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Hans H Storm

Publications and source records attributed to Hans H Storm.

At least 19 recordsLinked to original sources
PubMed2006

Depleted uranium and cancer in Danish Balkan veterans deployed 1992-2001.

In a population based retrospective cohort study we studied cancer risk in Danish soldiers deployed to the war in the Balkans. In particular, leukaemia, earlier linked to ammunition enforced with depleted uranium (DU) in other deployed soldiers, was a concern. Military personnel, 13,552 men and 460 women, without known cancer at first deployment to the Balkans, January 1, 1992 to December 31, 2001 were followed through December 2002. We found 96cases of cancer, 84 among men (standardised incidence ratio (SIR) 0.9) and 12 among women (SIR 1.7). Only four male bone cancers (SIR 6.0), with three during the first year of follow-up, exceeded expectations. Earlier reports on increased risk of leukaemia and testis cancer among deployed military personnel to the Balkans are not corroborated by our study. Quick and open communication about potential risks, a health check, a telephone counselling line and careful monitoring, and diminished anxiety all helped contain the 'Balkan syndrome' in Denmark.

Adult↗
PubMed2006

Cancer risk among patients with multiple sclerosis: a population-based register study.

Cancer occurrence in patients with multiple sclerosis (MS) has been little studied, but associations with brain tumours, breast cancer, Hodgkin lymphoma and nasopharyngeal carcinoma have been suggested. We took advantage of population-based registers of MS and cancer to assess the risk of cancer following diagnosis of MS. Patients registered in the Danish Multiple Sclerosis Register were linked with the Danish Cancer Register to obtain information on cancer occurrence. The ratio of the observed to the number of expected cancers based on population-based incidence rates, i.e., the standardised incidence ratio (SIR), served as measure of the relative cancer risk. A database comprising all Danish women born after April 1, 1935, with information on all live-born children, was used in the analyses of breast cancer to adjust for reproductive factors. Overall 1,037 cancers were observed in 11,817 MS patients during 153,875 person-years of follow-up vs. an expected number of 1,098 (SIR = 0.94 [95% confidence interval CI: (0.89-1.00)]. The risk of brain tumours and Hodgkin lymphoma was not increased. A 16% overall reduced cancer risk in men with MS was explained by reduced numbers of cancers of the digestive, respiratory and genital organs. Though the overall cancer risk was not increased [SIR = 1.01(0.94-1.09), n = 676], female MS patients had an increased risk of breast cancer [SIR = 1.21 (1.05-1.39), n = 193]. Adjusting for parity and age at first child delivery did not change this risk estimate materially. In general MS patients are not at increased risk of cancer. Women with MS, however, seem to have a small excess risk of breast cancer, which cannot be attributed to reduced parity or delayed first child birth.

Adult↗
PubMed2004

Familial clustering of Hodgkin lymphoma and multiple sclerosis.

BACKGROUND: Epidemiologic similarities between Hodgkin lymphoma in young adults (i.e., between 15 and 44 years old) and multiple sclerosis have led to the suggestion that these diseases may have related etiologies. Previous investigations have not supported this hypothesis, but the negative results could have been caused by methodologic problems. We therefore assessed the risk of developing Hodgkin lymphoma for patients with multiple sclerosis and for their families and the risk of developing multiple sclerosis for patients with Hodgkin lymphoma and for their families. METHODS: We identified 11,790 patients with multiple sclerosis and 19,599 of their first-degree relatives in Danish population-based registers and followed them for the occurrence of Hodgkin lymphoma. Analogously, we identified 4381 patients with Hodgkin lymphoma and 7388 of their first-degree relatives and followed them for the occurrence of multiple sclerosis. The relative risks (RRs) of Hodgkin lymphoma and multiple sclerosis were expressed as standardized incidence ratios (i.e., the ratio between observed and expected numbers of outcomes based on age, sex, and period-specific incidence rates). All statistical tests were two-sided. RESULTS: Overall, six cases of Hodgkin lymphoma were identified in patients with multiple sclerosis (RR for Hodgkin lymphoma = 1.40, 95% confidence interval [CI] = 0.63 to 3.12), two of which occurred in young adults (RR = 1.59, 95% CI = 0.40 to 6.37). The risk of young-adult-onset Hodgkin lymphoma was statistically significantly increased in the first-degree relatives of patients with multiple sclerosis (RR = 1.93, 95% CI = 1.01 to 3.71; n = 9 such lymphomas). Two cases of multiple sclerosis were identified among young adult patients with Hodgkin lymphoma (RR for multiple sclerosis = 0.82, 95% CI = 0.20 to 3.27), and the risk for multiple sclerosis was statistically significantly increased in their first-degree relatives (RR = 2.76, 95% CI = 1.44 to 5.31; n = 9 such multiple sclerosis cases). CONCLUSION: The observed familial clustering of multiple sclerosis and young-adult-onset Hodgkin lymphoma is consistent with the hypothesis that the two conditions share environmental and/or constitutional etiologies.

