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PubMed1990

Clinical engineering in Italy: the activity of the National Research Council.

The results of a five-year effort to rationalise the process of acquisition and management of medical instrumentation in Italy are reported and discussed. The research programme, sponsored by the National Research Council of Italy, was completed in 1988 and focused on (1) acquisition of technology by hospitals; (2) assessment of performance evaluation and preventive maintenance procedures for biomedical equipment; (3) cost analysis of high-technology health services; (4) analysis of clinical engineering activities in Italy. The present situation and guidelines for the future are outlined. In Italy there are no official positions for clinical engineers in public hospitals; however seven health-delivery institutions have established some activity in the field and a total of 15 engineers are involved in it. Despite the obvious advantage shown by the experience of these pilot institutions, the field has serious difficulties in developing due to the policy of the Ministry of Health and the consequent lack of positions. To reach the level of service provided in other European or North American countries, Italy would need at least 500 clinical engineers and 2500 biomedical equipment technicians. However, the lack of professional opportunities does not encourage training activities in the field.

Biomedical Engineering↗
PubMed1999

A comparison of psychiatric casemix in the UK and Italy.

BACKGROUND: The objective of this study was to compare casemix groups in Italy and the UK. Three hypotheses were tested. First, that length of stay would be shorter in Italy. Second, that diagnosis would not be an effective predictor of length of stay. Third, that diagnosis-based groups would be better predictors of length of stay in Italy due to shorter in-patient episodes. METHODS: In-patient episodes in Pavia (Italy) and Camberwell (UK) for patients with psychosis were allocated to four Healthcare Resource Groups. Average lengths of stay, and coefficients of variation in the two areas were compared. A regression model was constructed to determine the impact of diagnosis groups, gender, age and area on length of stay. RESULTS: Length of stay was significantly shorter in Pavia than in Camberwell for three of the four groups. The coefficient of variation was generally above 1, indicating a lack of within-group similarity. With outliers trimmed, the figures were below 1, except for one group in Camberwell. Pavia revealed greater group homogeneity than Camberwell, with one exception. The regression model explained 9% of variation when the two areas were both included, and around 5% when compared separately. Age had a non-linear impact on length of stay in Camberwell. CONCLUSIONS: We have again shown that diagnosis does not adequately predict length of stay. However, in Italy, where admissions are for shorter periods, diagnosis groups are more homogeneous. This may be because the initial part of a hospital stay is due to clinical factors, whereas prolonged stay is influenced by supply-side issues.

Adult↗
PubMed2005

Evaluation of flood and landslide risk to the population of Italy.

We have compiled a database of floods and landslides that occurred in Italy between AD 1279 and 2002 and caused deaths, missing persons, injuries, and homelessness. Analysis of the database indicates that more than 50,593 people died, went missing, or were injured in 2580 flood and landslide events. Harmful events were inventoried in 26.3% of the 8103 Italian municipalities. Fatal events were most frequent in the Alpine regions of northern Italy and were caused by both floods and landslides. In southern Italy, landslides were the principal agents of fatalities and were most numerous in the Campania region. Casualties were most frequent in the autumn. Fast-moving landslides, including rock falls, rockslides, rock avalanches, and debris flows, caused the largest number of deaths. In order to assess the overall risk posed by these processes, we merged the historical catalogs and identified 2682 "hydrogeomorphological" events that triggered single or multiple landslides and floods. We estimated individual risk through the calculation of mortality rates for both floods and landslides and compared these rates to the death rates for other natural, medical, and human-induced hazards in Italy. We used the frequency distribution of events with fatalities to ascertain the magnitude and frequency of the societal risks posed by floods and landslides. We quantified these risks in a Bayesian model that describes the probabilities of fatal flood and landslide events in Italy.

Bayes Theorem↗
PubMed1991

Adolescents' attitudes to abortion in samples from Italy and Sweden.

