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PubMed2006

Quality of life in adult transplant recipients more than 15 years after kidney transplantation.

BACKGROUND: With continuously rising survival rates following renal transplantation, health-related quality of life (HQOL) of long-term transplant survivors becomes increasingly important. METHODS: Recipients more than 15 years after successful renal transplantation were studied retrospectively. HQOL in 139 long-term transplant recipients was assessed using the SF-36 and the disease-specific kidney transplant questionnaire (KTQ-25). RESULTS: Long-term transplant recipients revealed satisfactory HQOL that was comparable to the healthy population in four of eight SF-36 categories (role physical, social functioning, role emotional and mental health). Other SF-36 categories such as physical functioning, physical pain, general health, and vitality were reduced. Among the study population, disease-specific HQOL was comparable or even improved to that of patients awaiting transplantation. In contrast to retired or unemployed patients, employed recipients revealed a highly significant improved HQOL in numerous SF-36 categories such as physical functioning (P<0.001), physical pain (P<0.001), general health (P<0.001), vitality (P<0.001), social functioning (P<0.005), and mental health (P<0.001), as well as for the KTQ-dimensions physical symptoms (P<0.001), fatigue (P>0.001), uncertainty/fear (P<0.01), and emotions (P<0.05). Other factors positively correlating with improved HQOL in certain dimensions were living situation, systolic blood pressure, and recipient age. CONCLUSIONS: More than 15 years after renal transplantation, recipients present satisfactory HQOL comparable to the general healthy population or at least to pretransplant patients. Vocational rehabilitation following renal transplantation is of highest importance among long-term survivors and is associated with improved HQOL.

Aging↗
PubMedDate not supplied

Occupational therapy for independent-living older adults. A randomized controlled trial.

CONTEXT: Preventive health programs may mitigate against the health risks of older adulthood. OBJECTIVE: To evaluate the effectiveness of preventive occupational therapy (OT) services specifically tailored for multiethnic, independent-living older adults. Design.-A randomized controlled trial. SETTING: Two government subsidized apartment complexes for independent-living older adults. SUBJECTS: A total of 361 culturally diverse volunteers aged 60 years or older. INTERVENTION: An OT group, a social activity control group, and a nontreatment control group. The period of treatment was 9 months. MAIN OUTCOME MEASURES: A battery of self-administered questionnaires designed to measure physical and social function, self-rated health, life satisfaction, and depressive symptoms. RESULTS: Benefit attributable to OT treatment was found for the quality of interaction scale on the Functional Status Questionnaire (P=.03), Life Satisfaction Index-Z (P=.03), Medical Outcomes Study Health Perception Survey (P=.05), and for 7 of 8 scales on the RAND 36-Item Health Status Survey, Short Form: bodily pain (P=.03), physical functioning (P=.008), role limitations attributable to health problems (P=.02), vitality (P=.004), social functioning (P=.05), role limitations attributable to emotional problems (P=.05), and general mental health (P=.02). CONCLUSIONS: Significant benefits for the OT preventive treatment group were found across various health, function, and quality-of-life domains. Because the control groups tended to decline over the study interval, our results suggest that preventive health programs based on OT may mitigate against the health risks of older adulthood.

Activities of Daily Living↗
PubMed2003

Integrating medical and substance abuse treatment for addicts living with HIV/AIDS: evidence-based nursing practice model.

