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Biomedical subjects

S J Schaffer

Publications and source records attributed to S J Schaffer.

At least 19 recordsLinked to original sources
PubMed2001

Adolescent immunization practices: a national survey of US physicians.

BACKGROUND: Adolescent immunization rates remain low. Hence, a better understanding of the factors that influence adolescent immunization is needed. OBJECTIVE: To assess the adolescent immunization practices of US physicians. DESIGN AND SETTING: A 24-item survey mailed in 1997 to a national sample of 1480 pediatricians and family physicians living in the United States, randomly selected from the American Medical Association's Master List of Physicians. PARTICIPANTS: Of 1110 physicians (75%) who responded, 761 met inclusion criteria. OUTCOME MEASURES: Immunization practices and policies, use of tracking and recall, opinions about school-based immunizations, and reasons for not providing particular immunizations to eligible adolescents. RESULTS: Seventy-nine percent of physicians reported using protocols for adolescent immunization, and 82% recommended hepatitis B immunization for all eligible adolescents. Those who did not routinely immunize adolescents often cited insufficient insurance coverage for immunizations. While 42% of physicians reported that they review the immunization status of adolescent patients at acute illness visits, only 24% immunized eligible adolescents during such visits. Twenty-one percent used immunization tracking and recall systems. Though 84% preferred that immunizations be administered at their practice, 71% of physicians considered schools, and 63% considered teen clinics to be acceptable alternative adolescent immunization sites. However, many had concerns about continuity of care for adolescents receiving immunizations in school. CONCLUSIONS: Most physicians supported adolescent immunization efforts. Barriers preventing adolescent immunization included financial barriers, record scattering, lack of tracking and recall, and missed opportunities. School-based immunization programs were acceptable to most physicians, despite concerns about continuity of care. Further research is needed to determine whether interventions that have successfully increased infant immunization rates are also effective for adolescents.

Adolescent↗
PubMed1999

Varicella immunization practices and the factors that influence them.

OBJECTIVES: To evaluate the varicella immunization practices of physicians in Rochester, NY, and to identify factors that predict whether physicians administer varicella vaccine to children. DESIGN: Evaluation of a 40-item survey addressing varicella immunization practices and opinions about varicella immunization that was sent to 241 pediatricians and family physicians. RESULTS: A total of 172 physicians (71.4%) completed the survey. Sixty-three percent administer the vaccine to some or all varicella-susceptible children aged 1 through 5 years, while 57% administer it to children aged 6 through 11 years, and 74% administer it to adolescents 12 years and older. Physicians who did not offer the immunization were more likely to believe that (1) the vaccine should not be given to preadolescent children because "varicella is a normal part of childhood"; (2) by giving the vaccine, varicella may shift from being primarily a childhood illness to being primarily an adult illness; (3) children get enough immunizations already and should not be given additional immunizations to prevent varicella; (4) it may be preferable to only immunize immunocompromised individuals and their close contacts; and (5) it would cost too much to immunize all American children who have not had varicella. Physicians most likely to offer the vaccine were pediatricians and those whose patients were covered primarily by private insurance plans. After becoming aware of morbidity and mortality rates for varicella-related complications, many physicians who did not administer the vaccine, or administered it only at the request of a parent, indicated that they would be more likely to offer it. CONCLUSIONS: Most physicians in the Rochester area administer varicella vaccine, especially to adolescents 12 years and older. Specialty, predominant insurance type billed, and various opinions characterized those who did not offer the immunization. Providing these physicians with information about varicella-related complications may make them more likely to immunize.

Adolescent↗
PubMed1999

Predicting the outcome of the CaNa2EDTA challenge test in children with moderately elevated blood lead levels.

