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USNS Comfort

USNS Comfort (T-AH-20) is a Mercy-class hospital ship of the United States Navy.

Comfort's duties include providing emergency, on-site care for U.S. combatant forces deployed in war or other operations. Operated by the Military Sealift Command, Comfort provides rapid, flexible, and mobile medical and surgical services to support Marine Corps Air-Ground Task Forces and Army and Air Force units deployed ashore, and naval amphibious task forces and battle forces afloat. Secondarily, she provides mobile surgical hospital service for use by appropriate U.S. government agencies in disaster or humanitarian relief or limited humanitarian care incident to these missions or peacetime military operations. Comfort is more advanced than a field hospital but less capable than a traditional hospital on land.

From 30 March to 30 April 2020, Comfort was stationed in New York City to help combat the city's coronavirus pandemic by treating non-coronavirus, and later on, coronavirus-positive patients.

Complement
The USNS prefix identifies Comfort as a non-commissioned ship owned by the U.S. Navy and operationally crewed by civilians from the Military Sealift Command (MSC). A uniformed naval hospital staff and naval support staff is embarked when the Comfort is deployed, consisting primarily of naval officers from the Navy's Medical Corps, Dental Corps, Medical Service Corps, Nurse Corps, and Chaplain Corps, and naval enlisted personnel from the Hospital Corpsman rating and various administrative and technical support ratings (e.g., Yeoman, Personnel Specialist, Information Systems Technician, Religious Program Specialist, etc.).

In accordance with the Geneva Conventions, Comfort and her crew carry no offensive weapons. Firing upon Comfort would be considered a war crime as the ship only carries weapons for self-defense. In keeping with her status as a non-combatant vessel, naval personnel from the combat specialties are not assigned as regular crew or staff. Underway embarks by Navy Unrestricted Line officers (e.g., warfare qualified combat specialties), enlisted Naval Aviation, Surface Warfare, Submarine Warfare, Special Operations or Special Warfare/SEAL personnel, or any Marine Corps officers or enlisted personnel, are typically limited to official visits, helicopter or tilt-rotor flight operations or as patients.

Construction and conversion
Like her sister ship USNS Mercy (T-AH-19), Comfort was built as a San Clemente-class oil tanker oil tanker in 1976 by the National Steel and Shipbuilding Company. Her original name was SS Rose City and she was launched from San Diego, California. She is the third United States Navy ship to bear the name Comfort, and the second Mercy-class hospital ship. Her career as an oil tanker ended when she was delivered to the U.S. Navy on 1 December 1987.

After a quarter-century in Baltimore, Maryland, Comfort changed her homeport to Naval Station Norfolk in Norfolk, Virginia in March 2013. The move placed the ship closer to supplies, much of which come from Naval Medical Center Portsmouth, and to medical crew. Savings to the U.S. Navy are estimated at $2 million per year.

Persian Gulf War (1990–91)
During the Gulf War, Comfort received a call to activate for Desert Shield/Desert Storm 9 August 1990 and left Baltimore on 11 August. Comfort took station just off the coast of Saudi Arabia near Khafji and Kuwait. On 12 March 1991, Comfort headed home, arriving in Baltimore on 15 April 1991. She had traveled more than 30000 nmi and consumed almost 3 e6U.S.gal of fuel. More than 8,000 outpatients were seen, and 700 inpatients were admitted, including four sailors injured in a high-pressure steam leak on USS Iwo Jima (LPH-2). 337 surgical procedures were performed. Other notable benchmarks include: more than 2,100 safe helicopter activities; 7,000 prescriptions filled; 17,000 laboratory tests completed; 1,600 eyeglasses made; 800,000 meals served and 1,340 radiographic studies, including 141 CT scans.

Operation Sea Signal (1994)

In 1994, Comfort was ordered to serve as a processing center for Haitian migrants, the first ship to act as such a center. She set out for the Caribbean with 928 military and civilian personnel from various federal government and international agencies. On 16 June 1994 the first Haitian migrants were taken aboard. Over the months, her population swelled to 1,100. Shortly thereafter, Comfort sailed for Guantanamo Bay Naval Base, Cuba, to drop off the remaining 400 migrants.

Operation Uphold Democracy (1994)
On 2 September 1994, Comfort was directed to activate for an unprecedented second deployment in a year. Comfort was tasked to provide a 250-bed medically intensive patient capability for the 35,000 Cuban and Haitian migrants supported by Naval Station Guantanamo Bay, Cuba. Comfort departed Naval Base Norfolk, Virginia, with a specially configured crew of 566 personnel. Following the diplomatic agreement reached between the United States and Haiti, Comfort took up a position off Port-au-Prince ready to receive casualties that might result from the transfer of U.S. and allied forces ashore. From 16 September through 2 October 1994, Comfort personnel provided both medical and surgical support to U.S. and allied forces ashore and afloat, emergency humanitarian care to injured Haitian citizens, and participated in various aspects of the Civil Affairs Program in an effort to aid the rebuilding effort of the local healthcare system. She returned to Norfolk on 14 October 1994.

Operation Noble Eagle (2001)
Comfort was activated the afternoon of 11 September 2001, in response to the terrorist attack on the World Trade Center and sailed the next afternoon to serve as a 250-bed hospital facility at Pier 92 in midtown Manhattan. The ship arrived at Pier 92 in Manhattan about 8:30 p.m. 14 September. That evening a small number of relief workers arrived aboard the ship. As word about the ship spread, more workers began arriving over the next few days. The ship's clinic saw 561 guests for cuts, respiratory ailments, fractures, and other minor injuries, and Comfort's team of Navy psychology personnel provided 500 mental health consultations to relief workers. Comfort also hosted a group of volunteer New York area massage therapists who gave 1,359 therapeutic medical massages to ship guests.

Iraq War (2002–03)
Comfort was ordered to activate on 26 December 2002, and set sail for the U.S. Central Command area of operations on 6 January 2003. After stopping in Diego Garcia to embark additional medical personnel flown in from the National Naval Medical Center, the ship proceeded to the Persian Gulf to serve as an afloat trauma center in support of Operation Iraqi Freedom. Comfort remained in the Persian Gulf for 56 days providing expert medical care to wounded U.S. military personnel as well as injured Iraqi civilians and enemy prisoners of war. When Comfort returned to Baltimore on 12 June 2003, it marked the completion of a nearly six-month activation. During this time, the ship conducted more than 800 helicopter deck landings to bring aboard personnel, patients, and cargo. Comfort's Medical Treatment Facility had also performed 590 surgical procedures, transfused more than 600 units of blood, developed more than 8,000 radiographic images, and treated nearly 700 patients, including almost 200 Iraqi civilians and enemy prisoners of war.

Hurricane Katrina (2005)
Comfort deployed on 2 September 2005, after only a two-day preparation, to assist in Gulf Coast recovery efforts after the devastation of Hurricane Katrina. Starting in Pascagoula, Mississippi and then sailing to New Orleans, Comfort personnel saw 1,956 patients total. She returned on 13 October 2005 after a 7-week deployment.

Partnership for the Americas (2007)
Comfort's Partnership for the Americas humanitarian mission, which began on 15 June 2007, was a major component of the President's "Advancing the Cause of Social Justice in the Western Hemisphere" initiative. Comfort visited 12 Central American, South American, and Caribbean nations where her embarked medical crew provided free health care services to communities in need. The missions objective was to offer valuable training to U.S. military personnel while promoting U.S. goodwill in the region. In all, the civilian and military medical team treated more than 98,000 patients, provided 386,000 patient encounters and performed 1,100 surgeries. The embarked medical crew was made up of more than 500 military and non-governmental organization (Project Hope and Operation Smile) doctors, nurses, and healthcare professionals. Their primary focus was to support medical humanitarian assistance efforts ashore. A secondary mission was outpatient shipboard health service support. Also supporting Comfort's medical mission was a SEABEE detachment from the East Coast-based Mobile Construction Battalion Maintenance Unit 202, which performed civic action repair and minor construction projects in the host countries. Also on the deployment was the U.S. Navy Showband from Norfolk, Virginia, which performed in each port.

Comfort was operated and navigated by a crew of 68 civil service mariners (CIVMARS) from the U.S. Navy's Military Sealift Command (MSC). This mission incorporated various non-government organizations and government agencies, such as Operation Smile, Project Hope, LDS Humanitarian Services, the Atlanta Rotary Club, U.S. Air Force, U.S. Coast Guard, U.S. Army, U.S. Health and Human Services and the Canadian Armed Forces. Patient encounters included a single patient receiving multiple treatments, students in training sessions, and even veterinary care services. Dentists and staff treated 25,000 patients, extracting 300 teeth, and performing 4,000 fillings, 7,000 sealings, and 20,000 fluoride applications. In addition to treating patients, bio-medical professionals fixed about a thousand pieces of medical equipment at local health facilities. The ship's crew also delivered nearly $200,000 worth of donated humanitarian aid.

