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PubMed1993

Diagnostic approach to acute pancreatitis: diagnosis, assessment of etiology and prognosis.

The aims of initial diagnostic procedures leading to early treatment in an appropriate setting in acute pancreatitis are: initial diagnosis and differential diagnosis, assessment of etiology and assessment of prognosis. Etiology can be assessed with certainty only by endoscopic retrograde cholangiopancreaticography. This method allows us to differentiate between pancreatic duct abnormalities as seen in so-called alcoholic pancreatitis as an exacerbation of chronic pancreatitis and biliary causes of the disease. Contrast-guided computed tomography is useful for detecting necroses and their infection. As in other inflammatory diseases, the prognosis in acute pancreatitis seems to be determined by mediators leading to "whole body inflammation", confirmed by high concentrations of interleukin-8 as a major attractant of neutrophils, by interleukin-6 preceding high levels of CRP, as well as by leukocyte immigration into the pancreas. Besides these determinants of the course of acute pancreatitis the prognosis can be assessed by simple clinical means. A clinical score based on physical examination seems to be the best standard for assessing prognosis. Measurement of PMN-elastases and CRP may be additionally helpful.

Acute Disease↗
PubMed1993

[Epidemiology and prognosis of myocardial infarct and chronic heart failure].

The incidence of coronary heart disease and myocardial infarction fell gradually during the seventies. Reasons for this decline are not well understood. Speculations include changes of life style and health care. However, cardiovascular disease is still the leader of mortality in Western developed countries. Mortality of myocardial infarction has also declined. The major benefit was associated with broad establishment of coronary care units, smaller steps were achieved by various progresses in medical treatment. In contrast, the incidence of heart failure has increased. The major etiology of heart failure nowadays is coronary heart disease, especially large or recurrent myocardial infarction. The incidence of heart failure in patients having recovered from myocardial infarction is dramatically higher than in normal population. The Framingham Study showed an incidence of 14% in five years following a myocardial infarction. Prognosis of patients with manifestation of symptoms of heart failure is very poor. Patients with heart failure had an overall six years mortality of 55%. These observations suggest that coronary care units, thrombolysis and modern treatment as developed so far, suppressed in-hospital mortality and improved survival for the first year after a myocardial infarction. Thus, patients with larger infarcts who had succumbed early under previous regimens, survived. They carry, however, the burden of severely impaired left ventricular function, high probability to develop heart failure, and of a dubious long-term prognosis. Large efforts have put upon development of scores to estimate long-term prognosis after a myocardial infarction. With the development of techniques, composition of scores changed. However, residual ischemia, major left ventricular dysfunction, and ventricular arrhythmias are the basis of most scores indicating an adverse prognosis after an infarction. This review will be limited to the prognostic impact of left ventricular dysfunction and development of heart failure post myocardial infarction. A hypothetic cascade of events which may lead from myocardial infarction to heart failure and death is schematically outlined in Figure 1. Loss of contractile myocardium results in left ventricular dysfunction which may induce dilatation of the left ventricle, heart failure and ultimately death. This paper focuses on the evidence for the prognostic impact of the single steps and the whole cascade. Figure 1 shows in parenthesis the variables which were frequently measured to assess loss of contractile tissue, left ventricular dysfunction, and dilatation. Since heart failure is understood as a clinical syndrome of symptoms, it may only be semi-quantitated according to the classification of the New York Heart Association (NYHA).(ABSTRACT TRUNCATED AT 400 WORDS)

Cause of Death↗
PubMed1993

[Doppler echocardiographic evaluation of mitral flow velocity and prognosis of cardiac insufficiency].