Adolescent↗
PubMed2004

Frailty modelling of testicular cancer incidence using Scandinavian data.

The incidence of testicular cancer is highest among young men, and then decreases sharply with age. This points towards a frailty effect, where some men have a much greater risk of testicular cancer than the majority of the male population. Those with the highest risk get cancer, drain the group of individuals at risk, and leave a healthy male population which has approximately zero risk of testicular cancer. This leads to the observed decrease in incidence. We discuss a frailty model, where the frailty is compound-Poisson-distributed. This allows for a non-susceptible group (of zero frailty). The model is successfully applied to incidence data from the Danish and Norwegian registries. It is indicated that there was a decrease in incidence for males born during World War II in both countries. Bootstrap analysis is used to find the degree of variation in the estimates. In the Armitage-Doll multistage model, the estimated number of transitions needed for a cell to become malignant is close to 3 for non-seminomas and 4 for seminomas in both the Danish and Norwegian data. This paper demonstrates that a model including a frailty effect fits the incidence data well and gives interesting results and interpretations, although this is no proof of the effect's truth.

Adolescent↗
PubMed2003

Characteristics of Hodgkin's lymphoma after infectious mononucleosis.

BACKGROUND: Infectious mononucleosis-related Epstein-Barr virus (EBV) infection has been associated with an increased risk of Hodgkin's lymphoma in young adults. Whether the association is causal remains unclear. METHODS: We compared the incidence rates of Hodgkin's lymphoma in two population-based Danish cohorts of patients who were tested for infectious mononucleosis: 17,045 with serologic evidence of having had acute EBV infection, and 24,614 with no such evidence. We combined the cohort of patients who had serologically verified infectious mononucleosis with a cohort of 21,510 Swedish patients with infectious mononucleosis (combined total, 38,555). Biopsy specimens of Hodgkin's lymphomas occurring during follow-up in this combined cohort were tested serologically for the presence of EBV. Using this information, we modeled the relative risk of EBV-negative and EBV-positive Hodgkin's lymphoma in different periods after the diagnosis of infectious mononucleosis and estimated the median incubation time for mononucleosis-related EBV-positive Hodgkin's lymphoma. RESULTS: Only serologically confirmed infectious mononucleosis was associated with a persistently increased risk of Hodgkin's lymphoma. Sixteen of 29 tumors (55 percent), obtained from patients with infectious mononucleosis, had evidence of EBV. There was no evidence of an increased risk of EBV-negative Hodgkin's lymphoma after infectious mononucleosis. In contrast, the risk of EBV-positive Hodgkin's lymphoma was significantly increased (relative risk, 4.0; 95 percent confidence interval, 3.4 to 4.5). The estimated median incubation time from mononucleosis to EBV-positive Hodgkin's lymphoma was 4.1 years (95 percent confidence interval, 1.8 to 8.3). CONCLUSIONS: A causal association between infectious mononucleosis-related EBV infection and the EBV-positive subgroup of Hodgkin's lymphomas is likely in young adults.

Adolescent↗
PubMed2003

Prediction of cancer incidence in the Nordic countries: empirical comparison of different approaches.