The Centers for Disease Control and Prevention suggests the challenge test for children whose blood lead levels are 1.21-2.12 micromol/L (25-44 microg/dL). However, the challenge test is difficult to perform. By identifying children who are likely to have a negative challenge test, a medical provider can minimize the number of children undergoing this test. The goal of this study was to identify common tests that are likely to predict the outcome of the challenge test. It was conducted as a clinical descriptive study from a series of patients who underwent a CaNa2EDTA challenge test. Results from 178 challenge tests were eligible for analysis. The mean age of children undergoing the challenge test was 38.2 months, and the mean blood lead level was 1.83 micromol/L (38 microg/dL). Blood lead level, age, erythrocyte protoporphyrin level, and RATE (a measure of the rate of change of the blood lead level) were either not sensitive or not specific in predicting the outcome of a challenge test. However, based on a logistic regression model using blood lead level, age, and RATE, we determined criteria that would have identified all children who would have had a positive challenge test while excluding most children who would have had a negative challenge test. Based on this model, we recommend that the challenge test be conducted on children >=36 months of age who have a blood lead level between 1.45 and 1.64 micromol/L (30-34 microg/dL) and on children who have a blood lead level 1.69-2.12 micromol/L (35-44 microg/dL) regardless of age. This approach would have tested all children who subsequently would have had a positive challenge test while testing only 39% of children who would have had a negative challenge test.

Child, Preschool↗
PubMed1999

Primary prevention of childhood lead exposure: A randomized trial of dust control.

BACKGROUND: Dust control is recommended as one of the primary strategies to prevent or control children's exposure to residential lead hazards, but the effect of dust control on children's blood lead levels is poorly understood. OBJECTIVE: To determine the effectiveness of dust control in preventing children's exposure to lead, as measured by blood lead levels, during their peak age of susceptibility. DESIGN: A randomized, controlled trial. SETTING: Rochester, NY. PARTICIPANTS: A total of 275 urban children were randomized at 6 months of age, of whom 246 (90%) were available for the 24-month-old follow-up visit. INTERVENTIONS: Children and their families were randomly assigned to an intervention group (n = 140), which received cleaning equipment and up to eight visits by a dust control advisor, or a control group (n = 135). OUTCOME MEASURES: Geometric mean blood lead levels and prevalence of elevated blood lead levels (ie, >10 microg/dL, 15 microg/dL, and 20 microg/dL). RESULTS: At baseline, children's geometric mean blood lead levels were 2.9 microg/dL (95% confidence interval [CI] = 2.7, 3.1); there were no significant differences in characteristics or lead exposure by group assignment, with the exception of water lead levels. For children in the intervention group, the mean number of visits by a dust control advisor during the 18-month study period was 6.2; 51 (36%) had 4 to 7 visits, and 69 (49%) had 8 visits. At 24 months of age, the geometric mean blood lead was 7.3 microg/dL (95% CI = 6.6, 8.2) for the intervention group and 7.8 microg/dL (95% CI = 6.9, 8. 7) for the control group. The percentage of children with a 24-month blood lead >/=10 microg/dL, >/=15 microg/dL, and >/=20 microg/dL was 31% versus 36%, 12% versus 14%, and 5% versus 7% in the intervention and control groups, respectively. CONCLUSIONS: We conclude that dust control, as performed by families and in the absence of lead hazard controls to reduce ongoing contamination from lead-based paint, is not effective in the primary prevention of childhood lead exposure.

Dust↗
PubMed1998

Lead screening practices of pediatric residents.

OBJECTIVES: As part of their training, pediatric residents provide primary care services to young children, including youngsters who may have elevated blood lead levels. We set out to (1) determine the percentage of pediatric residents who screen children for elevated blood lead levels according to the guidelines of the Centers for Disease Control and Prevention and the American Academy of Pediatrics; (2) assess the likelihood of lead screening by residents based on demographic and practice-setting characteristics; and (3) compare the attitudes of residents who report that they are universal screeners, selective screeners, or nonscreeners. DESIGN: Confidential, cross-sectional survey of a nationally representative sample of pediatric residents conducted as part of the American Academy of Pediatrics 28th Periodic Survey of Fellows. SUBJECTS: One hundred forty-three responding pediatric residents (51% response rate). RESULTS: Seventy-five percent of pediatric residents reported screening all patients aged 9 to 36 months for elevated blood lead levels, 21% reported screening some, and 4% reported screening none. Pediatric residents who cared for patients in urban settings were more likely to report screening patients for elevated blood lead levels than were pediatric residents who cared for patients in suburban or rural settings (100% vs 73%; P < .001) and pediatric residents in the Northeast were more likely to report screening universally than were residents in the rest of the country (93% vs 63%; P < .001). Overall, pediatric residents who reported screening patients universally were more likely to believe that the benefits of screening outweigh the costs than were residents who reported screening patients selectively (67% vs 17%; P < .001). CONCLUSIONS: Most pediatric residents reported that they screened patients for elevated blood lead levels, either universally or selectively. Nevertheless, the screening practices of pediatric resident and their opinions concerning the relative benefits and costs of lead screening largely reflect the areas of the country and the practice settings in which they had their primary care experiences.