Forty-five active substance abusers with HIV/AIDS voluntarily participated in a substance abuse treatment research study with interviews at intake, 6 months and 12 months. These participants were engaged in treatment for a minimum of 45 days and a maximum of 90 days. The study used a nursing model of care, The Personalized Nursing LIGHT model, to integrate treatment for HIV/AIDS with substance abuse treatment. The LIGHT model seeks to enhance patient well being directly and thereby to support interventions that decrease substance use and improve management of chronic disease. The substance abuse treatment team included a nurse who used the LIGHT model and coordinated an integrated care protocol. The nurse accompanied clients on visits to their physicians for HIV treatment and facilitated the integration of medical recommendations with the substance abuse treatment. Six-month posttest data were gathered on all 45 participants and 12-month posttest interviews were accomplished with 29 of them. At 6 months, 78% of the respondents (35/45) reported no drug use in the past 30 days, and, at 12 months, 79% (23/29) were drug free for the past month. Significant decreases from intake to 6 months were detected on Addiction Severity Index (ASI) composite scores for drug use (p < 0.01), alcohol use (p < 0.04), medical severity (p < 0.02), psychiatric severity (p < 0.01), legal problems (p < 0.04), and employment difficulty (p < 0.01). Improvement of 6-month drug use composite scores was related significantly to treatment duration (R = 0.42; p < 0.01). Significant decreases in ASI measures of drug use (p < 0.01), alcohol use (p < 0.01), employment difficulty (p < 0.01), and family/social problems (p < 0.01) also occurred at 12 months. Well being, as measured by a Global Well Being Index, was found to improve significantly at 6 months (p < 0.02) and 12 months (p < 0.07). Concurrently, significant improvement was observed on Medical Outcomes Study-36-Item Short-Form Health Survey (SF-36) measures of general health and health functioning. These changes were noted at 6 months in the general health (p < 0.02), mental health (p < 0.01), social functioning (p < 0.01), role/emotional status (p < 0.04), and vitality (p < 0.01) subscales. At 12 months, the social functioning (p < 0.01) subscale responses were further decreased.

Adult↗
PubMed1994

The outcome of targeting community mental health services: evidence from the West Lambeth schizophrenia cohort.

OBJECTIVES: To report outcome of targeting community mental health services to people with schizophrenia in an inner London district who had been shown, one year after discharge, to have high levels of psychotic symptomatology and social disability but very low levels of supported housing and structured day activity. DESIGN: Repeat interview survey of symptoms, disability, and receipt of care four years after index discharge. SETTING: Inner London health district with considerable social deprivation and a mental hospital in the process of closure. SUBJECTS: 51 patients originally aged 20-65 years who satisfied the research diagnostic criteria for schizophrenia. MAIN OUTCOME MEASURES: Contact with services during the three months before interview, levels of symptoms (from present state examination), global social disability rating. RESULTS: 65% (33/51) of the study group had been readmitted at least once in the three years between surveys. Recent contacts with community psychiatric nurses and rates of hospital admission increased (8 at one year v 24 at four years, p < 0.01; 5 v 13, p < 0.06). Conversely, fewer patients were in contact with social workers (17 v 7, p < 0.03). Proportions in supported housing, day care, or sheltered work did not change. Unemployment rates remained very high. A considerable reduction (almost a halving) in psychiatric symptoms was observed, but there was no significant change in mean levels of social disability. CONCLUSIONS: The policy of targeting the long term mentally ill resulted in significant increases in professional psychiatric input to the cohort but failed to improve access to social workers or suitable accommodation. Improvements in social functioning did not follow from reductions in the proportions of patients with psychotic mental states. Social interventions are likely to be crucial to achieving the Health of the Nation target of improving social functioning for the seriously mentally ill, as improving mental state seems in itself to be insufficient.

Adult↗
PubMed1993

Functional health and well-being in patients with severe atherosclerotic peripheral vascular occlusive disease.

Functional health and sense of well-being are known to be adversely affected by chronic illness. The extent to which peripheral vascular occlusive disease (PVOD) alters these factors independent of other comorbid conditions is unknown. Sixty patients with PVOD severe enough to have required aortobifemoral bypass (AFB) between 1985 and 1990 were selected for evaluation. Although all were heavy smokers and 20% had suffered previous myocardial infarction, all had adequate cardiopulmonary function to survive AFB. The SF-20 questionnaire, validated in the Medical Outcomes Study (MOS), was used to evaluate patients' functional health and well-being at least 6 months after AFB. All grafts were patent at the time of questionnaire completion. Three measures of functional health (physical function, role function, and bodily pain) and three measures of well-being (mental health, health perception, and social function) were scored from SF-20 responses using the MOS protocol. These PVOD patients were then compared to MOS norms for patients without any chronic disease, to MOS norms adjusted for age and other comorbidities of the PVOD patients sampled, and to patients with congestive heart failure or recent myocardial infarction. Physical function, role function, and health perception were worse and bodily pain greater in patients with severe PVOD after surgical treatment as compared with MOS patients even after adjustment for comorbidities. Decrements in physical function, role function, and health perception for PVOD patients were comparable to MOS patients with congestive heart failure or recent myocardial infarction, whereas level of bodily pain was worse in PVOD patients than in these other groups. After adjustment for comorbidities, social function and mental health were not independently affected by PVOD. Functional health and well-being were not significantly different when PVOD patients with limb threat were compared to those with claudication. Severe PVOD is associated with decrements in functional health and well-being comparable to or greater than other severe chronic illness, even after successful revascularization. Further study is needed to examine the effect of revascularization on functional health.

