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T Bourne

Publications and source records attributed to T Bourne.

At least 37 records · Page 2Linked to original sources
PubMed2004

Should we be examining the ovaries in pregnancy? Prevalence and natural history of adnexal pathology detected at first-trimester sonography.

OBJECTIVE: To assess the prevalence and natural history of ovarian pathology in pregnancy. METHODS: Three thousand consecutive pregnant women presenting before 14 weeks' gestation at the early pregnancy unit at St George's Hospital, London, underwent ultrasound examination during which both ovaries were visualized. Women found to have a simple ovarian cyst with a minimum diameter > or =25 mm or a complex ovarian cyst of any size were included in the study. They were followed up with ultrasound scans every 4-6 weeks until either resolution of the ovarian cyst occurred, intervention was required or the pregnancy was concluded. If the cyst persisted at 20 weeks' gestation, these women were rescanned 6 weeks after conclusion of the pregnancy. Women were managed expectantly throughout their pregnancy. RESULTS: One hundred and sixty one women with a total of 166 cysts were included for analysis. At presentation, 43.7% of the women were asymptomatic and 56.3% had pain and/or vaginal bleeding. The mean gestational age at presentation was 53 (range, 28-98) days, the mean maternal age was 30 (range, 17-42) years, and the mean ovarian cyst diameter was 48 (range, 12-115) mm. The first-trimester pregnancy diagnoses were 106 intrauterine pregnancies, 40 miscarriages, five ectopic pregnancies, three pregnancies of unknown location and seven terminations of pregnancy. The sonographic features of the ovarian cysts included: 117 simple and anechoic, 21 hemorrhagic, 16 with mixed echogenicity, seven with a ground-glass appearance, three solid/cystic with papillary projections and two with low-level echoes. One hundred and nineteen (71.7%) of the cysts resolved spontaneously and were presumed to be physiological, 40 (24.1%) persisted and seven (4.2%) required intervention, four of these as an emergency because of pain. There was one case of borderline malignancy and no cases of malignancy. Five (3.0%) of the cysts underwent torsion. Only 0.13% (4/3000) of all women who initially presented to our unit required acute intervention during their pregnancy. CONCLUSIONS: The majority of cysts detected in early pregnancy are physiological and resolve. Very few persist and intervention during the pregnancy is rarely indicated. The expectant management of ovarian cysts detected in the first trimester is safe and should be encouraged. Examining the ovaries in the first trimester is of limited value.

Adolescent↗
PubMed2004

Human chorionic gonadotrophin and progesterone levels in pregnancies of unknown location.

OBJECTIVE: To evaluate accuracy, user variability and impact of experience on the use of serum hCG and progesterone in women who have a pregnancy of unknown location (PUL's). MATERIALS AND METHODS: This was a retrospective study. Presenting 1932 consecutive women to an Early Pregnancy Unit had a transvaginal scan. The location of the pregnancy could not be found in 189 women (Pregnancy of unknown location, PUL), and so blood was taken to measure serum hCG and progesterone at presentation and subsequently after 48 h, according to the protocol. All women were monitored at regular intervals until the final outcome was known, which was a failing PUL, a viable or failing intra-uterine pregnancy, an ectopic pregnancy or a persisting PUL. The final study group comprised 185 PUL, as four cases of persisting PUL were treated and excluded from the analysis. Five investigators assessed the hormonal data independently. The investigator's experience as defined by the number of years working in obstetrics and gynecology ranged from 2 to 15 years. Each investigator knew the women were clinically stable and that the scan result was consistent with a PUL, i.e. there were no signs of intra- or extra-uterine pregnancy, and there was no hemoperitoneum on TVS. When assessing the PUL's, each investigator was given the hormonal results at time 0 and 48 h for serum hCG and progesterone and asked to classify the PUL's as failing PUL's, immediately viable intra-uterine PUL's and ectopic PUL's. No other clinical information about the women was made available. RESULTS: Complete data 185 women (89%): 102 failing PUL's, 63 immediately viable intra-uterine PUL's and 20 ectopic PUL's (total 185). The most experienced investigator obtained the best accuracy 163/185 (88.1%); not significantly different from those obtained by less experienced investigators (range 85.9-87.6%). Mean correct classification of failing PUL and immediately viable intra-uterine PUL's was 93% (range 89-95%); corresponding value for ectopic PUL's was 42% (range 25-60%). Agreement between observers for classification of failing PUL's and immediately viable intra-uterine PUL's was almost perfect (Cohen's kappa 0.86-0.90), whereas the value for ectopic PUL's group was fair to moderate (Cohen's kappa 0.39-0.67). All 5 investigators misdiagnosed same 35% of ectopic PUL's. CONCLUSIONS: Serum hCG and progesterone levels at defined times can be used to predict the immediate viability of a PUL, but cannot be used reliably to predict its location. Clinical experience does not significantly improve the ability to assess PUL outcome.