Adult↗
PubMed1998

Community characteristics associated with elevated blood lead levels in children.

OBJECTIVES: To identify community characteristics associated with children having elevated blood lead levels (> or = 10 micrograms/dL) and examine whether these characteristics can be used to identify children with elevated blood lead levels. PARTICIPANTS AND SETTING: A total of 20,296 children in Monroe County, New York (< 6 years old) who had blood lead testing in the first 12 months after statewide mandated reporting of blood lead tests began. DESIGN: A logistic regression analysis was conducted to examine the association of children's blood lead levels and community characteristics by using community characteristics of 653 census block groups. RESULTS: The following community level variables were associated with increased risk of elevated blood lead levels in children: residence within the city [odds ratio (OR), 2.0; 95% confidence interval (CI), 1.6, 2.7]; block groups with a higher proportion of individuals of Black race (OR, 1.6; CI, 1.4, 2.0); higher screening rate (OR, 1.9; CI, 1.6, 2.4); lower housing value (OR, 1.6; CI, 1.2, 2.0); housing built before 1950 (OR, 1.5; CI, 1.3, 1.8); higher population density (OR, 1.5; CI, 1.3, 1.8); higher rates of poverty (OR, 1.4; CI, 1.2, 1.8); lower percent of high school graduates (OR, 1.3; CI, 1.1, 1.6), and lower rates of owner-occupied housing (OR, 1.2; CI, 1.0, 1.4). Community characteristics were comparable with clinic-based individual risk assessment to identify children with elevated blood lead levels. CONCLUSIONS: These data demonstrate that community characteristics can be used to develop screening strategies to identify children who have elevated blood lead levels and shift our efforts toward identifying houses containing lead hazards before occupancy and before children are unduly exposed.

Child, Preschool↗
PubMed1997

Attitudes, practices, and recommendations by obstetricians about infant feeding.

BACKGROUND: Little information is available about the degree to which obstetricians promote breastfeeding through patient care practices and educational activities. The purpose of this study was to determine the attitudes, practices, and recommendations of obstetricians regarding infant feeding selection. METHODS: A written survey was mailed to 148 obstetrician/gynecologists in Monroe County, New York (78% response rate, n = 116). RESULTS: Of the 104 physicians in active obstetric practice, 86 percent conducted prenatal discussions about infant feeding with patients, 80 percent recommended breastfeeding, and 68 percent were commonly contacted postpartum by patients to address breastfeeding questions. Overall, 57 percent routinely incorporated these breastfeeding supportive practices into their prenatal and postpartum patient care. Attitudes about obstetric responsibility for infant feeding counselings and about the importance of counseling independently predicted the provision of these services. Infant feeding information was given to patients by 98 percent of obstetricians; 75 percent used written and 39 percent used videotaped materials. Formula company-produced infant feeding literature (41%), pregnancy literature (57%), and free formula offers (61%) were commonly used. Of those surveyed, 58 percent lacked training and 22 percent reported inadequate training in infant nutrition. CONCLUSIONS: Although most obstetricians in Monroe County provide infant feeding education and recommend breastfeeding, most report that their training about infant nutrition is inadequate, and they distribute infant formula company materials and offers to patients. Such discrepancies in patient care are inconsistent with promoting breastfeeding as optimal infant nutrition.

Breast Feeding↗
PubMed1996

A comparison of screening strategies for elevated blood lead levels.