Both Italy and Sweden have legislated abortion without grounds since the 1970s but background conditions in the two countries are bipolar. The overall purpose of the present study was to investigate a sample of adolescents from Italy and Sweden regarding their attitudes towards abortion and their knowledge of family planning and to compare the results from the two countries. A questionnaire was distributed among 400 adolescents, 177 from Stockholm, Sweden and 223 from Rome and Locri, Italy. Whereas Sweden is a relatively homogeneous country. Italy has large regional differences regarding social and other aspects. For this reason two regions of Italy were studied separately. The participants were all secondary school students. The results indicated that nearly all adolescents in both countries were concerned about abortion and its consequences, although their concern was expressed differently, in accordance with their religious and cultural norms and also with their background in sexual education. The present study raises questions concerning the knowledge level as an outcome of sex education programs. In fact comparing the answers between the Italian and the Swedish samples no particular difference, in favour of the Swedish adolescents was noticed.

Abortion, Induced↗
PubMed2003

Current status and epidemiological observation of Thelazia callipaeda (Spirurida, Thelaziidae) in dogs, cats and foxes in Italy: a "coincidence" or a parasitic disease of the Old Continent?

Thelazia callipaeda is a spirurid nematode which causes ocular infections in dogs and man and, occasionally, in cats, foxes and rabbits. The intermediate host and vector of T. callipaeda is unknown. For a long time T. callipaeda incidence was reported only from the Russian Federation and the Far East, but recently it has also been found in Italy. In order to investigate the spread of T. callipaeda in Italy, a survey was carried out in two sites, site A in the Piedmont region (North West Italy), and site B in the Basilicata region (Southern Italy). Dogs, cats and foxes in site A and dogs in site B were examined for eyeworms, using different procedures and timing. From January 1995 to August 2002, 91 dogs, 4 cats and 903 fox carcasses were examined in site A, and from October 1999 to January 2003, 443 dogs were examined in site B, and the eyeworms collected were identified using morphological keys. Twenty-one (23.07%) and 185 (41.76%) of the dogs from sites A and B, respectively, were found to be infected by eyeworms; furthermore, all the cats examined and 46 fox carcasses (5.1%) were positive for eyeworms. All the nematodes collected were identified as T. callipaeda. These results indicate that T. callipaeda is not confined to Eastern Europe and Asia, but that it has spread to the Old Continent, and to both Northern and Southern Italy. Considering the high prevalence of infected dogs reported in some municipalities (e.g. 60.14% of 138 dogs examined in a municipality from site B), it is assumed that one or more vectors are significantly present in the areas under investigation. Furthermore, there is good reason to believe that T. callipaeda is also present in other European countries. Speculation as to the origins of this parasitic infestation in Europe and the biology of T. callipaeda and its vector/s is also discussed.

Animals↗
PubMed1997

A serological survey of bovine herpesvirus-1 infection in selected dairy herds in northern and central Italy.

Serum samples from a total of 6979 dairy cattle from 55 herds in northern Italy (51 herds) and central Italy (4 herds), were examined by the serum neutralization test for the presence of antibody to bovine herpesvirus-1 (BHV-1). It was found that 84.31% of the farms selected in northern Italy and all the farms from central Italy had seropositive animals at titers of 1:4 or higher. The prevalence of infection was essentially the same among the cattle populations of the two selected areas of the country, being of 34.99% in the north and of 38.65% in central regions. A comparison of the data from the present study with those obtained in a serological survey conducted in Italy in 1966, shows that the rate of seropositive cattle to BHV-1 has increased by about 5.0% in the last 30 years.

Animals↗
PubMed1996

Deaths from asthma in Italy (1974-1988): is there a relationship with changing pharmacological approaches?

In this article we consider the relationship between asthma mortality rates, obtained from the Italian National Institute of Statistics (ISTAT), and the doses of all antiasthmatic drugs except systemic steroids sold in Italy in the years 1974-1988. The total asthma mortality rate showed three different trends: it decreased slowly until 1978 (period A); increased 10-fold from 1979 to 1985, rising from 0.30 to 4.17/100,000 (period B); and remained stable until 1988 (period C). More than half of the deaths in 1988 occurred in people 75 years of age or more. Men died more in the older age groups, while the mortality of women prevailed in the 35- to 54-year age group. In the 5- to 34-year age group the rate rose from 0.01 in 1978 to 0.21 /100,000 in 1986. Coding changes due to the 9th revision of the International Classification of Disease, adopted in Italy in 1979, probably increased the number of deaths being attributed to asthma in case of contemporary mention of bronchitis, a common diagnosis in older men, which showed the greatest increase in mortality. Increased prevalence and awareness of asthma may also have played a role. Although international comparisons strongly suggest undertreatment of asthma in Italy, the doses of anti-asthma drugs sold in Italy grew from 276 to 1,080 million from 1974 to 1985. During period B xanthine sales rose sevenfold and grew from 6.5 to 23.3% of the total doses, along with a twofold increase in beta 2-agonist and cromolyn sales. Period C was characterized by stable total doses (1155 million in 1988), with increases only in antiinflammatory and preventive drug sales. The increase in asthma deaths in Italy has been striking despite the contemporary rise in sales of all antiasthma drugs, particularly of beta 2-agonist metered aerosols and xanthine tablets. The increase in antiinflammatory and preventive drug sales may have contributed to the stabilization of asthma deaths during period C.