The aim of this study was to determine the role of Doppler echocardiography in establishing the prognosis of Stages to 4 cardiac failure. The echocardiographic indices of left ventricular filling were correlated with catheter data and the 2 year out come of patients. The study population included 54 patients examined prospectively in the context of an evaluation of their cardiac failure. Two years after the initial examination, 19 patients were dead or transplanted. Of the remaining 35 patients, 18 were reevaluated at 6 months. Of the echocardiographic parameters, "hyper normal" mitral flow with a high E/A ration indicated poor prognosis; when E/A > 2, the one year survival was 50% and the 2 year survival 42%. There was overlap between the groups of dead or transplanted and surviving patients only when the E/A ratio was between 2 and 3. The patients with E/A < 2 were all alive without any major events at 2 years. All patients with E/A > 3 had a poor prognosis. The E/A ratio was closely correlated with pulmonary capillary pressure levels (p < 0.001, r = 0.55) and lees closely with cardiac index (p < 0.05, r = 0.4) and radionuclide ejection fraction (p < 0.05, r = 0.28). After 6 months' vasodilator treatment with an angiotensin converting enzyme inhibitor (captopril) the E/A ratio decreased significantly from 1.85 +/- 0.78 to 1.0 0.55 (p < 0.02). A "hyper-normal" mitral flow is related to many factors, including high left ventricular filling pressures, mitral regurgitation and reduced left ventricular compliance. This appearance of mitral flow is a poor prognosis factor in severe cardiac failure.

Actuarial Analysis↗
PubMed1993

[Short-term prognosis in patients with congestive heart failure and normal left ventricular systolic function].

Congestive heart failure (CHF) has been traditionally associated with impairment of the left ventricular systolic function (LVSF). There are few clinical assays that describe the prognosis of patients with CHF and intact LVSF. The aims of this prospective assay are: to describe a group of 70 patients admitted to an internal medicine department with the clinical syndrome of CHF, to determine the contractile state of the left ventricle with echocardiography and to establish the short term prognosis. There were 39 males and 31 females with a mean age of 76.4. The LVSF was impaired in 38 (54.3%) [Group I] and preserved in 32 (45.7%) [Group II] (Table 1). Sex distribution was different between both groups with women predominating in group II (Figure 1). Fourteen patients belonging to Group II had diastolic function impairment according to cardiac Doppler. There was no other evidence of cardiac abnormality that could justify CHF. During an average of 8 months follow-up 20 (28%) patients died. There were no differences in overall mortality between Groups I and II (Figure 2). Multivariate analysis was used to determine the relative risk in prognosis of the covariates age, gender, systolic function and diameters of the LV. None of these were statistically significant (Table 2). In our series 45.7% of the patients with CHF had normal LVSF. The short term prognosis proved to be the same in patients with and without impaired LVSF.

Aged↗
PubMed1993

[Evaluation of prognosis and myocardial ischemia using thallium in myocardial tomoscintigraphy].

Thallium scintigraphy holds a unique position amongst the methods available for evaluating the prognosis of coronary patients: it enables quantification of underperfused myocardium and evaluates already constituted ventricular damage (irreversible necrosis) and areas at risk of future coronary events (viable but ischemic myocardium). In a series of 1,926 patients who underwent exercise stress or dipyridamole Thallium myocardial scintigraphy for angina pectoris and followed up fort an average of 34 months, the following features were observed: the long-term prognosis in patients with normal myocardial scintigraphy (715 patients) was identical to that of a normal population of the same age (0.11% cardiovascular deaths per year) whereas the cardiovascular mortality was 15 times higher in cases with a pathological scintigraphy: finally, the long-term prognosis (cardiovascular deaths, infarcts or secondary revascularisation) was directly related to the severity of the initial lack of Thallium uptake. This method was used to assess the prognosis and evaluate the myocardial ischaemia in 75 patients who underwent complete surgical revascularisation fort ischaemia, 50 of whom had previous myocardial infarction: all patients had at least one arterial bypass graft: 39% of the myocardium was underperfused before revascularisation; this procedure reduced by 80% (p < 0.0001) the zones of reversible underperfusion but also zones of irreversible underperfusion by 17% (p = 0.04). The results were particularly impressive in patients who underwent revascularisation with an arterial pedicle (left and right internal mammary, gastroepiploic alone or in association) as 91% of the ischemic territories recovered on average 13 days after revascularisation.(ABSTRACT TRUNCATED AT 250 WORDS)

Dipyridamole↗
PubMed1993

[Prognosis in unstable angina as a function of the clinical presentation].

