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Biomedical subjects

Hitoshi Furuya

Publications and source records attributed to Hitoshi Furuya.

At least 55 records · Page 3Linked to original sources

[The effect of inhalation induction with sevoflurane on left ventricular systolic and diastolic function. A transthoracic echocardiographic study].

BACKGROUND: The effect of inhalation induction with sevoflurane on left ventricular(LV) function has not been evaluated in adults. We assessed the effect of inhalation induction with sevoflurane on left ventricular systolic and diastolic function in adult patients using transthoracic echocardiography. METHODS: Twenty-five patients (ASA 1-2 and age < 70 years) received inhalation induction with 5% of sevoflurane. LV systolic function was evaluated by fractional shortening (FS), ejection fraction (EF), rate-corrected mean velocity of circumferential fiber shortening (Vcfc) and a contractile index, LV end-systolic wall stress (ESWS) versus Vcfc relation (ESWS-Vcfc relation). LV diastolic function was assessed by analysis of transmitral flow velocity, peak early diastolic and late diastolic filling velocities (E wave and A wave), E/A ratio and E wave deceleration time (DT). RESULTS: After induction, sevoflurane caused significant decreases in FS, EF, Vcfc, ESWS-Vcfc relation, E wave, and A wave, and a significant increase in E/A and maintained DT. CONCLUSIONS: During inhalation induction with sevoflurane in adult patients, sevoflurane caused negative inotropic effects, but preserved LV diastolic function.

Adult↗

[Retrospective analysis of postoperative nausea and vomiting after craniotomy].

BACKGROUND: Postoperative nausea and vomiting are important complications after craniotomy. METHODS: One hundred and seventy eight patients who had undergone brain tumor resection at Nara Medical University were retrospectively divided to one of two groups; with or without PONV within 24 hours postoperatively. Variables compared between the groups include gender, age, weight, height, site of surgery (supratentorial versus infratentorial craniotomy), size of brain tumor, type of anesthesia (inhalation versus intravenous anesthesia with nitrous oxide), intraoperative fentanyl dose, duration of surgery as well as anesthesia, and intraoperative posture. RESULTS: PONV occurred in 87 patients (49%). The incidence of PONV in patients undergoing infratentorial craniotomy was significantly higher than that in patients undergoing supratentorial craniotomy (75% vs 45%, P = 0.0011). There were no significant associations between PONV and other variables analyzed. CONCLUSIONS: These results indicate that the incidence of PONV after brain tumor resection is high and infratentorial surgery is a risk factor for PONV. Strategies for the prevention of PONV after craniotomy are required.

Anesthesia, General↗

[Incidence and characteristics of perioperative pulmonary thromboembolism in Japan].

BACKGROUND: Perioperative pulmonary thromboembolism (preoperative PTE) is widely recognized as one of the life-threatening perioperative complications in Japan. However, incidence of perioperative PTE is not well surveyed. The Japanese Society of Anesthesiologist (JSA) mailed the questionnaire about incidence of perioperative PTE and its characteristics to the institutions registered in JSA. METHODS: The questionnaire was mailed to 844 institutions. The items of the survey included age, sex, type of surgery and risk factors of the cases performed in 2002. Data were analyzed using chi-square test and Fisher's test, and P < 0.05 was taken as significant. RESULTS: Four-hundred sixty-seven out of 844 institutions responded (55.3%) effectively. There were 369 cases of perioperative PTE in 208 institutions (44.5% of the institutions responded). The incidence of perioperative PTE was 4.4 per ten thousand cases. Massive PTE or cardiac arrest at the onset occurred in 57 cases (15.4%). Out of these patients, 117 patients (31.7%) had obesity, and bed-ridden rest (> 4 days) patients and cancer patients were each 105 (28.5%). Sixty-six patients died from perioperative PTE, out of which 5 patients (7.5%) died during operation, 31 patients (47.0%) died within 7 days after the operation, and 30 patients (45.5%) died 8 days after the operation. The commonest type of surgery among mortality cases was abdominal surgery (20 cases: 30.3%), and the commonest risk factor was being bedridden (34.5 cases: 51.5%). The patients who had developed PTE during surgery counted 64, among whom the major type of operation was lower limb/pelvic surgery (36 cases: 56.3%). Major risk factors were being bed-ridden in 25 cases (39.1%) and lower limb/pelvic fracture in 25 cases (39.1%). Despite having dangerous risk factors, 128 patients (57.7%) received the measures not recommended or did not receive any preventive measure for PTE. CONCLUSIONS: This survey revealed that the incidence of perioperative PTE in Japan is considerable. On the ground that most PTE could be prevented, it is suggested that by employing preventive measures for PTE, the incidence of perioperative PTE will decrease.

