Biomedical subjects

J B Carlin

Publications and source records attributed to J B Carlin.

At least 55 records · Page 3Linked to original sources

PubMed1999

Respiratory symptoms and duration of residence in immigrant teenagers living in Melbourne, Australia.

OBJECTIVE: Examination of the relation between respiratory symptoms and time since arrival in Australia in immigrant teenagers living in Melbourne. DESIGN: Two stage, stratified, cross sectional survey. SETTING: High schools (n = 51). SUBJECTS: 9794 people aged 13-19 years. MAIN OUTCOME MEASURES: Prevalence of wheeze during a 12 month period, region of birth, duration of residence in Australia. RESULTS: The estimated population 12 month period prevalence of wheeze was 18.9% (95% confidence interval (CI), 18.0 to 19.9). In subjects born outside Australia, residence for five to nine years in Australia was associated with a 2.1-fold (CI, 1.1 to 4.0) increase in the odds of self reported wheeze; after 10-14 years, this risk increased 3.4-fold (CI, 1.8 to 6.7). There was no difference in severity of wheeze, measured by reported frequency of attacks, between Australian born and non-Australian born subjects. CONCLUSIONS: The notion of a continued secular increase in the prevalence of wheezing is not supported. There is a time dose effect on the prevalence of symptoms in subjects born outside Australia and now living in Melbourne, which is independent of age and country of birth.

Adolescent↗

PubMed1998

Rotavirus infection and rates of hospitalisation for acute gastroenteritis in young children in Australia, 1993-1996.

OBJECTIVE: To determine rates of hospitalisation of young children for acute gastroenteritis in Australia, and to estimate the proportion of these admissions caused by rotavirus infection. DESIGN: Analysis of hospital admission records, and parallel, prospectively collected data on rotavirus-positive admissions. SETTING: Hospitals admitting young children in all Australian States and Territories in 1993-1996. PATIENTS: All children under five years admitted to hospital for acute gastroenteritis (International Classification of Diseases, ninth revision principal diagnosis codes 003.0, 004.0-009.3 and 558.9). MAIN OUTCOME MEASURES: Rate of hospital admission per 1000 children per year by State, and the proportion of admissions caused by rotavirus infection. RESULTS: There were almost 20,000 hospital admissions annually in Australia for acute gastroenteritis in children under five years, at an average rate of 15/1000. An estimated 50% of these were attributable to rotavirus infection, implying a rate of hospitalisation for rotavirus-related gastroenteritis of 7.5/1000/year. Among children under two years this rate was 11.6/1000. Rotavirus incidence rates generally followed a typical seasonal pattern in temperate regions of the country, with sharp peaks in mid to late winter. Rates of hospitalisation varied markedly, even between States with apparently similar patterns of disease, while the incidence in the Northern Territory was 3-5 times higher than other States. CONCLUSIONS: Rotavirus-related gastroenteritis is a major cause of hospital admissions in young children, and large savings to the healthcare system are possible if it can be prevented at reasonable cost. Variation in treatment practices between States may be worth studying in greater detail as another source of potential savings.

Acute Disease↗

PubMed1998

Prevalence of tuberculosis infection in Melbourne secondary school students.

OBJECTIVE: To estimate the prevalence of asymptomatic Mycobacterium tuberculosis infection in Melbourne secondary school students. DESIGN: Cross-sectional Mantoux testing of a partly random and partly targeted sample of secondary school students, designed to enable estimation of prevalence by region of birth. SETTING: Fifty-one State and Catholic secondary schools in metropolitan Melbourne during 1995. PARTICIPANTS: Australian and overseas-born students in Years 9 and 10. OUTCOME MEASURES: Proportions of students with positive Mantoux reactions (defined as induration at 48 hours of > or = 5 mm with a history of recent exposure; > or = 10 mm and no prior BCG vaccination; > or = 15 mm and prior BCG vaccination). RESULTS: Of 2586 students potentially eligible for testing, evaluable results were obtained from 1274 (49%). The overall prevalence of infection for Melbourne students in Years 9 and 10 was 2.5% (95% CI, 1.1-3.9%). Main predictors of a positive test were birth overseas and number of years residing overseas. Prevalence varied considerably by region of birth, and was very low in students born in Australia (0.7%), "other developed countries" (0.7%), and Southern Europe (0). The highest rates were observed in students born in Indochina (15.9%), other countries in South East Asia (10.2%), and Eastern Europe (10.2%). CONCLUSIONS: The risk of a young person becoming infected with M. tuberculosis while living in Melbourne is very low. Our results do not indicate a need for the reintroduction of mass screening in Victorian schools. If targeted screening were to be considered, the group most likely to benefit would be recently arrived migrants from Indochina.