OBJECTIVE: To assess the prognosis of Unstable Angina according to its clinical presentation using Braunwald's Classification. DESIGN: Retrospective study of hospital admissions from January 1982 to September 1990. SETTING: Coronary Care Unit and a Cardiology Department of a Central Hospital. PATIENTS: There were 132 patients, 109 men and 23 women, with a mean age of 56 +/- 9 years, all submitted to cardiac catheterization at least 90 days after hospital admission followed up during 34.2 +/- 24.2 months. MATERIAL AND METHODS: Patients were divided in three groups according to the clinical presentation of Unstable Angina: Group A--Aggravated Chronic Angina and/or "De Novo" Angina; Group B--Angina at Rest but not in the last 48 hours, and Group C--Angina at Rest in the last 48 hours. Group A was also sub-divided, and the patients with Unstable Angina after myocardial infarction were excluded. The previous clinical profile was evaluated as well as the circumstances in which Unstable Angina occurred, need of Coronary Care Unit, angiographic findings and follow-up. RESULTS: Within the 132 patients, 86 were in the group A, (59 with Aggravated Angina and 27 with "De Novo" Angina), 11 in group B, and 35 in group C. The group with Aggravated Angina had higher incidence of previous myocardial infarction and bypass surgery (p < 0.01 and p = 0.05), compared to group with "De Novo" Angina and B, and also three vessels disease associated to ventricular dysfunction. "Culprit Lesion" appeared more frequently as eccentric type I in group A, and as concentric in group C. Revascularization procedures were performed in 95 patients (CABG in 66 and PTCA in 29) being respectively: 21 and 6 were urgent, 19 and 18 were elective and 26 and 5 were late procedures. CABG were more frequent in group A. There were 73 major cardiac events in 44 patients (8 deaths, 12 myocardial infarction and 53 new episodes of Unstable Angina), which were more frequent in group with Aggravated Angina and group C. The chance of patients with major cardiac events was in a 78 months follow-up, about 25% for group with "De Novo" Angina, 50% for patients with Aggravated Chronic Angina, and was greater than 75% in patients with Angina at Rest and episodes in the last 48 hours (p < 0.05)--Log-rank Test. The worse prognosis was seen in patients with Aggravated Chronic Angina, when a gathering of clinic patterns of Braunwald's classification were present. CONCLUSIONS: In summary, the group with Aggravated Angina and group C had more severe disease, required more urgent CABG and PTCA, and had also a higher incidence of cardiac events. The group with better prognosis was the group with "De Novo" Angina, which should be distinguished of the group with Aggravated Angina who was the worst prognosis.

Aged↗
PubMed1996

Usefulness of Japanese staging in the prognosis of patients treated operatively for adenocarcinoma of the head of the pancreas.

BACKGROUND: Differences in the clinical staging in Japan from that of the Union Internationale Contre le Cancer (UICC) staging system may account for discrepancies in the prognosis of carcinoma of the pancreas between Japan and the United States of America. STUDY DESIGN: This study compares the usefulness of Japanese staging with the UICC staging in 1,689 patients who underwent resection for carcinoma of the pancreatic head registered with the Japan Pancreas Society. RESULTS: The survival rate was correlated with the Japanese stage classification. The survival rate of patients with T4 tumors was surprisingly better than for those with T2 or T3 tumors. The extent of lymph node involvement and of extrapancreatic tissue invasion reflected the prognosis. The UICC staging system did not reflect differences in prognosis among the four stages, especially between stages II and III. CONCLUSIONS: To establish a more practical and universal staging system for carcinoma of the pancreas, the Japanese system may offer improvements in predicting the prognosis of American or European patients with this disease.

Adenocarcinoma↗
PubMed1995

[Fructosamine determination as a tool in the prognosis of diabetes mellitus in dogs].

It is difficult to give the prognosis of diabetes mellitus after castration of the bitch. An algorithm using the blood glucose and fructosamine level is suggested to evaluate the prognosis of diabetes: While the algorithm classifies 19 bitches with good prognosis 18 (95%) are cured. 18 are classified with poor prognosis and all of them undergo a long difficult insulin-therapy or are not treated with success. 6 bitches are classified as indifferent, 2 of them are cured by castration, 2 are managed with insulin and 2 are treated without success. The limits can be described by the following equations: lower limit y = 5.04x + 321, upper limit y = 7.74x + 433. If blood glucose is available only in mg/dl, the equations are: lower limit y = 0.28 + 321, upper limit y = 0.43x + 433. The algorithm is statistical high significant but it should be verified by calculation of a larger number of patients.

Algorithms↗
PubMed1996

Prognosis for return to racing after recovery from infectious pleuropneumonia in thoroughbred racehorses: 70 cases (1984-1989).