Chorionic Gonadotropin↗
PubMed2003

Placental site trophoblastic tumor masquerading as an ovarian ectopic pregnancy.

The vast majority of pregnancies of unknown location (PUL) will be failing pregnancies and early intrauterine or ectopic pregnancies (EPs) that are too early to visualize on transvaginal scan. Very rarely, a positive pregnancy test in the presence of a negative scan will reflect an underlying human chorionic gonadotropin (hCG)-secreting tumor. We report a case in which elevated serum hCG led to the initial diagnosis of an EP which was subsequently found to be a placental site tumor of the ovary. This case shows that a misinterpretation of signs of EP can result in a delay in accurate diagnosis.

Adult↗
PubMed2003

The conservative management of early pregnancy complications: a review of the literature.

Early pregnancy complications include miscarriage, ectopic pregnancies, adnexal masses and pregnancies of unknown location. In this review, we evaluate the role of conservative management in these complications. We also evaluate the role of transvaginal sonography for diagnosis, treatment and follow up. When managing women with early pregnancy complications, it is important to recognise the normal sonographic milestones in the first trimester. Understanding the pattern of serum human chorionic gonadotropin change in early normal pregnancy and the correlation between low serum progesterone levels and the spontaneous resolution of a pregnancy are also important concepts. Guidelines for assessing suitability for conservative management should be strictly governed by evidence based protocols. Women can then be offered expectant or medical treatment as appropriate.

Abortion, Spontaneous↗
PubMed2001

The characterization of common ovarian cysts in premenopausal women.

OBJECTIVES: The evaluation of the predictive value of transvaginal ultrasound in the assessment of benign adnexal pathology in premenopausal women, based on the recognition of characteristic morphologic patterns particular to endometriotic and dermoid ovarian cysts. METHODS: This was a prospective study. All premenopausal women undergoing surgery for a suspected ovarian cyst underwent a transvaginal ultrasound examination in the week prior to surgery. Between June 1997 and January 2000, 132 women underwent surgery for a suspected ovarian endometrioma or dermoid cyst. The endpoints were either the direct visualization of the cyst wall and contents at surgery, or the histologic evaluation of removed tissues. RESULTS: Of 83 suspected endometriomas (11 bilateral), 80 were confirmed at surgery and of 68 suspected benign cystic teratomas (eight bilateral), 66 were confirmed by histology. The positive predictive value of transvaginal ultrasonography for the diagnosis of endometrioma and dermoid cysts was 96.4% and 97.1%, respectively. The false positive rates were 3.8% and 3.0%, respectively. There were no malignancies in either group. CONCLUSIONS: Based on the recognition of characteristic ultrasound patterns alone, the positive predictive value of transvaginal ultrasonography for the diagnosis of these common, benign cysts in premenopausal women is very high and can be used reliably to select women for appropriate surgery.

Adolescent↗
PubMed2001

The feasibility of a 'one stop' ultrasound-based clinic for the diagnosis and management of abnormal uterine bleeding.