Adolescent↗

[The influence of intermittent hemodialysis (HD) on bispectral index (scale) (BIS) and serum propofol concentration under postoperative intravenous sedation].

We experienced a case of postoperative intravenous sedation with propofol during intermittent hemodialysis (HD), and investigated the correlation between the clinical sedation level based on bispectral index scale (BIS) together with Ramsay score, and the serum concentration of propofol. One adult oral cancer patient (carcinoma of the lower gingiva) with end-stage renal dysfunction needing HD was selected for this study. The day after operation, HD was commenced under intravenous sedation with propofol. Clinical sedation level was assessed using BIS and Ramsay score, and serum propofol concentrations were determined in arterial blood samples. Serum concentrations were measured every 15 times until 51 hours after operation. The initial dose of propofol was set at 3.5 mg x kg(-1) x h(-1) on the basis of clinical symptoms. According to BIS and Ramsay score, sedation level decreased lineally for 1 hour after commencement of HD. In contrast, serum propofol concentration incresed from 1.71 microg x ml(-1) to 2.21 microg x ml(-1). Total serum concentration of propofol was enhanced during HD because of dialytic dehydration, but, according to BIS and Ramsay scores, the possibility was suggested that the fraction of albmin-unbound propofol with pharmacological activities was eliminated or absorbed by membrane during HD.

Anesthesia, General↗

[Present state of guidelines for perioperative management of deep vein thrombosis and pulmonary embolism in Japan].

To clarify the present state of local institutional guideline for perioperative deep thrombosis and pulmonary embolism in individual hospitals, a questionnaire was sent to anesthesia departments in Japan. According to the replies, 82 hospitals have original guidelines. Forty of them reported the contents of their guidelines. However, 37 hospitals have some problems regarding their guidelines. Cost for these perioperative managements and application of spinal or epidural anesthesia for heparinized patients appears to be commonly recognized as pending questions in their guideline. It seems to be difficult to make a stereotyped standard guideline in Japan because each local guideline has a specific strategy according to their situations. However, it is needless to say that a further nationwide survey and collaboration, and governmental support for these diseases would be required.

Anesthesia Department, Hospital↗

[The effects of propofol on left ventricular systolic and diastolic function during induction of anesthesia--a transthoracic echocardiographic study].

BACKGROUND: The effects of clinical doses of propofol on left ventricular (LV) systolic function remain controversial and LV diastolic function has not been evaluated during induction of anesthesia with propofol. We assessed the effects of propofol on LV systolic and diastolic function during induction of anesthesia in adult patients with transthoracic echocardiography. METHODS: Twenty-three patients, ASA 1-2 and age < 70 y.o., received propofol 2 mg x kg(-1) for induction of anesthesia. LV systolic function was evaluated by fractional shortening (FS), ejection fraction (EF), rate-corrected mean velocity of circumferential fiber shortening (Vcfc) and a contractile index, LV end-systolic wall stress (ESWS) versus Vcfc relation (ESWS-Vcfc relation). LV diastolic functions were assessed by analysis of transmitral flow velocity, peak early diastolic and late diastolic filling velocities (E wave and A wave), E/A ratio and E wave deceleration time (DT). RESULTS: After induction, propofol preserved FS, EF, Vcfc and ESWS-Vcfc relation and caused a significant decrease in E wave and A wave, and a significant increase in E/A ratio and maintained DT. CONCLUSIONS: During induction of anesthesia in adult patients, propofol preserved LV systolic and diastolic functions.

Adult↗

[Patient dissatisfaction with anesthetic care].