Activities of Daily Living↗
PubMed2005

Impact of hormonal therapy prior to radical prostatectomy on the recovery of quality of life.

BACKGROUND: We investigated the changes in health-related quality of life (HRQOL) in patients who underwent prostatectomy (RP) with or without neoadjuvant hormonal therapy (NHT). METHODS: A total of 72 patients undergoing direct RP (DRP group) and 26 patients receiving neoadjuvant hormonal therapy (NHT group) were enrolled in the present study. The baseline interview was conducted before RP (not initiation of therapy). Follow-up interviews were conducted in person at scheduled study visits of 3, 6, and 12 months after surgery. We measured general and disease specific HRQOL with the Medical Outcomes Study 36-Item Short Form and University of California, Los Angeles Prostate Cancer Index, respectively. RESULTS: At baseline, the NHT group scored statistically lower for not only sexual function (P < 0.001), but also the general HRQOL, such as role limitations due to physical problems (P = 0.007), social function (P = 0.045) and mental health (P = 0.034), than the DRP group. The NHT group reported lower scores in social function and mental health at 3 months (P = 0.040 and 0.006, respectively). Patients who received NHT for more than 3 months continued to show significantly lower scores for some HRQOL domains 12 months later. CONCLUSION: Neoadjuvant hormonal therapy may decrease not only sexual function, but also general HRQOL before surgery. The recovery of HRQOL appeared to be further prolonged in patients who received long-term NHT.

Aged↗
PubMed2001

Disability and mental health of patients waiting for total hip replacement.

We performed a cross sectional study to examine the relationship between physical function and mental health of patients waiting for total hip replacement surgery, and the relationship between physical and social function and mental health to time spent waiting for surgery. We found that, in addition to the expected poor hip function, limited mobility and pain, one-quarter of the patients had clinically significant mood disorders and another quarter were in the borderline range. No association was found between severity of mental disorder and assessment of hip function. The patients had been waiting for 1-26 months (median 6 months) for surgery: yet those waiting longest were no worse on any of the outcome measures and their mental health was better. We conclude that mental disorders are common in patients waiting for hip replacements, are not directly related to hip function and their origins are unknown, but they require clinical assessment and treatment. There is no evidence that physical or social function or mental health are worse in those waiting longer for hip replacement surgery. Even so, these patients are severely disabled and some have to wait too long.

Adult↗
PubMed1996

Four behavioural syndromes of schizophrenia.

BACKGROUND: A complementary approach to defining symptomatic subtypes of schizophrenia is to identify characteristic patterns of 'problem behaviours' associated with the capacity of patients to function in the community. METHOD: In a large epidemiological survey, patients fulfilling Feighner criteria for schizophrenia were identified by key informants and assessed using the MRC Social Behaviour Schedule (SBS) and the Manchester Scale. An exploratory factor analysis was used to extract behavioural syndromes from the SBS data in order to compare the syndrome profiles in community, acute and long-stay subgroups and to examine their associations with symptoms and social functioning. RESULTS: Four behavioural syndromes were identified: 'Thought disturbance', 'Social withdrawal', 'Depressed behaviour' and 'Anti-social behaviour', which distinguished between the patient subgroups and had significant differential relationships to symptoms and social functioning variables. CONCLUSIONS: The evaluation of disability in schizophrenia and effectiveness of treatment interventions is incomplete without an assessment of problem behaviours.

Adult↗
PubMed1998

Is the SF-36 suitable for assessing health status of older stroke patients?