OBJECTIVES: We have established a 'one stop' clinic for the management of women with abnormal uterine bleeding based on transvaginal sonography and saline contrast sonohysterography. This report reviews our experience with the first 93 patients attending the clinic. DESIGN AND METHODS: Patients were seen with the intention of performing a transvaginal scan, saline contrast sonohysterography, endometrial biopsy, full blood count and thyroid function tests. The findings were prospectively recorded on a computer database and a management plan formulated. RESULTS: A transvaginal scan was performed on 89 (95.7%) women, 70 (75.3%) also undergoing saline contrast sonohysterography. An endometrial biopsy was carried out in 67 (72%) women aged 40 years and above, and 79 (84.9%) had blood tests. The median age of patients was 44 (range, 21-78) years. The majority of women presented with menstrual disorders. Uterine pathology was detected on transvaginal scan in 42 (47.2%) cases. Adnexal pathology was detected in 12 (13.5%) of the patients. Endometrial biopsy detected three (4.5%) cases of endometrial atypia, and three (4.5%) cases of adenocarcinoma. A hemoglobin level of < 10 g/dL was detected in 3 (3.4%) patients. A single clinic visit was thought sufficient for 83 (89.2%) women. Medical therapy was started in 47 (50.5%) patients, 15 (16.3%) were brought back for inpatient diagnostic hysteroscopy, and nine (9.7%) were booked for operative endoscopy, while six (6.5%) had conventional surgery; the remainder were reassured. CONCLUSIONS: This study demonstrates that a 'one stop' management philosophy based on pelvic ultrasound is feasible. Our data suggest that diagnostic hysteroscopy can be decreased using this approach, and challenge the use of hysteroscopy as the first stage test.

Adult↗
PubMed2001

Transvaginal ultrasonography sonohysterography and operative hysteroscopy for the evaluation of abnormal uterine bleeding.

OBJECTIVE: To evaluate the diagnostic accuracy of transvaginal ultrasonography, sonohysterography and hysteroscopy in patients presenting with abnormal uterine bleeding. DESIGN: Prospective, blind, comparative study. SETTING: Outpatient clinic and day surgery unit of a district hospital specializing in operative hysteroscopy. PATIENTS: One hundred consecutive patients referred with abnormal uterine bleeding (AUB). INTERVENTIONS: Transvaginal ultrasonography and sonohysterography were performed in the outpatient clinic. Within 1 week, all patients underwent operative hysteroscopy. MAIN OUTCOME MEASURES: All diagnoses established by transvaginal ultrasonography, and sonohysterography were compared to the appearance of the cavity using hysteroscopy as well as the histological diagnosis from removed tissues. RESULTS: In 88 patients information suitable for analysis was obtained by all methods. The detection rate of focal intrauterine pathology using sonohysterography was (94.1%), but was significantly lower with transvaginal ultrasonography (23.5%). In about 75% of all cases none of the methods used was able to correctly detect endometrial hyperplasia. CONCLUSIONS: Sonohysterography was significantly better than transvaginal ultrasonography in detecting focal intrauterine pathology. Visual examination at operative hysteroscopy yielded no additional information to the detection or exclusion of focal lesions than was obtained at outpatient sonohysterography. All methods performed equally in assessing endometrial pathology. We conclude that sonohysterography may replace diagnostic hysteroscopy in many patients with AUB.

Adult↗
PubMed2000

The endometrium in breast cancer patients on tamoxifen.

We restudied histologically and immunohistochemically 17 endometrial carcinomas, 2 malignant mixed tumors and 180 endometria with benign changes during or after tamoxifen therapy. The carcinomas were subtyped according to the 1994 WHO-classification. Endometrial biopsies were taken only if the endometrial thickness was > 8 mm sonographically, when a polyp was seen, or for postmenopausal bleeding. About half of the endometrial specimens showed simple or cystic atrophy, 55-76% had cystic-atrophic polyps or regressive hyperplasia. Depending upon the dose of tamoxifen, 7-19% (30 mg) to 27-36% (20 mg) showed moderate glandular proliferation. 20-33% had foci of mucinous, clear cell or serous-papillary metaplasia. 68-70% revealed diffuse extensive fibrosis of the endometrial stroma. None of 11 patients biopsied before starting tamoxifen therapy had advanced endometrial glandular proliferation in the second endometrial biopsy after tamoxifen treatment. None of the 19 endometrial neoplasms after tamoxifen therapy was of the endometrioid type: 11 were mucinous adenocarcinomas, 4 clear cell carcinomas, 2 serous-papillary carcinomas, one carcinosarcoma and one malignant Mullerian mixed tumor. The reasons for discrepancies between suspicious sonograms and endometrial atrophy are discussed.

Adenocarcinoma, Clear Cell↗
PubMed2000

A simplified ultrasound based infertility investigation protocol and its implications for patient management.