Prediction of the future number of cancer cases is of great interest to society. The classical approach is to use the age-period-cohort model for making cancer incidence predictions. We made an empirical comparison of different versions of this model, using data from cancer registries in the Nordic countries for the period 1958-1997. We have applied 15 different methods to 20 sites for each sex in Denmark, Finland, Norway and Sweden. Median absolute value of the relative difference between observed and predicted numbers of cases for these 160 combinations of site, sex and country was calculated. The medians varied between 10.4 per cent and 15.3 per cent in predictions 10 years ahead, and between 15.1 per cent and 32.0 per cent for 20 year predictions. We have four main conclusions: (i) projecting current trends worked better than assuming that future rates are equal to present rates; (ii) the method based on the multiplicative APC model often overestimated the number of cancer cases due to its exponential growth over time, but using a power function to level off this growth improved the predictions; (iii) projecting only half of the trend after the first 10 years also gave better long-term predictions; (iv) methods that emphasize trends in the last decade seem to perform better than those that include earlier time trends.

Cohort Studies↗
PubMed2003

Pleural mesothelioma incidence in Europe: evidence of some deceleration in the increasing trends.

OBJECTIVE: To summarize the geographical and temporal variations in incidence of pleural mesothelioma in Europe, using the extensive data available from European general cancer registries, and consider these in light of recent trends in asbestos extraction, use and import in European countries. MATERIAL AND METHODS: The data were extracted from the European Cancer Incidence and Mortality database (EUROCIM). The inclusion criteria was acceptance in Volume VII of Cancer Incidence in Five Continents. Truncated age-standardized rates per 100,000 for the ages 40-74 were used to summarise recent geographical variations. Standardized rate ratios and 95% confidence intervals for the periods 1986-1990 and 1991-1995 were compared to assess geographical variations in risk. To investigate changes in the magnitude of most recent trends, regression models fitted to the latest available 10-year period (1988-1997) were compared with trends in the previous decade. Fitted rates in younger (40-64) and older adults (65-74) in the most recent period were also compared. RESULTS: There was a great deal of geographical variation in the risk of mesothelioma, annual rates ranging from around 8 per 100,000 in Scotland, England and The Netherlands, to lower than 1 per 100,000 in Spain (0.96), Estonia (0.85), Poland (0.85) and Yugoslavia, Vojvodina (0.56) among men. The rank of the rates for women was similar to that observed for men, although rates were considerably lower. Between 1978 and 1987, rates in men significantly increased in all countries (excepting Denmark). In the following 10 years, there was a deceleration in trend, and a significant increase was detectable only in England and France. In addition, the magnitude of recent trends in younger men was generally lower than those estimated for older men, in both national and regional cancer registry settings. CONCLUSIONS: While mesothelioma incidence rates are still rising in Europe, a deceleration has started in some countries. A decrease may begin in the next few years in certain European populations considering the deceleration of observed trends in mesothelioma and asbestos exposure, as well as the recent ban on its use.

Asbestos↗
PubMed2003

Glomerulonephritis and malignancy: a population-based analysis.

BACKGROUND: An association between glomerulonephritis and malignant tumors has previously both been found and discarded in clinical series, but to our knowledge never has been tested in a population-based setting. METHODS: The Danish Kidney Biopsy Registry includes all kidney biopsies performed from 1985. Using a unique personal identification number, each person in the registry to the National Population Registry and the Danish Cancer Registry were linked. Cancer occurrence after the biopsy was compared in patients with morphological, glomerular diseases with that of the general Danish population, taking into account sex, age, calendar period and time since biopsy, and the 95% confidence interval (95% CI) for the observed-to-expected rates was calculated, assuming a Poisson distribution. Cancer occurrence was stratified to <1 year, 1 to 4, and >or=5 years after a biopsy. RESULTS: A total of 102 de novo cancers were found in 1958 patients. These cancers represent a two- to threefold excess of the expected number at <1 and 1 to 4, but not >or=5 years after a biopsy. Non-Hodgkin's lymphomas were observed six to eight times more than expected. Cancer excess was seen in glomerulonephritides with a known or suspected virus etiology. CONCLUSIONS: The excess cancer rate could be the result of underlying undiagnosed tumors whose antigens have initiated glomerulonephritis, or the immunosuppressive therapy that initiated or energized tumor cells. Based on the findings in our study, there is some support for an association to persistent viruses causing first the glomerulonephritides and then the malignancies, perhaps through a common pathogenesis. This calls for other studies to be done that are specifically designed to investigate this issue, with more data on patient characteristics and confounders.

Female↗
PubMed2003

Validity and representativity in the Danish Breast Cancer Cooperative Group--a study on protocol allocation and data validity from one county to a multi-centre database.