Operation Unified Response (2010)
On 13 January 2010, Comfort was ordered to assist in the humanitarian relief efforts following the 2010 Haiti earthquake as part of Operation Unified Response. Three days later on 16 January Comfort left the Port of Baltimore bound for Haiti. She arrived Wednesday, 20 January 2010 and began medical treatment early that day. The deployment marks the first time the ship has reached full operational capacity, utilizing all 12 operating rooms and 1,000 beds, since she was delivered to the Navy in 1987. The mission also saw the ship's first on-board delivery, of a 4-pound, 5-ounce premature baby named Esther. Although the ship is less capable than a traditional hospital on land, she offered the most advanced medical care available in Haiti following the earthquake. Between 19 January and 28 February 2010 the ship's staff treated 1,000 Haitian patients and performed 850 surgeries. By 8 March 2010, Comfort had discharged the last patient. On 10 March 2010, the ship ended her mission in the Joint Task Force Haiti area as part of Operation Unified Response, and returned to her home port.

Operation Continuing Promise (2011)
In 2011, the ship deployed on Operation Continuing Promise. The ship deployed for five months providing medical and surgical services to nine locations in the Caribbean and Latin America – Jamaica, Peru, Ecuador, Colombia, El Salvador, Nicaragua, Guatemala, Costa Rica, and Haiti. The ship's crew set up medical and surgical civil action program sites. These temporary medical clinics included primary care, internal medicine, obstetrics, and pediatric physicians as well as optometry, physical therapy, dental, radiology, laboratory, and pharmacy services. On board the ship general surgery, ophthalmology, oral and maxillofacial, and orthopedic surgeries were performed on pre-screened patients.

The mission included a Navy SeaBee (Construction Battalion) Unit, a Navy helo squadron, the United States Navy Band and a Navy Security Force unit. US Army veterinarians and veterinary technicians, US Air Force biomedical repair technicians, and dentists and dental technicians from the Canadian Navy also participated.

Although it was primarily a medical/humanitarian mission, several programs and projects, commonly referred to as Community Relations (COMREL) projects were also provided to the local populace throughout the mission. Veterinarians worked with local farmers on pest control and vaccinations, SeaBees completed building improvements in local schools and other facilities, Navy Band was a staple in all programs involving US military personnel and local government officials.

Hurricane Maria (2017)
On 29 September 2017, the ship set sail for Puerto Rico to bring assistance to the island after Hurricane Maria had hit it nine days earlier. She arrived the evening of 3 October 2017. While in San Juan, Comfort hosted a summit with key stakeholders to synchronize efforts for the ship's mission throughout the area. The ship's 835 personnel partnered with Federal DMAT teams DMAT/COMFORT partnership and evaluated 6,003 patients, 1,912 patients were sent to Comfort 290 patients admitted, and 192 surgeries performed. She provided over 40,000 lab tests, over 16,000 prescriptions, 343 CT scans, and 1,169 radiology studies. Dental services provided acute dental care for 312 patients. However, she was there to support the sickest patients on the island. Comfort's 50-bed ICU had the highest acuity patients of any military hospital in the world. The ship acted as a support structure for all the islands hospitals taking their sickest ICU patients, the only oxygen producing plant on the island, she filled every hospital's oxygen tanks to help them support their patients. Additionally her sterilizers were used to sterilize, clean, and wrap surgery kits for multiple hospitals, using her ability to be a force multiplier allowing other hospitals to continue to provide care, and surgeries while they stabilized their power and facilities. She provided life saving care, including dialysis as well as fixed dialysis shunts and placed portacath shunts as the only working interventional radiology capability. This along with partnering with Puerto Rico's Health Department was able to diagnose cancers and assist in getting patients started on cancer therapy. She even had two births on board after receiving mothers who had been in labor in hallways for days. Her skilled providers provided necessary orthopedic surgeries, provided CT scans for her patients or ones referred from one of the other over 60 hospitals on island. This was at a cost of about $180,000 a day. As the island infrastructure improved the admission rate to the ship declined to 1% of patients presenting, she was ordered home on 17 November.

Operation Enduring Promise (2018)
In October 2018, Comfort departed for an eleven-week operation in Latin America, with a primary mission being to assist countries that received refugees who fled the crisis in Venezuela. The main goal was to relieve health systems in Colombia, Ecuador, Peru and Honduras, which faced the arrival of thousands of Venezuelan migrants. She provided care for nearly 27,000 patients and performed 599 surgeries in 23 clinical days in five stops in four countries.

New York COVID-19 response (2020)
Comfort began deployment from Norfolk, Virginia, to New York Harbor on 28 March to help deal with the impact of the COVID-19 pandemic. Comfort arrived in New York on 30 March 2020. Initially, her mission was to treat patients who did not have the virus, freeing up land-based hospitals to focus on patients with COVID-19. But later half of the ship's 1000 beds were removed so that she could isolate and treat coronavirus patients. On 6 April 2020, COVID-19 patients were allowed onto the ship. One day later, the Navy announced that one crew member aboard Comfort had tested positive for the coronavirus and that several other crew members were put into isolation.

On 17 April the U.S. Northern Command announced that "the USNS COMFORT is prepared to admit patients within a one-hour traveling radius from the ship", and preparations were made to receive coronavirus patients from the Philadelphia area. On 21 April, Governor Andrew Cuomo told President Donald Trump that the ship was no longer needed in New York. Comfort departed on 30 April, having treated 179 patients.

Awards and decorations

 * Combat Action Ribbon – (26 Feb 1991)
 * Joint Meritorious Unit Award – (Apr 1991–Dec 1996) Operation Provide Comfort
 * Navy Unit Commendation – (Aug 1990–Mar 1991, May–Jul 1994)
 * Navy Meritorious Unit Commendation – (Sep 1994–Mar 1995, Sep 2001–Jun 2005, Jun–Oct 2007)
 * Armed Forces Expeditionary Medal – (Sep–Oct 1994)
 * Southwest Asia Service Medal – (Aug 1990–Mar 1991)
 * Humanitarian Service Medal – (Sep–Oct 2001, Sep–Oct 2005, Jan–Feb 2010, Sep–Nov 2017)

In 2008, the United Seamen's Service at its annual Admiral of the Ocean Sea Awards (AOTOS) event honored the masters and crews of hospital ships Comfort and Mercy with special Humanitarian Service Recognition Mariner's Plaques for their respective four-month humanitarian deployments to Latin America and the Caribbean in 2007 and Southeast Asia and the Pacific in 2008.

General characteristics

 * Specifications
 * Displacement:
 * Full Load: 69,390 Tons
 * Light: 24,275 Tons
 * Length:
 * Overall: 894 Feet (272.6 Meters)
 * Waterline: $854 5/6$ Feet (260.6 Meters)
 * Beam: $105 3/4$ Feet (32.25 Meters)
 * Draft: $32 5/6$ Feet (10.0 Meters)
 * Propulsion: 1 Steam Turbine, 2 Boilers, 1 Shaft, 24500 shp
 * Speed: 17.5 Knots
 * Range: 13,400 Nautical Miles (24,817 Kilometers) at 17.5 kn
 * Personnel:
 * Merchant Marine: 16 ROS; 61 Active
 * Navy Communications & Support: 58 (6 Officers, 52 Enlisted)
 * Medical and Dental (Active Only): 1,156
 * Aviation: Helicopter Landing Platform, 1 Spot
 * Radars: SPS-67 Surface Search
 * Patient capacity:
 * Intensive care wards: 80 beds
 * Recovery wards: 20 beds
 * Intermediate care wards: 280 beds
 * Light care wards: 120 beds
 * Limited care wards: 500 beds
 * Total Patient Capacity: 1000 beds
 * Operating Rooms: 12
 * Departments and facilities:
 * Casualty reception
 * Intensive care unit
 * Radiological services
 * Main laboratory plus satellite lab
 * Blood bank
 * Central sterile receiving
 * Medical supply/pharmacy
 * Physical therapy and burn care
 * Dental services
 * Optometry/lens lab
 * Morgue
 * Laundry
 * Oxygen producing plants (two)
 * Medical Photography
 * Four distilling plants to make drinking water from sea water (300000 gal per day)

title: USNS Comfort


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Talk:Kellermann

Untitled
This page appears to be not much more than a rant in support of Dr Kellermann with a bunch of mumbo jumbo about how the misspelling of his name is to distract people from finding articles in support of his work.