OBJECTIVE: To determine the percentage of Thoroughbred racehorses that would be capable of racing performance after recovery from infectious pleuropneumonia. DESIGN: Retrospective case series. ANIMALS: 70 Thoroughbred horses that had recovered from pleuropneumonia. Only horses < or = 5 years old and horses > 5 years old known to be in race training at the time of illness were included in the study. RESULTS: Forty-three of the 70 (61%) horses raced after recovery, and 24 of the 43 (56%) won at least 1 race. Horses that required placement of an indwelling thoracic drain apparently did not have a worse prognosis than did horses that did not require placement of a drain. The prognosis for racing for horses that developed pleuropneumonia-associated complications (pulmonary abscess, cranial thoracic mass, bronchopleural fistula) was worse than the prognosis for horses that did not develop these complications. Duration of hospitalization was not considered indicative of outcome. CLINICAL IMPLICATIONS: In Thoroughbreds, the prognosis for return to racing after recovery from uncomplicated pleuropneumonia appears to be good.

Animals↗
PubMed1995

The response of "de novo" Parkinson's disease patients to bromocriptine in a "low and slow" regimen is predictive for prognosis.

It is possible that Bromocriptine only determines a complete antiparkinson effect in a subset of P.D. patients that have a good dopaminergic reserve. Our study intent to demonstrate that a good short-term response to Bromocriptine used in a "low and slow" regimen is a marker of long term good prognosis. We studied a series of 36 sequential "de novo" P.D. patients treated with Bromocriptine in a "low and slow" regimen. The principal end-point was the introduction of Levodopa. "Good prognosis" was defined as no need of Levodopa until five years of follow-up. An improvement greater than 33% in the Columbia rating scale, at the 6th month of treatment, was the cut-off point to decide that a patient had a good short term response to Bromocriptine. Nine patients fulfilled the criteria for being good short term responders. Multiple regression analysis showed that this outcome could not be predicted by the clinical characteristics of the patients at admission. The sensitivity and the specificity of the short term response to Bromocriptine to predict a good prognosis were 70% and 90.5% respectively. We conclude that Bromocriptine in monotherapy is an efficient antiparkinson agent in 1/3 of "de novo" P.D. patients and good short term response to Bromocriptine is an acceptable marker for a good prognosis. Therefore it is possible that the response to Bromocriptine is a discriminator for a subset of P.D. patients in the early phases of the disease.

Adult↗
PubMed1996

[Prognosis of gliomas].

In a given patient harbouring a glioma, prognosis is simply a question of survival duration rather than projecting the course of illness. The marked variability among glioma patients is due to prognosis factors. That are currently divided into four broad categories: characteristics of the host, characteristics of the tumor, factors related to the influence of the tumor on the host and factors related to treatment. For astrocytomas the three factors most closely related to duration of survival are age, functional status and histological grading. Age is fundamental because it underlies histological grade, functional status, accessibility for treatment and therapeutical responses Histological grading can now be evaluated with features actually correlated with duration of survival. Clinical examination should be recorded using functional scales that more precisely reflect the influence of the tumor on the host than simple clinical signs. Morphological data provided by neuroradiology, such as correct localization or existence of a mass effect provide supplementary prognosis factors. The identification, knowledge and quantification of prognostic factors and their influence are important and useful for understanding the natural history of the disease, to predict the expected survival for individual patient and to evaluate the beneficial effects of treatments. In spite of much work dealing with gliomas, several questions remain to be answered. The role of treatments in grade II astrocytomas is, for example, matter of debate. In malignant gliomas, surgical resection could improve the quality of survival, radiation therapy the duration of survival and chemotherapy the rate of survivors at one and two years. However, many questions are still unanswered. The utility of data from the literature is limited, partly due to flaws in the application of statistical methods, and partly to wide differences in histological and clinical selection criteria. Progress in the field of glioma prognosis is more likely to emerge from purely biological tumor research than from clinical studies.

Glioma↗
PubMed1996

The computer-assisted microscope analysis of Feulgen-stained nuclei linked to a supervised learning algorithm as an aid to prognosis assessment in invasive transitional bladder cell carcinomas.

