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PubMed2000

High dose IVIG in the post partum period for prevention of exacerbations in MS.

The influence of pregnancy on the course of autoimmune diseases is well documented. In multiple sclerosis the European PRIMS study confirmed an ameliorating effect during pregnancy but on increase of exacerbations after delivery. The efficacy of IVIG in autoimmune mediated diseases has been frequently reported. Based on the experiences of Achiron we recommend IVIG to prevent exacerbations after delivery. Since 1995 we recommend 60 g IVIG within 3 days after delivery and 10 g monthly in patients estimated to be on high risk for exacerbation. The data were compared to the PRIMS study. The baseline data were comparable, but the exacerbation rate after delivery in our observation was 33% lower than expected. The lowest risk for an exacerbation within the first 3 months after delivery we observed in women treated with long-term IVIG monthly. Until now the overall tolerance was excellent The results with IVIG after delivery suggest that immunoglobulins may be a promising therapeutical approach not only in MS but also in other autoimmune mediated diseases with a risk of exacerbation after delivery. A European wide study with IVIG after delivery in MS is in preparation to confirm our preliminary data.

Adult↗
PubMed2001

[Usefulness of chest X-ray during cystic fibrosis exacerbation in adult patients].

PURPOSE: Verify the real usefulness of chest X-ray during clinical exacerbation of cystic fibrosis (FC). MATERIAL AND METHODS: The study was based on a group of 46 adult patients affected by FC. For every subject we selected one or more pair of chest films, of which the first was used as reference image (To), whereas the second (T1) was selected among the following controls, either in course of clinical obvious exacerbation, or during another routine control. The 64 pairs of chest films (32 representing phases of clinical stability, 32 documenting evolution towards clinical deterioration) were subjected to evaluation by two radiologists, who were first asked to judge if stability, improvement or worsening of the overall radiographic picture could be observed; then to estimate the improvement, worsening, stability or absence of the 12 radiographic signs, selected among those more frequently correlating with the acute phase of disease. RESULTS: The comprehensive radiological evaluation, which shows a statistically significant difference (p=0.012) between the two groups considered, weakly correlates with the patient clinical status. Among the patients with exacerbation, the radiographic picture appeared worsened in only 18/32 cases (sensibility 56%, specificity 78%), while on the contrary 7/32 clinically stable patients exhibited a radiographic deterioration. Among the considered radiographic-sings, some were exclusively observed during exacerbation (specificity 100%), but with low sensitivity (pneumothorax: 6%, increment of bronchiectasis: 9%, air space disease 22%); the most common alterations (mucoid impactions and bronchial wall thickening) were observed in both groups of patients. DISCUSSION AND CONCLUSIONS: Our results demonstrate that there is not a precise correlation between the radiographic picture and the clinical manifestations of exacerbation and confirm the poor usefulness of chest X-ray in such a phase of disease. Chest X-ray is needed to exclude pnemothorax or extensive air space disease, rather then to accurately diagnose exacerbation.

Acute Disease↗
PubMed2001

Exacerbations of COPD: predictive factors, treatment and outcome.

Chronic obstructive pulmonary disease (COPD) is a leading cause of death, and constitutes a major medical and an increasing economic problem for acute and long term care. A low level of irreversible airway obstruction when in stable condition, hypercapnia, hypoxia, the presence of comorbid heart disease, right ventricular failure, and low serum albumin are the main factors related to risk of exacerbations. Bronchial infections, bronchospasm, left ventricular failure, pneumonia, pneumothorax and thromboembolism are described as the most frequent relapsing causes of COPD. During exacerbation, the inflammatory process, the ventilation/perfusion (V'A/Q') mismatching, an increased airflow resistance and dynamic hyperinflation (PEEPidyn) expose the respiratory muscles to the risk of fatigue, eventually leading to ventilatory pump failure and rising hypercapnia. Prevention of exacerbations and subsequent hospitalisations may be obtained with careful rehabilitation programs, a strict drug protocol, long term oxygen therapy and sometimes using home noninvasive mechanical ventilation (NMV). During exacerbation proper management of infection and lung mechanics derangement has to be adopted using an accurate assessment of severity and standardized treatment protocols. Patient history and examination and functional tests are beneficial to decide how and where to treat these patients. Mechanical ventilation (possibly noninvasive) may be required to reverse the acute episode. The aims of all these procedures remain: i) to prolong length and quality of life; ii) to save costs. Both hospital and post-discharge mortality of exacerbated COPD remain high while quality of life appears to be poor. Future studies will elucidate the relation between number and severity of exacerbations and prognosis.