Keeping this page would set a precedent which would encourage the development of slighty-off spelled pages with various political agendas.
 * Aecarol 03:54, 5 Aug 2004 (UTC)

Well, one man's analysis of the branching off and speciation of a mutated meme in the virtual environment of internet search engines as a model in information theory of the process of genetic mutation, reproductive isolation, and speciation is another man's rant full of mumbo jumbo, as my Daddy always said. Gzuckier 15:28, 6 Aug 2004 (UTC)

On social engineering the article has merit. On Dr Kellermann, it's not encycolpedic
I would support it staying in the context of examples of the art of social manipulation. That is, covering the concept of mispellings to trap people into searches they want you to find. That's actually pretty interesting. If we keep this article specific to Dr Kellermann, we are opening the door to other POV articles which will round-about attack/defend whom ever using the same justification. The encyclopedia should not host rebuttals to off site attacks, which this article in effect is.
 * Aecarol 04:11, 7 Aug 2004 (UTC)

So we'll just make it a redirect page, and we'll all whistle and go fishing in heaven. Gzuckier 15:10, 9 Aug 2004 (UTC)

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/

title: Talk:Kellermann


text: Category:Australian swimmers

title: Category:Australian swimmers


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User:Lancer

Hi!

title: User:Lancer


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Leukoplakia

Oral leukoplakia is a potentially malignant disorder affecting the oral mucosa. It is defined as "essentially an oral mucosal white lesion that cannot be considered as any other definable lesion." Oral leukoplakia is a white patch or plaque that develops in the oral cavity and is strongly associated with smoking. Leukoplakia is a firmly attached white patch on a mucous membrane which is associated with increased risk of cancer. The edges of the lesion are typically abrupt and the lesion changes with time. Advanced forms may develop red patches. There are generally no other symptoms. It usually occurs within the mouth, although sometimes mucosa in other parts of the gastrointestinal tract, urinary tract, or genitals may be affected.

The cause of leukoplakia is unknown. Risk factors for formation inside the mouth include smoking, chewing tobacco, excessive alcohol, and use of betel nuts. One specific type is common in HIV/AIDS. It is a precancerous lesion, a tissue alteration in which cancer is more likely to develop. The chance of cancer formation depends on the type, with between 3–15% of localized leukoplakia and 70–100% of proliferative leukoplakia developing into squamous cell carcinoma.

Leukoplakia is a descriptive term that should only be applied after other possible causes are ruled out. Tissue biopsy generally shows increased keratin build up with or without abnormal cells, but is not diagnostic. Other conditions that can appear similar include yeast infections, lichen planus, and keratosis due to repeated minor trauma. The lesions from a yeast infection can typically be rubbed off while those of leukoplakia cannot.

Treatment recommendations depend on features of the lesion. If abnormal cells are present or the lesion is small surgical removal is often recommended; otherwise close follow up at three to six month intervals may be sufficient. People are generally advised to stop smoking and limit the drinking of alcohol. In potentially half of cases leukoplakia will shrink with stopping smoking; however, if smoking is continued up to 66% of cases will become more white and thick. The percentage of people affected is estimated at 1–3%. Leukoplakia becomes more common with age, typically not occurring until after 30. Rates may be as high as 8% in men over the age of 70.

Classification
Leukoplakia could be classified as mucosal disease, and also as a premalignant condition. Although the white color in leukoplakia is a result of hyperkeratosis (or acanthosis), similarly appearing white lesions that are caused by reactive keratosis (smoker's keratosis or frictional keratoses e.g. morsicatio buccarum) are not considered to be leukoplakias. Leukoplakia could also be considered according to the affected site, e.g. oral leukoplakia, leukoplakia of the urinary tract, including bladder leukoplakia or leukoplakia of the penis, vulvae, cervix or vagina. Leukoplakia may also occur in the larynx, possibly in association with gastro-esophageal reflux disease. Oropharyngeal leukoplakia is linked to the development of esophageal squamous cell carcinoma, and sometimes this is associated with tylosis, which is thickening of the skin on the palms and soles of the feet (see: Leukoplakia with tylosis and esophageal carcinoma). Dyskeratosis congenita may be associated with leukoplakia of the oral mucosa and of the anal mucosa.

Mouth
Within the mouth, leukoplakia is sometimes further classified according to the site involved, e.g. leukoplakia buccalis (leukoplakia of the buccal mucosa) or leukoplakia lingualis (leukoplakia of the lingual mucosa). There are two main clinical variants of oral leukoplakia, namely homogeneous leukoplakia and non-homogeneous (heterogenous) leukoplakia, which are described below. The word leukoplakia is also included within the nomenclature of other oral conditions which present as white patches, however, these are specific diagnoses that are generally considered separate from leukoplakia, with the notable exception of proliferative verrucous leukoplakia, which is a recognized sub-type of leukoplakia.

Homogeneous leukoplakia
Homogeneous leukoplakia (also termed "thick leukoplakia") is usually well defined white patch of uniform, flat appearance and texture, although there may be superficial irregularities. Homogeneous leukoplakia is usually slightly elevated compared to surrounding mucosa, and often has a fissured, wrinkled or corrugated surface texture, with the texture generally consistent throughout the whole lesion. This term has no implications on the size of the lesion, which may be localized or extensive. When homogeneous leukoplakia is palpated, it may feel leathery, dry, or like cracked mud.

Non-homogeneous leukoplakia
Non-homogeneous leukoplakia is a lesion of non-uniform appearance. The color may be predominantly white or a mixed white and red. The surface texture is irregular compared to homogeneous leukoplakia, and may be flat (papular), nodular or exophytic. "Verrucous leukoplakia" (or "verruciform leukoplakia") is a descriptive term used for thick, white, papillary lesions. Verrucous leukoplakias are usually heavily keratinized and are often seen in elderly people. Some verrucous leukoplakias may have an exophytic growth pattern, and some may slowly invade surrounding mucosa, when the term proliferative verrucous leukoplakia may be used. Non-homogeneous leukoplakias have a greater risk of cancerous changes than homogeneous leukoplakias.

Proliferative verrucous leukoplakia
Proliferative verrucous leukoplakia (PVL) is a recognized high risk subtype of non-homogeneous leukoplakia. It is uncommon, and usually involves the buccal mucosa and the gingiva (the gums). This condition is characterized by (usually) extensive, papillary or verrucoid keratotic plaques that tends to slowly enlarge into adjacent mucosal sites. An established PVL lesion is usually thick and exophytic (prominent), but initially it may be flat. Smoking does not seem to be as strongly related as it is to leukoplakia generally, and another dissimilarity is the preponderance for women over 50. There is a very high risk of dysplasia, transformation to squamous cell carcinoma with high mortality (PVL does not transform into verrucous carcinoma, which is a lesion with a good prognosis usually; the similarity of names does not reflect the common origin, but only the resemblance of their appearance).

Erythroleukoplakia
Erythroleukoplakia (also termed speckled leukoplakia, erythroleukoplasia or leukoerythroplasia) is a non-homogeneous lesion of mixed white (keratotic) and red (atrophic) color. Erythroplakia (erythroplasia) is an entirely red patch that cannot be attributed to any other cause. Erythroleukoplakia can therefore be considered a variant of either leukoplakia or erythroplakia since its appearance is midway between. Erythroleukoplakia frequently occurs on the buccal mucosa in the commissural area (just inside the cheek at the corners of the mouth) as a mixed lesion of white nodular patches on an erythematous background, although any part of the mouth may be affected. Erythroleukoplakia and erythroplakia have a higher risk of cancerous changes than homogeneous leukoplakia.

Sublingual keratosis
Sometimes leukoplakia of the floor of mouth or under the tongue is called sublingual keratosis,. though this is not universally accepted to be a distinct clinical entity from idiopathic leukoplakia generally, as it is distinguished from the latter by location only. Usually sublingual keratoses are bilateral and possess a parallel-corrugated, wrinkled surface texture described as "ebbing tide".

Candidal leukoplakia
Candidal leukoplakia is usually considered to be a largely historical synonym for a type of oral candidiasis, now more commonly termed chronic hyperplastic candidiasis, rather than a subtype of true leukoplakia. However, some sources use this term to refer to leukoplakia lesions that become colonized secondarily by Candida species, thereby distinguishing it from hyperplastic candidiasis.

Oral hairy leukoplakia
Oral hairy leukoplakia is a corrugated ("hairy") white lesion on the sides of the tongue caused by opportunistic infection with Epstein-Barr virus on a systemic background of immunodeficiency, almost always human immunodeficiency virus (HIV) infection. This condition is not considered to be a true idiopathic leukoplakia since the causative agent has been identified. It is one of the most common oral lesions associated with HIV infection, along with pseudomembraneous candidiasis. The appearance of the lesion often heralds the transition from HIV to acquired immunodeficiency syndrome (AIDS).

Syphilitic leukoplakia
This term refers to a white lesion associated with syphilis, specifically in the tertiary stage of the infection. It is not considered to be a type of idiopathic leukoplakia, since the causative agent Treponema pallidum is known. It is now rare, but when syphilis was more common, this white patch usually appeared on the top surface of the tongue and carried a high risk of cancerous changes. It is unclear if this lesion was related to the condition itself or whether it was caused by the treatments for syphilis at the time.