Adjuvants, Immunologic↗

PubMed1998

Severe viral respiratory infections in infants with cystic fibrosis.

Limited data in children with cystic fibrosis (CF) suggest that respiratory viral infections during infancy result in substantial morbidity. Eighty of 101 (79%) infants with CF diagnosed by neonatal screening during 1991-1996 were recruited into a prospective, multiple-birth cohort study. We aimed to perform an initial, then annual bronchoalveolar lavage (BAL) for bacterial and viral culture, cytology, IL-8, and elastolytic activity over the following 2 years. When possible, BAL was also performed during any hospitalization for a pulmonary exacerbation, and additional specimens for viral culture were collected by nasopharyngeal aspiration. Thirteen infants undergoing bronchoscopy for congenital stridor served as disease controls. During infancy, 31 children (39%) were hospitalized for respiratory disease and 20 (65%) cases had an etiologic agent identified. Respiratory viruses were detected in 16/31 (52%) cases, including four with simultaneous bacterial infection. Another four were infected with Staphylococcus aureus. Respiratory syncytial virus predominated and was found in seven infants. In the absence of bacteria, those with viral infections had acute onset of respiratory distress, were not treated with antibiotics, and had an uncomplicated hospital course. Compared to noninfected CF subjects and controls, infected infants had elevated BAL inflammatory indices (P < 0.01). Eleven of 31 (35%) hospitalized infants followed for 12-60 months acquired Pseudomonas aeruginosa, compared with only three of 49 (6%) subjects not hospitalized for respiratory symptoms during infancy (risk ratio 5.8, CI 1.9, 24). We conclude that respiratory viruses are important causes of hospitalization in CF infants. While viral infections were self-limited, they were accompanied by airway inflammatory changes, and admission to hospital was associated with early acquisition of Pseudomonas aeruginosa and persistent respiratory symptoms.

Bronchoalveolar Lavage↗

PubMed1998

The Melbourne House Dust Mite Study: long-term efficacy of house dust mite reduction strategies.

BACKGROUND: Asthma severity among mite-sensitized individuals appears to be related to the degree of mite allergen exposure. OBJECTIVES: The objective of this study was to assess the long-term effectiveness of mite avoidance measures in the homes of asthmatic children in Melbourne, Australia. METHODS: The concentration of house dust mite allergen (Der p 1) was measured on the child's mattress surfaces and bedroom floors in 85 homes on 10 occasions over a 16-month period. After the first three visits, all mattresses were covered with a semipermeable encasement, and carpeted bedroom floors were randomly allocated to regular applications of a placebo or an "anti-mite" shampoo. RESULTS: The concentration of Der p 1 recovered was initially high in the carpeted bedrooms (n = 66) (41.1, 95% confidence interval, 30.7 to 55.0 microg Der p 1 per gm) and mattresses (n = 85) (39.6, 27.2 to 57.7). During the initial observation period the concentration of mite allergen fell in the treatment, placebo, and parental control groups. During the seven treatment periods, no differences were seen between the Der p 1 concentrations in the groups using the "anti-mite" shampoo, placebo shampoo, or the parental control group (e.g., at visit 4; 12.6, 8.2 to 19.5; 14.8, 8.6 to 25.1; and 12.0, 8.1 to 17.7 microg/gm, respectively). In contrast, the concentration of Der p 1 in samples from uncarpeted floors and mattress encasements was low (4.1, 2.1 to 8.0 microg/gm and 4.2, 2.6 to 6.5 microg/gm, respectively) and insufficient dust for analysis was frequently obtained from these sites. CONCLUSIONS: There was no additional benefit from the use of an "anti-mite" shampoo. The absence of carpets and the use of mattress encasements was a useful long-term strategy for mite allergen avoidance.

Animals↗

PubMed1998

The course of early smoking: a population-based cohort study over three years.