Combined Modality Therapy↗
PubMed2002

Eotaxin and CCR3 are up-regulated in exacerbations of chronic bronchitis.

BACKGROUND: Eosinophils and T lymphocytes represent constant features in the airways of subjects with exacerbated chronic bronchitis. Eotaxin is the most potent and selective eosinophil chemoattractant which can also attracts lymphocytes. The aim of the study was to evaluate the expression of eotaxin and its receptor, CCR3, in bronchial airways during exacerbation of chronic bronchitis. METHODS: By immunohistochemistry we studied eotaxin and CCR3 expression in the lamina propria of 14 subjects with acute exacerbation of chronic bronchitis. 20 asthmatics, and 8 healthy subjects. We determined the cell types expressing the CCR3 receptor by colocalization experiments. We finally studied the relationship between eotaxin and CCR3 and eosinophils and T lymphocytes. RESULTS: The number of eotaxin+ and CCR3+ cells was significantly higher in exacerbated chronic bronchitis (P<0.003 and P<0.002) and asthma (P<0.002 and P<0.0001) when compared to healthy subjects. CCR3 was mainly expressed by eosinophils and to a lesser extent by CD4+ and CD8+ lymphocytes. In exacerbated chronic bronchitis the number of CCR3+ cells was strongly correlated to the number of eosinophils (P<0.0002. r=0.85) and to the number of CD4+ lymphocytes (P<0.05, r=0.57). CONCLUSION: Our study suggests that eotaxin and CCR3 are up-regulated and could be involved in the eosinophil and CD4+ lymphocyte recruitment into the airways which occur during acute exacerbations of chronic bronchitis.

Adult↗
PubMed2002

[Update on the use of levofloxacin in the management of acute exacerbations of chronic bronchitis with risk factors].

INDICATIONS FOR ANTIBIOTICS: In patients with acute exacerbation of chronic bronchitis depend on the stage of the chronic disease. Theoretically, antibiotics are not necessary for acute exacerbation of simple chronic bronchitis, but may be needed to reinforce bronchodilatation therapy and respiratory physical therapy. If fever persists for more than three days, group 1 antibiotics can be prescribed. In a second stage (obstructive chronic bronchitis), antibiotic therapy can be useful for patients with two or three Anthonisen criteria: group 1 antibiotics for occasional exacerbation, group 2 antibiotics in case of failure or as first line treatment for patients with frequent exacerbations; anti-pneumococcal fluoroquinolones are a possible alternative. At a third stage (chronic respiratory failure), first line therapy should include group 2 antibiotics. THE BRONCHEA STUDY: Was designed to search for risk factors favoring frequent acute exacerbation of chronic bronchitis in adults. The findings suggest that certain classical risk factors such as age should be revisited. This study demonstrated the crucial need for rigorous surveillance by a lung specialist, the importance of not smoking, and the beneficial effect of optimized treatment. It was also found that earlier initiation of group 2 antibiotic therapy may be useful for patients with a high risk of exacerbation.

Acute Disease↗
PubMed2003

How environmental exposures influence the development and exacerbation of asthma.

Environmental exposures may increase a child's risk of developing asthma and also may increase the risk of asthma exacerbations. This article reviews several environmental exposures and suggests whether they contribute to asthma prevalence, asthma exacerbations, or both. Outdoor air exposures and violence are not likely to cause the increase in asthma prevalence. Exposure to outdoor air pollutants primarily leads to increased exacerbations, sometimes manifested as asthma clusters. Clinicians should be alert for space-time clusters of asthma exacerbations in the community, because these clusters may suggest a modifiable point-source exposure. Indoor air exposures are more strongly linked to the increase in asthma prevalence. Exposure to dust mites and tobacco smoke are risk factors for the development of asthma and may also exacerbate existing asthma. Effective measures to prevent exposures to these pollutants are available. With proper management, the amount of environmental exposures can be decreased. Whether decreasing these exposures will result in decreases in asthma prevalence and exacerbations is not yet documented.