Esophagus
Leukoplakia of the esophagus is rare compared to oral leukoplakia. The relationship with esophageal cancer is unclear because the incidence of esophageal leukoplakia is so low. It usually appears as a small, nearly opaque white lesion that may resemble early esophageal squamous cell carcinoma. The histologic appearance is similar to oral leukoplakia, with hyperkeratosis and possible dysplasia.

Bladder
In the context of lesions of the mucous membrane lining of the bladder, leukoplakia is a historic term for a visualized white patch which histologically represents keratinization in an area of squamous metaplasia. The symptoms may include frequency, suprapubic pain (pain felt above the pubis), hematuria (blood in the urine), dysuria (difficult urination or pain during urination), urgency, and urge incontinence. The white lesion may be seen during cystoscopy, where it appears as a whitish-gray or yellow lesion, on a background of inflamed urothelium and there may be floating debris in the bladder. Leukoplakia of the bladder may undergo cancerous changes, so biopsy and long term follow up are usually indicated.

Anal canal
Leukoplakia of the anal canal is rare. It may extend up to the anorectal junction. On digital examination it feels hard and granular, and at proctoscopy, it appears as white plaques which may be diffuse, circumferential, or circumscribed. The histologic appearance is similar to oral leukoplakia, with hyperkeratosis and acanthosis. It may be asymptomatic, with symptoms due to other lesions such as hemorrhoids or fissures. Progression to anal stenosis has been described. The malignant potential is seemingly low, and few cases of anal carcinoma have been reported associated with anal leukoplaka.

Signs and symptoms
Most cases of leukoplakia cause no symptoms, but infrequently there may be discomfort or pain. The exact appearance of the lesion is variable. Leukoplakia may be white, whitish yellow or grey. The size can range from a small area to much larger lesions. The most common sites affected are the buccal mucosa, the labial mucosa and the alveolar mucosa, although any mucosal surface in the mouth may be involved. The clinical appearance, including the surface texture and color, may be homogeneous or non-homogeneous (see: classification). Some signs are generally associated with a higher risk of cancerous changes (see: prognosis).

Leukoplakia may rarely be associated with esophageal carcinoma.

Causes
The exact underlying cause of leukoplakia is largely unknown, but it is likely multifactorial, with the main factor being the use of tobacco. Tobacco use and other suggested causes are discussed below. The mechanism of the white appearance is thickening of the keratin layer, called hyperkeratosis. The abnormal keratin appears white when it becomes hydrated by saliva, and light reflects off the surface evenly. This hides the normal pink-red color of mucosae (the result of underlying vasculature showing through the epithelium). A similar situation can be seen on areas of thick skin such as the soles of the feet or the fingers after prolonged immersion in water. Another possible mechanism is thickening of the stratum spinosum, called acanthosis.

Tobacco
Tobacco smoking or chewing is the most common causative factor, with more than 80% of persons with leukoplakia having a positive smoking history. Smokers are much more likely to develop leukoplakia than non-smokers. The size and number of leukoplakia lesions in an individual is also correlated with the level of smoking and how long the habit has lasted for. Other sources argue that there is no evidence for a direct causative link between smoking and oral leukoplakia. Cigarette smoking may produce a diffuse leukoplakia of the buccal mucosa, lips, tongue and rarely the floor of mouth. Reverse smoking, where the lit end of the cigarette is held in the mouth is also associated with mucosal changes. Tobacco chewing, e.g. betel leaf and areca nut, called paan, tends to produce a distinctive white patch in a buccal sulcus termed "tobacco pouch keratosis". In the majority of persons, cessation triggers shrinkage or disappearance of the lesion, usually within the first year after stopping.

Alcohol
Although the synergistic effect of alcohol with smoking in the development of oral cancer is beyond doubt, there is no clear evidence that alcohol is involved in the development of leukoplakia, but it does appear to have some influence. Excessive use of a high alcohol-containing mouth wash (> 25%) may cause a grey plaque to form on the buccal mucosa, but these lesions are not considered true leukoplakia.

Sanguinaria
Sanguinaria (Bloodroot) is a herbal extract that is included in some toothpastes and mouthwashes. Its use is strongly associated with development of leukoplakia, usually in the buccal sulcus. This type of leukoplakia has been termed "sanguinaria associated keratosis" and more than 80% of people with leukoplakia in the vestibule of the mouth have used this substance. Upon stopping contact with the causative substance, the lesions may persist for many years. Although this type of leukoplakia may show dysplasia, the potential for malignant transformation is unknown.

Ultraviolet radiation
Ultraviolet radiation is believed to be a factor in the development of some leukoplakia lesions of the lower lip, usually in association with actinic cheilitis.

Micro-organisms
Candida in its pathogenic hyphal form is occasionally seen in biopsies of idiopathic leukoplakia. It is debated whether candida infection is a primary cause of leukoplakia with or without dysplasia, or a superimposed (secondary) infection that occurs after the development of the lesion. It is known that Candida species thrive in altered tissues. Some leukoplakias with dysplasia reduce or disappear entirely following use of antifungal medication. Smoking, which as discussed above can lead to the development of leukoplakia, can also promote oral candidiasis. Candida in association with leukoplakia should not be confused with white patches which are primarily caused by candida infection, such as chronic hyperplastic candidiasis ("candidal leukoplakia").

The involvement of viruses in the formation of some oral white lesions is well established, e.g. Epstein-Barr virus in oral hairy leukoplakia (which is not a true leukoplakia). Human papilloma virus (HPV), especially HPV 16 and 18, is sometimes found in areas of leukoplakia, however, since this virus can be coincidentally found on normal, healthy mucosal surfaces in the mouth, it is unknown if this virus is involved in the development of some leukoplakias. In vitro experimentation has demonstrated that HPV 16 is capable of inducing dysplastic changes in previously normal squamous epithelium.

Epithelial atrophy
Leukoplakia is more likely to develop in areas of epithelial atrophy. Conditions associated with mucosal atrophy include iron deficiency, some vitamin deficiencies, oral submucous fibrosis, syphilis and sideropenic dysphagia.

Trauma
Another very common cause of white patches in the mouth is frictional or irritational trauma leading to keratosis. Examples include nicotine stomatitis, which is keratosis in response to heat from tobacco smoking (rather than a response to the carcinogens in tobacco smoke). The risk of malignant transformation is similar to normal mucosa. Mechanical trauma, e.g. caused by a sharp edge on a denture, or a broken tooth, may cause white patches which appear very similar to leukoplakia. However, these white patches represent a normal hyperkeratotic reaction, similar to a callus on the skin, and will resolve when the cause is removed. Where there is a demonstrable cause such as mechanical or thermal trauma, the term idiopathic leukoplakia should not be used.

Tumor suppressor genes
Tumor suppressor genes are genes involved in the regulation of normal cell turnover and apoptosis (programmed cell death). One of the most studied tumor suppressor genes is p53, which is found on the short arm of chromosome 17. Mutation of p53 can disrupt its regulatory function and lead to uncontrolled cell growth. Mutations of p53 have been demonstrated in the cells from areas of some leukoplakias, especially those with dysplasia and in individuals who smoke and drink heavily.

DNA damage
DNA damage was measured in oral leukoplakia patients using single cell gel electrophoresis (also called the “comet assay”) applied to peripheral blood samples. The level of DNA damage was found to increase in a stepwise manner from healthy controls, through patients with non-dysplastic epithelium to patients with varying grades of dysplasia. In another study, DNA damage, also measured by the comet assay, was found to be greater in oral leukoplakia and squamous-cell carcinoma than in control subjects.

Definition
Leukoplakia is a diagnosis of exclusion, meaning that which lesions are included depends upon what diagnoses are currently considered acceptable. Accepted definitions of leukoplakia have changed over time and are still controversial. It is possible that the definition will be further revised as new knowledge becomes available. In 1984 an international symposium agreed upon the following definition: "a whitish patch or plaque, which cannot be characterized clinically or pathologically as any other disease, and is not associated with any physical or chemical agent except the use of tobacco." There were, however, problems and confusion in applying this definition. At a second international symposium held in 1994, it was argued that whilst tobacco was a likely causative factor in the development of leukoplakia, some white patches could be linked directly to the local effects of tobacco by virtue of their disappearance following smoking cessation, suggesting that this kind of white patch represents a reactive lesion to local tissue irritation rather than a lesion caused by carcinogens in cigarette smoke, and could be better termed to reflect this etiology, e.g. smokers' keratosis. The second international symposium, therefore, revised the definition of leukoplakia to: "a predominantly white lesion of the oral mucosa that cannot be characterized as any other definable lesion."

In the mouth, the current definition of oral leukoplakia adopted by the World Health Organization is "white plaques of questionable risk having excluded (other) known diseases or disorders that carry no increased risk for cancer". However, this definition is inconsistently applied in the medical literature, and some refer to any oral white patch as "leukoplakia".