The aim of the present work is to ascertain whether additional information to grading and staging can be obtained for the prognosis of invasive bladder tumours (T2, T3, T4) by means of two computer-assisted methodologies. The first methodology relates to the digital image analysis of Feulgen-stained nuclei and the second to a supervised learning algorithm named Decision Tree. The digital image analysis of Feulgen-stained nuclei generated 11 variables for nuclear DNA content and 15 for quantitatively describing chromatin pattern. These 26 variables were submitted to a Decision Tree technique which produces multi-attribute logical classification rules by selecting informative variables and determining discriminatory values for each of them. A series of 41 patients for which the majority of the T2 bladder tumours (68%) were associated with a 'good' prognosis (remission) while the majority of the T3-T4 ones (77%) were associated with a 'bad' one (clinical progression or death) were submitted to the proposed approach. The results show that the decision tree was able to characterise the tumours associated with a 'bad' prognosis in the T2 sub-group (32%) and the tumours associated with a 'good' prognosis in the T3-T4 one (23%), by using only few image-generated variables (added to the clinical stage).

Adult↗
PubMedDate not supplied

Hyperthermia combined with chemotherapy and irradiation for the prolongation of the postoperative prognosis in the patients with esophageal carcinoma invading neighbouring structures.

Preoperative hyperthermo-chemo-radiotherapy (HCR) has been performed on patients with esophageal carcinoma, especially in advanced cases with invasion to the neighbouring structures (a3 carcinoma), and is considered to have contributed to the favorable postoperative prognosis. 163 patients with operated locally advanced esophageal carcinoma with invasion to the neighbouring structures (a3 carcinoma) were analyzed. 40 cases were treated with preoperative HCR (HCR group), while 85 cases were treated with other preoperative adjuvant therapies including 35 with chemo-radiotherapy (CR group) and 42 with radiotherapy (R group), and the remaining 38 were operated on without any preoperative treatments. The effectiveness of the therapies and the prognosis were investigated. The survival rates of the HCR group were significantly better than those of the CR group (p < 0.05). The prognosis of cases with Grade 3 effectiveness was significantly better than those of others, moreover, in 5 cases with Grade 3 effectiveness in the HCR group, there was no case of early recurrence or metastasis after resection, while in addition, three patients have since survived for 4, 5, and 7 years, respectively. Our data showed that for the patients with locally advanced esophageal carcinoma with invasion to the neighbouring structures (a3 carcinoma), hyperthermia combined with chemotherapy and irradiation has demonstrated a favorable influence on the prognosis.

Aged↗
PubMed1996

[Prognosis of hepatic metastasis from colorectal cancer following arterial infusion chemotherapy--assessment from the percentage of tumor involved area and tumor markers].

Prognosis of hepatic metastasis from colorectal cancer following arterial infusion chemotherapy was studied from the percentage of tumor involved area (PTIA) and tumor markers. The PTIA was calculated by the following formula: sigma S'/ sigma S, with S' as the tumor area and S as the liver area on each CT slice. The PTIA was 0.76 to 31.1%, and the average was 6.84%. As for the correlation between the PTIA and the prognosis, a statistically significant reverse correlation was found in the cases of death (r = -0.455, p < 0.05, n = 22). In the tumor regression effect of NC cases, the 50% survival time was 24.4 months in cases showing a decrease in CEA or CA19-9 and 18.7 months in the cases showing an increase. Prognosis of the former cases was significantly better than that of the latter cases (p < 0.05). Therefore, PTIA and the decrease in CEA or CA19-9 in the cases of hepatic arterial infusion chemotherapy for metastasis from colorectal cancer seemed important factors reflecting prognosis.

Antineoplastic Agents↗
PubMed1996

The prognosis of rheumatoid arthritis.

Sixty patients with early diagnosed rheumatoid arthritis according ARA criteria were followed up for 6.6 years with the goal to determine prognosis. The parameters relevant to patient and physician were selected for follow up. Radiological and functional deterioration was evident after 6.6 years in 3/4 of patients and there was no one of them to satisfy remission criteria. The most unfavourable predictor of final outcome was the degree of functional incapacity in early stage of rheumatoid arthritis. Second important predictor of poor prognosis was degree of radiological destructive changes especially on feet. Poor prognosis could be expected in patients with previous attacks and the beginning of disease in elderly age. General symptoms and affection of mesomelic joints can be also undesirable predictor. Sex, morning stiffness, joint pattern, laboratory findings and rheumatoid factor were not significant predictors for prognosis but they could influence certain variables of global assessment.

