schools because of concerns regarding their status,” said Dr. Yohualli Balderas-Medina Anaya, a resident physician in the department of family medicine at the David Geffen School of Medicine at UCLA and the paper’s lead author.

The authors suggest that Deferred Action for Childhood Arrivals (DACA), an initiative signed by the Obama administration in 2012 that allows certain young undocumented immigrants to work legally in the U.S. without fear of deportation, could help shore up the numbers.

“With DACA,” Anaya said, “undocumented pre-med students can help address this growing shortage. We are calling upon the medical and academic community to support undocumented students applying to medical school. We can all benefit from helping these students enter and successfully complete medical school.”

Read more

For more health news, visit UC Health, subscribe by email or follow us on Flipboard.

CATEGORY: NewsComments Off