The term has been incorrectly used for white patches of any cause (rather than specifically referring to idiopathic white patches) and also to refer only to white patches which have a risk of cancerous changes. It has been suggested that leukoplakia is an unhelpful term since there is so much inconsistency surrounding its use, and some clinicians now avoid using it at all.

Biopsy
Tissue biopsy is usually indicated to rule out other causes of white patches and also to enable a detailed histologic examination to grade the presence of any epithelial dysplasia. This is an indicator of malignant potential and usually determines the management and recall interval. The sites of a leukoplakia lesion that are preferentially biopsied are the areas that show induration (hardening) and erythroplasia (redness), and erosive or ulcerated areas. These areas are more likely to show any dysplasia than homogeneous white areas.

Brush biopsy/exfoliative cytology is an alternative to incisional biopsy, where a stiff brush is scraped against the lining of the mouth to remove a sample of cells. This is then made into a smear which can be examined microscopically. Sometimes the biopsy site can be selected with adjunct methods which aim to highlight areas of dysplasia. Toluidine blue staining, where the dye is preferentially retained by dysplastic tissue, is sometimes used, but there is high false positive rate. Other methods involve the use of luminescence, relying on either the property of normal autoflorescent molecules in mucosa such as collagen and keratin which is lost from areas of dysplasia or carcinoma under blue light or by initially staining of the mucosa with toluidine blue or dilute acetic acid and examination under white light.

Histologic appearance
Leukoplakia has a wide range of possible histologic appearances. The degree of hyperkeratosis, epithelial thickness (acanthosis/atrophy), dysplasia and inflammatory cell infiltration in the underlying lamina propria are variable. In mucous membranes, hyperkeratosis can be defined as "an increase in the thickness of the keratin layer of the epithelium, or the presence of such a layer in a site where none would normally be expected." In leukoplakia, the hyperkeratosis varies in thickness and may be either ortho- or para-keratosis, (depending upon whether cell nuclei are lost or retained in the superficial layers respectively), or a mixture of both in different areas of the lesion.

The epithelium may show hypertrophy (e.g. acanthosis) or atrophy. Red areas within leukoplakia represent atrophic or immature epithelium which has lost the ability to keratinize. The transition between the lesion and normal surrounding mucosa may be well-demarcated, or poorly defined. Melanin, a pigment naturally produced in oral mucosa, can leak from cells and give a grey color to some leukoplakia lesions.

Hyperkeratosis and altered epithelial thickness may be the only histologic features of a leukoplakia lesion, but some show dysplasia. The word "dysplasia" generally means "abnormal growth", and specifically, in the context of oral red or white lesions, refers to microscopic changes ("cellular atypia") in the mucosa that indicate a risk of malignant transformation. When dysplasia is present, there is generally an inflammatory cell infiltration in the lamina propria. The following are commonly cited as being possible features of epithelial dysplasia in leukoplakia specimens:
 * Cellular pleomorphism, in which cells are of abnormal and different shapes.
 * Nuclear atypia, in which the nuclei of cells varies in size, any may be increased in size relative to the cytoplasm, shape, and may stain more intensely. There may also be more prominent nucleoli.
 * Increased number of cells seen undergoing mitosis, including both normal and abnormal mitoses. Abnormal mitosis may be abnormally located, e.g. occurring in suprabasal cells (cell layers more superficial to the basal cell layer) or of abnormal form, e.g. "tri-radiate mitoses" (a cell splitting into 3 daughter cells rather than only 2)
 * Loss the normal organization of the epithelial layers. The distinction between the epithelial layers may be lost. Normally stratified squamous epithelium shows progressive changes in the form of cells from the basal to the superficial layers, with cells becoming more flat ("squames") towards the surface as a continuous maturation process. In dysplastic epithelium, cells may become vertically orientated rather than becoming flat towards the surface.
 * There may be abnormal keratinization, where keratin is formed below the normal keratin layer. This can occur in individual cells or groups of cells, forming an intraepithelial keratin pearl. There may be an increase in the number of basal cells, and they may lose their cellular orientation (losing their polarity and long axis).
 * Alteration of the normal epithelial-connective tissue architecture - the rete pegs may become "drop shaped". wider at their base than more superficially.

Generally, dysplasia is subjectively graded by pathologists into mild, moderate or severe dysplasia. This requires experience as it is a difficult skill to learn. It has been shown that there is high degree of inter-observer variation and poor reproducibility in how dysplasia is graded. Severe dysplasia is synonymous with the term carcinoma in situ, denoting the presence of neoplastic cells which have not yet penetrated the basement membrane and invaded other tissues.

Differential diagnosis
There are many known conditions that present with a white lesion of the oral mucosa, but the majority of oral white patches have no known cause. These are termed leukoplakia once other likely possibilities have been ruled out. There are also few recognized subtypes of leukoplakia, described according to the clinical appearance of the lesion.

Almost all oral white patches are usually the result of keratosis. For this reason, oral white patches are sometimes generally described as keratoses, although a minority of oral white lesions are not related to hyperkeratosis, e.g. epithelial necrosis and ulceration caused by a chemical burn (see: Oral ulceration). In keratosis, the thickened keratin layer absorbs water from saliva in the mouth and appears white in comparison with normal mucosa. Normal oral mucosa is a red-pink color due to the underlying vasculature in the lamina propria showing through the thin layer of epithelium. Melanin produced in the oral mucosa also influences the color, with a darker appearance being created by higher levels of melanin in the tissues (associated with racial/physiologic pigmentation, or with disorders causing melanin overproduction such as Addison's disease). Other endogenous pigments can be overproduced to influence the color, e.g. bilirubin in hyperbilirubinemia or hemosiderin in hemochromatosis, or exogenous pigments such as heavy metals can be introduced into the mucosa, e.g. in an amalgam tattoo.

Almost all white patches are benign, i.e. non-malignant. The differential diagnosis of a white lesion in the mouth can be considered according to a surgical sieve (see table).

Leukoplakia cannot be rubbed off the mucosa, distinguishing it readily from white patches such as pseudomembraneous candidiasis, where a white layer can be removed to reveal an erythematous, sometimes bleeding surface underneath. The white color associated with leukoedema disappears when the mucosa is stretched. A frictional keratosis will generally be adjacent to a sharp surface such as a broken tooth or rough area on a denture and will disappear when the causative factor is removed. Some have a suggested as general rule that any lesion that does not show signs of healing within 2 weeks should be biopsied. Morsicatio buccarum and linea alba are located at the level of the occlusal plane (the level at which the teeth meet). A chemical burn has a clear history of placing an aspirin tablet (or other caustic substance such as eugenol) against the mucosa in an attempt to relieve toothache. Developmental white patches usually are present from birth or become apparent earlier in life, whilst leukoplakia generally affects middle aged or elderly people. Other causes of white patches generally require pathologic examination of a biopsy specimen to distinguish with certainty from leukoplakia.

Management
A systematic review found that no treatments commonly used for leukoplakia have been shown to be effective in preventing malignant transformation. Some treatments may lead to healing of leukoplakia, but do not prevent relapse of the lesion or malignant change. Regardless of the treatment used, a diagnosis of leukoplakia almost always leads to a recommendation that possible causative factors such as smoking and alcohol consumption be stopped, and also involves long term review of the lesion, to detect any malignant change early and thereby improve the prognosis significantly.

Predisposing factors and review
Beyond advising smoking cessation, many clinicians will employ watchful waiting rather than intervene. Recommended recall intervals vary. One suggested program is every 3 months initially, and if there is no change in the lesion, then annual recall thereafter. Some clinicians use clinical photographs of the lesion to help demonstrate any changes between visits. Watchful waiting does not rule out the possibility of repeated biopsies. If the lesion changes in appearance repeat biopsies are especially indicated. Since smoking and alcohol consumption also places individuals at higher risk of tumors occurring in the respiratory tract and pharynx, "red flag" symptoms (e.g. hemoptysis - coughing blood) often trigger medical investigation by other specialties.

Surgery
Surgical removal of the lesion is the first choice of treatment for many clinicians. However, the efficacy of this treatment modality cannot be assessed due to insufficient available evidence. This can be carried out by traditional surgical excision with a scalpel, with lasers, or with eletrocautery or cryotherapy. Often, if biopsy demonstrates moderate or severe dysplasia then the decision to excise them is taken more readily. Sometimes, white patches are too large to remove completely and instead they are monitored closely. Even if the lesion is completely removed, long term review is still usually indicated since leukoplakia can recur, especially if predisposing factors such as smoking are not stopped.