Population-based cancer registries collect basic information on incident cases, whereas clinical databases hold a broad range of variables that make them attractive sources in epidemiological research. Quality, completeness and representativeness of the clinical database in the Danish Breast Cancer Cooperative group (DBCG) were compared with those in a complete population-based database holding detailed information on patients with breast cancer. The study included 1765 patients diagnosed in Aarhus County between 1983 and 1989. Data on tumour characteristics were of high quality. Fifty percent of patients were included in DBCG trials and a total of 83% were notified in the DBCG register, the rest having significantly poorer stage distribution and survival probabilities. However, for patients younger than 70 years of age, the difference in overall survival between all patients and those notified in the DBCG register was only 2%. Follow-up was incomplete in patients treated outside the programme, and this had a major impact on recurrence-free survival. The DBCG database holds high-quality data, but as a population-based database, it is neither comprehensive nor representative.

Adult↗
PubMed2003

Stage and survival in breast cancer patients in screened and non-screened Danish and Swedish populations.

Comparisons between the Danish and Swedish Cancer Registry revealed a 9% difference in 5-year survival for breast cancer patients diagnosed between 1983 and 1989. The purpose of this study was to determine whether previous differences in survival and stage still exist or whether the Danish figures approach those of the Swedish registry. Complete population-based cohorts of patients with breast cancer in the years 1996-1997 from well-defined areas in Denmark and Sweden were compared. The study regions were a Danish (Funen) and a Swedish (Malmö) county with mammography screening and two Danish counties without screening. No difference in extent of disease or survival was observed between screening areas regardless of country. However, there were significant differences in stage distribution and survival between screening populations and Danish non-screening populations, to the benefit of populations provided with a screening programme. Five-year survival was 5-6%, higher in screening populations than in Danish non-screening counties. Corresponding disease-specific survival enhanced the difference. In a multivariate analysis increasing age, tumour size and stage decreased survival. Adjusting for these factors eliminated differences in survival according to country/county. Survival difference could be attributed to early diagnosis and favourable stage in populations offered mammography screening and was not related to nation. Denmark may, through early detection, approach the beneficial stage distribution and survival observed in Sweden.

Aged↗
PubMed2003

Site-specific cancer incidence and mortality after cerebral angiography with radioactive thorotrast.

Few opportunities exist to evaluate the carcinogenic effects of long-term internal exposure to alpha-particle-emitting radionuclides. Patients injected with Thorotrast (thorium-232) during radiographic procedures, beginning in the 1930s, provide one such valuable opportunity. We evaluated site-specific cancer incidence and mortality among an international cohort of 3,042 patients injected during cerebral angiography with either Thorotrast (n = 1,650) or a nonradioactive agent (n = 1,392) and who survived 2 or more years. Standardized incidence ratios (SIR) for Thorotrast and comparison patients (Denmark and Sweden) were estimated and relative risks (RR), adjusted for population, age and sex, were generated with multivariate statistical modeling. For U.S. patients, comparable procedures were used to estimate standardized mortality ratios (SMR) and RR, representing the first evaluation of long-term, site-specific cancer mortality in this group. Compared with nonexposed patients, significantly increased risks in Thorotrast patients were observed for all incident cancers combined (RR = 3.4, 95% CI 2.9-4.1, n = 480, Denmark and Sweden) and for cancer mortality (RR = 4.0, 95% CI 2.5-6.7, n = 114, U.S.). Approximately 335 incident cancers were above expectation, with large excesses seen for cancers of the liver, bile ducts and gallbladder (55% or 185 excess cancers) and leukemias other than CLL (8% or 26 excess cancers). The RR of all incident cancers increased with time since angiography (P < 0.001) and was threefold at 40 or more years; significant excesses (SIR = 4.0) persisted for 50 years. Increasing cumulative dose of radiation was associated with an increasing risk of all incident cancers taken together and with cancers of the liver, gallbladder, and peritoneum and other digestive sites; similar findings were observed for U.S. cancer mortality. A marginally significant dose response was observed for the incidence of pancreas cancer (P = 0.05) but not for lung cancer. Our study confirms the relationship between Thorotrast and increased cancer incidence at sites of Thorotrast deposition and suggests a possible association with pancreas cancer. After injection with >20 ml Thorotrast, the cumulative excess risk of cancer incidence remained elevated for up to 50 years and approached 97%. Caution is needed in interpreting the excess risks observed for site-specific cancers, however, because of the potential bias associated with the selection of cohort participants, noncomparability with respect to the internal or external comparison groups, and confounding by indication. Nonetheless, the substantial risks associated with liver cancer and leukemia indicate that unique and prolonged exposure to alpha-particle-emitting Thorotrast increased carcinogenic risks.