PURPOSE: To evaluate whether a simplified infertility investigation protocol, focusing on the use of hysterocontrast sonography (HyCoSy), one blood test, and a semen analysis, would be sufficient as an initial screening test to select couples for specific treatment. METHODS: The infertile couples underwent gynaecological examination, cervical sampling for cytology and Chlamydia trachomatis culture, B-mode transvaginal ultrasonography and basic hormonal analyses followed by a HyCoSy, and a semen analysis. A preliminary diagnosis was made for all patients. A management plan for treatment was suggested when possible; otherwise further examinations were recommended. The data were stored for later analysis and the routine investigation protocol was then adhered to and a final diagnosis and treatment were decided upon. RESULTS: Agreement between the diagnosis based on HyCoSy and our routine protocol was present in 74% of cases (N = 73). In 13% (N = 13) there was partial agreement. In 36% the HyCoSy based protocol was considered sufficient to suggest treatment. CONCLUSIONS: A simplified approach may lead to a significant reduction in both the time and cost of investigating an infertile couple.

Evaluation Studies as Topic↗
PubMed2000

Psychological impact of endometrial monitoring in tamoxifen-treated postmenopausal breast cancer patients.

In view of the higher incidence of endometrial pathology in tamoxifen-treated breast cancer patients, it has been recommended that endometrial surveillance be performed on these women by means of transvaginal sonography. Our study investigated how breast cancer patients experience the endometrial surveillance and which personality factors influence this experience. We also studied compliance with the recommended examination. Fifty-three consecutive asymptomatic postmenopausal breast cancer patients who had taken tamoxifen for at least 6 months were included. Our results show that 23% of the women felt very anxious just before the examination. One woman in five evaluated the procedure as annoying, unpleasant, invasive and awkward, but only 3% found it really unacceptable. Difficulties in coping with mastectomy as well as anxiety negatively affected the experience of the examination. One in six women were doubtful about their ability to comply with such an examination in the future. Women who have difficulties in coming to terms with the mastectomy, anxious women, and women with a low tolerance towards common medical procedures are at especial risk of becoming dropouts. Suggestions are made for developing strategies that might improve these women's compliance.

Adaptation, Psychological↗
PubMed1999

The assessment of endometrial pathology and tubal patency: a comparison between the use of ultrasonography and X-ray hysterosalpingography for the investigation of infertility patients.

OBJECTIVES: The aim of the present study was to examine the role of hysterosalpingocontrast sonography (HyCoSy) as a screening test for endometrial and tubal pathology at the start of the infertility investigation protocol. METHODS: HyCoSy was compared with X-ray hysterosalpingography (HSG) for the assessment of the endometrial cavity and Fallopian tube patency. A total of 103 women with a history of at least 1 year's infertility were included. Each woman underwent both HyCoSy and HSG on the same day. Laparoscopy was performed in 43 cases. For HyCoSy examinations, saline was used for evaluation of the endometrial cavity and Echovist contrast medium to assess Fallopian tube patency. RESULTS: The concordance between HyCoSy and HSG for the presence of endometrial cavity pathology was 90%, but for tubal patency the concordance was lower (72%). HyCoSy classed more examinations of tubal patency as uncertain. HSG more frequently classified tubes as occluded. In the subset of patients in whom all three techniques were used, HSG and HyCoSy demonstrated a high concordance with laparoscopy (83% and 80%, respectively). The prevalence of occluded tubes according to laparoscopy as the reference standard was 13%. The two methods had a high negative predictive value for tubal disease (HSG, 94%; HyCoSy, 88%), and the positive predictive values were 47% and 75%, respectively. The detection rate for occluded tubes was 73% and 27%, and specificity 87% and 90%, respectively. CONCLUSIONS: Our data demonstrate that HyCoSy obtains similar information about the status of the endometrial cavity and Fallopian tube patency to that of HSG. It is possible that in some cases HyCoSy may replace HSG in order to select women with patent tubes who may be suitable for further infertility treatment without more invasive investigation.

Adolescent↗
PubMed1999

Uterine anomalies and failed surgical termination of pregnancy: the role of routine preoperative transvaginal sonography.

Although used extensively in the assessment of many gynecological conditions, transvaginal ultrasonography is not performed routinely prior to termination of pregnancy in the UK. We describe a case in which surgical evacuation of the uterus failed. Postoperatively, transvaginal ultrasonography demonstrated a bicornuate uterus with a viable pregnancy within the left horn. Subsequent medical termination of pregnancy was successful. This case shows the potential value of transvaginal ultrasonography prior to termination of pregnancy. A prospective trial is needed to assess whether its routine introduction into clinical practice will lead to a reduction in morbidity resulting from termination.