Adolescent↗
PubMed2002

Epidemiology of measles, mumps and rubella in Italy.

A serosurvey for measles, mumps and rubella was conducted in Italy; incidence based on statutory notifications over the last three decades was also calculated. In Italy the diseases followed an endemic-epidemic pattern, with an incidence peak every 2-4 years, and had a limited reduction of incidence attributable to childhood immunization. Lower notification rates were observed in the Southern regions. This is possibly related to greater under notification in the South and is confirmed by our seroprevalence data. Incidence of measles and rubella and proportion of cases among young adults increased significantly in the three decades considered, but not for mumps. Serological data confirmed that these infections are still very frequent in Italy, without significant geographic variation in the country. In the age groups 2-4 and 5-9 years the percentage of individuals still susceptible to each virus was higher than 30%. The proportion of susceptible subjects older than 15 years was similar for the three infections (6.1, 11.7 and 8.8% for measles, mumps and rubella, respectively). The low vaccine coverage for rubella and measles in Italy has so far only partially affected the occurrence of the diseases. No impact of mumps vaccination is visible. The average number of deaths, for each disease, has decreased during the three study periods. Today the priority in Italy is to halt the progressive increase of the mean age of acquisition of the three infections, to eliminate differences in coverage among regions and to conform to European standards. This will be achieved through a combination of increasing MMR vaccine coverage before 2 years of age, implementing vaccination campaigns for low seroprevalence age groups, and/or introducing a second dose of MMR, depending on the level of current MMR coverage.

Adolescent↗
PubMed1999

Surveillance of acute flaccid paralysis in Italy: 1996-1997. AFP Study Group. Acute flaccid paralysis.

The last case of poliomyelitis due to transmission of indigenous wild poliovirus occurred in Italy in 1982. To achieve the certification of the eradication of poliomyelitis in Italy, an active surveillance of acute flaccid paralysis (AFP) in the population aged less than 15 years was set up following the World Health Organization (WHO) guidelines. The survey started in 1996 with a pilot study involving 4 out of 21 regions, and was gradually extended to a national level in 1997. The two-year survey identified five patients with diagnosis of vaccine associated paralytic poliomyelitis (VAPP). Polioviruses type 2 and 3 Sabin-like were isolated and characterized in three of them. In the remaining two cases, samples were collected late after the onset of symptoms, and poliovirus could not be isolated. No wild polioviruses were detected during the survey. The rate of non-polio AFP found in Italy in 1997 was 0.61 cases per 100,000, which is lower than the level of 1.0 case per 100,000 considered as acceptable by the WHO. This was mainly due to the delay in organizing the hospital network and starting the active search of AFP cases in the largest and most densely populated regions. Therefore, the overall rate of AFP found in Italy underestimates the global effectiveness of the program, which however will be better evaluated in the next few years. This study is the first systematic attempt to determine the rate of AFP in Italy.

Adolescent↗
PubMed2000

Comparison of diets of diabetic and non-diabetic elderly men in Finland, The Netherlands and Italy.