OBJECTIVE: To calculate and compare the average expected cost per child screened (hereafter referred to as COST) among various screening strategies. DESIGN: A decision analysis of 5 strategies: (1) conduct risk assessment and screen high-risk children by venipuncture, low-risk children by fingerstick; (2) screen all children by fingerstick; (3) screen all children by venipuncture; (4) conduct risk assessment, screen high-risk children by fingerstick; and (5) conduct risk assessment, screen high-risk children by venipuncture. We assumed all fingerstick blood lead levels of 0.72 mumol/L or higher (> or = 15 micrograms/dL) would be confirmed by venipuncture. Baseline variables taken from the literature included prevalence of elevated blood lead levels in the pediatric population (2%), sensitivity and specificity of fingerstick blood lead assay (90% each), specificity of risk assessment (50%), sensitivity of risk assessment at blood lead levels of 0.48 to 0.68 mumol/L (10-14 micrograms/dL) and 0.72 mumol/L or higher (> or = 15 micrograms/dL) (65% and 85%, respectively), cost of blood lead assay ($6), cost to obtain blood by venipuncture ($4) and fingerstick ($2), and cost to get a child who has a fingerstick blood lead level of 0.72 mumol/L or higher (> or = 15 micrograms/dL) to return ($0.18). Sensitivity analysis determined whether selected variables affected the COST. RESULTS: The COSTs for strategies 1 through 5 were $9.07, $8.16, $10, $4.13, and $5.04, respectively. Among the universal strategies, screening children by fingerstick had the lowest COST at a prevalence of less than 38% and fingerstick blood lead assay a specificity of greater than 62%. Among the selective strategies, screening high-risk children by fingerstick had the lowest COST at a prevalence of less than 38% and fingerstick blood lead an assay specificity of greater than 63%. CONCLUSION: At a readily attainable specificity of the fingerstick blood lead assay, practices serving a patient population with a prevalence of elevated blood lead levels of less than 38% will have the lowest COST when a fingerstick screening strategy is used.

Costs and Cost Analysis↗
PubMed1996

Lead poisoning risk determination in a rural setting.

OBJECTIVES: To determine the prevalence of elevated blood lead levels among children living in a rural area and to determine the effectiveness of the Centers for Disease Control and Prevention (CDC) Lead Risk Assessment Questionnaire and additional questionnaire items in correctly identifying rural children having elevated blood lead levels. RESEARCH DESIGN: Comparison of results of a questionnaire that is intended to identify children as being at low or high risk for lead poisoning with children's blood lead levels. SETTING: The three practice sites of the only pediatric group in a rural county of upstate New York. PATIENTS: A consecutive sample of 705 children ages 6 to 72 months who were seen for health supervision visits between June and September 1993. RESULTS: Sixty-nine percent of the children were considered to be at high risk for lead poisoning by the CDC questionnaire. Overall, 8.4% of the children in the study had blood lead levels of 10 micrograms/dL (0.48 mumol/L) or higher, and 2.1% had blood lead levels of 15 micrograms/dL (0.72 mumol/L) or higher. No significant difference was noted between the percentages of high- and low-risk children who had elevated blood lead levels. To devise a more effective lead risk assessment tool for children in this setting, the two items from the CDC questionnaire and the two additional items that had the greatest predictive utility were combined to form a short alternative questionnaire. The alternative questionnaire thus consisted of items concerning whether the child has a sibling or playmate with lead poisoning, whether the child lives near an industry that potentially may release lead, whether the child lives in rented or owner-occupied housing, and whether the child has a parent who is a migrant farm worker. Children categorized as high risk with the alternative questionnaire were much more likely to have elevated blood lead levels than those who were categorized as low risk. The alternative questionnaire was very effective in correctly identifying children with elevated blood lead levels. Eighty-eight percent of children having blood lead levels of 10 micrograms/dL or higher and 100% of children having blood lead levels of 15 micrograms/dL or higher were classified as high risk by the questionnaire. Children classified as low risk were very unlikely to have elevated blood lead levels; 98% of low-risk children had blood lead levels of less than 10 micrograms/dL, and 100% had blood lead levels of less than 15 micrograms/dL. CONCLUSIONS: These results suggest that the CDC lead risk assessment questionnaire is of limited benefit in identifying rural children with blood lead levels 10 micrograms/dL or higher or 15 micrograms/dL or higher. An alternative questionnaire, however, seems to have marked clinical utility for identifying rural children with elevated blood lead levels.

Centers for Disease Control and Prevention, U.S.↗
PubMed1996

Blood lead screening practices among US pediatricians.