Medications
Many different topical and systemic medications have been studied, including anti-inflammatories, antimycotics (target Candida species), carotenoids (precursors to vitamin A, e.g. beta carotene), retinoids (drugs similar to vitamin A), and cytotoxics, but none have evidence that they prevent malignant transformation in an area of leukoplakia. Vitamins C and E have also been studied with regards a therapy for leukoplakia. Some of this research is carried out based upon the hypothesis that antioxidant nutrients, vitamins and cell growth suppressor proteins (e.g. p53) are antagonistic to oncogenesis. High doses of retinoids may cause toxic effects. Other treatments that have been studied include photodynamic therapy.

Prognosis
The annual malignant transformation rate of leukoplakia rarely exceeds 1%, i.e. the vast majority of oral leukoplakia lesions will remain benign. A number of clinical and histopathologic features are associated with varying degrees of increased risk of malignant transformation, although other sources argue that there are no universally accepted and validated factors which can reliably predict malignant change. It is also unpredictable to an extent if an area of leukoplakia will disappear, shrink or remain stable.
 * Presence and degree of dysplasia (mild, moderate or severe/carcinoma in situ). While the degree of dysplasia has been shown to be an important predictor of malignant change, many have challenged its use due to the low predictive value from the lack of objectivity of grading dysplasia.  While 10% of leukoplakia lesions show dysplasia when biopsied, as many as 18% of oral lesions undergo malignant change in the absence of dysplasia.
 * Leukoplakia located on the floor of the mouth, the posterior and lateral tongue, and the retromolar areas (the region behind the wisdom teeth) have higher risk, whereas white patches in areas such as the top surface of the tongue and the hard palate do not have significant risk. Although these "high risk" sites are recognized, statistically, leukoplakia is more common on the buccal mucosa, alveolar mucosa, and the lower labial mucosa. Leukoplakia of the floor of the mouth and tongue accounts for over 90% of leukoplakias showing dysplasia or carcinoma on biopsy. This is thought to be due to pooling of saliva in the lower part of the mouth, exposing these areas to more carcinogens held in suspension.
 * Red lesions (erythroplasia) and mixed red and white lesions (erythroleukoplakia/"speckled leukoplakia") have a higher risk of malignant change than homogeneous leukoplakia.
 * Verrucous or nodular areas have a higher risk.
 * Although smoking increases risk of malignant transformation, smoking also causes many white patches with no dysplasia. This means that statistically, white patches in non-smokers have a higher risk.
 * Older people with white patches are at higher risk.
 * Larger white patches are more likely to undergo malignant transformation than smaller lesions.
 * White patches which have been present for a long period of time have a higher risk.
 * Persons with a positive family history of cancer in the mouth.
 * Candida infection in the presence of dysplasia has a small increased risk.
 * A change in the appearance of the white patch, apart from a change in the color, has a higher risk. Changes in the lesion such as becoming fixed to underlying tissues, ulceration, cervical lymphadenopathy (enlargement of lymph nodes in the neck), and bone destruction may herald the appearance of malignancy.
 * White patches present in combination with other conditions that carry a higher risk (e.g. oral submucous fibrosis), are more likely to turn malignant.
 * Although overall, oral cancer is more common in males, females with white patches are at higher risk than men.

Epidemiology
The prevalence of oral leukoplakia varies around the world, but generally speaking it is not an uncommon condition. Reported prevalence estimates range from less than 1% to more than 5% in the general population. Leukoplakia is, therefore, the most common premalignant lesion that occurs in the mouth. Leukoplakia is more common in middle-aged and elderly males. The prevalence increases with increasing age. In areas of the world where smokeless tobacco use is common, there is a higher prevalence. In the Middle East region, the prevalence of leukoplakia is less than 1% (0.48%).

Etymology
The word leukoplakia means "white patch", and is derived from the Greek words λευκός - "white" and πλάξ - "plate".

History
The term leukoplakia was coined in 1861 by Karl Freiherr von Rokitansky, who used it to refer to white lesions of the urinary tract. In 1877, Schwimmer first used the term for an oral white lesion. It is now thought that this white lesion on the tongue represented syphilitic glossitis, a condition not included in the modern definitions of oral leukoplakia. Since then, the word leukoplakia has been incorporated into the names for several other oral lesions (e.g. candidal leukoplakia, now more usually termed hyperplastic candidiasis). In 1930, it was shown experimentally that leukoplakia could be induced in rabbits that were subjected to tobacco smoke for 3 minutes per day. According to one source from 1961, leukoplakia can occur on multiple different mucous membranes of the body, including in the urinary tract, rectum, vagina, uterus, vulva, paranasal sinuses, gallbladder, esophagus, eardrums, and pharynx. Generally, oral leukoplakia is the only context where the term is in common usage in modern medicine. In 1988, a case report used the term acquired dyskeratotic leukoplakia to refer to an acquired condition in a female where dyskeratotic cells were present in the epithelia of the mouth and genitalia.

title: Leukoplakia


text:
Mercy-class hospital ship

The Mercy class of hospital ships are converted San Clemente-class supertankers used by the United States Navy. Originally built in the 1970s by the National Steel and Shipbuilding Company, they were acquired by the Navy and converted into hospital ships, coming into service in 1986 and 1987.

Mercy class replaced the Haven-class hospital ships.

The ships are operated by Military Sealift Command and are designed to provide emergency, on-site care for American combatant forces, and also for use in support of disaster relief and humanitarian operations. Each ship contains twelve fully equipped operating rooms, a 1,000-bed hospital facility, radiological services, a medical laboratory, pharmacy, optometry lab, CT scan equipment, and two oxygen-producing plants.

Ships
Two ships of the class were put into service:

 * USNS Mercy (ex SS Worth)
 * USNS Comfort (ex SS Rose City)

Missions
Stationed in San Diego, California, Mercy primarily operates in the Pacific and Indian Oceans. Her inaugural mission in 1987, was a humanitarian cruise to the Philippines and South Pacific. Her first military mission was serving coalition troops in the First Gulf War. The first disaster relief came in the wake of the 2004 tsunami as Operation Unified Assistance. Her latest was in 2013, when she came to the aid of the Philippines, and other nations in the aftermath of Typhoon Haiyan.

Stationed out of Norfolk, Virginia, Comfort operates primarily in the Caribbean and Latin America. Her first mission was a combat one: serving coalition troops off the coast of Kuwait, during Operation Desert Storm. Her first humanitarian missions both happened in 1994, helping Haitian and Cuban immigrants looking to come to America. In the aftermath of 9/11, Comfort was activated and sent to Manhattan, to provide medical and mental health services. Comfort headed into combat again for Operation Iraqi Freedom. In 2005, she was back saving American citizens following the devastation of Hurricane Katrina. In 2010, she undertook another disaster relief mission, in response to an earthquake in Haiti. In May 2015, Comfort was in Kingston, Jamaica. Once again in 2017, Comfort was deployed to aid American citizens in Puerto Rico after Hurricane Maria.

In March 2020, the ships were deployed to aid in the fight against the coronavirus pandemic. Both ships were to function as trauma centers at erstwhile-disused cruise ship terminals in San Pedro and Manhattan. This, at that time, would have been expected to have enabled nearby hospitals to have freed up beds for coronavirus patients. On 21 April, Governor Cuomo told President Trump that Comfort was no longer needed in New York. While docked in the city, she treated 182 patients.

Criticism
The Mercy-class ships' size gives them a substantial radar signature that, combined with lack of manoeuvrability, makes them vulnerable to attack. In theory, this should never occur, as attacking a hospital ship is a war crime under the Hague Convention of 1907, but the ships are left vulnerable to terrorist organizations and other entities that do not follow such established warfare conventions, due to the fact that both ships are outfitted only with defensive weapons. If within a battle fleet they could be vulnerable to missile strikes aimed at the fleet as a whole, and their radar signature could be confused with troop ships, landing ships, helicopter carriers or become a target for weapons that miss or are decoyed away from combatant ships.

In mid-2004 Vice Admiral Michael L. Cowan, the Surgeon General and chief of the Bureau of Medicine and Surgery, said that Comfort and Mercy should be retired. "They're wonderful ships, but they're dinosaurs. They were designed in the '70s, built in the '80s, and frankly, they're obsolete".

title: Mercy-class hospital ship


text:
Talk:Charles XV

Date of death
An anonymous editor changed the date of death. Can you cite a verifiable source for this information? Accurizer 11:05, 18 September 2006 (UTC)

 * Good question. A quick web search (excluding wiki and its clones) yields several dates : 18 Aug, 19 Aug, 18 Sep/18 Sep, 19 Sep. At least they agree on Malmö as the place. -- Abut 21:44, 24 January 2007 (UTC)

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Re: paternal grandson
Please see and use the talk page at Talk:Nils Bolander without removing this well-sourced fact again. --SergeWoodzing (talk) 10:00, 4 March 2018 (UTC)

Move discussion in progress
There is a move discussion in progress on Talk:Carl XVI Gustaf of Sweden which affects this page. Please participate on that page and not in this talk page section. Thank you. —RMCD bot 11:16, 9 June 2020 (UTC)

Requested move 20 June 2020

 * The following is a closed discussion of a requested move. Please do not modify it. Subsequent comments should be made in a new section on the talk page. Editors desiring to contest the closing decision should consider a move review after discussing it on the closer's talk page. No further edits should be made to this discussion.