OBJECTIVE: To evaluate whether dietary recommendations for subjects with diabetes are met among Finnish, Dutch and Italian elderly men with diabetes, and whether the diets of diabetic and non-diabetic men differ in these three countries. DESIGN: A dietary survey using cross-check dietary history method. A cross-sectional comparison. SETTING: Thirty-year follow-up of survivors from the Finnish, Dutch and Italian cohorts of the Seven Countries Study. SUBJECTS: 227 elderly men from Finland, 537 from The Netherlands, and 417 from Italy, of whom 8-9% had diabetes. MAIN RESULTS: The diets of non-diabetic men from the three countries differed markedly from each other. In all three countries diabetic men consumed less added sugar than non-diabetic men. In Italy, in addition, diabetic men consumed more fruits and berries and vegetables. The Dutch diabetic men ate relatively more cereal products, fruits and berries, milk and milk products, cheese, and meat and meat products and drank less alcoholic beverages than non-diabetic men. The diet of both diabetic and non-diabetic Finnish and Dutch men was characterized by high fat content (41% and 40% of energy, respectively). The fat content of the diet was even higher for diabetic than non-diabetic men in Finland and The Netherlands, but not in Italy. The fibre content of the diet was the highest among Dutch men and diabetic men received more dietary fibre than non-diabetic men in The Netherlands and Italy, but not in Finland. The diet of diabetic and non-diabetic Finnish men differed little from each other and was characterized by high nutrient density of several vitamins and minerals. The proportion of protein of energy intake was higher among diabetic than non-diabetic Dutch and Italian men. CONCLUSIONS: The diet of the diabetic men from Finland, the Netherlands, and Italy resembled more the diet of non-diabetic men from the respective countries than the diet of diabetic men from the other countries. In the diet of Italian diabetic men, the proportions of fat, saturated fatty acids and carbohydrates were nearest the recommended levels. SPONSORSHIP: The National Institute on Aging, Bethesda, USA, the Dutch Prevention Foundation, the Hague, The Netherlands, the Academy of Finland, and the Sandoz Gerontological Foundation.

Aged↗
PubMed2003

Dietary and nutritional patterns in an elderly rural population in Northern and Southern Italy: (I). A cluster analysis of food consumption.

OBJECTIVE: To describe the food consumption patterns of Italian elderly subjects and the factors associated with different dietary habits. DESIGN: Cross-sectional study. SETTING: Population-based study. SUBJECTS: A total of 847 men and 1465 women aged 65 y or older, living in rural areas in the province of Pavia (Northern Italy) and near Cosenza (Southern Italy) in 1992-1993. INTERVENTIONS: The dietary information was collected by means of a quantitative food-frequency questionnaire, with cluster analysis being used to segregate the subjects on the basis of similarities in their food consumption. A generalised logistic regression model including residence, age, living status, education, physical activity and degree of disability was fitted to assess the factors associated with different food consumption habits. RESULTS: Six dietary clusters were selected for men and seven for women. The largest cluster for both genders was "small eaters" (46% of men and 51% of women); "big eaters", "light diet" and "alcohol" clusters were also identified for both genders. The men were also grouped into "balanced diet" and "cheese" clusters, and the women into "sweet", "greens" and "butter" clusters. CONCLUSIONS: In addition to the influence of the area of residence--residents in Northern Italy consume greater amounts of animal fats, sugar and alcoholic beverages, and those living in Southern Italy have a greater intake of fruit, vegetables, fish and olive oil--all of the other studied variables predicted the probabilities of falling into a specific dietary cluster. SPONSORSHIP: National Research Council (Italy)--Invecchiamento Project No. 95.01048. PF40.

Aged↗
PubMed1998

Fasting serum leptin levels in the analysis of body mass index cut-off values: are they useful for overweight screening in children and adolescents? A school population-based survey in three provinces of central Italy.