Abortifacient Agents↗
PubMed1999

Lack of evidence from HPLC 32P-post-labelling for tamoxifen-DNA adducts in the human endometrium.

Tamoxifen is associated with an increased incidence of endometrial cancer in women. It is also a potent carcinogen in rat liver and forms covalent DNA adducts in this tissue. A previous study exploring DNA adducts in human endometria, utilizing thin layer chromatography 32P-postlabelling, found no evidence for adducts in tamoxifen-treated women [Carmichael,P.L., Ugwumadu,A.H.N., Neven,P., Hewer,A.J., Poon,G.K. and Phillips,D.H. (1996) Cancer Res., 56, 1475-1479]. However, subsequent work utilizing HPLC 32P-post-labelling [Hemminki,K., Ranjaniemi,H., Lindahl,B. and Moberger,B. (1996) Cancer Res., 56, 4374-4377] suggested that very low levels could be detected. We have sought to investigate this question further by reproducing the HPLC methodology at two centres, and analysing endometrial DNA from 20 patients treated with 20 mg/day tamoxifen for between 22 and 65 months. Liver DNA isolated from tamoxifen-treated rats was used as a positive control. We found no convincing evidence for tamoxifen-derived DNA adducts in human endometrium. HPLC elution profiles of post-labelled DNA from tamoxifen-treated women were indistinguishable from those obtained with DNA from 14 untreated women and from six women taking toremifene, an analogue of tamoxifen.

Aged↗
PubMed1998

A randomized trial on the use of ultrasonography or office hysteroscopy for endometrial assessment in postmenopausal patients with breast cancer who were treated with tamoxifen.

OBJECTIVE: Our purpose was to compare the screening effectiveness and acceptability of transvaginal ultrasonography (with sonohysterography if endometrial thickness was >4 mm) with office hysteroscopy. STUDY DESIGN: This randomized crossover study comprised 53 consecutive asymptomatic (without vaginal bleeding) postmenopausal patients with breast cancer who had taken tamoxifen (20 or 40 mg/day) for at least 6 months. RESULTS: Two patients had endometrial cancer (1 primary, 1 breast secondary), both detected only by transvaginal ultrasonography. Twenty-six patients had at least 1 polyp (total 47, all benign). The women who had polyps were not significantly different in their age, body mass, months of tamoxifen intake, or the cumulative dose. The sensitivity and specificity of transvaginal ultrasonography were 85% and 100%, respectively. The corresponding values for office hysteroscopy were 77% and 92%. It was significant that more patients preferred transvaginal ultrasonography to hysteroscopy (P < .001). CONCLUSION: Transvaginal ultrasonography (plus sonohysterography) may be more effective and acceptable than office hysteroscopy for detecting endometrial abnormalities in women taking tamoxifen.

Aged↗
PubMed1998

Preovulatory changes of blood flow in different regions of the human follicle.