The result of the move request was: Consensus to move to Charles XV. (t · c)  buidhe  05:43, 30 June 2020 (UTC)

Charles XV of Sweden → ? – Procedural nomination. I performed a move of this article from Charles XV of Sweden to Charles XV per this discussion, but that discussion did not consider the fact that Charles XV is also called Charles IV. Per a request on my talk, I am re-nominating this for further discussion. Best, Mdaniels5757 (talk) 15:13, 20 June 2020 (UTC)
 * Oppose Should not be moved, as per info now supplied by nom. --SergeWoodzing (talk) 15:32, 20 June 2020 (UTC)
 * Comment Recommend this RM be merged with the RM at Charles XIV John of Sweden article. GoodDay (talk) 15:47, 20 June 2020 (UTC)
 * I cannot help raising an eyebrow about this, Mdaniels5757. A move discussion involving this article was held just days ago. SergeWoodzing took part in the discussion and had plenty of time to present his arguments there. But he did not; instead he asked you to reverse the consensus-based move after the discussion ended and you obliged? And now we are supposed to discuss something we already discussed in the past two weeks? That is bizarre. The consensus reached here was to use common names per policy. That means "Charles XV" for this man. Surtsicna (talk) 16:06, 20 June 2020 (UTC)
 * Uh ... this is not about me. It's about a king who reigned in 2 countries and is called a different thing in each; whether or not his article name in English Wikipedia more clearly than before only should reflect one of the 2 countries, only one of the two names. If we all stick to topic and deal with it, perhaps this can be constructive. --SergeWoodzing (talk) 15:31, 21 June 2020 (UTC)
 * But it is about your actions. You took part in the move discussion and decided to abstain. After it ended, you interfered with the result by asking for an out-of-process reversion of the decision reached by consensus. The user most at fault, however, is the one who obliged. This topic was dealt with only this week. Surtsicna (talk) 15:43, 21 June 2020 (UTC)
 * Please see and try to respect WP:TPYES, all of it: "Comment on content, not on the contributor: Keep the discussions focused on the topic of the talk page, rather than on the editors participating." --SergeWoodzing (talk) 16:42, 21 June 2020 (UTC)
 * The topic is your underhanded subversion of the community's decision and I am very much focusing on it. Surtsicna (talk) 16:52, 21 June 2020 (UTC)
 * (The topic now became this crystal clear personal attack & whether or not I should take action against the user's behavior again and be more assertive this time. In any case, none of it belongs on this talk page. --SergeWoodzing (talk) 16:18, 25 June 2020 (UTC))

 * Move back to Charles XV as previously discussed. During his lifetime he was known in Norway as Carl XV, e.g. on Norwegian coins. Opera hat (talk) 12:40, 21 June 2020 (UTC)
 * Move to "Charles XV" per Columbia Encyclopedia and Britannica. Allan Rice (talk) 02:00, 22 June 2020 (UTC)
 * Comment we need something to handle such monarchs with multiple regnal numbers, per multiple countries. GoodDay (talk) 15:21, 26 June 2020 (UTC)
 * We have a policy: WP:COMMONNAME. Surtsicna (talk) 15:53, 26 June 2020 (UTC)

Discussion at Wikipedia_talk:Naming_conventions_(royalty_and_nobility)
You are invited to join the discussion at Wikipedia_talk:Naming_conventions_(royalty_and_nobility). Interstellarity (talk) 13:31, 24 June 2020 (UTC)

RfC of interest
(non-automated message) Greetings! I have opened an RfC on WT:ROYALTY that may be of interest to users following this article talk page! You are encouraged to contribute to this discussion here! Hurricane Andrew (444) 19:38, 24 November 2023 (UTC)

Revert
On 22:00, 24 November 2023, I made an edit with the rationale, " copyedited lead, moved names info to Names section, per MOS:ALTNAME". MOS:ALTNAME states,

Regardless, on 19:26, 25 November 2023, User:SergeWoodzing made a revert with the rationale, "not helpful; clearer before; incomplete sentence; bold text in wrong place". It is to note that SergeWoodzing left the first sentence with the clutter of 5 alternative names in place. I don't see how that is clearer. There was an incomplete sentence in the move in the new section (Charles XV, also known as Carl (Carl Ludvig Eugen) and in Swedish: Karl XV.) with bold font. But that could have been easily fixed instead of bringing back the cluttering (which is not helpful and not more clear) to the first sentence against the advice of the aforementioned guideline. Regards, Thinker78  (talk) 20:19, 26 November 2023 (UTC)
 * Article talk pages are for discussion of article content, not for commenting on other users, nor for pointless complaints.
 * A good idea is always to look at an article and see what has happened just after a revert. There are often additional improvements. There were, in this case, and seeing them would have made this section unnecessary. In other words, some of the reasons for the original action were good ones, which was addressed promptly in subsequent changes. --SergeWoodzing (talk) 15:43, 27 November 2023 (UTC)
 * @SergeWoodzing Yes, article talk pages are for discussion of article content. No idea why you mention it. Not for pointless complaints. Exactly, I can second that regarding your reply.
 * I discussed article content and I pointed out the shortcomings of your edit. Yes, I saw the latest version not just your revert, which is where I got the number of alternative names. Therefore, I am still wondering why you ignore the guideline I mentioned. Sincerely, Thinker78  (talk) 19:48, 27 November 2023 (UTC)
 * "You/your" 5 times in one short comment! A classic example of personalizing a discussion on an article talk page. I have not mentioned anyone here at all. So, it can be done.
 * I have now edited the top of the article again, removing even more clutter. There should be no problem with MOS:ALTNAME now. A special section just to give his full birth name or his name in Swe/Nor or his numeral in Norway seems a worse choice. --SergeWoodzing (talk) 23:49, 28 November 2023 (UTC)
 * In my first post it was appropriate to mention the editor's name for clarity. I still don't see how the current first sentence is agreeable with MOS:ALTNAME, as there are four alternative names there. Foreign alternative names are still alternative names. Sincerely, Thinker78  (talk) 00:03, 29 November 2023 (UTC)
 * None of our WP rules and guidelines are carved in stone, and exceptions can be made as per WP:UCS. In this case I think the lead now is fine, and that a special section on his names should ot be added to the article. --SergeWoodzing (talk) 01:22, 29 November 2023 (UTC)
 * I agree that "none of our WP rules and guidelines are carved in stone". I guess it's simply a matter of editorial preference we disagree with. I think your edit, or how was it before my edits, has too much clutter. You on the other hand think my edit is less clear and not helpful The caveat is that my preference is backed by the guideline although your preference, in contradiction with the guideline, seems to be tacitly supported by other editors who watch this page. Sincerely, Thinker78  (talk) 04:08, 29 November 2023 (UTC)
 * Third opinion: I think we should follow MOS and not have three or more alternative names in the first sentence. Pyrrho the Skipper (talk) 15:00, 29 November 2023 (UTC)
 * Thank you! What wording would you suggest then? --SergeWoodzing (talk) 16:45, 29 November 2023 (UTC)
 * Cf. James II of England and have something like: Charles XV (Swedish and Norwegian: Karl Ludvig Eugen, ####-####) was King of Sweden as Charles XV and King of Norway as Charles IV" Furius (talk) 17:01, 29 November 2023 (UTC)
 * Thank you for a valid attempt! 2 problems: (1) I count more 4 names there, not less than three; (2) Carl is too significant to ignore, as he is often called that in modern English literature, as are all the Swedish royal Charleses. In other words, I do not think we can manage better than what's there now. And I do not find it cluttered, since recent adjustments were made. To me the guideline primarily wants us to avoid clutter. That has been accomplished as well as what's reasonable, in this case. --SergeWoodzing (talk) 12:14, 30 November 2023 (UTC)
 * What is "Carl Ludvig Eugen"? The article currently seems to be presenting it as his full English name, but that would be "Carl Ludwig Eugene". Furius (talk) 12:28, 30 November 2023 (UTC)
 * It's his full birth name in Swedish. I see no point in trying to translate that with English exonyms; Ludvig e.g. could be Louis or Lewis in English. Better left alone. --SergeWoodzing (talk) 12:34, 30 November 2023 (UTC)
 * So is his Swedish name Carl or Karl? Furius (talk) 13:30, 30 November 2023 (UTC)
 * If it's Carl, why are we claiming it's Karl later in the sentence? If it's Karl, why are we giving his full name on a mixture of English and Swedish (better: all in Swedish) Furius (talk) 13:32, 30 November 2023 (UTC)
 * These are good queastions. It's complicated, especially to the uninitiated. Swedish tradition holds that kings named & spelled Carl at birth after death always are referred to as Karl. Karl seems to have been the official regnal name, of sorts, of all those kings up until the current one, sort of like the fact that the same has been the case with Charles in English officialdom, until the 20th century.. --SergeWoodzing (talk) 19:12, 2 December 2023 (UTC)
 * That's the sort of bizarreness that I expect from a monarchy! And it might be worth a note, if there's a source explaining it? Furius (talk) 19:23, 2 December 2023 (UTC)
 * It's complicated, especially to the uninitiated. That's why I think best to move all the complication to a dedicated Names section instead of leaving it in the first sentence. Regards, Thinker78  (talk) 17:09, 6 December 2023 (UTC)

title: Talk:Charles XV


text:
Talk:Transatlantic telegraph cable

Dead Whale
I found information about the dead Sperm Whale found tangled up in the cable. The incident was in 1932 when a cable repair ship, All America, off the Pacific coast of Columbia, dragged up a cable from 3240 feet with a 40-foot whale tangled in it. Unfortunately, the two sources that I've found are juvenile books and don't have more information. The phrasing of the Wheat book hints that there may have been more instances than the 1932 one mentioned.
 * Whales and Dolphins; G. Collins Wheat (Golden Press; 1963)
 * The Great Whales; Herbert S. Zim (1951)