INTRODUCTION: The Medical Outcomes Study short form 36 health survey (SF-36) is being increasingly used and recommended as a suitable measure of subjective health status. However, it is unlikely that any measure will be appropriate for all groups. We wished to determine the suitability of the SF-36 for assessing quality of life in older stroke patients. METHODS: A screening questionnaire was used to identify prevalent cases of stroke from a random sample of 2000 subjects aged 45 years and over. The SF-36 was included as part of a self-completion questionnaire posted to each stroke patient. Data quality indicators were analysed. RESULTS: We identified 104 cases of stroke and the response rate for the SF-36 questionnaires sent was 83%. Completion rates for individual items ranged from 66 to 96%. All items in the role physical and role emotional scales had completion rates < 75%. The percentage of subjects for whom an individual scale score could be computed ranged from 67 to 96%, being lowest for the role physical and role emotional scales. Floor effects were high (> 15%) for these two scales and for the social functioning and physical functioning scales. Ceiling effects were substantial (> 15%) for the two role effect scales and for social functioning and bodily pain. CONCLUSIONS: This study has shown high response rates from older stroke patients to a postal questionnaire incorporating the SF-36. The poor completion rates and consequent inability to compute scores for a large proportion of responders in certain scales raises concerns about the perceived relevance of these sections. Results for the response effects suggest that, on its own, the instrument is not suitable for assessing outcome. When data quality indicators were examined, it appears that postal administration of the SF-36 is not appropriate for assessing quality of life of older stroke patients.

Activities of Daily Living↗
PubMed1995

Negative symptoms at discharge and outcome in schizophrenia.

BACKGROUND: The clinical significance in schizophrenia of positive and negative symptoms at discharge was assessed. METHOD: Of schizophrenic patients fulfilling DSM-III criteria, 113 were recruited for this study. Personal, social and psychopathological data were collected and all cases were followed up at one and two years after discharge. RESULTS: The presence of positive symptoms (64 cases), without concomitant negative symptoms, did not predict the follow-up social function and positive symptom score. Conversely, the presence of negative symptoms (31 cases) predicted worse social functioning (P < 0.05 to P < 0.005) and higher positive symptom scores (P < 0.01) at follow-up using MANOVA: Eighteen cases (15.9%) had neither positive nor negative symptoms and had the best clinical outcome. CONCLUSIONS: Negative, but not positive, symptoms assessed at discharge are an important predictor of poor outcome. In addition, negative symptoms may themselves expose a biological vulnerability to the presence of positive symptoms.

Adult↗
PubMed1999

Determining Quality of Life in Older and Younger Women With Congestive Heart Failure and Myocardial Infarction.

The purpose of this study was to compare quality of life (QOL) between older and younger women diagnosed with congestive heart failure (CHF) or myocardial infarction (MI) and to ascertain if QOL varied with age. Using the Medical Outcomes Survey (MOS-SF-36) we examined 131 women: 69 diagnosed with CHF and 62 with MI. Older women (age equals 65 years) with CHF had a higher mean for general health, whereas younger women (age equals 64 years) had higher mean scores for role physical, vitality, role emotion, and social functioning. Older women with MI had higher mean scores on role emotion, mental health, and social functioning. The younger MI women had higher mean scores on physical functioning, and role physical. Aspects of QOL may vary in subsets of women depending on age and cardiac diagnosis. This suggests the need for age appropriate intervention in women with MI and CHF.

Journal Article↗
PubMed1996

Measuring social disabilities in mental health.

Social functioning is important in relation to mental illness as it can limit the ability to function independently and because it may vary separately from symptoms. This paper summarises and critically reviews the development of the WHO Classification of Impairments, Disabilities and Handicaps. The value of social role theory is described followed by a classification of the relevant assessment scales in this field. Mental disorders are in general strongly associated with social dysfunctioning, particularly in schizophrenia and the major affective disorders. For a long time social dysfunctioning was considered an epiphenomenon and just a part of the disease process. Criteria for the diagnosis of a mental disorder were and still are often derived from the domains of work and social relationships. There are at least two related reasons why social functioning deserves a closer look: 1. There is an increasing trend to treat patients in the community instead of in the hospital: the changing orientation on community care needs careful evaluation with respect to its consequences. To what extent is survival in the community possible and what is the quality of life like there? Are community programs better than hospital treatment, and for whom? Therefore, separate measurement is justified for evaluation of outcome and costs and benefits. 2. There is growing evidence that the courses of symptomatology and social dysfunctioning may vary relatively independently: social disablement of a patient may be characterized much more by social disabilities than by persistent psychiatric symptoms; the former may call for another kind of action than usually available. For example, psychosocial rehabilitation focuses on cognitive and social abilities of the patient which are crucial for a more or less independent life. Therefore, separate measurement is justified for the sake of the right choice of treatment. The usual diagnostic systems such as the ICD and the DSM offer no adequate solution to the problem of classification and assessment of social dysfunctioning as a consequence of mental disorder. We have to look for other classification systems such as the International Classification Impairments, Disabilities and Handicaps (ICIDH) of the WHO (1980, 1993) which offers a conceptual model to study the long-term consequences in terms of functional disabilities and experienced social handicaps, and the effectiveness of health care to handle these kind of problems.