OBJECTIVE: To assess regional changes in ultrasound-derived indices of blood flow in the dominant human follicle after the plasma LH surge. DESIGN: A cross-sectional, prospective study. SETTING: Reproductive medicine unit at a university. PATIENT(S): Women attending an assisted conception clinic to determine the appropriate time to transfer previously frozen embryos during a natural cycle. INTERVENTION(S): Transvaginal ultrasonography with color Doppler imaging and pulsed Doppler spectral analysis was used to obtain indices of blood flow and velocity from vessels in the base, lateral part, and apex of the dominant follicle on days 10-12 (from day 1 of menses) and after the LH surge, but before rupture. Immunoassays were used to measure the blood concentrations of LH twice daily (at 8-10 A.M. and 4-6 P.M.) from cycle day 10. MAIN OUTCOME MEASURE(S): The pulsatility index (PI), resistance index (RI), peak systolic velocity (PSV), and time-averaged maximum velocity (TAMXV) in the uterine arteries and three regions of the dominant follicle (apical, lateral, and basal parts); follicular volume; the day and time of the onset of the LH surge (defined as first concentration of LH > 22 U/L) and the times of each scan. RESULT(S): Twenty-two women (aged 28-39 years) were studied and seven were scanned on days 10-12. A retrospective examination of the data from the remainder showed that eight were scanned < 20 hours after onset of the LH surge and seven were scanned > 20 hours after the onset of the LH surge. There was a significant increase in follicular volume after the LH surge. The PI was similar in vessels from the base (0.86 +/- 0.11; mean +/- SEM), lateral part (0.72 +/- 0.51) and apex (0.67 +/- 0.09) at cycle days 10-12 and then gradually decreased in the apex. There were similar changes in the RI. The PSV (mean +/- SEM; cm/s) was similar in vessels from the base (10.1 +/- 1.64), lateral side (8.2 +/- 1.43), and apex (9.2 +/- 1.91) in follicles of days 10-12. Within 20 hours of the onset of the LH surge, the PSV had increased in basal vessels (23.4 +/- 4.10), remained similar in lateral vessels (11.64 +/- 3.18), and was undetectable in apex vessels from six of eight follicles. Twenty hours after the LH surge, there was no pulsatile blood flow observed in the apical part of the follicle, but there was a sustained high PSV in the base (15.73 +/- 3.42) and lateral side (9.02 +/- 1.5). There were corresponding changes in the TAMXV. CONCLUSION(S): During the ovulatory process there are prominent changes in the regional blood flow of the follicle with a marked increase of the flow to the base of the follicle and a concomitant decrease of blood flow to the apex. These changes may be essential for the release of a mature oocyte.

Adult↗
PubMed1998

The effects of norethisterone on endometrial abnormalities identified by transvaginal ultrasound screening of healthy post-menopausal women on tamoxifen or placebo.

Tamoxifen (tam) is used extensively for treatment of patients with breast cancer and is being evaluated for chemoprevention in healthy women. It has, however, been reported to increase the risk of endometrial cancer in post-menopausal women, probably by an oestrogenic effect on the endometrium. It also causes endometrial cysts and polyps. The aims of this study were to identify the incidence of endometrial thickening, polyps and cysts by transvaginal ultrasound (TVUS) screening of a population of post-menopausal healthy women in the Royal Marsden tamoxifen chemoprevention trial and to evaluate the possible benefit from the use of intermittent norethisterone (NE) in women with persistent changes. Since 1990, we have undertaken regular TVUS, using an endovaginal B mode probe, of the 463 post-menopausal women in the trial randomized to tam (20 mg day(-1)) or placebo (plac), without breaking the randomization code. Endometrial thickening (ET) was defined as > or = 8 mm at the widest point across the myometrial cavity in the longitudinal plane, including any stromal changes. Cystic changes were defined as more than one hypoechogenic area > 1 mm. Polyps were identified using saline hydrosonography. Oral NE (2.5 mg day(-1)) was used for 21 days out of 28 for three consecutive cycles by women with persistent endometrium > or = 8 mm, including cystic and polypoid changes. TVUS was repeated after the three courses to evaluate any change caused by NE and endometrial biopsies, including hysteroscopy, was performed on those women with persistent abnormalities. A persistent ET > or = 8 mm was identified in 56 (24%) of the 235 women on tamoxifen compared with only 5 (2%) of 228 women on placebo (P <0.0005). Stromal changes, including cysts, were detected in 36 (15%) and polyps in 26 (11%) of the women on tamoxifen compared with only two (< 1%) of the women on placebo (P << 0.0005). After 3 months of cyclical norethisterone, 39 of 47 women (83%) on tamoxifen had persistent ultrasound changes. However, 45 (96%) had a progesterone withdrawal bleed. Hysteroscopy was performed in 39 women on tamoxifen (28 endometrial biopsy, 15 polypectomy), five of whom had histological evidence of a proliferative endometrium and a further three had an atypical hyperplastic endometrium (one of whom had a focus of invasive carcinoma). The cysts and polyps which were detected in women on tam could not be reversed by NE and were presumably stromal and not of malignant risk. However, 96% of the women had withdrawal NE bleeding, indicating an oestrogenically primed endometrium which could be a mechanism for an increased risk of endometrial cancer. Further studies are required to ascertain whether a progestin would protect against this risk. As in other studies, these results indicate that any increased risk of endometrial cancer caused by tamoxifen is low, and that TVUS screening is probably not justified for asymptomatic women on tamoxifen.

Aged↗