AIMS: To examine the uptake and course of smoking in a representative adolescent cohort. DESIGN: Six-wave cohort study. PARTICIPANTS: Secondary school students initially aged 14-15 years at 44 schools in the state of Victoria, Australia. MEASUREMENTS: Computerized questionnaire including 7-day retrospective recall for tobacco use. FINDINGS: Prevalence rates for smoking in the past month rose from 25% to 31% and daily smoking 9% to 18% across the 3-year follow-up. Forty-five per cent of the sample smoked at some point but only 18% were daily smokers at the end-point. High rates of short-term cessation were observed for both experimental and daily smokers, but 70% of daily smokers relapsed within 12 months. Occasional smoking at the outset was the strongest predictor of later daily smoking and was also predictive of lower cessation and higher relapse rates. Parental divorce and parental daily smoking were associated with smoking at the outset and parental smoking was strongly predictive of the course of daily smoking. In contrast, prevalence rates of smoking in a subject's school did not significantly predict either smoking initiation or subsequent course. Female daily smokers were half as likely as males to cease smoking, a finding that accounted for gender differences in smoking prevalence in this sample. CONCLUSIONS: The strength of association between occasional and later daily smoking indicates the importance of primary prevention but the variability in the early course indicates that there should be much scope for promotion of adolescent efforts to quit. Both the diminished likelihood of smoking cessation in young women and parental influences on smoking course deserve further exploration.

Adolescent↗

PubMed1998

Immunogenicity and reactogenicity associated with an 18-month booster dose of a new diphtheria-tetanus-whole cell pertussis vaccine.

OBJECTIVE: To establish safety and immunogenicity of a reformulated whole cell pertussis based diphtheria-tetanus-pertussis vaccine (DTPw) at the 18-month booster stage following a 2, 4, and 6-month primary immunization course. METHOD: Open trial in suburban Melbourne in 100 healthy children initially recruited through maternal and child health centres. Thirty-five subjects were bled prior to vaccination, and 4-6 weeks after vaccination. A 7-day diary card was used to record subject temperatures and other systemic and local clinical signs. RESULTS: The increase in antibody geometric mean titres (GMT) after boosting was 19.5-fold (95%ci 14.2, 27.2) for tetanus and 26.5-fold (95%ci 16.6, 42.4) for diphtheria. Pertussis antibody GMTs also all showed substantial increases following the booster, with mean fold changes in titre ranging from 7.3 (Agg2) to 31.3 (Fha). Seventeen percent of subjects (95%ci 10%, 26%) experienced axillary temperatures > or = 38 degrees C during the 24-h period following vaccination. Low rates of significant (> 25 mm) injection site redness (13%) and swelling (8%) were recorded at 24 h postvaccination. CONCLUSION: This vaccine was well tolerated by children at 18 months of age, and showed substantial boosting of antibody to all components.

Diphtheria-Tetanus-Pertussis Vaccine↗

PubMed1998

Distress at induction of anaesthesia in children. A survey of incidence, associated factors and recovery characteristics.

This study analysed the frequency of distress at induction (DAI) in 2122 paediatric patients. The data were analysed to assess predictors of DAI and to examine associations between predictors of DAI and recovery characteristics. Patient age, preoperative behaviour, premedication (oral midazolam, n = 480) and venue for anaesthesia induction were associated with changes in the incidence of DAI. Distressed preoperative behaviour was a good predictor of DAI in all age groups. Premedication reduced the incidence of DAI in children aged 0.5-2 years old, and in older children who were distressed preoperatively. Induction in the Day Surgery Unit was associated with a reduction of the incidence of DAI in younger children. Children with DAI were more likely to suffer from distress at arousal (P = 0.001). Average early recovery time was prolonged 4.4 minutes and average discharge time in day patients was delayed 36 minutes by the use of oral midazolam premedication. Premedication was not significantly associated with arousal distress. We conclude that a policy of optimizing nonpharmacological approaches for minimizing induction distress, combined with selective premedication with oral midazolam, can produce a low incidence of induction distress and adverse effects.

Adjuvants, Anesthesia↗

PubMed1998

Accuracy of two pulse oximeters at low arterial hemoglobin-oxygen saturation.