Humans↗
PubMed2004

P300 event-related potentials and cognitive function in social phobia.

The aim of the study was to investigate abnormalities of event-related potentials (ERPs) in social phobia patients indicating deficits in speed and amount of perceptual and cognitive resources as well as relationships between ERPs and cognitive functioning. ERPs were recorded from 19 EEG leads in a two-tone oddball paradigm in medication-free patients with DSM-IV social phobia (n=25) and in age- and sex-matched healthy controls (HC). Neuropsychological test performance was administered. Compared with the HC group, patients with social phobia showed reductions in N1 at temporal leads, N2 and P300 amplitudes, predominantly centroparietally, and longer P300 latencies. The observed P300 latency prolongation was associated with reduced Non-Verbal Learning Test (NVLT) but not the Wisconsin Card Sorting Test (WCST) scores. The reduction in N1 amplitude indicates an impairment in perceptual processing. The reduced P300 amplitudes may reflect reduced cognitive resources for the evaluation of relevant information. The increased P300 latency, indicating longer stimulus evaluation time, was correlated to deficits in learning processes as measured by the Non-Verbal Learning Test but not to executive function as measured by the Wisconsin Card Sorting Test. It may therefore be concluded that social phobia patients show deficits in cognitive information processing as reflected by ERPs.

Adult↗
PubMed2002

Acute alcohol effects on cognitive function in social drinkers: their relationship to drinking habits.

RATIONALE: Several studies suggest that cognitive deficits seen in late stages of alcoholism are related to executive function. However, little is known about the acute effects of alcohol on cognitive executive functions. AIMS: The present investigation examined the acute effects of a moderate alcohol dose on tests of planning and spatial working memory as well as on tests of spatial and pattern recognition. The relationship between the acute alcohol effects on performance in these tasks and extreme drinking patterns were also studied. METHODS: Alcohol (0.8 g/kg) or placebo was administered to 95 social drinkers. In the planning task, alcohol decreased the number of solutions with the minimum moves. Alcohol also decreased the thinking time before initiating a response, while it increased the subsequent thinking time in the same task. Under alcohol, participants recognised fewer items in the spatial recognition task; however no effect of alcohol was found in a spatial working memory task and in a pattern recognition task. Among the participants with moderate to heavy use of alcohol, those who were 'bingers' performed worse in the spatial working memory and in the pattern recognition task than 'non-bingers'; no interaction between treatment and drinking pattern was found. CONCLUSION: These data suggest that alcohol given acutely impairs executive-type cognitive functions and that binge drinking may be associated with impaired cognitive function in a working memory and a pattern recognition task.

Adolescent↗
PubMed1988

The relationship of early adolescent functioning to parent-reported and adolescent-perceived interparental conflict.

Is an adolescent's perception of interparental conflict important or is the parents' report of such conflict sufficient to predict adolescent functioning? To examine this question, a study was undertaken with 178 young adolescents and their mothers, fathers, and social studies teachers. Adolescents completed a measure of their perceptions of interparental conflict while mothers and fathers completed a self-report measure of their conflict. Teachers provided an assessment of each adolescent's cognitive and social functioning at two separate times, 1 year apart. Results indicated that both parental report, particularly maternal, and adolescent perception of interparental conflict were significantly related to adolescent cognitive and social functioning, and the magnitude of the correlations did not differ significantly. Hierarchical regression analyses were performed in which mother and father report of conflict was forced into the equation initially and adolescent perception of such conflict was allowed to enter freely. These analyses indicated that adolescents' perceptions accounted for unique variance in their functioning, beyond that accounted for by parental report. The results are discussed in terms of the specific roles that parental conflict and adolescent perceptions of such conflict play and the possible mechanisms by which each operates.

Adaptation, Psychological↗
PubMedDate not supplied

The burden of illness associated with headache disorders among young adults in a representative cohort study.