BACKGROUND: The evaluation of services by patients is an essential component of quality improvement in anesthesiology. Therefore, it is important to identify the factors for patient dissatisfaction. METHODS: We retrospectively studied 9974 consecutive patients who had received spinal or general anesthesia for elective surgery between 1999 and 2002. Pre-anesthetic, intra-anesthetic and post-anesthetic variables were recorded and patient satisfaction was assessed using direct interviews at the post-anesthetic clinic. Qualitative data on dissatisfaction were obtained by asking patients' reasons for dissatisfaction. RESULTS: 348 of the 8843 respondents (3.9%) had dissatisfaction with anesthesia. The rates of dissatisfaction were higher in women than in men and in spinal anesthesia than in general anesthesia, and were observed mostly in the patients aged from 20 to 39 years. Qualitative data show that the common reasons for dissatisfaction with anesthesia were spinal anesthesia as the most dissatisfactory factor, followed by epidural anesthesia, postoperative pain, vomiting/nausea and memory of tracheal extubation. However, other various factors were associated with dissatisfaction. CONCLUSIONS: It is difficult for anesthesiologists to satisfy all patients, because patients' senses of values were varied. However, we conclude that anesthesiologists can improve the quality of anesthesia by enlightenment of the patient about anesthesia, and moreover, by better peri-anesthetic management for dissatisfactory factors with anesthesia.

Adult↗

[Ilioinguinal/iliohypogastric nerve block for pediatric inguinal herniorrhaphy; evaluation of the dose of ropivacaine].

BACKGROUND: The aim of this study was to investigate the appropriate dose of ropivacaine in efficacy and safety when administered for ilioinguinal/iliohypogastric nerve block in children undergoing inguinal herniorrhaphy. METHODS: Forty six children (aged 1-8 yr, classified ASA I-II) undergoing ambulatory surgery for inguinal herniotomy were randomly assigned to one of the three groups, according to the dosage of ropivacaine: group I (n = 15), group II (n = 16) and III (n = 15) received 1.875, 0.9375 and 0.5625 mg x kg(-1) of ropivacaine, respectively. Intraoperative hemodynamics and modified CHEOPS score at 1, 3 and 5 hours after operation were recorded. RESULTS: There were no significant differences among the three groups in the intraoperative hemodynamics, whereas postoperative modified CHEOPS scores were significantly higher in group III than the other groups. Trivial femoral nerve palsy occurred in one patient of the group II, and no other adverse effects were seen in any groups. CONCLUSIONS: These results suggest that more than 0.9375 mg x kg(-1) of ropivacaine might be recommended to obtain sufficient postoperative analgesia for the ilioinguinal/iliohypogastric nerve block in children undergoing inguinal herniorrhaphy.

Amides↗

[Effects of low dose colforsin daropate hydrochloride in patients undergoing off-pump coronary artery bypass grafting].

BACKGROUND: We evaluated retrospectively the effectiveness of low dose colforsin daropate hydrochloride (CDH) in 12 patients undergoing off-pump coronary artery bypass grafting (CABG). METHODS: Low dose CDH was administered intravenously at a rate of 0.05-0.1 microg x kg(-1) x min(-1) from sternotomy to the end of coronary artery anastomosis. Hemodynamic measurements were made before infusion of CDH, and before, during, and after coronary artery anastomosis. RESULTS: Heart rate was significantly higher before, during and after the anastomosis compared with the value before the infusion of CDH. Heart rate was also significantly higher after the anastomosis compared with the value before the anastomosis. Systolic blood pressure, mean pulmonary pressure, right atrial pressure and pulmonary artery wedge pressure showed no significant changes after the start of infusion of CDH. Cardiac output was significantly higher before, during and after the anastomosis compared with the value before the infusion of CDH. Systemic vascular resistance was significantly lower before and during anastomosis compared with the value before the infusion of CDH. CONCLUSIONS: Infusion of low dose CDH prevents the elevations of mean pulmonary artery pressure, right atrial pressure and pulmonary artery wedge pressure without reducing systolic bood pressure during coronary artery anastomosis. Cardiac output was significantly increased, and SVR as well as PVR were significantly decreased after the infusion of CDH. In patients undergoing off-pump CABG, we recommend infusion of low dose colforsin daropate hydrochloride from sternotomy to the end of coronary artery anastomosis.

Cardiotonic Agents↗

Noxious stimuli do not modify myogenic motor evoked potentials by electrical stimulation during anesthesia with propofol-based anesthesia.