OBJECTIVE: To evaluate the performance of two pulse oximeters in the measurement of arterial hemoglobin saturation in hypoxemic children. DESIGN: Prospective, repeated-measures observational study. SETTING: A 16-bed pediatric intensive care unit in a children's tertiary hospital. PATIENTS: Sixty-six patients with arterial saturation of <90%. INTERVENTIONS: Three arterial blood samples were taken from each subject during a 48-hr period. Pulse oximeter measurements of arterial saturation were compared with arterial saturation determined by cooximetry. MEASUREMENTS AND MAIN RESULTS: Arterial saturation was measured using one or both pulse oximeters (SpO2) and compared with the arterial hemoglobin saturation determined by cooximetry (SaO2). Sixty-two subjects were studied, using the Ohmeda pulse oximeter giving 185 data points (78 with saturations <75% [defined by the average of pulse oximeter and cooximeter]); 53 subjects were studied, using the Hewlett-Packard pulse oximeter yielding 155 data points (60 with saturations <75%). SpO2 ranged from 24% to 94%. Bias and precision of the Ohmeda pulse oximeter were -2.8% and 4.8% >75% and -0.8% and 8.0% <75%. Bias and precision of the Hewlett-Packard pulse oximeter were -0.5% and 5.1% >75% and 0.4% and 4.6% <75%. Intrapatient regression coefficient (r) for the differences between pulse oximeter and cooximeter was 0.58 for the Ohmeda and 0.59 for the Hewlett-Packard. Regression coefficients for predicting change in cooximeter value given a change in the Ohmeda pulse oximeter were 0.59 and 0.71 <75% and >75%, respectively. Similar coefficients for the Hewlett-Packard pulse oximeter were 0.50 and 0.70, respectively. CONCLUSION: The performance of the Ohmeda pulse oximeter deteriorated below an SpO2 of 75%. The Hewlett-Packard pulse oximeter performed consistently above and below an SpO2 of 75%. The ability of both pulse oximeters to reliably predict change in SaO2 based on change in pulse oximetry was limited. We recommend measurement of PaO2 or SaO2 for important clinical decisions.

Child↗

PubMed1998

A randomised, placebo controlled trial of inhaled salbutamol and beclomethasone for recurrent cough.

AIMS: To test the hypothesis that inhaled salbutamol or beclomethasone will reduce the frequency of cough in children with recurrent cough. A secondary aim was to determine if the presence of airway hyperresponsiveness (AHR) can predict the response. DESIGN: Randomised, double blind, placebo controlled trial. METHODS: During a coughing phase, 43 children (age 6-17 years) with recurrent cough were randomised to receive inhaled salbutamol or placebo (phase I) for 5-7 days and then beclomethasone or placebo (phase II) for 4-5 weeks, and in a subgroup of children for 8-9 weeks. The children used an ambulatory cough meter, kept cough diaries, and performed the capsaicin cough sensitivity, hypertonic saline bronchoprovocation, and skin prick tests. RESULTS: Salbutamol or beclomethasone had no effect on cough frequency or score, irrespective of the presence of AHR. CONCLUSIONS: Most children with recurrent cough without other evidence of airway obstruction, do not have asthma and neither inhaled salbutamol nor beclomethasone is beneficial.

Administration, Inhalation↗

PubMed1998

School based bicycle safety education and bicycle injuries in children: a case-control study.

OBJECTIVES: To evaluate possible benefits of a school based bicycle safety education program ("Bike Ed") on the risk of bicycle injury in children. METHODS: A population based case-control study was undertaken in a region of Melbourne, Australia. Cases were children presenting at hospital emergency departments with injuries received while riding bicycles. Controls were recruited by calling randomly selected telephone numbers. Data were collected by personal interview. RESULTS: Analysis, based on 148 cases and 130 controls aged 9 to 14 years, showed no evidence of a protective effect and suggested a possible harmful effect of exposure to the bicycle safety course (odds ratio (OR) 1.64, 95% confidence interval (CI) 0.98 to 2.75). This association was not substantially altered by adjustment for sex, age, socioeconomic status, and exposure, measured as time or distance travelled. Subgroup analysis indicated that the association was strongest in boys (OR 2.0, 95% CI 1.1 to 3.8), younger children, children from families with lower parental education levels, and children lacking other family members who bicycle. CONCLUSIONS: It is concluded that this educational intervention does not reduce the risk of bicycle injury in children and may possibly produce harmful effects in some children, perhaps due to inadvertent encouragement of risk taking or of bicycling with inadequate supervision.