 * There is a similar incident mentioned in Submarine communications cable where a whale got caught in a cable in the Persian Gulf in 1873. Neither of those incidents are relevant to this article, which is about a different cable. SpinningSpark 09:30, 5 March 2022 (UTC)

Number format and English variety
Can you please explain how MOS:NUMNOTES is relevant to your recent edits? Spelling out single-digit numerals is not only an acceptable style, but is actually required by MOS:NUMERAL bullet #1. I'm also inclined to challenge the change from BritEng. The template on this talk page seems to be an undiscussed drive-by addition without any accompanying edits actually establishing American English. As far as I can see, no particular variety was established until my major reqorking in April 2020 which is unarguably in BritEng.

Although a very minor issue, I also don't much care for the removal of double sentence spacing. I believe that I have requested you before not to do that. That's given me three reasons to revert your edits. SpinningSpark 10:42, 27 August 2022 (UTC)
 * MOS:NUMNOTES says: "Comparable values nearby one another should be all spelled out or all in figures, even if one of the numbers would normally be written differently". If you have questions about some particular edits, please be specific.
 * has been here . I see your edits of this talk page, so you must have seen it and already had a lot of time to challenge it. I personally have no preferences and was only bringing the inconsistent spelling within the article to the style declared here. (The same applies to my edits of the dates. Although in this case I personally prefer dmy, the article says , so I've changed the inconsistently formatted ones according to that.)
 * Removing double spacing is fine as long as it's not the only purpose of an edit, but considering it as a "reasons to revert" is definitely not acceptable (see WP:Cosmetic edit), especially since most of the article wikicode used single spacing and I, again, made only minor changes in very few places (~10 among the hundreds of sentences) for consistency.
 * I believe that my edits (at least the vast majority of them) are according to WP:MOS and are improvements. Thus your intention to revert them based solely on your personal taste would be considered Edit warring (see also WP:OWNBEHAVIO(U)R, just in case). — Mikhail Ryazanov (talk) 15:57, 27 August 2022 (UTC)
 * Sorry for the slow response, I've been busy outside Wikipedia recently. No I hadn't seen the ENGVAR banner previously.  I don't read all the talk page headers every time I post on a talk page.  If I had seen it, I would have done something about it at the time I made the article expansion.  I know it's been there for a long time, but as I say, it was a drive-by addition without any real justification.  I propose to restore this article to BRITENG and since dmy is conventional in BRITENG I will change that too.  I'll wait a few days to see if others have any comments. SpinningSpark 09:52, 7 September 2022 (UTC)
 * I've already expressed my point of view, so no need to ping me. If you've failed to notice the style templates for so many years, it's not my problem. Ask and, who have added them in 2014, and all other users (including yourself) who have edited the article since then without questioning that choice. (And frankly, I'm surprised that all these minor issues bother you so much. Have you read WP:OWNBEHAVIOR?) — Mikhail Ryazanov (talk) 01:29, 9 September 2022 (UTC)
 * You seem just as bothered by "these minor issues" as I am. Please don't turn a content disagreement into a behavioural issue.  Your behaviour in not giving way is very much on a par.  If you think it's that minor you shouldn't be bothered about not getting your way. SpinningSpark 17:35, 11 September 2022 (UTC)

MOS:NUMNOTES
I'm breaking this out into a new section because it is a quite separate issue and makes it easier to discuss. You wrote "MOS:NUMNOTES says: "Comparable values nearby one another should be all spelled out or all in figures, even if one of the numbers would normally be written differently". If you have questions about some particular edits, please be specific."
 * I don't see your changes as being "comparable values". MOS:NUMNOTES gives examples of numbers in a list of things of the same kind.  For instance, The cable consisted of seven copper wires is not comparable, in the sense of NUMNOTES, with the the cable strands weighing 26 kg/km.  The two things are "nearby" but they are not being compared.  All of your changes are similar, two figures that are not being compared forced into all numerals.  We even have from MOSNUM Adjacent quantities not comparable should ideally be in different formats.  There are no examples of this kind in the article, but it is relevant as it shows that MOSNUM is quite happy with nearby non-comparable items being in different formats. SpinningSpark 10:08, 7 September 2022 (UTC)
 * I think that "7 copper wires" and "18 strands, each of 7 iron wires" discuss "comparable values". The various numbers of "words a/per minute" are even more comparable (they are, literally, compared in the article text). "Adjacent quantities" in MOS:NUMNOTES means directly adjacent numbers, as in the examples there. You can clarify at WT:MOSDATE. Or consult at WP:RD/L whether spelling out some or all numbers in these cases would improve the readability (I don't think so). — Mikhail Ryazanov (talk) 01:29, 9 September 2022 (UTC)
 * I don't agree with you, the two parts of the cable construction are not being compared and are not in a comparative list. Technically, comparing them is meaningless, the two parts serve entirely different functions.  The steel wire armour is what makes it a cable and is for mechanical protection.  The copper cores are for electrical transmission.  They are made in two entirely separate factories.  The words per minute figures are being compared, but they are not nearby with any sensible meaning of the term.  They are not even in the same paragraph. SpinningSpark 18:17, 19 September 2022 (UTC)

Conditions for sufficiently low dispersion
Except for the heaviside condition, the article fails to mention how improvements to the cable construction reduced dispersion or improved throughput. The article also fails to tell when the heaviside condition was first met.

@User:Constant314 suggested other conditions exist, but what are they? Comfr (talk) 01:32, 14 April 2023 (UTC)

 * The condition has never been met on any cable anywhere. It is a hypothetical solution that only applies when R, C, G, and L are constants that are independent of frequency.  That never happens.  No where close. Constant314 (talk) 02:32, 14 April 2023 (UTC)
 * I see what you mean—Heaviside is a theoretical solution for a specific frequency. The section Transatlantic_telegraph_cable identifies only Heaviside as contributing to lower dispersion, implying that Heaviside was the main solution to the problem.  The ISCPC reference is not a reliable reference and does not support the contents of the paragraph in which it is used.  Do you have a reference to support your statement, " The conditions for sufficiently low dispersion are far less stringent than the heaviside condition."?  If so, I would like to improve the article by telling readers how transmission speed was increased.  Thanks for alerting me about the limitations of Heaviside.    Comfr (talk) 12:26, 14 April 2023 (UTC)
 * Well, after Heaviside made his analysis, he suggested adding inductance. He was on the right track for low frequency transmission lines such as were used for telegraphy.  Unfortunately, he was ignored and even ridiculed.  His analysis made no contribution to the solution.  It should have.  The technology would have advanced faster.  But it didn't.  The added inductance solution was discovered independently by others.  The following is speculation:  at the frequencies used for communication by the trans-Atlantic telegraph cable, the transmission line can readily be analyzed as a multi-section, LCR filter.  The theory of these filters was well developed by the early 20th century.  From that analysis, it would be obvious that an increase in inductance was needed.  Again, that is my speculation.  I have read brief excerpts from discussions from back then.  Unfortunately, the jargon has changed, but is sounded to me like they were talking about the theory of electrical filters.
 * The requirement for acceptable dispersion is simply to have a sufficiently constant velocity (or constant group delay) in the band of use. At telegraphy frequencies, this can be achieved by adding inductance, but nowhere near as much inductance as would be required to reach the Heaviside condition. Modern cables have mostly constant velocities at frequencies above a few MHz, hence no added inductance needed for high bit rate data.
 * I plan to open a discussion on Heaviside condition and would like to invite you to continue the discussion there. Constant314 (talk) 13:31, 14 April 2023 (UTC)

title: Talk:Transatlantic telegraph cable