PURPOSE: To investigate whether motor evoked potentials (MEP) to transcranial electrical stimulation under constant blood propofol concentration are affected by the arousing effect of surgical noxious stimuli. METHODS: Twenty patients who underwent elective spinal surgery were studied. Patients were anesthetized with 50% nitrous oxide in oxygen, fentanyl, and propofol to maintain the bispectral index (BIS) score around 50. MEP in response to a multipulse transcranial electrical stimulation at stimulus sites of C3-C4 were recorded over the right abductor pollicis brevis muscle. Changes of peak-to-peak amplitude and onset latency of MEP, BIS score before and after surgical stimuli were evaluated. Propofol plasma concentration was measured at the same time points. RESULTS: Both MEP amplitude and latency did not change significantly after surgical stimuli although BIS increased significantly (48 +/- 6 to 58 +/- 5; P < 0.05). Plasma propofol concentration was maintained at the same level between the two measurement points (3.3 +/- 0.7 to 3.3 +/- 0.7 micro g*mL(-1)). There was no relation between BIS change and changes of MEP amplitude and latency, and propofol plasma concentration. CONCLUSION: MEP to the transcranial electrical stimulation under a constant and clinically appropriate blood propofol concentration are not affected by surgical noxious stimuli.

Anesthesia, General↗

Evaluation of rapid ischemic preconditioning in a rabbit model of spinal cord ischemia.

BACKGROUND: Rapid ischemic preconditioning (IPC) has been shown to reduce cellular injury after subsequent cardiac and cerebral ischemia. However, the data on rapid IPC of the spinal cord is limited. The authors investigated whether pretreatment with sublethal ischemia of spinal cord can attenuate neuronal injury after spinal cord ischemia in rabbits. METHODS: Forty-seven male New Zealand white rabbits were randomly assigned to one of three groups (n = 15 or 16 each). In the IPC(-) group, the infrarenal aorta was occluded for 17 min to produce spinal cord ischemia. In the IPC(+) group, 5 min of aortic occlusion was performed 30 min before 17 min of spinal cord ischemia. In the sham group, the aorta was not occluded. Hind limb motor function was assessed at 3 h, 24 h, 4 days, and 7 days after reperfusion using Tarlov scoring (0 = paraplegia; 4 = normal). Animals were killed for histopathologic evaluation at 24 h or 7 days after reperfusion. The number of normal neurons in the anterior spinal cord (L4-L6) was counted. RESULTS: Neurologic scores were significantly higher in the IPC(+) group than the IPC(-) group at 3 and 24 h after reperfusion (P < 0.05). However, neurologic scores in the IPC(+) group gradually decreased and became similar to those in the IPC(-) group at 4 and 7 days after reperfusion. At 24 h after reperfusion, the numbers of normal neurons were significantly higher in the IPC (+) group than in the IPC(-) group (P < 0.05) and were similar between the IPC(+) and sham groups. At 7 days after reperfusion, there was no difference in the number of normal neurons between the IPC(+) and IPC(-) groups. CONCLUSION: The results indicate that rapid IPC protects the spinal cord against neuronal damage 24 h but not 7 days after reperfusion in a rabbit model of spinal cord ischemia, suggesting that the efficacy of rapid IPC may be transient.

Animals↗

Long-term assessment of hind limb motor function and neuronal injury following spinal cord ischemia in rats.

Recent evidence suggests that brain injury caused by ischemia is a dynamic process characterized by ongoing neuronal loss for at least 14 days after ischemia. However, long-term outcome following spinal cord ischemia has not been extensively examined. Therefore, we investigated the changes of hind limb motor function and neuronal injury during a 14-day recovery period after spinal cord ischemia. Male Sprague-Dawley rats received spinal cord ischemia (n = 64) or sham operation (n = 21). Spinal cord ischemia was induced by inflation of a 2F Fogarty catheter placed into the thoracic aorta for 6, 8, or 10 minutes. The rats were killed 2, 7, or 14 days after reperfusion. Hind limb motor function was assessed with the 21-point Basso, Beattie, and Bresnahan (BBB) scale during the recovery period. The number of normal and necrotic neurons was counted in spinal cord sections stained with hematoxylin/eosin. Longer duration of spinal cord ischemia produced severer hind limb motor dysfunction at each time point. However, BBB scores gradually improved during the 14-day recovery period. Neurologic deterioration was not observed between 7 and 14 days after reperfusion. The number of necrotic neurons peaked 2 days after reperfusion and then decreased. A small number of necrotic neurons were still observed 7 and 14 days after reperfusion in some of the animals. These results indicate that, although hind limb motor function may gradually recover, neuronal loss can be ongoing for 14 days after spinal cord ischemia.