This study investigated the functional impairment (work and social functioning and general health status) associated with migraine and tension-type headache (TTH) among young adult members of the Dunedin Multidisciplinary Health and Development Study. Using criteria based on the International Headache Society classificatory system, the 1-year prevalence for migraine headache was 7.4%, TTH was 11.1%, and combined headache (coexisting migraine and TTH) was 4.3%. All comparisons were against a health control group (headache free) and a diagnostic control group (individuals without headache currently using medication for asthma). Although those suffering from migraine and combined headache had the most severe impairment in work- and social-related activities, those with TTH reported significantly poorer social and mental health functioning and poorer emotional and physical functioning while performing everyday roles than did headache-free controls. Study members with combined headache had the poorest self-reported health, with significantly lower ratings on physical, vitality, and mental health measures than asthmatics currently using medication. The pervasive impairment reported across multiple life domains among young headache sufferers illustrates the significant burden of illness associated with headache disorders.

Adult↗
PubMed2006

Measuring social-cognitive functions in children with somatotropic axis dysfunction.

Growth hormone (GH) and insulin-like growth factor I (IGF-I) are expressed in specific regions of the central nervous system during early human development. They may consequently influence aspects of cognition, or emotional and behavioural adjustment from childhood to adulthood, in conditions associated with abnormalities of the somatotropic axis. GH receptors are relatively common within hippocampal and perihippocampal regions that are primarily involved in declarative memory for facts and events. They are also located in structures (e.g. the putamen) that are involved in the processing of social perceptions. IGF-I receptors have been discovered in the amygdala and prefrontal cortex, which contribute to the neural circuits known as the 'social brain'. The evaluation of emotional, social and behavioural adjustment among children who have deficiencies in GH or IGF-I functional integrity requires the objective assessment of their social-cognitive competence. We describe a computerized test battery, the Schedules for the Assessment of Social Intelligence (SASI), which has been shown to possess excellent psychometric properties in terms of reliability and validity. The SASI, which can be used by both children and adults, may provide new evidence for deficits and treatment effects of GH/IGF-I on emotional, behavioural and cognitive functions.

Adolescent↗
PubMed2000

Nortriptyline versus fluoxetine in the treatment of depression and in short-term recovery after stroke: a placebo-controlled, double-blind study.

OBJECTIVE: This study compared nortriptyline and fluoxetine with placebo in the treatment of depression and in recovery from physical and cognitive impairments after stroke. METHOD: A total of 104 patients with acute stroke enrolled between 1991 and 1997 entered a double-blind randomized study comparing nortriptyline, fluoxetine, and placebo over 12 weeks of treatment. The majority of patients were recruited from a rehabilitation hospital in Des Moines, Iowa, but other enrollment sites were also used. Both depressed and nondepressed patients were enrolled to determine whether improved recovery could be mediated by mechanisms unrelated to depression. Nortriptyline in doses of 25 mg/day gradually increased to 100 mg/day or fluoxetine in doses of 10 mg/day gradually increased to 40 mg/day or identical placebo were given over 12 weeks. Response to treatment of depression for individual patients was defined as a greater-than-50% reduction in scores on the Hamilton Rating Scale for Depression and no longer fulfilling diagnostic criteria for major or minor depression. Improved recovery for a treatment group was defined as a significantly higher mean score from baseline to end of the treatment trial, compared with patients treated with placebo, on measures of impairment in activities of daily living and levels of cognitive and social functioning. RESULTS: Nortriptyline produced a significantly higher response rate than fluoxetine or placebo in treating poststroke depression, in improving anxiety symptoms, and in improving recovery of activities of daily living as measured by the Functional Independence Measure. There was no effect of nortriptyline or fluoxetine on recovery of cognitive or social functioning among depressed or nondepressed patients. Fluoxetine in increasing doses of 10-40 mg/day led to an average weight loss of 15. 1 pounds (8% of initial body weight) over 12 weeks of treatment that was not seen with nortriptyline or placebo. CONCLUSIONS: Given the doses of medication used in this study, nortriptyline was superior to fluoxetine in the treatment of poststroke depression. Demonstrating a benefit of antidepressant treatment in recovery from stroke may require the identification of specific subgroups of patients, alternative measurement scales, or the optimal time of treatment.

Activities of Daily Living↗