OBJECTIVE: In 1991, the Centers for Disease Control and Prevention (CDC) decreased the blood lead level of concern to 10 micrograms/dL (0.48 mumol/L) and recommended universal screening. Because these guidelines continue to provoke controversy, we conducted a study to: 1) estimate the proportion of pediatricians who are members of the American Academy of Pediatrics (AAP) who report screening for elevated blood lead levels; 2) describe their clinical practices regarding screening for elevated blood lead levels; 3) compare attitudes of universal screeners, selective screeners, and nonscreeners; and 4) identify characteristics of pediatricians who universally screen. DESIGN: Confidential, cross-sectional survey of a nationally representative random sample of 1610 pediatricians conducted through the AAP Periodic Survey. SUBJECTS: The study included 1035 responders (64% response rate). Analysis was limited to the 734 pediatricians who provide well-child care (ie, primary-care pediatricians). RESULTS: Fifty-three percent of pediatricians reported screening all their patients aged 9 to 36 months, 39% reported screening some, and 8% reported screening none. Among those who screen, 96% use a blood lead assay. The primary risk factors for which selective screeners screen are: history of pica (94%); living in an older home with recent renovations (92%); living in an older home with peeling paint (93%); and having a sibling who had an elevated blood lead level (88%). Among primary-care pediatricians, 73% agree that blood lead levels > or = 10 micrograms/dL should be considered elevated, and 16% disagree. However, 89% of primary-care pediatricians believe that epidemiologic studies should be performed to determine which communities have high proportions of children with elevated blood lead levels, and 34% of primary-care pediatricians believe that the costs of screening exceed the benefits. CONCLUSIONS: Three years after the Centers for Disease Control and Prevention issued new guidelines for the management of elevated blood lead levels, a slight majority of primary-care pediatricians in the United States who are members of the AAP report that they universally screen their appropriately aged patients, while most of the remaining pediatricians report screening high-risk patients. Many pediatricians may want additional guidance about circumstances under which selective screening should be considered.

Attitude of Health Personnel↗
PubMed1995

Immunization status and birth order.

OBJECTIVE: To determine whether an association exists between immunization status and birth order. DESIGN: Medical record review of immunization dates for matched siblings. SETTING: Pediatric clinic at a university medical center. SUBJECTS: A total of 892 children (446 sibling pairs of firstborn and secondborn children) born between 1983 and 1991 who received regular pediatric care at the clinic. OUTCOME MEASURES: Median ages at which firstborn children and their secondborn siblings had been immunized with the initial four doses of diphtheria and tetanus toxoids and pertussis vaccine (DTP1, DTP2, DTP3, and DPT4) and the initial dose of measles-mumps-rubella vaccine; point prevalences of firstborn and secondborn children up-to-date with all immunizations at each month of life to 2 years of age. RESULTS: Between 5 and 12 months of life, the percentage of secondborn children who were fully immunized was significantly lower than the percentage of fully immunized firstborn children (P values ranging from < .0001 to < .05). Firstborn children were much more likely than their secondborn siblings to have been immunized on time with DTP2 (z = 3.80, P = .0001) and DTP3 (z = 3.31, P = .0009). Overall, DTP2 immunizations were given at median ages 10 days later, and DTP3 immunizations, 20 days later to secondborn children than to their firstborn siblings. In addition, late immunization of a firstborn child was found to increase the risk that a secondborn sibling would also be immunized late. CONCLUSIONS: Secondborn children are likely to be immunized later than firstborn children. Secondborn children with an older sibling who was immunized late are at particular risk for delayed immunizations.

Age Factors↗
PubMed1995

Physician and parent opinions. Are children becoming pincushions from immunizations?

OBJECTIVE: To determine parent and physician opinions regarding the administration of multiple childhood immunizations by injection. DESIGN: Confidential mailed survey to physicians and residents; interview of parents during office visits for immunizations. PARTICIPANTS: Physicians and parents from Rochester, NY. RESULTS: The survey included 215 practicing physicians and 74 residents; response rate was 82%. Of the 197 parents interviewed, 93% were mothers, 68% were white; the mean (+/- SD) age was 25.8 +/- 5.2 years, with 12.8 +/- 1.8 years of education; 59% had private insurance, and 35% had Medicaid coverage. Of the parents, 31% had strong concerns about their child receiving a single injection; an additional 10% (total, 41% vs 31%; chi 2 = 4.05, P = .04) had the same concerns about their child receiving three injections. More practicing physicians than parents had strong concerns about children 7 months old or younger receiving three injections (60% vs 41%; chi 2 = 7.71, P < or = .01). Physician concern increased further when physicians were asked about administration of four injections (80% vs 60%; chi 2 = 18.77, P < .001). Of the parents, 64% preferred one rather than two visits to have three injections administered, if their physician recommended it; 58% still preferred one visit even if four injections were needed. CONCLUSIONS: Physicians have more concerns than parents about the administration of multiple injections at a single visit. Pain for the child was the main concern of all respondents. While most physicians have strong concerns about administering three or more injections at one visit, most parents prefer this practice. Continued education and reassurance of parents and physicians is needed to address concerns about children becoming "pincushions" from immunizations.