Animals↗

Influence of patient variables and sensor location on regional cerebral oxygen saturation measured by INVOS 4100 near-infrared spectrophotometers.

Cerebral oximeter based on near-infrared spectroscopy has been used as a continuous, noninvasive monitoring of regional cerebral oxygen saturation (rSO2). Although the absolute rSO2 values have a wide range of variability, the factors affecting a variability of rSO2 values have not been extensively investigated. The authors investigated the influence of patient variables and sensor location on rSO2 measured by the cerebral oximeter INVOS 4100 in 111 patients anesthetized with sevoflurane, fentanyl, and nitrous oxide in oxygen. The sensors for rSO2 measurements were applied on the right forehead (R), 1 cm lateral to R (R1), on the left forehead (L), 1 cm lateral to L (L1), and on the center of the forehead (C). The relationship between the rSO2 values and patient variables were also analyzed. Values of rSO2 at R1 and L1 were significantly lower than those at R and L, respectively. Values of rSO2 at C were significantly higher compared with those at other sites. There were no significant correlations between the rSO2 values and values of weight, height, and head size. Values of rSO2 were similar between males and females. A significant negative correlation between the rSO2 values and age and a positive correlation between the rSO2 values and hemoglobin concentration were observed. These data indicate that patient age, hemoglobin concentration at the measurement, and sensor location can affect rSO2 values.

Adolescent↗

The influence of induced hypothermia for hemostatic function on temperature-adjusted measurements in rabbits.

UNLABELLED: In hypothermic patients, a tendency to bleed may be observed even when hemostatic tests seem to be normal. Coagulation and platelet function tests are usually performed at 37 degrees C. We investigated the influence of induced hypothermia on temperature-adjusted hemostasis function testing using Sonoclot Analyzer (Sonoclot) and Thromboelastography (TEG). Anesthesia was induced and maintained with IV ketamine and fentanyl on 15 male New-Zealand White rabbits. A water blanket was used to induce hypothermia to 30 degrees C and to rewarm to 37 degrees C. Blood samples were obtained at four points: before hypothermia, at 34 degrees C, at 30 degrees C, and after rewarming. Standard coagulation tests were performed at 37 degrees C (C method), and simultaneously, real temperature hemostasis function tests (R method) were run. In Sonoclot(R), activated clotting time and time to peak increased and clot rate decreased significantly at 30 degrees C in the R method compared with those in the C method. In TEG(R), reaction time and clot formation time were prolonged and clot formation rate was diminished at 30 degrees C in the R method compared with those in the C method. Induced hypothermia delayed the coagulation cascade and reduced platelet function. During hypothermia, hemostatic measurements should be performed at real temperature to avoid overestimating patient hemostatic function based on results measured at the standard 37 degrees C. IMPLICATIONS: We investigated the influence of induced hypothermia on temperature-adjusted hemostasis function tests in rabbits using Sonoclot Analyzer and Thromboelastography. Induced hypothermia delayed the coagulation cascade and reduced platelet function. The conventional coagulation tests performed at 37 degrees C failed to detect these hypothermia-induced degradations in hemostasis performance.

Anesthesia↗

The effect of hypothermia on myogenic motor-evoked potentials to electrical stimulation with a single pulse and a train of pulses under propofol/ketamine/fentanyl anesthesia in rabbits.