Adult↗
PubMed1996

[Improved prognosis of first episode HIV associated Pneumocystis carinii pneumonia without preventive treatment: etiology and sequelae].

OBJECTIVE: The prognosis of first episodes of HIV-associated PCP has markedly improved. The knowledge about the reasons for this progress could bear important implications for the management of HIV-infected patients. PATIENTS AND METHODS: Clinical and laboratory parameters, as well as therapy and clinical course were documented. Prognostic analysis was performed using a logistic regression model. Early (1985-1988) and late (1989-1994) episodes were compared with regard to the results of the prognostic analysis. RESULTS: 67 patients (61 male, six female, mean age 35 +/- 12 years) without any prophylaxis presenting with a first episode of PCP were treated from 1985 until 1994. 95% of patients had a known HIV-serostatus prior to the diagnosis of PCP. Hemoglobin, percentage of neutrophils in BALF as well as AaDO2 were variables significantly associated with lethal outcome. The prognosis of late episodes was significantly improved (7 versus 32% lethal outcomes, log rank p < 0.01). AaDO2 as the only parameter found to be significantly associated with outcome was significantly lower in the late episodes, accordingly. The mean time until diagnosis of PCP was five days shorter in this group. Moreover, CD8 cell-count and serum albumin were found to be significantly higher, and mean loss of weight prior to diagnosis of PCP significantly lower. CONCLUSIONS: The prognosis of first episodes of PCP without any prophylaxis is most closely associated to the severity of pneumonia as reflected by AaDO2. Causes for a minor severity of PCP include an earlier diagnosis as well as better immunity and a better clinical performance at the time of PCP. The improved prognosis therefore results from the experience of the treatment center. A known HIV-serostatus and regular medical care by an experienced treatment center contributes significantly to improved outcome of PCP also in the group non-compliant to distinctive recommendations with regard to prophylaxis for PCP.

AIDS-Related Opportunistic Infections↗
PubMed1996

[MR imaging of the femoral marrow in adult acute leukemia: correlation of MRI patterns with FAB subtype and prognosis].

MR imaging of the femoral marrow was performed in 36 patients with untreated acute myeloid leukemia (AML) and 7 patients with acute lymphocytic leukemia (ALL). The MRI appearance was classified into five patterns: 1) fatty marrow; 2) faint signal; 3) nodular pattern; 4) heterogeneous infiltration; and 5) diffuse infiltration. The MRI patterns of the femoral marrow were compared among the FAB subtypes of acute leukemia, and the MRI patterns were correlated with prognosis. All five MRI patterns were observed in the femoral marrow in adult acute leukemia, and diffuse infiltration was most commonly seen (41.9%). A completely fatty marrow was also depicted in two cases (4.7%) and faint signal in four cases (9.3%) in spite of untreated acute leukemia. The M2 subtype of AML tended to be demonstrated as a minimally abnormal MRI finding, which was significantly different from the other types of AML. The patients who showed fatty marrow or faint signal were thought to have a good prognosis, while diffuse or heterogeneous infiltration was regarded as a poor prognostic sign. However, there were some exceptions to these rules, and no significant differences were revealed in prognosis between minimally abnormal and advanced MRI patterns. We concluded that MRI of the femoral marrow could be useful in the assessment of tumor volume of adult acute leukemia, and that there were limitations to predicting prognosis on the basis of the MRI manifestations.

Acute Disease↗
PubMed1996

Prognosis and actual treatment outcome of periodontally involved teeth.

The purpose of this study was to determine to what extent a given long-term prognosis of a periodontally involved tooth is in agreement with the actual outcome after periodontal therapy. Five hundred and eighty teeth in 24 subjects diagnosed with adult periodontitis and treated 5-13 years ago were evaluated. Subject's age, gender, race, plaque index, gingival index, missing teeth, tooth mobility, probing depth, presence of furcation, alveolar bone level, and frequency of supportive periodontal therapy were recorded. A prognosis was then determined for each tooth and compared to the initial prognosis using the same measures retrieved from the subject's record. Results of the study suggest that (1) it is less common to project accurately the progress of individual teeth when a prognosis is other than good; and (2) it is more difficult to predict correctly the outcome of multirooted teeth than single-rooted ones.

Adult↗