Air Pollution↗
PubMedDate not supplied

Ratio of serum eosinophil cationic protein/blood eosinophil counts in children with asthma: comparison between acute exacerbation and clinical remission.

Serum eosinophil (Eo) cationic protein (ECP) concentrations during acute exacerbations in asthma patients are significantly elevated compared with those during clinical remission. We measured the ratio of serum ECP concentration to peripheral blood Eo counts (ECP/Eo ratio), to determine whether the ECP release from Eo differs between the two clinical asthma situations. Forty-six children with asthma underwent spirometric assessment and blood sampling at the times of acute exacerbation and clinical remission. Twenty healthy children also were studied as a control group. The peripheral blood Eo count (468 +/- 262 per microL, mean +/- SD), the serum ECP concentration (41.7 +/- 16.9 micrograms/L), and the ECP/Eo ratio (0.104 +/- 0.049) during acute asthma exacerbations were significantly higher than the respective values during clinical remission (383 +/- 191 per microL, 27.4 +/- 11.5 micrograms/L, 0.084 +/- 0.041, all p < 0.05). The ECP/Eo ratio as well as the serum ECP concentration during acute exacerbations correlated significantly with the degree of airflow obstruction (both, p < 0.01). Both the increased peripheral blood Eo counts and the possible enhanced Eo activation may account for the elevated serum ECP concentration observed during acute exacerbations compared with that during clinical remission. Our results suggest a differential release of ECP by the Eo, depending on the disease status and asthma exacerbation severity.

Acute Disease↗
PubMed2003

[Bronchial asthma infectious exacerbations].

Bronchial asthma and asthma-like form of COPD often undergo exacerbations with symptoms of infection. Currently, there is a general agreement, that most of these infections that exacerbate asthma especially in children are caused by viruses. Several "common cold" viruses are known to cause these exacerbations (RSV, parainfluenza virus, rhinoviruses). To date, there is no certainty, if viruses exacerbate asthma alone or in combination with allergen. It is also unknown, whether they can induce primary asthma symptoms. There is a growing support for the opinion, that in infectious exacerbations of asthma also bacteria can play an important role. These include both typical as well as atypical bacterial strains (Chlamydia pneumoniae). The effectiveness of antibiotics and bacterial immunotherapy with vaccines seems to support the role of bacteria in asthma exacerbations. Another very important problem is related to the role of infectious agents in prevention of atopy. Many facts have been gathered supporting the so called "hygienic theory".

Asthma↗
PubMed2004

[Adequacy of immediate Lamivudine trial for chronic hepatitis B patients with acute exacerbation].

BACKGROUND/AIMS: It has been unclear whether immediate antiviral therapy or observation under the expectation of spontaneous inactivation of hepatitis B virus (HBV), is more appropriate for the treatment of chronic hepatitis B (CHB) with acute exacerbation. We intended to analyze the short-term natural course of CHB with acute exacerbation and evaluate the efficacy of lamivudine. METHODS: We analyzed 35 CHB patients with acute exacerbation (positive HBV DNA or HBeAg and ALT>400 IU/L) between March 2000 and May 2003. We regularly checked serum HBV DNA, HBeAg and liver function tests including ALT every 1 to 3 months. If ALT was above 100 IU/L during the follow-up period, patients were treated with 100 mg lamivudine orally once a day. We compared the efficacy of lamivudine use between this group and the group provided with immediate lamivudine trial at their first visit. RESULTS: 27 CHB patients with acute exacerbation were observed without immediate lamivudine trial. In 5 of these patients normal ALT, negative HBeAg and HBV DNA were maintained during 19 months (group 1a). Slightly elevated or normal ALT was maintained without HBeAg seroconversion in 3 patients (group 1b). However, serum ALT flared up above 100 IU/L in 19 patients within 5 months. So, lamivudine was tried on these patients (group 2). The serum HBV DNA was extremely low, being 6.5 pg/mL in group 1a compared to 518.1 pg/mL in group 2. Spontaneous inactivation of HBV was observed in 71.4% (5/7) of patients with HBV DNA less than 20 pg/ mL at the first visit. ALT was lower and HBV DNA was higher in group 2 than the 8 patients who received immediate lamivudine trial at the first visit (group 3). The response rate of lamivudine was similar between group 2, 56.3% (9/16) and group 3, 62.5% (5/8). CONCLUSIONS: Spontaneous inactivation of HBV was expected in CHB with acute exacerbation and extremely low level of HBV DNA (less than 20 pg/mL) in a short term follow-up period. Immediate lamivudine therapy might be more appropriate in most CHB patients with acute exacerbation.