UNLABELLED: In the present study, we investigated the effect of hypothermia on myogenic motor-evoked potentials (MEPs) in rabbits. The influence of stimulation paradigms to induce MEPs was evaluated. Twelve rabbits anesthetized with ketamine, fentanyl, and propofol were used for the study. Myogenic MEPs in response to electrical stimulation of the motor cortex with a single pulse and a train of three and five pulses were recorded from the soleus muscle. After the control recording of MEPs at 38 degrees C of esophageal temperature, the rabbits were cooled by surface cooling. Esophageal temperature was maintained at 35 degrees C, 32 degrees C, 30 degrees C, and 28 degrees C, and MEPs were recorded at each point. MEP amplitude to single- pulse stimulation was significantly reduced with a re-duction of core temperature to 28 degrees C compared with the control value at 38 degrees C (0.8 +/- 0.4 mV versus 2.3 +/- 0.3 mV; P < 0.05), whereas MEP amplitude to train-pulse stimulation did not change significantly during the cooling. MEP latency was increased linearly with a reduction of core temperature regardless of stimulation paradigms. In conclusion, these results indicate that a reduction of core temperature to 28 degrees C did not influence MEP amplitudes as long as a train of pulses, but not a single pulse, was used for stimulation in rabbits under propofol/ketamine/fentanyl anesthesia. IMPLICATIONS: Intraoperative monitoring of myogenic motor-evoked potentials (MEPs) may be required under hypothermic conditions because of its neuroprotective efficacy. However, data on the influence of hypothermia on myogenic MEPs are limited. The results indicate that multipulse stimulation may be better than single-pulse stimulation when monitoring MEPs during hypothermia.

Anesthesia, General↗

[Effect of teeth protector on dental injuries during general anesthesia].

BACKGROUND: Dental injuries are the most common reason for complaints against anesthetists. The purpose of this study was to investigate the effect of teeth protector on dental injuries during general anesthesia. METHODS: Incidence of dental injuries was evaluated retrospectively in 5,946 consecutive patients between November 1998 and October 2001. All the patients were interviewed directly at a post-anesthetic clinic. RESULTS: Dental injuries were observed in 2.1% of the patients, and the injuries occurred more frequently in the patients undergoing difficult tracheal intubation. The teeth protector used in the present study was made of cellulose aceto-butylate and was produced using eruko-pressed disks molded from own teeth form. One hundred and eighty five patients (3.1%) requested teeth protectors, and none of them had their teeth injured during anesthesia. CONCLUSION: Our results showed that the teeth protector could protect the teeth from dental injuries and increased the satisfaction with anesthesia. Preoperatively anesthesiologists should know the characteristics of patients' teeth and inform the patients of the risk of injury. We conclude that the custom-made protector might be useful and necessary to preserve the teeth from dental injuries during anesthesia.

Adult↗

[Anesthetic management of a patient with congenital plasminogen activator inhibitor-1 deficiency].

Congenital plasminogen activator inhibitor-1 (PAI-1) deficiency is an extremely rare disorder characterized by a bleeding diathesis due to hyperfibrinolysis as a result of decreased PAI-1 activity. A 21-year-old male with congenital PAI-1 deficiency underwent wisdom teeth extraction of the mandible under general anesthesia using propofol, nitrous oxide, sevoflurane, fentanyl, and vecuronium. No complications including prolonged bleeding and rebleeding after the operation were observed because hemostatic management was successful by using intravenous tranexamic acid.

Adult↗

[Evaluation of the different doses of olprinone for continuous infusion after cardiopulmonary bypass for coronary artery bypass surgery].

BACKGROUND: We evaluated the hemodynamic efficacy of combined cathecholamine and three different continuous infusion doses of olprinone (0.05, 0.1, 0.3 microgram.kg-1.min-1) in 24 cases (0.05 group: 8 cases, 0.1 group: 8 cases, 0.3 group: 8 cases) undergoing coronary artery bypass grafting (CABG). METHODS: Olprinone was administered as a single dose (0.1 mg.kg-1) into the venous reservoir of the CPB circuit 15 min prior to the end of emergence from CPB, followed by continuous infusion. Hemodynamics were measured at the time of preCPB (M 0), just after the end of CPB (M 1), pre chest closure (M 2) and after chest closure (M 3). Cathecholamines were used to maintain mean arterial pressure (> 65 mmHg) and cardiac index (> 3.0 l.min-1.m-2). Hemodynamics (at M 0, M 1, M 2 and M 3) and the number of cases requiring combined cathecholamine were compared among the 3 doses. RESULTS: Three doses showed no significant difference on hemodynamics. In the number of cases requiring combined cathecholamine, group 0.3 were significantly lower than group 0.05 at dobutamine, and group 0.05 were significantly higher than group 0.1 and 0.3 at norepinephrine. CONCLUSIONS: The higher continuous infusion dose of olprinone (0.3 > 0.1 > 0.05 microgram.kg-1.min-1) can diminish the number of cases requiring combined cathecholamine administration during coronary artery bypass grafting.

Aged↗