Adult↗
PubMed2002

Risk for tumor and other disease transmission by transplantation: a population-based study of unrecognized malignancies and other diseases in organ donors.

BACKGROUND: Organ donation may involve the risk of transmittal of unwanted host factors such as infections and malignancy. These may be concealed in the emergent donation process. It may be unavoidable if first observed in a donor postmortem. A number of reports on transferred cancers have been published, but quantification of the risk has never been reliably performed. We report here the first population-based analysis of unrecognized malignancies and other diseases in cadaveric or living-related donors and the possible consequences for the recipients. METHODS: We compiled a cohort of all organ donors through 27 years (1969-1996) in one single kidney transplant center covering a population on one million people. This cohort was linked to the Danish Cancer Registry, the Danish National Hospital Register, and the Danish Register of Causes of Death by means of the unique personal identification number, and all cancers, diagnosis from hospital admissions, and causes of death were identified. Follow-up was to the end of 1996. RESULTS: A total of 626 donors (491 cadaveric and 135 living-related donors) was included in the study. Ten carcinoma in situ or dysplasia cervix uteri (by definition nonmalignant), and 13 malignant tumors (5 of these were detected in living-related donors after donation) were detected by linkage to the cancer registry. All together, 17 recipients received organs from donors with carcinoma in situ or dysplasia cervix uteri and 20 from donors with malignancies. Two recipients from organ donors with carcinoma in situ or dysplasia of the cervix uteri and two recipients from donors with malignancies had a cancer detected; however, these were likely unrelated. One died 1 year after transplantation from a melanoma transmitted from the donor. Two cadaveric donors had previous admissions for glomerulonephritis, five for pyelonephritis, five for nephrolithiasis or ureterolithiasis, four for cystitis, and one for hydronephrosis. CONCLUSION: Despite all efforts to secure a safe organ for transplantation, transmission of donor malignancy and other diseases nevertheless can happen, as is recorded many times in the literature. We have quantified the risk using the population-based cancer registry and found a risk of 8 in 626 (1.3%) for having a donor with undetected malignancy and a risk of 1 in 626 (0.2%) for transmitting a cancer. The risk for getting some transmitted glomerulonephritis is 2 in 626 (0.3%). None of the donors with cerebral malignancies transmitted any tumors to the recipients. Compared with the benefits of organ transplantation, these risks are small; however, if time allows, a search for additional medical information from registries could further minimize the risk of transmission of malignancies or other diseases. However, this requires updated, accurate, and accessible registries and legislation that allows access to personal data and transmission of such data across administrative borders.

Humans↗
PubMed2002

[Relative survival of Danish cancer patients diagnosed 1981 to 1997 and followed to 2001. A status report].

INTRODUCTION: The last comprehensive estimation of survival for Danish cancer patients was carried out 10 years ago. Based on this estimation and on Nordic and international survival comparisons, a national cancer plan was formulated in order to improve the poor relative survival in Danish cancer patients as compared to other Nordic countries. MATERIAL AND METHODS: We used the national cancer register data validated until the end of 1997 and followed up patients below 90 years of age, known from sources other than death certificates and autopsies to the end of 2000. One-, five-, and 10-year relative survival were computed for age groups 0-44, 45-64, 65-74 and 75-89 from 1981 and onwards in five-year calendar periods, ending with a two-year period, 1996-1997. RESULTS: Altogether 396,248 patients were studied. The five-year relative survival improved substantially over time for all sites together (except the skin) to 39% for men and 51% for women. This improvement was seen for cancer of the colon, rectum, breast, bladder, kidney, cervix and corpus uteri, testis, brain, haematological cancers, and malignant melanoma. No improvement was seen for cancer of the lungs in particular, the oesophagus, stomach, oral cavity, and the pharynx. In general, the prognosis was better for the younger age groups than the older groups. DISCUSSION: Future analysis compared to the present will demonstrate the immediate effect, and later the long-term effect, of the National Cancer Plan.