Acute Disease↗
PubMed2004

Antioxidant vitamins (A, C and E) and malondialdehyde levels in acute exacerbation and stable periods of patients with chronic obstructive pulmonary disease.

BACKGROUND: People with chronic obstructive pulmonary disease (COPD) undergo oxidative damage during exacerbations that continues in stable periods, gradually contributing to pathogenesis. Since serum concentrations of antioxidant vitamins in COPD patients have been little investigated, we studied antioxidant vitamin and lipid peroxidation concentrations in patients during acute exacerbations and stable periods. METHODS: We prospectively recruited 24 patients with COPD (mean age 51.8 yr, standard deviation [SD] 6.7 yr) in acute exacerbation. Serum concentrations of vitamins A, C and E and malondialdehyde (MDA) were determined before treatment and during stable periods with high-performance liquid chromatography, and in 23 healthy controls (mean age 48.0 yr; SD 5.9 yr) with established methods. RESULTS: The mean vitamin A level in patients during acute exacerbation was 0.8 (SD 0.2) microg/mL, rising to 1.0 (SD 0.2) microg/mL during stable periods, both significantly less than that of controls (1.0 [SD 0.2] microg/mL; p <0.01); vitamin C, 5.0 (SD 2.2) microg/mL acute and 7.5 (SD 2.7) stable, neither significantly differing from the mean level in controls (8.6 [SD 1.8] microg/mL; p > 0.05); vitamin E, 10.0 (SD 2.4) microg/mL acute and 11.1 (SD 2.6) stable, both lower than in controls (11.0 [SD 2.86] microg/mL; p <0.01); and MDA, 2.4 (SD 0.7) nmol/mL acute and 1.2 (SD 0.4) stable, both higher than in controls (0.9 [SD 0.2] nmol/mL; p< 0.01). CONCLUSIONS: Whereas patients with COPD undergo increased oxidative stress during exacerbations and in stable periods, their serum concentrations of antioxidant vitamins A and E decrease during exacerbations. Our findings suggest that the administration of vitamins A and E may be beneficial in the prevention and treatment of the harmful effects of COPD.

Antioxidants↗
PubMed2004

Surgical treatment of lung cancer combined with interstitial pneumonia: the effect of surgical approach on postoperative acute exacerbation.

UNLABELLED: Postoperative acute exacerbation of interstitial pneumonia (IP) is known to be a serious complication in the surgical treatment for primary lung cancer combined with IP. This retrospective study was conducted to investigate the influence of three different approaches to the thorax on postoperative acute exacerbation of IP in lung cancer patients. Forty-seven lung cancer patients who developed it underwent pulmonary resection between 1982 and 2003. Among them, approaches to the thorax consisted of posterolateral thoracotomy (PLT) (n=15), muscle-sparing thoracotomy (MST) (n=15), and video-assisted thoracic surgery (VATS) (n=17). Seven of 47 suffered from acute exacerbation of IP. Single variable analysis suggested that exertion dyspnea (Hugh-Jones classification), serum C-reactive protein, serum lactate dehydrogenase and total lung capacity were considered to be preoperative risk factors of acute exacerbation. As for the VATS patient, there was little frequency of postoperative complication in comparison with the other two approaches. However no significant difference was shown in the incidence of acute exacerbation between the three approaches. CONCLUSION: The use of VATS did not prevent acute exacerbation of IP. However, the incidence of postoperative complications in VATS seemed to be low, therefore further trials are required.

Acute Disease↗
PubMed1992

[Uneven ventilation-perfusion ratio distribution during acute exacerbation of chronic pulmonary diseases].