OBJECTIVE: Body mass index (BMI) was determined in a population of school students from three provinces of central Italy. Fasting serum leptin concentrations were assayed in a large number of subjects from the same area, to determine their distribution as plotted against the standard deviation score (z-score) of BMI. DESIGN, SUBJECTS AND MEASUREMENTS: Height and weight were recorded from 31170 subjects (16175 male and 14995 female), aged 3-18 y, to construct BMI charts of children and adolescents from central Italy. Percentiles and z-score were calculated using the LMS method of Cole. Serum leptin concentrations were assayed in 1929 subjects (996 male and 933 female) after overnight fasting. RESULTS: BMI percentiles of central Italy were higher than those from standards of other European and USA populations. When plotted against the z-score of BMI, serum leptin values were distributed according to an exponential curve, showing a steep pattern and a wide distribution, as BMI values increased. The hypothesis of the existence of two subgroups, based on a different relation between leptin and BMI, was verified and a separation point between the two subgroups was identified using cluster analysis, discriminant analysis and a novel method developed by our group, hereafter referred to as 'regression clustering'. This method allows identification of the value of the independent variable (z-score of BMI) which can be taken as a separation point. This analysis provided the best results and indicated the following separation points: central Italy standard, z-score = 0.72 (76.4th percentile) for males and z-score = 0.69 (75.5th percentile) for females; French standard (the one suggested for a European population by the European Childhood Obesity Group, ECOG), z-score = 1.46 (92.8th percentile) for males and z-score = 1.96 (97.5th percentile) for females. Similar but variable results were obtained when the same analysis was performed on serum leptin concentration, subdivided according to pubertal development (stage I, stage II-III, stage IV-V). CONCLUSIONS: Children and adolescents from central Italy had greater BMI percentiles when compared to other European populations. Fasting serum leptin concentrations showed a distribution pattern related to z-score, thus allowing to identification of two different subgroups. The z-scores of BMI, identified as separation points, indicated a trend to leptin production by adipocytes that could be taken as indicators of significant increases of fat mass. This study proposes criteria and a statistical approach that could be useful in the identification of BMI cut-off values when screening children and adolescents for overweight.

Adolescent↗
PubMed1997

Nutrition in general practice in Italy.

Since the early 1950s the health promoting qualities of the Mediterranean diet (characterized by low intakes of total and saturated fat and high intakes of fiber and complex carbohydrates) have been acknowledged. Unfortunately, this dietary pattern, effective in lowering the risk of coronary artery disease as well as oxidative stress and carcinogenesis, is widespread only in the southern part of Italy, whereas the eating style and morbidity pattern in northern Italy are similar to those in northern Europe. Moreover, trends in eating behaviors in southern Italy are at risk of impairing the comparative advantage given by the Mediterranean diet. The current eating profile in northern Italy and the trend in southern Italy are therefore a suitable field for educational interventions by general practitioners (GPs) to preserve and promote healthier dietary patterns. Nutrition training of GPs does not yet appear sufficient to enable them to tackle this need. The undergraduate curriculum used to include (and no longer does) only an optional course in basic nutrition; little more teaching is added during vocational training. In Piedmont, a north-western region around Turin, two four-hour seminars for vocational trainees deal with the topics of basic nutrition in children, adolescents, and adults; malnutrition in the elderly; and diet treatment of chronic renal failure. Continuing medical education covers the same topics and a further module deals with diet in the control of diabetes. An effort is needed in the nutritional training of Italian GPs to enable them to give to their patients more than merely commonsense advice.

Adolescent↗
PubMed2005

Prevalence of hepatitis A among drug users in north-eastern Italy. Is vaccination necessary in low prevalence areas?

BACKGROUND: The authors report on the prevalence of, and risk factors for, hepatitis A virus (HAV) in a group of drug users in Italy. METHODS: 404 heroin users were recruited and compared with a control group of 107 subjects in the general population. RESULTS: Drug users born in north-eastern Italy have a prevalence of anti-HAV similar to the control group. A much higher prevalence was found in drug users born in southern Italy. CONCLUSION: The similar prevalence of anti-HAV in drug users born in north-eastern Italy and in the general population, suggests that their lifestyle does not involve a substantial additional risk of HAV. The much higher prevalence found in drug users born in southern Italy is more likely to be related to infection during infancy.

Adult↗
PubMed2000

Proximity of older women to their children: a comparison of Britain and Italy.

This research examined differences between Britain and Italy in the proximity of older women (aged 60-74) to their children. We hypothesized that in Britain proximity is more likely to result from the needs of the older generation, whereas in Italy it is more likely to reflect a cultural preference. Employing data from the British Retirement Survey follow-up in 1994, and the 1995 Italian Indagine Multiscopo sulle Famiglie, we applied multinomial logit models to examine the correlates of proximity. Our findings showed that, in Britain, mothers' health had a greater impact on proximity than in Italy, suggesting that the needs of the older generation in Britain were important for determining proximity. An additional analysis showed that children's characteristics were also important in determining proximity in Italy, mainly because of delayed adult transitions. This supports the hypothesis that intergenerational proximity in Italy is more likely to be a response to the needs of children than of parents.

Activities of Daily Living↗
PubMed1996

Socioeconomic status, migration and the risk of breast cancer in Italy.