Case-Control Studies↗

PubMed1998

Subjective scoring of cough in children: parent-completed vs child-completed diary cards vs an objective method.

Cough is often used as an outcome measure, although the reporting of cough is unreliable. Using a 24 h ambulatory cough meter to measure cough frequency, the aim of this study was to compare: 1) the correlation of child-completed diary cards to the objective measurement, with that of parent-completed diary cards; and 2) the visual analogue scale (VAS) to the verbal category descriptive (VCD) score. The cough meter consisted of a previously validated Holter monitor and a cough processor. Eighty four children (39 with recurrent cough and 45 controls, aged 6-17 yrs) used a cough meter at least once. Thirty three subjects used the cough meter twice. Parents and children completed separate diary cards using the VAS and VCD scores. The strength of the relationship between the subjective scores and the objective recordings was analysed by spearman's rank correlation coefficient. For daytime cough, child-completed diary cards and the VCD correlated better to the objective measurement than parent-completed diary cards and the VAS, respectively. In subjects that used the cough meter twice, the difference between the cough frequency correlated to the difference in the subjective scores. The confidence intervals for the correlation coefficients were wide. The agreement between the objective and subjective presence of daytime cough was good but that for night-time cough was poor. We conclude that the severity of cough defined on diary cards may not represent cough frequency. Objective readings are first choice but currently not yet practical. The verbal category descriptive diary card completed by children and assisted by parents has the highest correlation to cough frequency measured objectively.

Adolescent↗

PubMed1998

Depression, anxiety, and smoking initiation: a prospective study over 3 years.

OBJECTIVES: This report considers the extent to which depression and anxiety predict smoking onset in adolescence. METHODS: A 6-wave cohort design was used to study a sample of 14- and 15-year-old students (n = 2032) drawn from 44 secondary schools in the state of Victoria, Australia. The students were surveyed between 1992 and 1995 with a computerized questionnaire that included a 7-day retrospective diary for tobacco use and a structured psychiatric interview. RESULTS: Experimental smokers were 29 times more likely than non-smokers to make a transition into daily use in the subsequent 6 months. Depression and anxiety, along with peer smoking, predicted initiation of experimental smoking. Specifically, depression and anxiety accentuated risks associated with peer smoking and predicted experimentation only in the presence of peer smoking. CONCLUSIONS: The finding that experimental smoking is an overwhelmingly strong predictor of later daily smoking focuses attention on smoking initiation. Depressive and anxiety symptoms are associated with higher risks for initiation through an increased susceptibility to peer smoking influences. Promoting the psychological well-being of adolescents and addressing perceived interpersonal benefits of smoking may play a role in the prevention of adolescent tobacco use.

Adolescent↗

PubMed1997

Childhood asthma and lung function in mid-adult life.

The longitudinal lung function data in 286 subjects from a 28 year follow-up of childhood asthma is reported. Airway obstruction in mid-adult life was present mainly in those with moderately severe asthma. Subjects who had been wheeze free for at least 3 years, even if asthma had been persistent in childhood, had normal lung function and no increased bronchial reactivity. Only two subjects, both with persistent asthma from childhood, failed to show an improvement in FEV1 of greater than 10% following inhalation of a beta-adrenergic agonist. Subjects with relatively mild asthma who had not taken inhaled steroids did not appear to be disadvantaged with respect to lung function.

Adult↗

PubMed1997

The predictive value of dementia screening instruments in clinical populations.