Adult↗
PubMed1994

The new CDC and AAP lead poisoning prevention recommendations: consensus versus controversy.

A considerable body of evidence has surfaced over the past several decades indicating that low-level lead exposure has detrimental effects for young children. As neurocognitive deficits have increasingly been found to be associated with lead levels as low as 10 micrograms/dL, the CDC has progressively lowered the threshold lead level designated as elevated to the present level of 10 micrograms/dL. The CDC also has recommended universal screening of all children for lead. These recommendations have engendered much controversy. After independently reviewing the relevant literature, the AAP and the National Academy of Science concurred with the CDC's conclusions and recommendations. As additional prevalence information becomes available, a more targeted approach to screening based on local prevalence data eventually may replace universal screening. However, as long as lead is found everywhere in the environment, children will continue to develop lead poisoning and suffer from its adverse effects. The problem of lead poisoning can be summarized best by a quote from a report of the Agency for Toxic Substances and Disease Registry to Congress, "Lead is toxic wherever it is found, and it is found everywhere."

Centers for Disease Control and Prevention, U.S.↗
PubMed1994

Lead poisoning risk determination in an urban population through the use of a standardized questionnaire.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) has recommended using a five-item questionnaire at every regular office visit for all children 6 to 72 months of age to identify those at risk of high-dose exposure to lead. OBJECTIVE: To determine how well the questionnaire identifies children with elevated lead levels. RESEARCH DESIGN: Comparison of results of the questionnaire, which is intended to identify children as being low-risk or high-risk for lead poisoning, with children's blood lead levels. SETTING: A pediatric continuity clinic located in a major teaching hospital in Rochester, NY. PATIENTS: A consecutive sample of 476 children aged 6 to 72 months without a prior history of lead poisoning who were seen in the clinic in July and August 1992, and (for those aged < 36 months) or 12 months (for those aged 36 to 72 months). MEASUREMENTS AND MAIN RESULTS: Fingerstick lead samples were obtained from all children, and those > or = 15 micrograms/dL (0.72 mumol/L) were confirmed by subsequent venous lead determinations. Twenty-eight percent had blood lead levels > or = 10 micrograms/dL (0.48 mumol/L), 8% had levels > or = 15 micrograms/dL (0.72 mumol/L), and 5% had lead levels > or = 20 micrograms/dL (0.96 mumol/L). According to responses on the questionnaire, 44% were initially classified as low-risk, and 43% were high-risk. In 13% risk could not be determined because one or more items on the questionnaire had not been answered or were answered equivocally, whereas all other items were answered "No." Children for whom risk could not be determined were presumed to be at high risk and were added to that category, resulting in 56% of the study population so designated. The questionnaire was moderately effective in identifying children with elevated lead levels. Seventy percent of children having lead levels > or = 10 micrograms/dL (0.48 mumol/L) and 82% of children having lead levels > or = 15 micrograms/dL (0.72 mumol/L) had been classified as high-risk by the questionnaire. Children classified as low-risk were very unlikely to have elevated lead levels. Eighty-one percent of low-risk children had lead levels < 10 ug/dL, and 97% had lead levels < 15 ul/dL. An abbreviated questionnaire using only the first three items from the CDC questionnaire had almost identical effectiveness. CONCLUSIONS: In this clinical setting, in which children are largely urban, poor, and have a moderate to high risk of developing elevated lead levels, the CDC risk assessment questionnaire is effective in identifying children with elevated lead burdens. However, an abbreviated version of the questionnaire may be as effective as the complete questionnaire. Additional questions should be added to the questionnaire to improve its overall sensitivity, and the questionnaire should be tested in other settings to see if it is effective with children having different environmental exposures to lead.

Centers for Disease Control and Prevention, U.S.↗