We studied ventilation-perfusion ratio (VA/Q) unevenness in terms of alveolar-arterial gas tension difference (AaDO2 and aADN2) and of multiple inert gas elimination technique during the chronic stable periods and the acute exacerbation periods of seven cases with chronic pulmonary diseases. Three had idiopathic pulmonary fibrosis, 2 had pulmonary emphysema, 1 had bronchiolitis and the other had a sequelae of pulmonary tuberculosis. Sulfur hexafluoride and cyclopropane dissolved in saline were infused into a peripheral vein at a constant rate and these 2 gases were used as the indicator gases to make analysis of two compartmental VA/Q. During exacerbation all cases showed lower PaO2 than in the stable period. All cases except idiopathic pulmonary fibrosis showed higher PaCO2. Five cases also had higher AaDO2 and aADN2. One case with pulmonary emphysema and one with bronchiolitis actually had lower AaDO2 and aADN2 values during acute exacerbation than during the chronic stable period. We introduced the difference between the logarithm of higher VA/Q and lower VA/Q values (log [(VA/Q)H/(VA/Q)L)] as an index of VA/Q unevenness. Two compartmental VA/Q analysis revealed greater VA/Q differences in all cases during acute exacerbation. This included cases who showed lower AaDO2 and aADN2 values in the acute exacerbation period. In conclusion, worsened VA/Q distribution, during the acute exacerbation period, was elucidated quantitatively using the multiple inert gas elimination technique.

Adult↗
PubMed2005

[Is microembolism present and is it important element of COPD exacerbation?].

UNLABELLED: Pulmonary embolism often coexists with chronic obstructive pulmonary disease (COPD) and it is difficult to diagnose because of similar clinical symptoms. IN OUR STUDY: To try to answer the question if basic laboratory investigations reveal hypercoagulability and if so, if it has any impact on the course of COPD exacerbation. MATERIAL AND METHODS: 28 patients (11F, 17M) with COPD exacerbation were enrolled to the study. Hematocrit, hemoglobin concentration, platelet count, the level of fibrinogen and D-dimers and arterial blood gases were investigated. Lung function was assessed by spirometry. Risk factors of pulmonary embolism, the number of COPD exacerbation in the past 12 months and the exacerbation triggering factors were established with the help of a questionnaire. RESULTS: On admission, abnormalities of the analysed parameters were found in 18 patients. This group was compared with the rest of the study group. There were no statistically significant differences in arterial blood gases and spirometrical values. There was a differences in the level of fibrinogen and D-domers. CONCLUSIONS: The data suggest that in some patients COPD may be accompanied by intravascular coagulation but the influence of this process on the course of the exacerbation is unclear. Further studies on hemostasis impairment and its impact on exacerbation in patients with COPD are required.

Aged↗
PubMed2005

[Relationship between disease severity, smoking index age and direct costs of hospital treatment of COPD exacerbations].

The aim of the study was the evaluation of influence of age, intensity of smoking habit and FEV1 value on the costs of inhospital treatment of COPD exacerbations. 71 cases of COPD exacerbation in current smoking males hospitalized in the Military Institute of Health Service in Warsaw were analyzed. The mean age of subjects was 68.8 +/- 9.5, the mean predicted value of FEV1 49.2 +/- 20.2% and the mean period of hospitalization 7.1 +/- 2.9 days. The mean smoking index (expressed in pack-years) was 41.9 +/- 17.7. The mean direct expenditure for treatment of COPD exacerbation per person amounted to PLN 2187.8 +/- 941.6 and included the cost of medical care PLN 1375.9 +/- 573.6, the cost of drugs PLN 393.3 +/- 287.5 and the cost of additional examinations PLN 415.5 +/- 200.4. In statistical analysis, multiple regression model was used and partial correlation coefficients were calculated for significantly different variables. No influence of age and predicted FEV1 value on the costs of COPD exacerbation was found. A significant relationship was found between the smoking index (expressed in pack-years) and disease severity, on the one side, and the direct costs of exacerbation treatment (r=0.281 and r=0.301 respectively, p<0.05). In active smokers male with COPD, smoking index and degree of the disease severity are independent factors, which equally strong determine the direct costs of hospital treatment of COPD exacerbation.

Age Distribution↗
PubMed2006

[Exacerbations in COPD: a burden to curtail].

Exacerbations of chronic obstructive pulmonary disease (COPD) play a very important role. Unfortunately they were neglected a long time in the therapeutic tests. However exacerbations influence the decline of the respiratory function over time, cause important deterioration of the quality of life of the patients, increase morbidity and mortality of COPD, and finally represent a burden for health care. Reducing the number of exacerbations could potentially slow down the progression of the disease. Thus the prevention of exacerbations should be the "corner stone" of the maintenance treatment of the COPD. In this review we propose to recall the importance of exacerbations in COPD and to present the treatment which have been shown to reduce exacerbation rate in COPD.