BACKGROUND: High socioeconomic status and migration to a higher risk area have been linked to increased breast cancer risk. To evaluate the occurrence of breast cancer in women of different social class and residential history, we conducted a multicentre case-control study in Italy. METHODS: A total of 2569 cases of incident breast cancer were ascertained in northern, central and southern Italy. The controls were 2588 women admitted for a wide spectrum of acute conditions to the same hospitals where cases had been hospitalized. The effect of socioeconomic variables was evaluated with multiple logistic regression after stratification and adjustment for age, origin, centre, and selected reproductive and dietary factors. RESULTS: Compared to housewives, managers and professionals had a 1.7-fold increased risk, whereas the relative risk was 0.7 and 0.6 respectively in helpers and manual workers. The risk of breast cancer also increased with increasing social level of the husbands's occupation and subjects's number of years of schooling. Women who originated in central and southern Italy, and migrated to northern Italy after age 24, but not those who migrated at a younger age, had a relative risk of 0.6 and 0.7 respectively, compared to lifelong residents in northern Italy. CONCLUSIONS: Our findings show that correlates of sociocultural level and place of origin exert an influence on breast cancer risk which is not accounted for completely by known risk factors (i.e. reproductive and menstrual characteristics and recent dietary habits). Such influence may thus occur early in life.

Breast Neoplasms↗
PubMed2005

Kaposi's sarcoma in transplant and HIV-infected patients: an epidemiologic study in Italy and France.

BACKGROUND: A follow-up study was conducted in Italy and in France to compare the epidemiology of Kaposi's sarcoma (KS) between human immunodeficiency virus (HIV)-infected people and transplant recipients. METHODS: In all, 8,074 HIV-positive individuals (6,072 from France and 2,002 HIV-seroconverters from Italy) and 2,705 Italian transplant recipients (1,844 kidney transplants, 702 heart transplants, and 159 liver transplants) were followed-up between 1970 and 2004. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were computed to estimate the risk of KS, as compared to sex- and age-matched Italian and French populations. Incidence rate ratios (IRRs) were used to identify risk factors for KS. RESULTS: A 451-fold higher SIR for KS was recorded in HIV-infected subjects and a 128-fold higher SIR was seen in transplant recipients. Significantly increased KS risks were observed in HIV-infected homosexual men (IRR=9.7 in France and IRR=6.7 in Italy vs. intravenous drug users), and in transplant recipients born in southern Italy (IRR=5.2 vs. those born in northern Italy). HIV-infected patients with high CD4+ cell counts and those treated with antiretroviral therapies had reduced KS risks. In relation to duration of immunosuppression, KS occurred earlier in transplant patients than in HIV-seroconverters. CONCLUSIONS: This comparison highlighted that the risk of KS was higher among HIV-infected individuals than in transplant recipients, and that different co-factors are likely to influence the risk of KS. Moreover, the early KS occurrence in transplant recipients could be associated with different patterns of progressive impairment of the immune function.

Adult↗
PubMed2006

Exposure to HAV infection in patients with chronic liver disease in Italy, a multicentre study.

We carried out a multicentre study on 2830 patients with chronic liver disease from 79 liver units (25 in northern, 24 in central and 30 in southern Italy) to evaluate naturally acquired immunity against hepatitis A virus (HAV) in relation to age, sex, geographical area of origin and entity of liver disease, and to define the strategy for specific vaccination. Antibody to HAV (anti-HAV) was detected in 1514 (53.5%) of the 2830 patients tested; the prevalence was 50.4% in males and 59.1% in females. Both in central and southern Italy the prevalence of anti-HAV positive subjects increased with increasing age from 43.3 and 44.7%, respectively, in the 0-30-year-old subjects to 80.1 and 68.3%, respectively, in those aged over 60 years. The overall prevalence was much lower in northern Italy, as were the variations from one age group to another, from 28.4% in the 0-30-year-old subjects to 38% in those aged over 60 years. 40.6% of patients with cirrhosis lacked naturally acquired protection against HAV; this percentage was higher in northern (60.5%) than in central (34.9%, P < 0.0001) and southern Italy (27.6%, P < 0.0001). The high prevalence of patients in Italy with chronic hepatitis or cirrhosis who lack naturally acquired immunity to HAV warrants the implementation of vaccination programmes against hepatitis A in such patients.

Adolescent↗