Adolescent↗
PubMed2002

[What is epidemiology and what is cancer epidemiology?].

We have the world's oldest cancer registry in Denmark. We also have a cancer society that has invested substantial funds in epidemiology, which have been well used by highly skilled cancer epidemiologists. This is the formula for success. Cancer epidemiology, which is now conducted at the highest international level in Denmark, is a subdiscipline within epidemiology, and most of its activities are related to public health problems. Clinical cancer epidemiology is, however, a field which will grow in the next decades. Cancer epidemiology requires data of good quality and access to data for use in research. New important results will emerge if trajectories of cancer occurrence can be studied in a lifelong perspective. Research involving genetic factors will also open up new avenues for studies, but it will not replace research, whose starting point is the population's social conditions, their lifestyle, and environmental influences.

Denmark↗
PubMed2002

[Prevention of cancer--what do we do in Denmark and what can we achieve?].

We know from our cancer registers and from epidemiological research that we have a major potential for cancer prevention. If the risk factors had been commonly known in the population and the population had been willing to change their risk behaviours, about one third or perhaps half of all new cases could have been avoided today. Cancer epidemiology has pointed to factors of major importance for public health, such as use of tobacco, dietary factors (including alcohol), physical activity, obesity, environmental exposure in leisure time (sun), and in the workplace. All of these can be subject to primary prevention, i.e. behavior to minimise the individual's risk of contracting cancer. Studies on secondary prevention such as screening for cancer have attracted much attention, perhaps at the expense of secondary prevention related to tobacco, alcohol, and diet in the treatment, thereby avoiding side effects and improving the outcome of therapy. Cancer epidemiology has a long tradition in Denmark, whereas translation of the epidemiological findings into prevention is lagging behind. In future, a close collaboration is needed between health professionals, communication and marketing experts, as well as specialists in education and psychology. Only by joining forces with different disciplines will it be possible to target primary and secondary prevention to ease the burden of disease in the population. Evidently, implementation of preventive measures, will benefit from political will and support.

Denmark↗
PubMed2002

Hematopoietic and lymphatic cancers in relatives of patients with infectious mononucleosis.

BACKGROUND: Young adults with a history of Epstein-Barr virus (EBV)-related infectious mononucleosis have an increased risk for Hodgkin's lymphoma. EBV is detected in Hodgkin's lymphoma Reed-Sternberg cells from some patients, but in young adult patients, it is detected at a relatively low frequency in these cells. Hodgkin's lymphoma and infectious mononucleosis are both associated with high social class, and unknown confounding factors that are also associated with socioeconomic status might explain or contribute to the apparent association between these diseases. To indirectly assess the importance of socioeconomic status on the association between these diseases, we determined the risk for hematopoietic and lymphatic cancers in first-degree relatives of patients with confirmed EBV-related infectious mononucleosis. METHODS: We identified parents, siblings, and offspring of 17,045 persons with serologically confirmed EBV-related infectious mononucleosis. Subjects in these cohorts were linked with the population-based Danish Cancer Register to identify those developing hematopoietic/lymphatic cancers after the index patient was diagnosed with infectious mononucleosis. The relative risk for cancer in the infectious mononucleosis family members was expressed as standardized incidence ratios (SIRs; i.e., the ratio between the number of cancers observed and the number of cancers expected, obtained from age-specific, sex-specific, and period-specific incidence rates). RESULTS: We identified 8052 parents, 5264 siblings, and 28,605 offspring of patients with EBV-related infectious mononucleosis who were followed for a total of 892,213 person-years at risk. The risk for Hodgkin's lymphoma was unaltered in the combined group of first-degree relatives of these patients (SIR = 0.99; 95% confidence interval [95% CI] = 0.62 to 1.59; number of cases [n] = 17), in the group of parents (SIR = 0.83; 95% CI = 0.31 to 2.22; n = 4), in the group of siblings (SIR = 0.96; 95% CI = 0.31 to 2.97; n = 3), and in the group of offspring (SIR = 1.08; 95% CI = 0.58 to 2.02; n = 10). CONCLUSION: The unremarkable risk for Hodgkin's lymphoma in family members of patients with EBV-related infectious mononucleosis indicates that socioeconomic confounding is an unlikely explanation for the association between EBV-related infectious mononucleosis and Hodgkin's lymphoma.

Adult↗