Humans↗
PubMed1983

[Double-blind comparative trial of cefroxadine and cephalexin in the treatment of acute suppurative otitis media and acute exacerbation of chronic suppurative otitis media].

A double-blind controlled trial of cefroxadine (CXD) 250 mg t.i.d. was undertaken to objectively evaluate its safety and effectiveness in the treatment of acute suppurative otitis media and acute exacerbation of chronic suppurative otitis media, using cephalexin (CEX) 250 mg q.i.d. as a control drug, and the following results were obtained. In the treatment of acute suppurative otitis media, the 2 drugs produced almost equal outcomes, showing no significant difference in assessments of both overall effects and usefulness. In the treatment of acute exacerbation of chronic suppurative otitis media, the 2 drugs exhibited no significant difference as well in overall effects by Wilcoxon's two-sample test. However, the CEX group had significantly more nonresponsive patients, i.e. 35.5% as compared with 9.7% of the CXD group (chi 2-test, P less than 0.05). In the assessment of clinical usefulness as well, no significant difference was observed between the 2 groups. In the assessment of overall effects based on the patients whose isolated organisms were sensitive to the drugs, CEX group had more patients not responding to the treatment of acute exacerbation of chronic suppurative otitis media (chi 2-test, P less than 0.05). Bacteriological effects were not significantly different between the 2 drugs in both acute suppurative otitis media and acute exacerbation of chronic suppurative otitis media. Overall safety rating was not significantly different between the 2 drugs. Side effects occurred as the symptoms of digestive organ in 2 patients each in both groups (equally an incidence of 2.6%). As for the improvement of each symptom after treatment (assessed on day 3), CXD was superior in the improvement rate of otorrhea volume as the main symptom of acute exacerbation of chronic suppurative otitis media, while CEX was superior in that of otoobstruction feeling. From the above findings, it is presumed that CXD is a safe drug which can exhibit equal or superior therapeutic effects to CEX in the treatment of acute suppurative otitis media and acute exacerbation of chronic suppurative otitis media, at 3/4 of the CEX dose level.

Adolescent↗
PubMed1995

[Role of viral infections in acute exacerbation of idiopathic interstitial pneumonia].

To evaluate the possibility that viral infections can trigger acute exacerbations of idiopathic interstitial pneumonia (IIP), we analyzed data from 105 patients with IIP. Acute exacerbation was defined as an increase in dyspnea, a decrease in PaO2 by more than 10 Torr, and worsening of chest radiographic findings within one month. Viral infection was said to be involved when patients had more than a 4-fold change in viral antibody titer or viral inclusion bodies in sputum during the acute exacerbation. Of the 105 patients with IIP, 30 had acute exacerbations. Among these 30 patients, viral infection was said to be involved in 11 (37%). Presumptive viruses were influenza virus (n = 6), parainfluenza virus (n = 1), herpes simplex virus (n = 1), RS virus (n = 1), and cytomegalovirus (n = 2). The levels of serum immunoglobulin A (IgA) before acute exacerbations were significantly lower (p < 0.05) in patients in whom viral infection was said to be involved. These results suggest that viral infection associated with a low value of serum IgA is an important trigger of acute exacerbations of IIP.

Aged↗
PubMed1995

Acute exacerbation and superinfection in patients with chronic viral hepatitis.

Recent studies, particularly those in Orientals, have shown that both acute exacerbation from the reactivation of the original virus and acute superinfection with other viruses occur frequently in patients with chronic viral hepatitis. The clinicopathologic features of acute exacerbation and acute superinfection are similar to those of acute hepatitis caused by a single virus, but acute exacerbation is usually less severe than acute superinfection. Recurrent acute exacerbations result from the host's intermittent but persistant efforts to eliminate the replicating virus by immune-mediated mechanisms, thus killing hepatocytes with viral replication. Severe acute exacerbation or acute superinfection may result in immediate hepatic decompensation, or even mortality, and late disease progression, including liver cirrhosis and hepatocellular carcinoma. Further studies are needed to elucidate the basic mechanisms and provide more effective ways to avoid acute exacerbation and acute superinfection in patients with chronic viral hepatitis.

Biomarkers↗