OBJECTIVE: To determine the positive predictive value of the Mini-Mental Status Examination (MMSE), the Abbreviated Mental Test (AMT) and the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) for dementia in different clinical settings. DESIGN: Sensitivity and specificity of tests were compared against the criterion standard of clinical diagnosis made by a geriatrician or psychogeriatrician. SETTING: Two groups of patients were studied, a referred group of outpatients to a memory clinic (MC) and a random selection of patients referred to an aged care assessment team (ACAT). PATIENTS: Of 437 eligible MC patients, 299 were used in analyses of whom 216 subjects had dementia. Of 100 randomly selected ACAT patients, 78 agreed to be studied, and 32 subjects had dementia. RESULTS: The correlation between the MMSE and AMT was 0.87 for the ACAT sample and 0.86 for the MC sample. The correlation between the MMSE and IQCODE was -0.65 for the ACAT sample and -0.56 for the MC sample. The correlation between the DMT and IQCODE was -0.62 for the ACAT sample and -0.54 for the MC sample. The AMT and MMSE had lower sensitivity and specificity in the MC sample compared with the ACAT sample. Using a sensitivity of 78% and a specificity of 88%, chosen on the basis of findings, the positive predictive value in clinical situations varied from 70% for patients over the age of 75 admitted to acute teaching hospitals to 84% for patients seen by ACATs, inpatient geriatric liaison patients or acute geriatric units. The positive predictive value for the general population aged 80-84 years was 45%. CONCLUSIONS: The use of these tests is appropriate for the clinical situations described above. Their use in an unselected elderly population is not recommended as the tests are likely to produce more false positives than true cases of dementia.

Aged↗

PubMed1997

The Melbourne house dust mite study: eliminating house dust mites in the domestic environment.

BACKGROUND: Hypersensitivity to house dust mite allergens is associated with increased asthma morbidity. Asthma severity appears to be related to the degree of mite allergen exposure. Short-term studies suggest that complete avoidance reduces disease severity. OBJECTIVE: The study was designed to assess the effect of different mattress covers and floor coverings on mite allergen concentrations in the homes of mite-sensitive children with asthma in the city of Melbourne, Australia. METHODS: Mite allergen Der p 1 concentration was measured on mattress covers, mattress surfaces, and carpeted and uncarpeted floors in 107 dwellings; and measurement was performed on three occasions over a 5-month period. After the first sampling, all mattress covers and impermeable encasements were permanently removed. RESULTS: The initial geometric mean concentrations of Der p 1 (micrograms per gram of fine dust) from the surfaces of sheepskin, wool, and cotton mattress coverings were greater than those from the surfaces of impermeable mattress encasements (116, 113, and 19 vs 0.4) (p < 0.001); corresponding concentrations on the underlying mattresses were 142, 38, 20, and 0.6, respectively (p < 0.05 to 0.001). At the end of the study these mattress surface concentrations were 79, 65, 9.7, and 3.1, respectively. In 24 dwellings an uncarpeted room was adjacent to a carpeted room. At each visit the concentration of Der p 1 in uncarpeted rooms was below the reported threshold for sensitization and significantly less than that in the adjacent carpeted room. CONCLUSION: In homes of children with asthma, "asthmogenic" concentrations of Der p 1 were found on nonencased mattresses and carpeted floors, but the use of impermeable mattress encasements and carpet exclusion were associated with concentrations of Der p 1 below the reported threshold for sensitization.

Adolescent↗

PubMed1997

Apparent change in caseness in longitudinal studies.

Unless positive responses are verified at a second stage of data collection, a questionnaire-based survey has limited ability to assess change in caseness in a longitudinal study of a condition of low prevalence, assuming imperfect validity of the survey instrument.

Health Surveys↗

PubMed1997

Adolescent suicidal behaviours: a population-based study of risk.

BACKGROUND: Reports of adolescent suicidal behaviour have generally derived from clinical settings but population-based studies are likely to provide a clearer epidemiological view. METHODS: Non-fatal suicidal behaviours were studied in 1699 Australian 15- to 16-year-old secondary school students at 44 schools in the state of Victoria, Australia. Self-reported episodes of self-harm were characterized using items from the Beck Suicide Intent Scale. RESULTS: The 12 month weighted prevalence estimate for deliberate self-harm was 5.1%. The commonest forms were self-laceration (1.7%), self-poisoning (1.5%) and deliberate recklessness (1.8%). Self-poisoning and self-laceration were commoner in girls. The prevalence of 'true suicide attempts' was 0.2%. Most self-harmers did not perceive death as likely, plan self-harming episodes at length or inform others of the episodes. Psychiatric morbidity had the strongest association with self-harm, an association which held for all subtypes. Antisocial behaviour and substance abuse were associated with self-harm in girls but not boys. Sexual activity was independently associated with self-harm in both genders. CONCLUSIONS: Deliberate self-harm was common but the great majority of episodes were not 'true suicide attempts'. It is, therefore, possible that attributable mortality and morbidity may be greater in self-harmers without definite suicidal intent.

Adolescent↗